Multicultural Orientation in Psychotherapy Supervision: Cultural Humility, Cultural Comfort, and Cultural Opportunities
Publication: American Journal of Psychotherapy
Abstract
As a complement to multicultural competence, the multicultural orientation (MCO) perspective has been proposed as a pragmatic way to enhance cultural understandings about psychotherapeutic dynamics, processes, and outcomes. Consisting of three core components—cultural humility, cultural comfort, and cultural opportunities—the MCO is considered relevant for both individual and group treatment. However, the MCO perspective has yet to be specifically applied to psychotherapy supervision. Because supervision often provides multicultural oversight for individual and group psychotherapy services, considering the ramifications of MCO for psychotherapy supervision (MCO-S) is important. In this article, the implications of MCO-S are reviewed, with attention given to the impacts of cultural humility, cultural comfort, and cultural opportunities on the supervisor-supervisee relationship. Case examples are provided to illustrate the ways in which MCO can affect the psychotherapy supervision process and outcome. Supervision research possibilities are also proposed.
HIGHLIGHTS
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The multicultural orientation, which has been fruitfully applied to psychotherapy, is equally relevant for and applicable to psychotherapy supervision.
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Three core components—cultural humility, cultural comfort, and cultural opportunities—provide the foundation for the multicultural orientation as applied to psychotherapy supervision (MCO-S).
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MCO-S is proposed as a complement to the attitude component of the knowledge-skills-attitudes supervisory competence framework.
Just as the multicultural orientation (MCO; i.e., considering our attitudes and values in our interactions) has been increasingly recognized as important for the therapeutic relationship (1–3), we contend that it is every bit as important for the psychotherapy supervision relationship. In what follows, we will show why and how that is so.
Our subsequent considerations revolve around three intertwined concepts: culture, multiculturalism, and intersectionality. Culture is defined as: “the dynamic and active process of constructing shared meaning, as represented by shared ideas, beliefs, attitudes, values, norms, practices, language, spirituality, and symbols, with acknowledgment and consideration of positions of power, privilege, and oppression” (4). Multiculturalism refers to multiple cultures and identities, inclusive of gender, race, ethnicity, sexual orientation, disability, age, socioeconomic status, and religion (5). Intersectionality refers to the unique social locations that exist at the convergence of those multiple cultures and identities across individual lives, social practices/institutions, and cultural ideologies and to the resulting outcomes related to those social locations (6, 7).
Issues in Multicultural Competence and Orientation
Is Multicultural Competence Enough?
Since the 1980s, multicultural competence (e.g., the ability to work effectively across multiple cultures and identities and to adapt treatments based on clients’ cultural identities) has emerged as a major theme across all mental health professions (e.g., psychiatry, psychology, social work, mental health counseling), and, accordingly, developing multicultural competencies (MCCs) has emerged as a major thrust in the training of psychotherapists (e.g., 8, 9). Catalyzed by research that has persuasively documented disparities in the mental health treatment of clients from racial/ethnic minority groups (10–12), the multicultural movement has proven robust, even being referred to as a fourth force in the psychological treatment arena (after psychoanalysis, behaviorism, and humanism) (13, 14). Models of MCCs, although not without overlap, can be grouped as follows: person based (emphasizing therapist cultural self-awareness, knowledge, and skills), adaptation based (emphasizing syncing treatment delivery with client cultural attitudes and behaviors), and process oriented (emphasizing the dynamics of the interaction occurring between therapist and client) (15, 16). The person-based model of cultural competency has been most widely recognized (15) and accentuates three components as being sine qua non: self-awareness, developing understanding about one’s own cultural background and how that background influences personal attitudes, values, and beliefs; knowledge, learning about the worldviews of individuals across diverse cultural backgrounds; and skills, learning to use culturally appropriate interventions in treatment (17–19). These components, often referred to as the tripartite framework (15), capture the essentials of multicultural knowledge, skills, and attitudes (KSAs) in action.
