Abstract
Although multicultural counseling competence is crucial to the field of counseling psychology and clinical assessment, there remains a gap in how cultural data can be collected and used in clinical case conceptualization. The present study evaluated the case conceptualizations of doctoral-level trainees and focused on whether the integration of culture into the conceptualizations/formulations was influenced by the use of the Wright-Constantine Structured Cultural Interview (WCSCI), as compared to the use of one of two other cultural interviews (the Patient Cultural Identity Assessment and the DSM-5 Cultural Formulation Interview). Unsurprisingly, clients with minoritized identities and supervisors (but not trainees) with minoritized identities produced case conceptualizations that integrated culture at higher rates. Further, those conceptualizations that utilized the WCSCI were around 3.5 to 4.5 times more likely to integrate culture than those that used one of the other two cultural interviews. Implications for psychology practice are discussed.
Keywords
Although the field of counseling psychology has long emphasized the need to integrate culture more fully into clinical case conceptualization and counseling work in general, few methods and models exist for doing so effectively. The Wright-Constantine Structured Cultural Interview (WCSCI) holds promise for increasing the integration of cultural context and history into clinical case conceptualization in counseling practice.Significance of the Scholarship to the Public
There is a general consensus that multicultural counseling competence (MCCC) is crucial to the field of counseling psychology and clinical assessment (Constantine & Ladany, 2001; D. G. Hays, 2020; Sue & Sue, 2012). All people are cultural beings with cultural ideals and experiences (including oppression) informing their behavior as well as how they present in counseling (Ridley, Sahu, et al., 2021). Furthermore, counseling itself exists and occurs within a cultural context (American Psychological Association [APA], 2017; Kirmayer, 2007; Pedersen, 1990). Thus, it is imperative for counselors and therapists to ensure that they do not overlook or discount the significance of culture in counseling (Ridley, Mollen, et al., 2021). With a growing diversity in clientele comes the need for preparing clinicians to utilize cultural awareness, knowledge, and skills to responsibly tailor their work to improve outcomes (Jones et al., 2017). Cultural competence emphasizes the role that identity plays in psychosocial adjustment, requiring clinicians to provide counseling that effectively integrates culturally-based conceptualizations, skills, and approaches in treatment (Jones, 2009).
Yet, there is still a gap in the literature in terms of how multicultural competency is generally reflected in clinical processes, especially in clinical conceptualizations and treatment approach considerations. Case conceptualizations and treatment strategies have historically discounted how cultural factors, such as living as a minoritized individual within a dominant, White supremacy culture, may impact clinical problems; without adequate consideration of client cultural identity and its integration in cases, clinicians may potentially disregard critical cultural factors and experiences that can shape the well-being of their culturally diverse clients (P. A. Hays & Iwamasa, 2006; Jones et al., 2017). Research has shown that culture has a critical impact on assessment, presenting problem identification, and treatment approaches (Bernal & Adames, 2017). In addition to cultural dimensions such as race, ethnicity, gender, social class, and sexual orientation, cognitive aspects such as worldviews, belief systems, and racial identity development are consistently recognized as critical to treatment outcomes (Fuertes et al., 2001; Lewis-Fernández et al., 2020; Oh & Shillingford-Butler, 2021). Thus, clinical assessment should incorporate the individual’s culture and experiences of oppression at every point of the clinical process, including case formulation and conceptualization.
Multicultural Counseling Competence in Case Conceptualization
Multicultural competence in psychology has traditionally been understood as a clinician’s attitudes, beliefs, knowledge, and skills in regards to working with clients who hold culturally diverse identities (Sue et al., 1992; Sue et al., 1998; Sue & Sue, 2012). Although, there have been major efforts to redefine and reconstruct the meaning of MCCC (Constantine & Ladany, 2001; Ridley, Mollen, et al., 2021; Sue & Sue, 2012), methodological and theoretical limitations, gaps between MCCC beliefs and practices, and a general lack of agreement on how MCCC should be defined, measured, and enhanced, continue to persist (Beagan, 2018; Constantine & Ladany, 2001; Fuertes, 2012; D. G. Hays, 2020; Huey et al., 2014; Metzger et al., 2010; Mollen & Ridley, 2021; Ridley, Mollen, et al., 2021; Smith et al., 2016; Worthington & Dillon, 2011).
The integration of cultural factors into clinical assessments (e.g., intakes, comprehensive assessments, treatment plans) has been recommended for decades (Ecklund & Johnson, 2007; Sanchez et al, 2021). Ridley, Sahu, et al. (2021) called for a deep-structure incorporation of culture into clinical competencies, positing that there should be a purposefulness and explicitness in the incorporation of culture in counseling practices, including integrating cultural data into the clinical case conceptualization.
