Multicultural Research and Practice:
Theoretical Issues and Maximizing Cultural Exchange
Andrew J. Fields
University of Denver
This article reviews literature on cross-cultural approaches to assessment, research, and clinical practice,
culminating in recommendations for using a “cultural exchange†approach when working with multicultural clients. It examines challenges in studying culture and mental illness, including methodological
issues and problems in defining constructs in multicultural research. Measurement of disorders crossculturally, including efforts to validate depression measures for use with multicultural populations, is also
discussed. Perspectives on cultural competence are presented, including the American Psychological
Association Multicultural Guidelines, and a “cultural exchange†approach to therapy is presented as a
tool for maximizing the benefit of therapy with multicultural clients. Three clinical vignettes are
presented to illustrate the use of this approach and how identifying the commission of Type I and Type
II multicultural errors can enhance clinical work.
Keywords: culture, cross-cultural, therapy, depression, assessment, case study
This article aims to provide a comprehensive framework for
clinicians and researchers working with multicultural clients. This
will be done by reviewing theory regarding the interaction of
culture with assessment, diagnosis, and treatment of depression.
Depression is used as an exemplar mental disorder because of
being common across cultures and widely researched; however,
most of the recommendations are applicable to other psychological
disorders. The article will examine current views on multicultural
competence, including the American Psychological Association
(APA) Multicultural Guidelines, which can be used to inform a
multicultural stance toward all therapy interactions, followed by a
discussion of issues related to cross-cultural validation of depression measures. It will be shown that defining culture and cultural
interaction is a complex and ever-changing phenomenon. Furthermore efforts to truly address culture and mental illness are only
just beginning to be realized. Methods of measuring and treating
disorders are evolving as traditional views are being challenged
and improved upon. Finally, clinical case vignettes are presented
to illustrate the use of a “cultural exchange†approach to therapy
with diverse clients. The aim is to illustrate the complexities of
multicultural counseling and how addressing such complexities
can lead to superior clinical work with all clients.
Studying Culture and Mental Illness
The earliest endeavors to create cross-cultural understanding of
mental illness are credited to Kleinman (1977), who argued that
cultural variations in mood disorders do exist based on a particular
culture’s shaping of normal and deviant behavior. He emphasized
the need to examine the social implications of illness. Professionals were encouraged to respect indigenous classifications and
conceptualizations for disorders. Further emphasis was placed on
understanding the limitations of current diagnostic categories, especially in a cross-cultural setting. Views on the relationship
between depression and culture fall into two general camps. The
universal view argues that depression is similar across cultures and
thus can be accounted for by one unitary quantitative measure,
whereas the social constructionist view asserts that depression is
culture-bound and measures cannot be generalized across cultures
(Redmond, Rooney, & Bishop, 2006; Draguns & TanakaMatsumi, 2003). These views have significant implications related
to how depression is studied across cultures.
Currently, the World Health Organization (WHO) studies depression as part of larger epidemiological research on disease and
illness. The 1996 publication of The World Health Report found
depression to be among the top disorders to cause disability
worldwide (fifth for women, seventh for men; Desjarlais et al.,
1996, cited in Lo´pez & Guarnaccia, 2000). An important finding of
the study was the relationship between mental illness and culture.
Factors such as hunger, work conditions, and domestic violence
were related to levels of depression in women. The authors thus
argue that depression is as much a social illness as it is a mental
illness. It seems that even a universalist view that a disorder has
commonalities across cultures will need to account for socially
constructed variations in perceptions of the disorder, pathways to
treatment, attitudes toward mental health care, and social factors
that create/sustain the disorder.
Methodological Issues in Cross-Cultural Research
One of the earliest large-scale studies of cultural differences in
mental illness was the United States–United Kingdom (US-UK)
Diagnostic Project (Cooper et al., 1972, cited in Draguns &
ANDREW J. FIELDS earned his MS in mental health counseling from the
University of Miami and is completing his PhD in counseling psychology
from the University of Denver. He recently completed his predoctoral
internship at the University of Iowa student counseling service. His areas
of research and practice include men and masculinity, multicultural issues,
diagnosis and assessment, and measurement issues.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to
Andrew J. Fields, University of Denver, Ammi Hyde Building, 2450 S.
Vine Street, Denver, CO 80208. E-mail: [email protected]
Professional Psychology: Research and Practice © 2010 American Psychological Association
2010, Vol. 41, No. 3, 196–201 0735-7028/10/$12.00 DOI: 10.1037/a0017938
196
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Tanaka-Matsumi, 2003). This study found that a larger percentage
of patients in New York were diagnosed with schizophrenia,
whereas patients in London were more likely to be diagnosed with
depression. The study found that differences disappeared when
using standardized diagnostic criteria (International Classification
of Diseases, Eighth Revision [ICD-8]). An important finding from
this study was that clinicians were likely to contribute to cultural
differences, not just patients, although the results suggest that use
of standardized diagnostic criteria can alleviate such bias. One
limitation of the study is the fact that British and U.S. cultures
share significant overlap.