Although the MCC tripartite framework continues to receive support and is implemented across a host of training programs (e.g., 20–22), the concept of MCCs has been increasingly scrutinized, particularly within the past decade (1, 15, 16, 23). The core ideas that form the MCC substrate (e.g., a defined set of MCCs exist and are predictive of therapy outcomes) largely remain unevaluated (1): “there has been little evidence suggesting that psychotherapists who are more multiculturally competent have better psychotherapy outcomes” (3). Stimulated by the yet unfulfilled promise of MCCs, questions have been increasingly raised about how that promise might come to be realized: Has something vitally important been missing in our study of MCCs? Or might these criticisms and questions instead largely result from some well-recognized, foundational variable in need of more conceptual/empirical attention and emphasis?
MCO as Attitudes Additive
Although multicultural knowledge and skills have received primary attention within the KSA framework, the attitudes component has comparatively lagged: “increasingly, concern has been raised that attitudes, which are at the core of competence, have been given inadequate attention” (24). Yet it is recognized that attitudes provide the foundation for the KSA framework and its successful multicultural implementation (14, 21): “the ‘big’ competencies with deep impact are attitude-value attributes” (25). Some multicultural scholars even prefer to place attitude first, making it instead an A (attitude), K (knowledge), and S (skills) acronym (e.g., 21). In best advancing MCC learning and practice, perhaps more attitude is needed in KSA (cf. 2). The MCO framework has been proposed as one way to address that need (e.g., 1–3, 26, 27). Having pertinence for individual, group, and couples’ therapy (e.g., 28), MCO is designed as an operationalization of a process-oriented perspective to capture cultural processes (cf. 16) and as a complement to the attitudes component of the KSA framework. Three pillars are posited as substrate: cultural humility, cultural comfort, and cultural opportunities (3). Research, limited though it may be (e.g., 15 studies), has been supportive of the MCO—linking key constructs (e.g., cultural humility) to therapy outcomes, processes, and effectiveness—and has affirmed its promise in advancing our multicultural understanding (1). All indications are that more such focus and research on MCO in psychotherapy can be expected (e.g., 26).
MCO and Psychotherapy Supervision
Although considered in various psychotherapy contexts, the MCO is just beginning to be considered with regard to the psychotherapy supervision setting (29, 30). Such consideration needs further explication. Psychotherapy supervision looms large in the training of psychotherapists across all mental health professions (31, 32). If psychotherapists in training are to learn about multiculturalism and make it matter practically, then psychotherapy supervision appears to be a, if not the, prime modality through which that desideratum can be rendered reality (33, 34). With that recognized, the central goal of this article is to examine how MCO applies to and potentially contributes to psychotherapy supervision. We posit that if beginning therapists are to be trained about the conceptualization and application of MCO in psychotherapy, then supervisors themselves need to be well informed about MCO treatment conceptualization and application and equipped to make that understanding a supervision reality (e.g., via modeling MCO in the supervision relationship).
Reasoning by Analogy
Reasoning by analogy refers to the process of critically reflecting upon what is known in one area to inform or extend thinking in another area (35). Analogizing from psychotherapy to psychotherapy supervision may prove particularly valuable “because the models and methods of the more sophisticated psychotherapy literature may help to formulate and illuminate supervision in some key, common areas” (35). Thus, we draw upon what is known about MCO in psychotherapy and use it as a fulcrum for informing our supervision elaborations. To build that bridge from therapy to supervision, we first summarize the critical features of MCO in psychotherapy and then consider how this perspective can be applied to psychotherapy supervision.
MCO in Psychotherapy
Defining MCO
The MCO accentuates the philosophy, attitudes, and values that therapists hold about culture (their own and others); the importance that therapists accordingly assign to culture in the clinical encounter; and the way therapists then translate those cultural views into treatment reality (e.g., 36). Drawing on a dictionary definition for clarification, Owen et al. (36) aptly indicated that the language of orientation is about a general and enduring direction in thought. MCO provides a consistent cultural lens through which and by which therapists see and apprehend the world around them and their work with clients (2). The MCO emphasizes the ways in which cultural dynamics influence the psychotherapy encounter—particularly how the therapist’s and client’s cultural worldviews interact to affect the formation and maintenance of the treatment relationship they co-create (1, 16). Thus, MCO is viewed here as a process-oriented, attitudes-additive perspective to the MCC KSA framework.
