Multicultural Streaming in Group Psychotherapy Supervision: Orientation to and Preparation for Culturally Humble Practice
Publication: American Journal of Psychotherapy
Abstract
How do psychotherapy supervisors most effectively integrate issues and concerns about multiculturalism and social justice (MSJ) into the supervisory experience? Concrete examples of how to best address this integration are needed, and this article provides one such example. The authors propose multicultural streaming as one approach to orient supervisees about, and prepare them for, incorporation of MSJ matters into group supervision and to foster their evolving sense of culturally humble practice. This article defines multicultural streaming, presents a plan for its implementation at the group’s outset, and identifies implementation guideposts for consideration. A set of cultural humility guidelines adapted for group supervision is also proposed for group facilitation. This perspective is presented with the hope of generating further discussion about integrating MSJ issues into the group supervisory experience.
“It is incumbent on the [group] supervisor to open the dialogue about culture.” (1)
Effective integration of multiculturalism and social justice (MSJ) into training programs across all mental health disciplines has increasingly become a concern in recent decades (2, 3). In addressing that concern, the critical question for psychotherapy educators remains, How do we most effectively make that integration happen? Programs have typically addressed MSJ through three avenues: a class or seminar specifically devoted to the area, infusion of MSJ into all curricular courses and experiences (e.g., practicum), or a combination of the two. The knowledge-skills-attitude model of multicultural competence has been widely embraced in that implementation and has been complemented in the past 10 years by the multicultural orientation and cultural humility perspective (4). Yet, even with heightened attention directed toward MSJ in psychotherapy education, making the area consequential to coursework and practicums continues to be a source of concern (5); that seems especially so for group psychotherapy supervision.
“Scholars have argued that therapy groups represent powerful opportunities for promoting social justice and cultural awareness [among clients]” (6), and we argue that supervision groups powerfully serve the same purpose for psychotherapy supervisees. Group supervision refers to “the regular meeting of a group of supervisees (a) with a designated supervisor or supervisors; (b) to monitor the quality of their work; and (c) to further their understanding of themselves as clinicians, of the clients with whom they work, and of service delivery in general” (7). Group supervision is used as an example here, because most psychotherapy supervisees experience group supervision at some point during their training (7), and it is an inherently multicultural gathering, where constituents—supervisors, supervisees, and the considered clients—have varying identities (e.g., religion, sexual orientation) that intersect with the identities of others throughout the group process.
If any approach is to make MSJ most important in group psychotherapy practicums, “multicultural streaming,” we contend, must occur. Drawing on a media term, multicultural streaming is defined by two critical components: a collaboratively constructed educational platform (e.g., a facilitative group relationship), within which MSJ matters are privileged in treatment and supervision, and a facilitative structure (e.g., a group plan) by which those matters are prioritized and monitored for inclusion in all treatment and supervision considerations. Much like a streaming service delivers multimedia content to service recipients, with multicultural streaming, psychotherapy educators and their mentees or supervisees build the service collectively (i.e., develop a guiding plan of action), provide MSJ content and ensure its routine delivery (e.g., via assigned readings, applying a multiculturally informed lens to reviewed video recordings), consistently monitor that content delivery process for fidelity adherence (i.e., keeping MSJ in focus), and engage in service repair (e.g., realignment where plan drift has occurred). Ideally, multicultural streaming would also contribute to an evolving sense of culturally humble practice among supervisees, in which an openness to, desire to understand, and willingness to incorporate difference and diversity into therapeutic practice prevails (4, 5). Below, we provide an example of multicultural streaming within the context of group psychotherapy supervision and offer a set of cultural humility guidelines adapted for group supervision to facilitate that process.
The Doctoral Program and MSJ Challenges
This article is a product of the challenges that we faced and continue to face as educators in a doctoral degree–granting psychology program accredited by the American Psychological Association. As program faculty, we made two decisions to better meet those challenges. First, we chose to diversify the body of admitted students each year; our student makeup remains 60% White, which is comparable to other American Psychological Association programs (https://www.accreditation.apa.org/data-and-research/aro; see Doctoral Program ARO Statistics), but an increase in students of other races and ethnicities has begun (e.g., approximately 20% of our students are Asian). Second, we chose to integrate MSJ issues into all courses and practicums. That decision was a product of two factors: consistent results from surveys of former and current doctoral students indicating that the focus on MSJ issues across the curriculum was insufficient and faculty, informed by that student feedback, who shared that opinion and decided to make MSJ a more pervasive force throughout the curriculum. Within this context, the concept of multicultural streaming arose.