A cultural formulation serves to provide a systematic overview of a client’s cultural background, the role of cultural context in the client’s expression of distress or disturbance, the client’s experience of oppression, and the effect that cultural differences may have on the client’s relationships, including the therapeutic alliance between client and clinician (Sanchez et al., 2021). A competent, integrated cultural formulation can facilitate the development of a collaborative, empowering relationship that cultivates growth, in addition to ensuring that cultural factors are not only considered but thoroughly incorporated into the case conceptualization and treatment plan. Clinical conceptualizations may then increase in complexity and nuance as connections are made between potential etiologies, coping and maintenance models, and other aspects of presenting concerns, which then become formulated into appropriate and culturally responsive treatment plans.
Culturally responsive case conceptualizations pave the way for adapting evidence-based treatments in order to prevent dropout and improve treatment outcomes (Cabassa & Baumann, 2013). Research has demonstrated that the integration of culturally responsive practices into psychotherapy can improve treatment outcomes and may be the most important part of the clinical process (Easden & Kazantzis, 2018; López et al., 2014). For example, Hinton et al. (2011) examined the impact of culturally responsive cognitive behavioral therapy and found that the inclusion of culturally adapted idioms and analogies that were accordant with the client’s cultural background were significantly related to reductions in trauma symptoms. Piña-Watson et al. (2015) found that integrating ethnic identity and cultural variables such as familismo into therapy sessions improved academic motivation for Mexican American students. There are additional studies that have found similarly promising results (e.g., González-Prendes et al., 2011; Weiss et al., 2011; Zigarelli et al., 2016) for various minority groups, including African Americans (Crosby-Cooper & Ferrell, 2020; Ecklund & Johnson, 2007) and Asian Americans (Wang & Kim, 2010). Thus, adequate, deep-structure cultural integration with clinical case conceptualizations is an important area for further training and research.
Factors Impacting Cultural Formulation
Previous research has examined the relationship between MCCC and several factors, including client and clinician demographics and clinician training, with varied findings (Berger et al., 2014; Chao et al., 2011; Constantine, 2001; Constantine & Ladany, 2001; Neville et al., 2006). In a study examining the link between client racial identity and case conceptualization, Schomburg and Prieto (2011) found that client race did not impact the likelihood of racial identity being included in case conceptualization; indeed, clinicians were equally inattentive to racial clinical considerations for both African American and European American clients. However, another study (Neufeldt et al., 2006) found that client racial identity did have a significant impact on the likelihood of integrating culture into clinical conceptualizations. Specifically, they found that clinical trainees were three times more likely to incorporate cultural references in their case conceptualizations for Asian American clients as opposed to White clients. Berger et al. (2014) found similar results for ethnically minoritized therapists, who were more likely to use a cultural framework in clinical practice as compared to their White counterparts. Conversely, several studies (Ladany et al., 1997; Lee & Tracey, 2008; Smith et al., 2006) have found no significant differences in multicultural case conceptualization skills between trainees of Color and White trainees. Furthermore, culturally competent supervision, and more specifically explicit supervisor instruction regarding the inclusion of client cultural identity in case conceptualization, may be linked to clinician multicultural case conceptualization ability (Inman & Ladany, 2014; Ladany et al.,1997). Weatherford and Spokane (2013) found that the presence of MCCC in a clinician’s training held a significant positive correlation with multicultural case conceptualization and treatment ability.
This review demonstrates that clinical concerns are inextricably linked to cultural and contextual experiences of clients. Yet, it also highlights the gaps in the field regarding how and why clinical case conceptualizations need to be improved for appropriate cultural competency (Skaistis et al., 2018). The information that counselors choose to incorporate in these conceptualizations communicates areas of importance and prioritization in the counseling process, as well as how sensitive counselors are or will be to new clients’ cultural identities and experiences (Cook et al., 2020). Additionally, cultural formulations are all too often sectioned off to only a single part of assessment procedures (O’Connor, 2000; Sattler, 2020); however, this type of compartmentalization of the functions of culture can minimize its importance and heighten the risk of it being overlooked both in the clinical intake and conceptualization processes (Ecklund & Johnson, 2007). Furthermore, there is little guidance on what cultural identity information to include in clinical conceptualizations and how to ask about it during the intake process (Cook et al., 2020; Hill, 2014; Welfare et al., 2017; Whiston, 2017).
Collecting Cultural Information
There are several components of culture that can be integrated into case conceptualization in a thoughtful, thorough, clinical way that not only makes room for contextual components to be mentioned but cohesively weaves in such factors as contributors to presenting symptoms, underlying mechanisms of dysfunction, and aspects of resiliency. For example, one may include a client’s experience with stress related to racism (e.g., institutionalized, interpersonal, collective, cultural–symbolic, sociopolitical; Harrell, 2000) or instances of challenging experiences related to power and privilege (McIntosh, 1993). Internalized racism (Constantine & Sue, 2005); stressors related to immigration, acculturation, and language acquisition; and the presence, meaning, and impact of multicultural family dynamics may also be interwoven into the clinical case conceptualization (Rogers & Lopez, 2002).