Why MCO Matters
MCO is founded and grounded in the core conviction that culture matters in society and matters greatly in psychotherapy. We contend that culture is inescapably in the room during every psychotherapy session (37). The hope and promise of MCO are that: “by attending to, infusing, and integrating the cultural dynamics that naturally occur between therapist and client into the psychotherapy process, client therapy outcomes can be enhanced” (2).
Assumptions Underlying the MCO Perspective
Four critical assumptions form the foundation of the MCO perspective: (a) therapist and client are joined together in a relationship that involves their co-creation of cultural expressions (i.e., the extent to which culture is given voice in the treatment situation); (b) although concerned with treatment behaviors and actions, MCO is foremost about the attitudes and values that give rise to those very behaviors and actions; (c) cultural processes, such as cultural humility, are eminently crucial to and pivotal for connecting with clients’ most salient cultural identities; and (d) a high degree of MCO serves as a prime therapist motivator, stimulating interest in and desire to learn more about one’s own as well as the client’s cultural perspectives and worldviews (2).
The Three Components of MCO
Cultural humility, cultural comfort, and cultural opportunities are the three pillars that support and energize the MCO perspective (3). Cultural humility has both intrapersonal and interpersonal components, respectively, involving an openness and willingness to reflect on oneself as an embedded cultural being and an openness to hearing about and striving to understand the cultural background and identity of others (38, 39). In addition to openness, cultural humility involves being curious about and respectful of others’ cultural identities and not making automatic or fore-ordained assumptions (40, 41). Cultural comfort can be defined as those “feelings that arise before, during, and after culturally relevant conversations in session between the therapist and client” (2). Hallmarks of cultural comfort include feelings of being at ease, open, and nondefensive, and calm and relaxed when discussing cultural content (42). Cultural opportunities refer to times in treatment when culture presents itself for consideration, where therapists either follow the clients’ cultural statements or miss those chances for discussion. Such opportunities are therapy markers, indicating that the client’s cultural beliefs or values are seemingly open for exploration (3).
As conceived in the MCO perspective, cultural humility, cultural comfort, and cultural opportunities are interdependent (2). Although serving as MCO anchor, cultural humility—a long-recognized critical component of care (43)—may in and of itself not be enough. Cultural comfort and recognized cultural opportunities also appear requisite for the occurrence of meaningful cultural exchange and transaction (3).
MCO Research: What Do the Data Say?
Existing empirical studies offer preliminary support for the MCO framework (1, 44): “the future [indeed] looks bright” (1). Research thus far suggests that (a) cultural humility is viewed by clients as a positive therapist attribute, is positively associated with perceived working alliance and client improvement, and is negatively associated with (and can buffer against engaging in) cultural ruptures or microaggressions (41, 44–47); (b) cultural comfort can affect the rate of treatment terminations by racial/ethnic minority clients (42); and (c) missed cultural opportunities can negatively affect treatment outcomes (27). These studies have included more than 5,000 clients, from a range of cultural backgrounds, who were in treatment for a variety of concerns.
MCO in Psychotherapy Supervision: Conceptualization and Application
Drawing on Milne’s (48) empirical construction, psychotherapy supervision can be defined as follows:
The formal provision, by approved supervisors, of a relationship-based education and training that is work focused and which manages, supports, develops, and evaluates the work of colleague/s [and trainees]. The main methods that supervisors use are corrective feedback on the supervisee’s performance, teaching, and collaborative goal-setting. Supervision’s objectives are “normative” (e.g., quality control), “restorative” (e.g., encourage emotional processing), and “formative” (e.g., maintaining and facilitating supervisees’ competence, capability, and general effectiveness).
Psychotherapy supervision serves several crucial purposes. It develops and enhances conceptual and treatment skills, develops and crystallizes psychotherapist identity, develops conviction about the meaningfulness of psychotherapy itself, monitors treatment efforts, and safeguards client care (49, 50). The highest duty of the supervisor is to protect the client throughout the treatment and supervision processes (48–50).