Group Supervision and MSJ
The multicultural-streaming approach appears to hold promise for group supervision, as shown through the following example of a group supervision experience. Our hope in presenting this example was to encourage dialogue among psychotherapy educators about ways to meaningfully make MSJ a crucial part of psychotherapy training and to foster an evolving sense of supervisee cultural humility. Experienced educators and supervisors previously have been urged to compile their teaching methods and personal experiences, to share what has and has not worked and why, and to start building a base of understanding about how to best educate our trainees (8, 9). What follows is shared with that aim in mind.
The Supervision Group
The supervision group in our example comprised 10 individuals: one supervisor (an able-bodied, non-Hispanic White, heterosexual, cisgender man) and nine supervisees, all of whom embodied differing marginalized or intersecting marginalized identities (e.g., primary self-designations included being African American and Caribbean American, Asian American, biracial, Italian American, Japanese American, Mexican American, Muslim American, and Salvadoran American). Admittedly, this highly diverse supervisee mix is not typical for a practicum team in terms of racial-ethnic composition (according to American Psychological Association demographic data). However, in our view, this atypical composition may have allowed MSJ issues to more easily and forcefully emerge, perhaps accentuating the importance of and need for student diversity within and across doctoral programs.
Six supervisees were regularly seeing therapy clients in the psychology clinic, whereas the other three were in their first program year and were primarily in a listening, observing, and learning role. At the group’s outset, the task was to follow the program’s mandate: to pervasively integrate MSJ into the group supervision experience. Whereas that mandate had typically been fulfilled through supervisor actions alone (i.e., deciding unilaterally what to do), a decision was made to present the charge to the group and work as a team to fulfill it.
Four initial steps were involved in realizing that objective: clearly and fully explaining the program’s mandate before the team, collectively engaging in pursuit of that charge, developing a joint-action plan, and reviewing and agreeing on that plan to guide all interaction and discussion in group supervision. This work involved everyone’s voice being heard, everyone contributing to the process and outcome, and everyone having ownership in the result. The group collaboratively worked to form a plan that privileged MSJ matters and structured a group experience wherein those matters would be prioritized and monitored for inclusion in all considerations related to discussion clients and team matters. The group’s plan is presented in Box 1 (10–16). The plan functioned much like a supervision contract, its purpose being to make all plan elements clear, to reach agreement from the outset, and to orient and prepare supervisees for what was to come. As seen in Box 1, a guiding definition, conviction, and action principle provided the conceptual groundwork for action; the identified steps and questions provided the means by which the conceptual was rendered practical.
BOX 1. Example of multiculturalism and social justice (MSJ) integration action plan for group supervision
GUIDING DEFINITION AND CONVICTION
Culture is defined as a “big-tent” term (10) and includes identities such as gender, race-ethnicity, sexual orientation, ability status, religion or spirituality, and socioeconomic status. We understand that identities intersect and that these intersections are life affecting and life defining. As therapists, we strive to understand how that intersection affects our clients and the therapeutic relationships we create together.
GUIDING ACTION PRINCIPLE
We will place MSJ considerations at the forefront of our practicum work and strive to make culture and advocacy a reality in all considerations related to group supervision.
GUIDING ACTION STEPS
We will enact our group plan through at least five avenues:
•
Being mindful of culture as forever permeating therapy and working to consistently apply a cultural lens to our client conceptualizations and video reviews, such as by using the ADDRESSING (age and generation influences, developmental disabilities, disabilities acquired later in life, religion and spirituality, ethnic and racial identity, socioeconomic status, sexual orientation, Indigenous heritage, national origin, gender) framework (11) or other frameworks as a point of orientation in client considerations. We hope to realize this objective in both individual and group supervision meetings.
•
Engaging in activities that help us each to better understand our own cultural perspectives and their impact on our work as teammates and therapists, such as completing and discussing the social identity wheel exercise (12) and having second- and third-year students present a multiculturally informed case conceptualization of one of their clients.
•
•
•
Holding foremost in mind the issues that we wish to discuss over the course of our work together and that will orient our discussions. Sample questions that we have identified for such purposes include the following:
○ What is our own cultural lens through which we each see ourselves, our clients, and each other? What is the impact of my own lens on me as a developing professional?
○ How do our own therapist identities intersect our clients’ identities? What are the effects of that intersection? How do we take that intersection into account in the therapeutic moment?
○ How can we best bring the client’s outside (culturally affected) world into therapy and have a constructive therapeutic impact on that outside world?
○ How do we as therapists deal with microaggressions that clients direct toward us?
○ Are my interventions culturally informed and culturally appropriate?
○ How can I best be an advocate for social justice in this situation with this person at this time?
The process of developing and implementing the plan focused on two functions of the group supervision experience: for learning about and discussing MSJ issues and concerns (e.g., through group readings and discussions that dealt with the intersection of these issues in psychotherapy) and for reviewing supervisees’ therapy session recordings with a MSJ lens foremost in mind and a set of MSJ-focused questions to guide that review and any subsequent feedback and discussion. The plan reflected an effort to orient, prepare, and guide the supervisees; to bring multicultural streaming to life via the group’s ongoing supervision experience; and, ideally, to foster an evolving sense of culturally humble practice in the process.