Although the call for the integration of relevant cultural factors in the clinical assessment process has been made for decades (Sanchez et al., 2021), and despite the importance of MCCC and psychology’s commitment to culturally responsive treatment that reflects the inextricable connection between clients’ cultural context and clinical presentation, there is limited instruction for how to effectively and meaningfully collect cultural information and integrate culture in case conceptualization (Ridley, Sahu, et al., 2021). Currently, cultural integration often means inquiring about clients’ cultural experiences separate from their presenting problems or other case material. In the field’s movement toward greater cultural inclusivity, several structured clinical interviews and models have been designed to encourage both client and clinician reflection on the relationship between aspects of their sociocultural identity and experiences and their psychological distress and intervention.
The Patient Cultural Identity Assessment (PCIA; Dadlani et al., 2012), the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Cultural Formulation Interview (CFI; DeSilva et al., 2015), and P. A. Hays’ (2001) ADDRESSING model are examples of such interviews and framework. The PCIA was designed in response to what was seen as the limitations of the DSM-IV’s cultural approach, specifically the lack of formal integration of culture in diagnostic classification (Dadlani et al., 2012). The cultural approach of the DSM-IV treated culture as peripheral, whereas the PCIA centers culture and is considered relevant to all and not simply those with marginalized identities. The PCIA is guided by four main cultural assertions: (a) clients have social identities and are influenced by their cultural locations and wider systemic factors; (b) it is not simply one social identity influencing individuals, but intersecting identities; (c) clinicians, like clients, are impacted by culture and have social identities that contribute to their approach to treatment and diagnosis; and (d) therapy is cultural and influenced by the social identities of both the client and clinician (Dadlani et al., 2012). However, there are currently no studies on the impact of using the PCIA in either case conceptualization or ongoing counseling work.
The CFI (American Psychiatric Association, 2013) from the DSM-5 was designed to bring greater clarity and inclusion to the role of culture in the clinical experience. It is a semistructured clinical assessment that is intended to move beyond the cultural approach of the DSM-IV and provide a frame for clinicians to assess the role of culture in clinical presentation and then to use that information to inform diagnosis and treatment planning (Aggarwal et al., 2020; DeSilva et al., 2015, 2018). Specifically, it focuses on: (a) getting a sense of the cultural definition of the problem, (b) the cultural understanding of the origins and meaning of the problem, (c) the role of culture in how the client has coped with and sought help in the past for the problem, and (d) the role of culture in the current engagement in help seeking (DeSilva et al., 2018). Although clinicians have rated the tool as useful in their work, direct assessment of the effects of using the CFI have not been published, despite being currently under way (Jarvis et al., 2020).
P. A. Hays’ (2001) ADDRESSING framework responds to the guidelines for working with culturally diverse populations put forth by the APA (1993). In addition to inviting clinicians to examine themselves, the ADDRESSING framework is intended to increase awareness of how clients are impacted by identification and experiences with specific marginalized cultural identities. Each letter in the ADDRESSING acronym reflects a sociocultural domain where an individual may experience marginalization or privilege: Age and generational influences, presence of a Developmental disability/acquired Disability, Religion and spirituality, Ethnic and racial identity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender. In keeping with the tenets of MCCC, ADDRESSING offers a model that allows for the enhancement of clinical cultural awareness and knowledge. However, there remains a gap when it comes to skill development. There is some research to suggest that the use of the ADDRESSING framework is beneficial to the development of MCCC skills. For example, Hagler (2020) found that when the ADDRESSING conceptual frame was explicitly identified as the model being used in supervision, both the supervisory experience and clinical work were more culturally informed and grounded. Similarly, Powell (2016) found that when ADDRESSING was used in the training of drama therapy students, the student clinicians reported increased facility in their thinking about intersecting identities and greater sensitivity to their clients’ cultural experiences. It has also been shown that the use of ADDRESSING can enhance the treatment of cognitive behavioral therapy with diverse clients, as it can improve therapeutic understanding and subsequently treatment planning and intervention (P. A. Hays, 1996). Further, Jones et al. (2016) found a connection between using ADDRESSING in the beginning of treatment and increased inclusion of cultural factors in clinical conceptualization and treatment, which was seen as a more culturally responsive therapy. However, the ADDRESSING framework is a general model to guide these processes, rather than a specific technique for collecting cultural information.