Just as culture and intersectionality (i.e., the simultaneous acknowledgment of multiple cultures and identities in relationship to one another) can be considered to define therapists and clients (3, 44), culture and intersectionality can also be considered to define supervisors and supervisees (51, 52), potentially affecting the supervisor/supervisee relationship and the supervisor/supervisee/client triadic configuration: “The supervision encounter is really an encounter between the supervisor’s, the therapist’s, and the client’s. . . cultural maps” (53, italics in original).
We believe that analogizing from MCO in the therapeutic relationship to MCO in the supervision relationship (MCO-S) enhances our understanding of supervision, complements our understanding about supervision MCCs, and provides a novel way by which to consider how those cultural maps intersect and influence the supervision endeavor. Indeed, MCO arguably is foundational to good supervision (54). Just as more attitude seems needed in competency implementation in psychotherapy (24, 25), more attitude also seems needed in competency implementation in supervision (55). MCO-S is designed as one such process-oriented, attitudes-additive complement. We next analogize the essentials of MCO to psychotherapy supervision, present two supervision case examples (one displaying cultural humility, cultural comfort, and cultural opportunities and the other displaying their absence), and consider the empirical possibilities of studying MCO in supervision.
Because the supervisor routinely is in a power position vis-à-vis the supervisee, sets the tone for the supervisory relationship, and holds an evaluative role (31, 32, 56), our focus in introducing MCO-S—while attending to both supervisee and client—will primarily be on the supervisor. Thus, we emphasize the supervisor→supervisee→client dynamic, our basic operational tenet being as follows: through the supervisor’s modeling of MCO and making this perspective integral to the supervisor-supervisee dyad, the therapist/supervisee is best positioned to most meaningfully learn about MCO and, accordingly, transfer that learning to the workings of the therapist-client dyad. The supervisor’s implementation of MCO ideally serves as a template, or prototype, that comes to inform the therapist/supervisee’s own treatment implementation of MCO (57).
Defining MCO-S
MCO-S accentuates the philosophy, attitudes, and values that supervisors, supervisees, and clients hold about culture; the importance of culture in the supervision encounter that supervisors, supervisees, and clients jointly create; and the way supervisors and supervisees then translate those cultural views into supervision reality (cf. 3, 36). MCO-S gives focus to the supervisor’s way of being with supervisees in the supervision situation, providing a consistent cultural lens through which and by which supervisors see and comprehend the world about them and their work with supervisees (cf. 2). As a complement to supervision MCCs, MCO-S focuses on the ways in which cultural dynamics influence the psychotherapy supervision encounter, in particular how the supervisor’s and supervisee’s cultural worldviews interact to affect the formation and maintenance of the supervision relationship that they co-create and how the supervisor’s, supervisee’s, and client’s cultural worldviews interact to affect the functioning of the supervision triad and the evolution of the supervisory field (54).
Why MCO-S Matters
MCO-S is grounded in the core conviction that culture matters and matters greatly in psychotherapy supervision. We contend that culture is inescapably in the room in each psychotherapy supervision session (29, 57, 58). The hope and promise of MCO-S are as follows: “by attending to, infusing, and integrating the cultural dynamics that naturally occur [between the supervisor and supervisee and] between therapist and client into the [supervision] process, [supervisee and] client. . . outcomes may be enhanced” (cf. 2).
Assumptions Underlying the MCO-S Perspective
Four critical assumptions form the analogized foundation of our MCO-S perspective: (a) supervisor and supervisee are joined together in an educational relationship that involves their co-creation of cultural expressions (i.e., the extent to which culture is given voice in the supervision situation); (b) although concerned with supervisory behaviors and actions, MCO-S is foremost about the attitudes and values (i.e., way of being) that give rise to those very behaviors and actions; (c) cultural processes, such as cultural humility, are crucial to and pivotal for connecting with supervisees’ and clients’ most salient cultural identities; and (d) a high degree of MCO-S serves as a prime supervisor motivator, stimulating interest in and desire to learn more about one’s own as well as the supervisee’s and client’s cultural perspectives and worldviews (2, 29).
The Three Components of MCO-S
Akin to MCO in psychotherapy, cultural humility, cultural comfort, and cultural opportunities are similarly proposed here as being eminently applicable to supervision. They form the three pillars that support and energize the MCO-S perspective (3, 29, 30).
Cultural humility.