Implementation Issues to Consider
The multicultural-streaming approach, the subject of continued practical evaluation, remains a work in progress. For instance, on the basis of anonymous, confidential ratings provided by the group supervisees described here (on a scale of 1, lowest, to 5, highest), an average satisfaction rating of 4.9 was given for the overall group supervision experience across the year. Other favorable ratings about the group supervision experience (ratings of 6 or 7 on a scale of 1, never, to 7 always) were given for the following supervisor items: “My supervisor engaged me in discussion of multiple diversity issues and [their] assessment, intervention, and conceptualization [impact]”; “My supervisor modeled self-reflection about her/his cultural identities, including limitations in knowledge”; and “My supervisor modeled respect for my diversity . . . experiences.” We are continuing to collect evaluation data on a semester-by-semester basis.
Four implementation issues seem most important to bear in mind. First, monitoring a group’s plan is vital to maintaining supervision fidelity. Second, review and revision of the plan is vital to maintaining its freshness and fluidity. As the group evolves, so too does need for the plan to evolve. Third, although such plans provide a working structure, they need structural flexibility so that they anchor and ground the process but do not immobilize implementation and prevent modification. Fourth, although plans across differing supervision groups may share similarities (e.g., using MSJ-focused questions for guidance), it is imperative that each group develop its own self-defined practicum plan of learning and action, thereby promoting plan ownership.
The cultural humility ground rules adapted for group supervision (Box 2) can be eminently useful in helping groups to optimally create and pursue their MSJ planning process (17), because they establish a framework for the group with the intention of making explicit the goals of diversity, inclusion, and social justice and they contribute to the cultivation of a group climate of beneficence and respect that begets constructive cultural discussion. Perhaps the key concepts that most stand out from Box 2 are openness, humbleness, supportiveness, flexibility, self-awareness, other-awareness, self-reflectivity, and respect. Being able to use these guidelines as the group begins work can help in orienting and preparing supervisees for the MSJ mission before them, ideally opening the door for development and enhancement of culturally humble practice.
BOX 2. Group supervision–adapted ground rules based on cultural humilitya
•
I will enter each group supervision experience with an open mind and possessing an attitude willing to explore new concepts.
•
I will be aware of my personal values, beliefs, and behaviors and will respect that other supervision team members may not abide by the same values and belief system.
•
I will focus on the feelings and experiences of other supervision team members as well as my own.
•
I will enter each group supervision meeting with a flexible and humble attitude and will not allow my ego to impede the learning experience.
•
I will engage in healthy, supportive interactions with my supervisor and group supervision peers to help foster an engaging learning environment.
•
I will engage in self-reflection as a lifelong psychotherapy learner and will strive to critique my own thoughts, actions, and behaviors as I interact with my supervisor and supervision team members who have views that are both similar to and in opposition with mine.
•
I will attempt to embrace conflicting viewpoints that are expressed in group supervision by giving those viewpoints my full consideration.
•
I will support my supervision team members as we engage in discussions and learning.
•
I will try to recognize supervision team power differences and minimize them.
•
I will strive to demonstrate respect for my supervisor and my supervision team members.
aAdapted from Smith and Foronda (17) with permission from Wolters Kluwer Health.
The Primary Hope of Multicultural Streaming
The primary hope for this approach is that multicultural streaming becomes and remains integral to the group’s working process and product. Thus, MSJ becomes a crucial part of the work of all therapy and supervision, is situated centrally within that work, and inculcates and perpetuates a culturally humble lens that becomes and remains nuclear for supervisees. As one group supervisee put it,
I think . . . this team incorporated MSJ into group supervision . . . through being inclusive towards each other . . . because of how supported and heard we feel in this space to express our identities. There is some safety that was created by saying at the onset that we want to integrate MSJ into group supervision, something communicated to each other that we care about every person in the room. We see that most of us have marginalized identities, and we want to honor those identities, just as we want to honor our clients’ identities. This made it easier for students to initiate MSJ conversations and take the risks to add [a] MSJ lens to their presentations, therapy, and assessment.
Group supervision indeed has the potential to contribute to supervisees’ multicultural competence and cultural humility and seems especially well suited for that purpose (18).
Implications for the Future
Just as there is a need to diversify the clinical and academic workforce (19, 20), it is equally important to diversify the clinical curriculum to address the needs of a diversified and ever-diversifying clientele and to promote multicultural competence among therapists in training. Our description here is but one example showing how we have attempted to privilege MSJ in group psychotherapy supervision. Our field lacks such concrete examples, and we hope that this article and the recommendations within it (Box 3) will serve as a stimulus for discussion, generating further dialogue and concrete examples about meaningfully integrating MSJ into group psychotherapy supervision.