Even with these established structured interviews and theoretical models, cultural sensitivity and consideration remain more broadly peripheral—or worse, superfluous—in clinical case conceptualization and treatment planning. There is a significant need to integrate client cultural beliefs, ideas, experiences, and values into case conceptualization and treatment planning at every level (Hwang, 2011). The Wright-Constantine Structured Cultural Interview (WCSCI; Wright & Constantine, 2020) was developed to be such a tool. Conceptually grounded in the P. A. Hays’ (2001) ADDRESSING model, it is intended to inquire directly about the influence of various sociocultural identity characteristics and cultural experiences on the lived experience of the client. The WCSCI centers the client’s viewpoint and values empowerment, making the client responsible for naming and identifying areas of identity salience and explicitly reflecting on and sharing their experiences. It ascribes to a holistic wellness view of cultural identity, one that does not seek to look at identity within the context of pathology, but rather provides a cultural foundation for understanding a person and their lived experience. The WCSCI also conceptualizes the self in relation to other perspectives, with the client guiding this lens. For example, it asks clients to share any perceived similarities and differences between themselves and others who share some aspects of their cultural identity.
Perhaps the greatest divergence from the PCIA is the deliberate effort on the part of the WCSCI developers to help clinicians probe more deeply into particular areas of cultural relevance, as needed, in an effort to promote the deep-structure understanding of culture within a client’s lived experience. There are structured questions and probes within each domain of the interview, as well as optional areas of inquiry in which clinicians are encouraged to explore more deeply whenever a client’s response is deemed vague, emphasizes an area of cultural identity or experience’s salience in their life and functioning, or seems to be a (conscious or unconscious) avoidance of a particular aspect of their identity. The WCSCI invites the clinician to use clinical judgment to determine where to probe further, hoping to create an atmosphere of more authentic engagement, in which the client’s cultural experience is seen as central, and not peripheral, to their clinical experience and therefore treatment. It is hypothesized that by asking directly about relevant cultural factors in the client’s life in general, clinicians will gain a better understanding of the role and impact of culture on presenting issues and therefore more readily integrate culture as an important factor into clinical case conceptualization.
Present Study
The present exploratory study asks the following questions: First, with regard to the integration of culture into clinical case conceptualizations, do client, clinician, and/or supervisor identification with minoritized identities impact such integration? The primary question of interest, though, is whether the use of WCSCI affects whether trainees ultimately incorporate culture into their clinical case conceptualization of clients. Although the WCSCI was developed to inform deep-structure integration of culture into case conceptualization, this first step is to see if its use impacts whether culture is integrated at all.
Method
Participants
The sample consisted of 118 clients seen for intake evaluations in a community mental health training clinic in New York City between September 2017 and March 2021. Participants included all clients of the clinic seen during that time who completed intake evaluations. As such, the present sample is a nonrandom clinical sample. In general, clients self-referred to the training clinic to receive low-fee therapy from graduate students in psychology. The overwhelming majority of intake clients were adults, although some children were seen as well.
Clients in the community mental health training clinic typically come from low socioeconomic backgrounds, as they typically do not have health insurance and cannot afford counseling services at typical market fees. In the present sample, ages ranged from 7 to 77 years old, with a mean of 30.81 and a standard deviation of 12.14. Thirty-eight percent (n = 45) of the clients came from traditionally minoritized racial and/or ethnic backgrounds (primarily Black and Latinx); additionally, 17.8% (n = 21) identified with a minoritized gender identity (e.g., transgender, gender nonbinary) or sexuality (e.g., gay, lesbian, bisexual, queer). There were 33.9% (n = 40) male identified, 63.6% (n = 75) female identified, and 2.5% (n = 3) gender nonbinary participants. For data analysis, clients were coded for whether they had a minoritized identity status for racial and/or ethnic identity (38.1%; n = 45) and for LGBTQ+ identity (17.8%; n = 21).
The clinicians conducting the intake evaluations included 29 doctoral students in clinical and counseling psychology programs primarily from the New York area (from multiple programs, not just the program that oversees the clinic). These students ranged in year of training from second-year students to fifth-year students, and all had undertaken coursework in some aspect of multicultural counseling, although none were specifically trained in cultural case conceptualization within the clinic. Of these intake clinicians, 45% (n = 14) came from traditionally minoritized racial and ethnic backgrounds, including 7% (n = 2) each of Black, Latinx, Middle Eastern, and South Asian descent and 21% (n = 6) of Asian/Asian American descent. Seven percent (n = 2) identified as having a minoritized sexual identity.
Supervisors included 13 licensed psychologists, 38% (n = 5) from traditionally minoritized racial and ethnic backgrounds (two self-identifying as Black, two as South Asian, and one as Latinx) and 8% (n = 1) who identified as having a minoritized sexual identity. Some of the supervisors were faculty in the program that houses the clinic, but most were adjunct supervisors with no other relationships with the students. For data analysis purposes, both intake clinicians and supervisors were coded for whether they held a minoritized identity status or not. Forty-eight percent (n = 14) of student clinicians and 46% (n = 6) of supervisors carried a minoritized cultural identity status.