Research on the cultural influences on mental illness has been
marred by methodological issues (Redmond et al., 2006). Although the US-UK project indicated that validity was improved
with the use of standardized diagnostic criteria, Canino, LewisFernandez, and Bravo (1997) state that such criteria drown out
cultural nuances and prevent the formation of relevant hypotheses
important to culture. They also argue that the criteria are problematic because they are bound in Euro-American ethnocentrism. One
difficulty in accurate assessment of psychopathology in crosscultural situations involves social distance and empathy. That is,
the more unfamiliar a person’s culture, the more difficult it is for
one to experience it empathically (Draguns & Tanaka-Matsumi,
2003). Indeed, psychologists’ tendency to group and categorize
people may prevent them from acknowledging the substantial
overlap among various cultures. This leads to pathologizing cultural variation in mental disorders.
Another struggle with studying mental illness cross-culturally is
difficulty finding common terminology. Some cultures do not have
a dictionary-equivalent word for depression, and most cultures
vary in terms of the connotative meaning of the word (TanakaMatsumi, & Marsella, 1976). Using U.S. criteria and definition,
there is broader cross-cultural support for a similar phenomenon
that one might call depression. The study by Weissman et al.
(1996) was one of the first major attempts at multicultural comparison of mood disorders. They found little variation in bipolar
mood disorder, which is not surprising because of the disorder’s
strong biological etiology. However, they found that sleep difficulties and loss of appetite were consistent depressive symptoms
found in ten countries. This evidence of course suggests that
depression may exist in similar form across cultures.
Chang et al. (2008) examined the validity of using Diagnostic
and Statistical Manual (DSM) diagnostic criteria with a Korean
population. They found that Koreans met diagnostic criteria for
depression about one-fourth as often as people in the United States,
suggesting that the diagnostic threshold may differ despite the
actual specific criteria being valid with a Korean population.
However, there were some variations. Koreans showed four times
the amount of work-related impairment than those in the United
States. The type of symptoms to first appear differed across cultures as well. Depressed mood was first noticed among those in the
United States (when the course of the disorder was less severe)
with psychomotor retardation or agitation and feelings of worthlessness and guilt occurring when depression was more severe. In
Koreans, concentration difficulty and low energy symptoms appeared earlier, while psychomotor retardation or agitation and
feelings of worthlessness and guilt appeared when depression was
more severe. Of important note is that depressed mood is often a
required symptom for a DSM diagnosis of depression (that or
anhedonia). Thus, the cultural differences in the endorsement of
depressed mood may be a factor in the observed prevalence
differences.
Measuring Mental Illness Cross-Culturally
There is empirical evidence suggesting that universal depression
scales can be used to measure depression across cultures (Arrindell, Steptoe, & Wardle, 2003). However, other research cautions
that such measures may still miss important cultural nuances and
can never avoid ethnocentric interpretation by the assessor (Redmond et al., 2006). Draguns and Tanaka-Matsumi (2003) examined a large body of research pertaining to studying depression
across cultures. Several important conclusions were found to guide
cross-cultural measurement. First, the authors note that the increase in efforts to standardize measures for cross-cultural use
have allowed researchers to test hypotheses about the variation of
psychopathology across cultures. The authors state that “cultural
research on psychopathology starts with the development of scales
and other instruments of assessment. It culminates with their
application across and within cultures†(p. 770). Thus, crosscultural validation is considered to be an integral part of a scale’s
validation process. The authors also found that cultural variability
was more pronounced when psychopathology was mild, and cultural difference dissipated as pathology became greater. Symptom
clusters such as guilt and somatization had the greatest variability
across cultures. Finally, a major issue noted in the extant research
is that culture of the clinician (researcher, assessor, etc.) was often
left out, overlooked, or deemed as unimportant. This further highlights the ethnocentric bias persistent in cultural research. The
majority of research on culture thus focuses on the participant’s or
client’s cultural factors, which is incomplete. True cultural research must look at the discrepancy between the observer (researcher, clinician, etc.) and the participant or client. Failure to do
so increases the likelihood to pathologize those that are culturally
different and understates the effects of cultural disparity on assessment and diagnosis.
Hofstede’s (Draguns and Tanaka-Matsumi (1980, 1991, 1980
2001, 1991, 2001) cultural measure is one of the more widely used
scales to quantify and describe culture in cross-cultural studies. It
measures five dimensions of culture (Power Distance; Uncertainty
Avoidance; Individualism/Collectivism; Masculinity/Femininity;
and Confucian Dynamism, cited in Redmond et al., 2006). A
variety of research has examined variability of depression and
culture using Hofstede’s scale (Arrindell et al., 1997; Diener,
Diener, & Diener, 1995). However, the scale has been criticized as
being redundant, overly narrow, and used inappropriately beyond
the scope it was originally intended for (Redmond et al., 2006).