Cultural humility involves supervisors being open and willing to reflect on themselves as embedded cultural beings and open to hearing about and striving to understand the cultural background and identity of their supervisees and their supervisees’ clients (29). Supervisors ideally are models of cultural humility, displaying deep curiosity about and respect for others’ cultural identities, not making fore-ordained or automatic assumptions about supervisees or clients, and being genuinely interested in and wanting to understand the other’s perspective (30, 59). Furthermore, culturally humble supervisors ideally strive to enact the Platinum Rule (“Do unto others as you would have others do unto others”) (60); champion a culturally self-aware mindset; overcome the seemingly natural tendency to view personal beliefs, values, and worldview as superior; hold in mind the reality that their knowledge and understanding of others’ cultural backgrounds are limited; and regard cultural humility itself as a lifelong learning process (29, 61, 62).
Cultural comfort.
Cultural comfort in the supervisory relationship can be defined as those feelings that arise before, during, and after culturally relevant conversations in session between the supervisor and supervisee. Hallmarks of supervisor cultural comfort include feelings of being at ease, open and non-defensive, and calm and relaxed (cf. 42). The basis of comfort or discomfort, however, is best understood and evaluated within context. For example, discomfort—rather than signaling a problem—may instead be a sign that the supervision dyad is being readied to enter difficult conversations, or that the supervisor may need to consult with others to better understand the cultural issues of concern. Unfortunately, supervisors too often engage in cultural discussions with high levels of fear, anxiety, or discomfort (29). (This may be one reason that supervisors tend to avoid discussions of culture). Supervisors committed to MCO will work through their cultural anxiety and discomfort so that they are better able to present a calming presence in supervision, even when discussing difficult or uncomfortable cultural issues.
Cultural opportunities.
Cultural opportunities refer to those times in supervision when culture presents itself for consideration, when supervisors either take advantage of or miss those chances for discussion with their supervisees. Such opportunities are supervision markers, indicating that the supervisee’s or client’s cultural beliefs or values are seemingly open for exploration (cf. 3). In many supervision sessions, there may be multiple avenues of direction (e.g., explore cultural opportunity, redirect focus on client’s clinical symptoms). Supervisors with high levels of MCO-S recognize and understand that culture is an important aspect of supervision and therapy and take the initiative to bring up aspects of culture for discussion when they arise in supervision (54, 57, 63). In doing so, supervisors will be able to model how to discuss cultural topics and ideally will address the safety within the relationship to make these conversations effective (e.g., 64).
A synergistic collective.
As conceived in the MCO-S perspective, cultural humility, cultural comfort, and cultural opportunities are interdependent (cf. 2). Although serving as an anchor for MCO-S, cultural humility—a recognized critical component of supervisory care (29)—may not be enough. Cultural comfort and recognized cultural opportunities also appear requisite for the occurrence of meaningful cultural exchange and transaction in supervision (cf. 57).
Two Supervision Case Examples
Because cultural humility, cultural comfort, and cultural opportunities are interrelated concepts, they often operate together in practice (e.g., 28). The first example captures the presence of all three components in the supervisory interaction, whereas the second example illustrates cultural discomfort and a missed cultural opportunity. These constructed case examples were inspired by actual supervision events; however, some details have been modified to disguise the situation and identities of those involved.
Case 1. Cultural Humility, Cultural Comfort, and Cultural Opportunities
Participants and setting.
The supervision context included an advanced doctoral student who self-identified as a 29-year-old, Asian-American cisgender woman, who was Christian, heterosexual, able bodied, and in the socioeconomic middle class. The supervisor self-identified as a 40-year-old, biracial cisgender man, heterosexual, able bodied, agnostic, and in the socioeconomic working or middle class. The treatment setting was a community clinic. The supervision included weekly individual supervision sessions and a group supervision session with the same supervisor. The client, who presented with anxiety and depressive symptoms, identified as a 34-year-old multiracial, bisexual, able bodied, woman and “somewhat religious.” The client was also wondering if her romantic relationship was healthy for her future. The supervisor and supervisee reviewed video recordings of the sessions, as well as client rating measures of psychotherapy outcome and working alliance.
Description of events.