Measures
Cultural Interviews
Student clinicians had a choice between one of three cultural interviews for each intake evaluation: the DSM-5’s CFI (American Psychiatric Association, 2013), the PCIA (Dadlani et al., 2012), or the WCSCI (Wright & Constantine, 2020). The former two interviews are discussed in depth in their respective cited articles. The WCSCI is a structured cultural interview developed around P. A. Hays’ (2001) ADDRESSING framework. The drafting and revision of the interview included feedback from several clients, the student trainees who first utilized the interview in practice, and several experts in the field of multicultural counseling. For each identity variable, the interview contains three components. First, there is a “decision” component, utilizing the client’s self-identification on that cultural variable. For example, for the religion/spirituality variable, the decision question asks both if they were raised in and if they currently belong to a specific religious community. Based on the decision for each variable, there are “first-order questions” that are asked of everyone who identifies in the same or a similar way as the client on that cultural variable. For example, for those who report identifying as an older adult (on the age variable), they are asked (among other questions): “Thinking about the time period when you grew up, how does that affect who you are and how you live now? Do you think any major events (in the world or your own life) affected who you have become?”
Finally, for each variable, there are “follow-up questions,” which are optional questions to be added when the clinical interviewer feels they are appropriate and would be useful for understanding the cultural background and context of the client. These questions are utilized when the client has either been vague in their answers to the first-order questions or discussed an aspect of cultural identity or experience that seems salient and important to them. These questions can be supplemented by the interviewer’s own probes, as well.
The WCSCI does not have an algorithm for decision making, as it is a data collection tool. Additionally, because it is built on the ADDRESSING framework, it does not explicitly address intersectionality (the components of identity that are created based on multiple, intersecting minoritized statuses), although intersectional issues often come up organically during the interview. For example, a Black woman being asked about her experience as a woman in the world is very likely to discuss it from the perspective of being a Black woman in the world, rather than artificially compartmentalizing and disaggregating her cultural statuses (as this is her lived experience).
Cultural Integration in the Clinical Conceptualization
In order to evaluate whether culture was truly incorporated into the clinical conceptualization, coders read only the clinical conceptualization section of the intake report for each participant (not knowing the identity of the clients, clinicians, and supervisors and their cultural identities). They then coded the conceptualization sections for whether culture was incorporated into the presenting concerns, in which clients’ lived experience—including their struggles and suffering—was presented within some cultural framework, and/or culture was integrated into the etiology, maintenance, coping, or resilience narrative of the client. It should be noted that the structure of intake reports in the clinic is standardized, such that there is some cultural information included in the background and history section of each report, but no separate section on multicultural concerns or other such sections to make the information explicitly expected. Each clinical conceptualization was coded as either not incorporating culture or incorporating culture. Although the present study did not evaluate the quality of the cultural incorporation (e.g., whether it made psychological sense within the conceptualization), the “low bar” of whether or not culture was even incorporated was examined as a beginning step in understanding the use of the WCSCI and other cultural interviews. In order to meet criteria for incorporating culture, the clinical conceptualization had to discuss some cultural information or variable as significantly and directly related to the case presentation, beyond just mentioning a demographic variable as an identifier. For example, a clinical conceptualization starting with “The client is a Black male, who…” and did not mention culture again would not be coded as integrating culture into the case conceptualization. Alternatively, an example of actual cultural integration would include a statement like: “The client’s difficulties with identity are related to the fact that he immigrated to the United States at the age of 13, at which point he felt he ‘straddled two worlds’ between his parents’ culture at home and his new American culture at school.”
Procedure
All clients who enter the clinic for counseling participate in an intake process and consent for their de-identified information to be used in research. The intake process in the community mental health training clinic is a comprehensive one, consisting of multiple data points. The student clinicians conduct the intake process over several sessions with a client. Included in the intake data collection process are a semistructured clinical interview; the Diagnostic Interview for Anxiety, Mood, and Obsessive-Compulsive and Related Neuropsychiatric Disorders (DIAMOND; Tolin et al., 2018); the Personality Assessment Schedule (Tyrer & Alexander, 1988); one of the three cultural interviews; the Personality Assessment Inventory (Morey, 2007); the NEO Personality Inventory, third edition (McCrae & Costa, 2010); and several other self-report survey measures, such as the Beck Depression Inventory, second edition (Beck et al., 1996), the Penn State Worry Questionnaire (Meyer et al., 1990), and the Difficulties with Emotion Regulation Scale (Gratz & Roemer, 2004).