BOX 3. Recommendations for integrating multiculturalism and social justice (MSJ) into psychotherapy supervision
•
Group psychotherapy supervision can be used as a primary venue for incorporating MSJ matters into psychotherapy education.
•
A MSJ lens can be profitably prioritized to enhance the benefits of group psychotherapy supervision.
•
The concept of “multicultural streaming” can be used to ground and guide the group supervision process.
•
Each supervision group can benefit from developing its own plan by which to implement multicultural streaming.
•
The spirit of cultural humility ideally looms large in informing all group supervision MSJ plan development and execution.
References
1.
Bandstra BS, Shah R, Tan M: Cultural issues within the supervisory relationship; in Supervision in Psychiatric Practice: Practical Approaches Across Venues and Providers. Edited by De Golia SG, Corcoran KM. Washington, DC, American Psychiatric Association, 2019
2.
Resource Document on Cultural Psychiatry as a Specific Field of Study Relevant to the Assessment and Care of All Patients. Washington, DC, American Psychiatric Association, 2013. https://www.psychiatry.org/psychiatrists/search-directories-databases/library-and-archive/resource-documents. Accessed Feb 21, 2020
3.
Resource Document: Advocacy Teaching in Psychiatry Residency Programs. Washington, DC, American Psychiatric Association, 2018. https://www.psychiatry.org/psychiatrists/search-directories-databases/library-and-archive/resource-documents. Accessed Feb 21, 2020
4.
Watkins CE Jr, Hook JN, Owen J, et al: Multicultural orientation in psychotherapy supervision: Cultural humility, cultural comfort, and cultural opportunities. Amer J Psychother 2019; 72:38–46
5.
Hook JN, Davis D, Owen J, et al: Cultural Humility: Engaging Diverse Identities in Therapy. Washington, DC, American Psychological Association, 2017
6.
Kivlighan DM III, Chapman NA: Extending the multicultural orientation (MCO) framework to group psychotherapy: a clinical illustration. Psychotherapy 2018; 55:39–44
7.
Bernard JM, Goodyear RK: Fundamentals of Clinical Supervision, 6th ed. Upper Saddle River, NJ, Merrill, 2019
8.
Dunn J: Toward a psychoanalytic way of teaching psychoanalysis. Psychoanal Rev 2013; 100:947–971
9.
Watkins CE Jr, Callahan JL, Vîşcu LI: The common process of supervision process: the supervision session pyramid as a teaching tool in the beginning supervision seminar. J Contemp Psychother 2020; 50:15–20
10.
Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, American Psychiatric Association, 2013
11.
Hays PA: Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, 2nd ed. Washington, DC, American Psychological Association, 2016
12.
Greathouse TR: Promoting multicultural humility: a strategy for building a foundational building block for multiculturally informed supervision. Reflections: Narratives of Professional Helping 2020; 26:101–106
13.
Ratts MJ, Singh AA, Nassar‐McMillan S, et al: Multicultural and social justice counseling competencies: guidelines for the counseling profession. J Multicult Couns Devel 2016; 44:28–48
14.
Branco SF, Bayne HB: Carrying the burden: counselors of color’s experiences of microaggressions in counseling. J Couns Dev 2020; 98:272–282
15.
Shaw S, Ford SJW: Developing Cultural Humility and Multicultural Orientation [video]. Alexandria, VA, Microtraining Associates, 2017
16.
Jordan JV: Relational Cultural Therapy Over Time [video]. Washington, DC, American Psychological Association, 2009
17.
Smith A, Foronda C: Promoting cultural humility in nursing education through the use of ground rules. Nurs Educ Perspect 2021; 42:117–119
18.
Rowell PC: Group supervision of individual counseling; in Counselor Supervision: Principles, Process, and Practice, 4th ed. Edited by Ladany N, Bradley LJ. Philadelphia, Brunner-Routledge, 2010
19.
Shah R, Tan M, Bandstra BS: Supervising cross-cultural topics in the clinical setting; in Supervision in Psychiatric Practice: Practical Approaches Across Venues and Providers. Edited by De Golia SG, Corcoran KM. Washington, DC, American Psychiatric Association, 2019
20.
Roberts LW, Maldonado Y, Coverdale JH, et al: The critical need to diversify the clinical and academic workforce. Acad Psychiatry 2014; 38:394–397
Information & Authors
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Received: 21 April 2021
Revision received: 18 June 2021
Accepted: 17 September 2021
Published online: 24 November 2021
Published in print: September 01, 2022
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Competing Interests
Authors two through 10 contributed equally to this article; their order of authorship was randomly determined.
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The authors report no financial relationships with commercial interests.
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