The supervision relationship began with some ground rules and processes for supervision that were co-created between the supervisor and supervisee (e.g., appropriate self-disclosures, boundaries of evaluation, and functional aspects of supervision). The supervisor initiated or broached the matter of culture with the supervisee; this led to a supervisor-supervisee discussion about how to best discuss cultural values, worldviews, and beliefs to develop safety in the supervision room and to promote the therapy process and therapist self-awareness. (The term broaching is being increasingly used to designate the purposeful introduction of culture into the treatment/supervision relationship) (65). This discussion laid the beginning foundation for infusion of critical MCO concepts (e.g., cultural humility, cultural comfort, and cultural opportunities) into the entirety of the therapy (and supervision) process as well as in the continued processing of each treatment session. For instance, the supervisee was able to inquire about the clients’ cultural values as they related to her distress and identity and then work with her supervisor to help build a sound multiculturally informed case conceptualization. During the fifth supervision session, the supervisor and supervisee watched a video recording of the most recent therapy session and had this exchange:
[Supervisor and supervisee watch the video.]
Client: My girlfriend doesn’t seem to give me any room to be myself, and I don’t want to be in a situation that I don’t feel myself.
Therapist/Supervisee: That sounds really hard. To feel pressure to be someone that isn’t true to yourself.
Client: YES! I want to feel free, and she just doesn’t get me.
Therapist/Supervisee: I wonder if this feeling of being pressured to be “not you” is familiar?
Client: Well, yes, I feel like many people want me to be something different than what I am. My parents don’t understand why I am not dating a man—like I used to do. My friends feel like me dating a white person is also a thing. . . they never liked her either.
[Video is paused by supervisee for supervision discussion.]
Supervisor: So, you stopped the recording here, what is going on for you? [A cultural opportunity is opened for discussion.]
Therapist/Supervisee: I am having a strong reaction about being pressured to be something that one is not. [Supervisee displays cultural comfort in sharing with supervisor.]
Supervisor: You are following the client’s narrative very well, and I am also interested in understanding your reaction. Do you feel comfortable to say more? [Gently facilitating cultural opportunity exploration, supervisor gauges supervisee cultural comfort in saying more.]
Therapist/Supervisee: I do, thanks. . . and I struggle with similar issues in my life. . . with my parents, and friends. I worry that is coming through here? [Supervisee cultural comfort leads to further treatment-specific sharing about countertransference concerns.]
Supervisor: I appreciate your concern, your own self-awareness, and that you are reacting in a way that is personal. All of this is normal and useful for helping this client and in finding your own voice as a therapist. [Supervisor normalizes both client and supervisee struggles and displays cultural humility.] I wonder what is sticking out to you in your reaction. [Supervisor continues focus on rendering cultural opportunity more concrete.]
Therapist/Supervisee: Yeah, I am not sure, can we replay the video?
Supervisor: Yes, of course, please stop the video when you first feel your internal reaction.
[Video is played. Supervision video review continues.]
Therapist/Supervisee: OK, I think it comes down to this. I most identify with her with regard to parental disapproval, because her narrative triggers within me recollections of my own parents’ disapproval—them often wanting to know why I’m not married yet, often asking when is that going to happen. I feel that pressure, and it hurts. [Supervisee making most of cultural opportunity, clarifying via cultural comfort.]
Supervisor: Sure, very insightful. Again, I really appreciate your openness and willingness to push through with this. How might you be able to use your own feelings, your own understandings about your personal circumstances, to bring further clarity and understanding to the treatment situation with your client? [Supervisor specifically expanding realized cultural opportunity to therapy encounter.]
The supervisor and supervisee continued to process the reactions in the video clip; they discussed how this exchange and connection could be helpful in the therapeutic relationship and case conceptualization and processed how self-identification with clients from marginalized identities could be informative to the development of the therapist’s self-efficacy and emotional capacity. Those discussions continued to occur over the course of the supervision relationship.
Case comments.