For child clients, the process is similar, except instead of utilizing the DIAMOND and the Personality Assessment Schedule, the student clinicians use the Schedule for Affective Disorders and Schizophrenia for School-Aged Children (Kaufman et al., 1997). Additionally, the self-report survey package is replaced with several informant-report measures for parents, such as the Disruptive Behavior Disorder Rating Scale (Barkley, 1997) and the Brief Problem Checklist–Child (Chorpita et al., 2010). The cultural interviews are then completed with the parents of child clients or with parent and child together for adolescent clients.
For the three cultural interviews, all student clinicians were trained during their orientation in a single training session focused on appropriate administration of each measure (rather than how to use the data that emerge from each in an intake or case conceptualization). Guidance for use of the data produced by each was left to individual supervision.
For the intakes, student clinicians chose between the WCSCI (Wright & Constantine, 2020), the PCIA (Dadlani et al., 2012), or the CFI (APA, 2013). Although not fully randomized (assigned), students were asked before receiving a referral to decide which of the three they would use, and they were expected to alternate through the three different cultural interviews throughout their year-long placement in the clinic. As such, which cultural interview was used was not expected to vary by client characteristics (both demographic and presenting complaints), by student and their program/training, or by supervisor. Of the 118 cases in the present sample, 33.9% (n = 40) utilized the WCSCI, while 30.5% (n = 36) used the CFI and 35.6% (n = 42) used the PCIA. Because students were expected to rotate through the different cultural interviews, they administered each of the three interviews to different clients, independent from the cultural identity of the student or supervisor. Chi-square analyses revealed no significant effect on which interview was used either by student minoritized identity status, χ2 = 2.608 (df = 2), p = .271, or by supervisor minoritized identity status, χ2 = 2.060 (df = 2), p = .357.
Once student clinicians collected all the data for an intake client, they worked with their supervisors to generate an intake report. As part of the report, students were asked to create a clinical conceptualization. The general prompt for the clinical conceptualization on the intake report template is as follows: This section should be a coherent narrative, putting together all the materials reviewed (including clinical and collateral interviews, reviews of records, behavioral observations, self-report measures, and/or diagnostic interviews) into a formulation of what is likely going on with the client. Include your assessment of the nature, causes, and processes related to the client’s problem. Also include an assessment of the client’s motivation and expectations for treatment, strengths and weaknesses, coping styles and strategies, and relevant contextual factors (e.g., do social patterns reinforce the presenting problem?).
The structure of the clinical conceptualization varies widely between supervisors, student clinicians, and clients.
For the present study, the principal investigator masked data from the electronic health records about clients’ demographics and, separately, built a file with newly created ID numbers and the clinical conceptualization sections from the intake reports. Whenever a client’s name (or other personally identifying information) was included in the clinical conceptualization, the principal investigator redacted this information.
In order to code whether or not culture was integrated into the clinical conceptualizations, two of the researchers read through and made decisions about the data. Of the 118 clinical conceptualizations coded, 31 (26%) were coded independently by both of the researchers coding the data. Of the 31 clinical conceptualizations independently coded by both researchers, they agreed on the coding of 30 of them (97% agreement; Cohen’s kappa = .919). For the one clinical conceptualization on which they disagreed, they and the third researcher discussed and came to an agreement, discussing the reasons for initial disagreement and using this information moving forward on the independent ratings.
Results
Of the 118 clinical conceptualizations evaluated in the present sample, 36 (30.5%) were determined to have integrated culture significantly into the clinical conceptualizations of the clients.
Minoritized Statuses and Culture in Conceptualizations
Chi-square statistics were utilized to evaluate if there was a significant relationship between whether or not culture was integrated into the clinical conceptualization and the minoritized status of the three individuals involved in the intake: the client, the student clinician, and the supervisor. Results revealed that clients with a minoritized racial and/or ethnic status were more likely to have culture infused into their clinical conceptualization, χ2 = 5.982 (df = 1), p = .013, than those who identified as White. This was not true for those who identified as sexual and/or gender minorities, χ2 = .096 (df = 1), p = .472, although it should be noted that only 21 clients (17.8%) identified as LGBTQ+. Supervisors who held a minoritized cultural identity status (racial, ethnic, and/or LGBTQ+) were also more likely to have culture integrated into the clinical conceptualizations they oversaw, χ2 = 3.770 (df = 1), p = .041. However, there was no significant relationship between student clinician minoritized identity (racial/ethnic and/or LGBTQ+) and culture integrated into clinical conceptualization, χ2 = .005 (df = 1), p = .554.
Use of the WCSCI and Culture in Conceptualization
Hierarchical Binary Logistic Regression Predicting Integration of Culture into Case Formulation
Note. Block 1 χ2 = 7.822 (df = 4), p = .098; Block 1 Nagelkerke’s R-Square = .091. Block 2 χ2 = 10.890 (df = 2), p = .004; Model χ2 = 18.712 (df = 6), p = .005; Model Nagelkerke’s R-Square = .207; Block 2 Nagelkerke’s R-Square Change = .116. CFI = DSM-5 Cultural Formulation Interview; PCIA = Patient Cultural Identity Assessment. The Wright-Constantine Structured Cultural Interview (WCSCI) was used as the comparison group.
Discussion
The purpose of this exploratory study was to determine whether the use of a deliberately deep-structured cultural interview (the WCSCI) would increase the likelihood that relevant cultural factors would be incorporated into clinical case conceptualizations, above and beyond the potential impact of client, clinician, and/or supervisor individual cultural identity characteristics. The fact that fewer than one third of the case conceptualizations incorporated culture is striking, given the fact that all intake procedures included one of three cultural interviews; however, this is consistent with the literature documenting the widespread omittance of sociocultural factors in case conceptualizations (Wilcox et al., 2020).
The results suggest that the use of the WCSCI is significantly more likely to prompt inclusion of culture in case conceptualization than the PCIA or the CFI. One potential explanation for the greater inclusion rate of culture in clinical conceptualization when using the WCSCI versus the PCIA or CFI might be the subtle differences between the tools. The WCSCI offers a more comprehensive and inclusive view of culture that reflects human development in the context of the world. The structure of the WCSCI embodies Ridley, Sahu, et al.’s (2021) proposal for a deep-structure incorporation of culture into clinical practice. As an intentional approach to cultural considerations, the WCSCI fulfills the three areas of competency for deep-structure integration through client identification of salient cultural data; client and clinician interpretation of said data; and finally, integration of the salient cultural elements within the clinical conceptualization. Further, in asking unambiguously about clients’ specific cultural identities and experiences at the time of intake, a direct link is made between salient cultural factors and experiences, psychological wellbeing, symptom presentation, and psychological functioning. This allows for a more authentic and organic conceptualization of how culture shapes the client, and therefore how it shapes any illness, struggles, and suffering that are being presented. The WCSCI takes a whole person view of the individual, of which cultural identity is a part, and thus makes culture much more difficult to ignore in the clinical presentation and case conceptualization.
Results also indicated a significant relationship between the minoritized identities of the client and supervisor and the integration of culture in the clinical conceptualization. Clients and supervisors with minoritized identities were more likely to have culture included in case conceptualizations. However, consistent with other research findings, student clinician minoritized identity status did not contribute to inclusion of culture in clinical conceptualization. Because the WCSCI purposefully asks the client to reflect on salient cultural identity factors and experiences, there is a greater likelihood for the client to recount the nature of their clinical presentation with culture specifically in mind, lending a more natural inclusion of culture in the clinical conceptualization. Clients with minoritized identities likely present issues that are more directly salient and applicable to their clinical presentation; as such, it makes sense that client identity status relates to higher integration of culture in conceptualization. For supervisors, depending on the salience of their own cultural identification, there might also be more direct instruction in supervision around the integration of culture into case conceptualization, similar to Ladany et al.’s 1997 study. For student clinicians, regardless of their identification with a minoritized identity or identities, they are likely to still be developing their conceptualization skills, which include the ability to prioritize and discern significant relevant clinical factors, culture being among them (Cook et al., 2020). Further, this finding may speak to the power and influence of supervision on the students and the case conceptualization process.
Limitations
The findings of this study should be considered in light of several limitations. The current sample included significant proximity and affiliation with the developers of the WCSCI to the intake process and eventual clinical conceptualization. Both developers serve as supervisors in the clinic and also have minoritized identities. Future studies should explore in greater detail whether or not the findings regarding the use of the WCSCI leading to a high rate of inclusion of cultural factors in the case conceptualizations are consistent without the presence of the two developers.
Additionally, driven by the relatively small sample size of student clinicians and especially supervisors, whether or not these individuals held a minoritized status was dichotomized, which is a significant limitation. Nuance in identity status, intersectionality, and personal biases is necessarily ignored when these variables are dichotomized. Given the coding of minoritized identity (primarily defined as ethnic/racial and/or LGBTQ+ identity) versus no minoritized identity, it is difficult to parse out the significance of the finding about supervisor minoritized identity status, especially as it does not honor the breadth of diversity and culture specifically aimed for in the WCSCI. Future research should examine in greater depth specific minoritized identities of supervisors and their potential impact on case conceptualization. For example, it may be that there is a difference between identification with different individual minoritized identities, as well as intersecting minoritized identities, which may contribute differently. Studies should also investigate the extent of the supervisor’s role and involvement in the final clinical conceptualization. That is, it is important to investigate just how much influence supervisors have in the process and what role their own marginalized or cultural identities play. Finally, the interaction between the student clinician and their level of exposure to MCCC content within their training should be assessed.