This brief example highlights several key aspects of the MCO-S. First, building on a cultural humility, cultural comfort, cultural opportunity perspective, the supervisor began the supervision relationship (broaching) with an understanding of how cultural dynamics can be part of the process and worked to collaboratively engage the supervisee in that very understanding. This aspect is essential in order to have meaningful conversations while processing cases. Importantly, if discussing cultural dynamics in supervision only takes place when a supervisee first raises an issue, then there is greater likelihood of in-the-moment missteps and missed cultural opportunities.
Second, because of her cultural comfort with the supervisor, the supervisee was able to discuss in supervision the cultural discomfort she felt in working with her client. Both supervisee and supervisor took advantage of this cultural opportunity. The supervisee’s cultural discomfort was in part due to her identifying with the client’s struggle. While there is less written about therapists/supervisees with marginalized identities, the supervisor in this case was supportive and exploratory in trying to understand the connection between the supervisee and the client. There was not a sense of judgment, rather the supervisor normalized the personal and interpersonal processes (cultural humility in action).
Case 2. Missed Opportunity and Cultural Discomfort
Participants and setting.
Group supervision of six doctoral students in clinical psychology was occurring once weekly in a mental health setting. The students were supervised by a licensed psychologist who self-identified as a 51-year-old, white, cisgender Catholic, heterosexual, able-bodied, middle-class man. Racially, the group had five white students—of these, four self-identified as cisgender heterosexual women and one self-identified as a bisexual cisgender man. The one nonwhite student in the group self-identified as American Indian (cisgender, heterosexual man). At each supervision meeting, one of the students showed a section of therapy video recording to get feedback from all involved and ideally advance understanding and treatment about the client.
The described events took place over two different supervision meetings, involving the same therapist and client. On these particular days, a white male student asked for the group’s help in getting a better sense of how to help a client (20-year-old, biracial, cisgender man, heterosexual, middle class, and spiritual but not religious) who was having difficulties in dealing with his parents’ divorce. The client’s mother was white, and his father was American Indian. The client also identified as American Indian and was particularly close with his father but lived with his mother. Unfortunately, even several years after the divorce, the relationship between his parents continued to be acrimonious.
Description of events.
Both of the sessions reviewed in this case revolved around the client bringing up the topic of race for discussion with the therapist. The client was distressed about his mother’s ongoing attacks on his father, how those attacks felt for him, and how he felt attacked in turn. In offering further context for the first reviewed session and the client’s distress, the therapist also let it be known that the mother (by the client’s report) would often refer to the father using racial slurs specific to American Indians, and the therapist then repeated those specific slurs aloud in the group. The supervisor, who had grown up near an Indian reservation and had often heard such slurs used to degrade and insult American Indians, cringed at hearing the derogatory language in the group setting, but he said nothing and allowed the moment to pass and the conversation to proceed (cultural discomfort, missed cultural opportunity). Although most group members joined in the case discussion, none mentioned the racial slurs spoken aloud. However, the American Indian supervisee grew quiet and withdrew from the conversation, especially during the review of the second session.
Some days later, the American Indian supervisee ap-proached the supervisor and expressed his concern about certain slur words being used in the supervision group without proper consideration of their personal impact on others. The student raised the issue as being a topic worthy of group discussion, citing the innumerable ways through which language can be used to dishonor and demean, diminish, and divide [cultural opportunity identified]. As he put it, “These are not idle words; they have a dark history and still affect our clients and us, too, as therapists. We need to give voice to their effect, to understand it, and make it part of who we are multiculturally.” He mentioned that no students had asked him how he felt about those slurs being said in group.
The supervisor expressed appreciation to the student for bringing the matter up for discussion. He agreed that it was important and that it needed to be discussed in the group. He also admitted that he had experienced a reaction to hearing those words spoken in supervision, cringed at their mention, and wondered how those words might have personally affected the student but did not know how to address it [cultural humility]. He further admitted to being uncomfortable with the issue [cultural discomfort], saw it as a potentially difficult team conversation, and had decided to let the whole matter pass without discussion. The supervisor recognized that this was a missed cultural opportunity, apologized for not rising to meet that opportunity, and vowed that they would have that discussion as a group at the next team meeting.
Case comments.
This case example illustrates an earlier point: When troubling issues of culture arise, cultural humility in and of itself is not necessarily enough to ensure that those issues will be readily identified and constructively addressed. Cultural humility unaccompanied by cultural comfort tends to result in cultural opportunities being missed. What we see here indeed is a missed cultural opportunity, which was due to the supervisor’s cultural discomfort with initiating a discussion about slur words and their impact. The supervisor, seeming to have some degree of cultural understanding and cultural humility, had even wondered about how the words in question might affect the American Indian student, but he had still opted to take no action.
That supervisor inaction, unfortunately, put the burden back on the student to raise awareness and hold the other group members and the supervisor accountable for their lack of response regarding the voiced slurs. The American Indian supervisee had the cultural courage to raise the unaddressed issue for discussion. He modeled cultural comfort and identified the missed cultural opportunity so that it could be addressed. Rather than placing the burden of action on the student, however, our hope is that psychotherapy supervisors instead will routinely rise to fill that role and serve as models of MCO for their supervisees.
Empirical Possibilities for MCO-S Research
If the MCO is to most fruitfully advance and contribute to our supervision understanding, then an MCO-S research base must be developed and fortified. How do we do that? Although measurement remains a most pressing issue in MCO psychotherapy research (1), existing MCO measures seemingly provide a means by which we could at least begin to think about and begin pursuing initial studies of MCO-S. Although thus far giving primary focus to ratings about the therapist-client relationship, Hook et al.’s (41) Cultural Humility Scale, Owen et al.’s (27) Cultural Opportunities Scale, and Owen et al.’s (42) Counselor Comfort Scale could all be easily adapted and validated for supervision research purposes (66). For example, taking into account the triadic nature of supervision, the Cultural Humility Scale could be adapted so as to obtain two ratings about the supervisee’s views on the supervisor’s in-session cultural humility—that which is displayed toward the supervisee and that which is displayed toward the supervisee’s client. Similar adaptations would seem possible for the Cultural Opportunities Scale and Counselor Comfort Scale and serve as a starting point from which to begin research.
In reasoning by analogy from existing MCO research, what further implications might be drawn for research about MCO-S? Do the hypotheses about MCO in psychotherapy provide reasoned extrapolations for us to consider with regard to MCO in psychotherapy supervision? Some analogized hypotheses suggested for supervision study are as follows:
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Supervisees who perceive their supervisors to be more (as opposed to less) culturally humble will hold more favorable perceptions about/be more satisfied with the supervisory alliance, the supervisory real relationship, the unfolding supervision process, and its eventual outcome.
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Supervisors who are more (as opposed to less) culturally humble will be more able to detect, and less likely to engage in, supervisory microaggressions.
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Supervisors who are more (as opposed to less) culturally humble will be more apt to detect, and more apt to act on, repairing ruptures in the supervision relationship.
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Supervisors who are more (as opposed to less) culturally humble will be more apt to see the need for, and more apt to engage in, ongoing cultural learning and continuing education experiences.
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Supervisors who are more (as opposed to less) culturally humble and who have a higher degree of cultural comfort will be more apt to detect, and more apt to take advantage of and address, cultural opportunities when they arise in supervision.
•
Supervisors who are more (as opposed to less) culturally humble and who have a higher degree of cultural comfort will be more apt to initiate, and more apt to see through to successful conclusion, discussions about culture in supervision.
Although by no means exhaustive, these analogized hypotheses, seemingly reasonable, testable, and construct-consistent, could offer beginning guidance for the study of MCO-S.
Conclusions
MCO privileges and prioritizes culture, cultural dynamics, and cultural processes. If culture, and intersections of cultural identities, provide the center for all work with clients (19), so it must be for psychotherapy supervision. Culture provides that very center—the anchor and touchstone—for all work with supervisees (29, 30, 54, 57). Cultural humility, cultural comfort, and cultural opportunities potentially figure prominently and play a crucial role in every supervision encounter. Just as MCO has advanced cultural conceptualization, application, and research in psychotherapy, we contend that it is every bit as applicable to and can provide similar advances in cultural conceptualization, application, and research in psychotherapy supervision.
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Received: 5 October 2018
Revision received: 26 December 2018
Accepted: 1 February 2019
Published online: 4 April 2019
Published in print: June 01, 2019
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The authors report no financial relationships with commercial interests.
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