Additionally, the present study did not evaluate the depth or appropriateness of the integration of culture into clinical case conceptualization (for those that did include culture). Although assessing whether or not culture was integrated is a first step of inquiry, it is a low bar for clinicians to reach (although fewer than one third of the cases did in fact reach this low bar). Future studies should more deeply evaluate how and how well culture is integrated, as well as taking a deeper inquiry into the features that distinguish the selected cultural interviews.
Finally, the most important limitation of the study includes multiple threats to internal validity due to the retrospective nature of the study design. That is, the cultural interviews were not randomly assigned to students, supervisors, and clients. Together with the preliminary nature of the outcome being whether culture was included in the conceptualization at all (versus level and depth of integration), future research should be specific in its research design and the depth, to more rigorously evaluate the effectiveness of use of the WCSCI, as well as other cultural interviews.
Implications for Practice, Advocacy, Education, Training, and Research
Overall, the study supports the field’s commitment and movement toward implementing the use of cultural assessment tools and models in the initial clinical intake to ensure that germane cultural factors are included in clinical conceptualizations, diagnoses, and treatment. The incorporation of culture into conceptualization (which may be bolstered by the use of the WCSCI) moves MCCC beyond theory directly into clinical practice, and ultimately pushes the field forward in providing culturally responsive treatment.
Practice
Scholars have invited the field to examine and re-engage the conversation surrounding how the established importance of culture has manifested in the actual clinical work of psychologists (Mollen & Ridley, 2021; Ridley, Mollen, et al., 2021; Vandiver et al., 2021). The findings of this study should encourage clinicians to consider cultural assessment tools like the WCSCI as potentially contributing to what Ridley, Sahu, et al. (2021) refer to as deep-structure incorporation of culture into clinical practice. Although it is noted that there is more work to be done with regard to the inclusion of culture in clinical conceptualization, this study suggests that having a structured tool guiding the inquiry is a start to this process. As such, clinicians are encouraged, at the beginning of treatment, to deliberately and genuinely inquire about the broader sociocultural and contextual factors that comprise the lived experiences of clients.
Advocacy
Considering the importance of context in cultural inclusivity, specifically the role of larger systemic forces such as power, privilege, and oppression, clinicians are encouraged to be deliberate in their use of cultural contextualization, utilizing tools like the WCSCI to facilitate clients’ self-empowerment and advocacy skills. Having concrete and broad cultural-contextual information, like that gained from procedures like the WCSCI, can also encourage clinicians to validate the experiences of clients and be conscious of not replicating behaviors that continue to marginalize and oppress. Further, clinicians can use the gathered information to advocate for the needs of their clients and participate in partnerships with organizations engaged in activism.
Training and Education
In order to enhance MCCC, student clinicians can be trained to use tools like the WCSCI to engage in a deliberate and deep-structure process that facilitates the incorporation of culture into clinical case conceptualization, which includes being able to help clients share the salient aspects of their identities and cultural experiences. The supervision process should specifically attend to student clinicians’ development of skills that both adequately and appropriately integrate culture in the clinical conceptualization. Culturally grounded supervision should guide training practices, including supervisors’ and student clinicians’ attention to their own cultural identity, experiences, and context and how that informs their work.
Research
With regard to cultural interviews, future research should explore the distinctions between the various available tools, exploring the different mechanisms underlying the interviews. For example, future studies on the WCSCI can evaluate the use of the follow-up questions, assessing whether the use or nature of the question has an impact on the integration of culture in the clinical case conceptualization. Also, given the preliminary findings of this study, counseling psychology and clinical practice would benefit from future research that explores the specific influence of minoritized identities and experiences and their possible influence on clients’ presenting concerns. It is also important to examine whether having intersecting minoritized identities or a specific single minoritized identity has a differential impact. Furthermore, it will also be helpful to understand if certain aspects of minoritized identity or experience might be driving or contributing to the greater inclusion of culture in clinical case conceptualization. The field would also benefit from future studies that examine the appropriateness of the incorporation of culture in the clinical conceptualization. It is necessary to elevate and move beyond just a discussion of inclusion. With that, the role of supervision is another area for deeper exploration. It is important to understand how much influence supervisors have or need to have in culturally-infused clinical case conceptualization.
ORCID iD
A. Jordan Wright https://orcid.org/0000-0002-8317-6727
Supplemental Material
Supplemental Material - A Test of Minority Stress Theory with Asian Americans
Supplemental Material for A Test of Minority Stress Theory with Asian Americans by Nina Lei, Brandon L. Velez, Judy M. Seoud, and Wei N. Motulsky in The Counseling Psychologist
Footnotes
References
Supplementary Material
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