Some researchers have critiqued the methodology used to extract
the factors (Bond, 2001), while others have failed to replicate
Hofstede’s factor structure and suggest that the factors are suspect
(Spector, Cooper, & Sparks, 2001). While the scale may have
continued use in cross-cultural research, the data suggest that the
scale should be used cautiously. At best, Hofstede’s factors appear
to be incomplete or too narrow to examine many cultural nuances
in socially mediated facets of depression and psychopathology.
MULTICULTURAL ISSUES 197
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Validating Instruments for Multicultural Use
There are a large number of studies that aim to ascertain crosscultural support for a variety of depression measures, including the
Depression in the Medically Ill Measure of State Depression
(DMI-10) (Chan, Parker, Tully, & Eisenbruch, 2007), the Beck
Depression Inventory II (BDI-II) and the Center for Epidemiologic
Studies Depression Scale (CES-D; Kojima et al., 2002), and the
Hamilton Rating Scale for Depression (HRSD; Fava, Kellner,
Munari, & Pavan, 1982). Many of these studies focus on the
examination of exploratory factor analysis (EFA) factor structure,
test–retest reliability, and internal consistency reliability of scales
translated from English to another language for use with the
latter’s native population. While consistency is an important facet
of the psychometrics of these translated scales, reliability is necessary but not sufficient to establish validity.
While many cross-cultural validations of depression inventories
have merely reported internal consistency reliability and EFA
results, researchers are beginning to believe that such methods are
not sufficient and arguing for use of confirmatory factor analysis
(CFA) to test specific hypotheses about the scale structure
(Furukawa et al., 2005). CFA is a form of scale analysis using
structural equation modeling to verify theoretical models purported to be measured by a scale. Models show relationships
among observations (i.e., scale item scores) and latent variables
(i.e., a construct, such as depression, thought to “load†onto the
score of the observation). Information about variances, covariances, and model fit are used to examine the hypothesized factor
structure of the scale. Use of CFA allows for the examination at the
scale (or item) level and allows the researcher to examine the
behavior of the factors predicted to be underlying the scale items.
Although EFA is more widely used in psychometric research, the
method is often erroneously extended beyond its intended use.
Perspectives on Cross-Cultural Competence
Definitions and perspectives of what it means to possess cultural
competence vary. Sue (1998) describes cultural competence as the
possession of the knowledge and skills of a particular culture to an
extent that allows the delivery of effective services to such a
population. Other theories point at the ability to move between two
cultural perspectives or, more broadly, the ability to recognize the
importance of culture and incorporating culture into assessment
and treatment delivery (see Whaley & Davis, 2007). Sue and
Torino (2005) more recently described cultural competence as
follows:
Cultural competence is the ability to engage in actions or create
conditions that maximize the optimal development of the client and
client systems. Multicultural counseling competence is achieved by
the counselor’s acquisition of awareness, knowledge, and skills
needed to function effectively in a pluralistic democratic society
(ability to communicate, interact, negotiate, and intervene on behalf of
clients from diverse backgrounds) and on an organizational/societal
level, advocating effectively to develop new theories, practices, policies, and organizational structures that are more responsive to all
groups. (p. 8)
This perspective on cultural competence includes the acquisition
of cultural knowledge, as well as a general approach to thinking
about, studying, teaching, and developing policy and practice to
reflect such thinking.
Whaley and Davis (2007) reviewed the literature related to the
increasing need for multicultural competence among clinicians.
They cite research to argue that there is an increased need for
cultural competency due to the increasing cultural diversity of the
U.S. population. In addition, they note issues related to underutilization and overutilization of mental health services. Underutilization refers to ethnic minority groups using dramatically fewer
mental health services than Caucasians, which the authors describe
as a case of unmet needs. Overutilization refers to ethnic minorities
being given diagnoses of more severe disorders or being in greater
distress. Other arguments made in the review state that cultural
competence research addresses needs put forth by the APA and the
American Counseling Association (ACA) code of ethics. Furthermore, issues of external validity are common with regard to
generalizing scientific findings to other cultures. Thus, research on
cultural competence is called for on grounds of empirical rigor as
well. Finally, the authors argue that cultural competence is an
essential component of evidence-based therapy. Traditionally,
evidence-based therapy research has failed to extend to ethnic
minority groups, and the authors see cultural competence as requisite evidence criteria for such therapies.
The APA’s six Multicultural Guidelines assert that cultural
competence involves more than cultural knowledge (APA, 2003).
While the first guideline emphasizes the importance of knowledge
of differences, the second guideline states “psychologists are encouraged to recognize that, as cultural beings, they may hold
attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are ethnically and
racially different from themselves†(p. 382). The notion of the
psychologist as “cultural being†highlights an important, and often
overlooked, aspect of cross-cultural work in research and clinical
practice. In addition to having an acute lens to assess the cultural
world, a psychologist must be aware of the lens itself and its
tendency to focus and bend images based on his or her own
cultural beliefs and values.
Not only is knowledge of cultures insufficient to work with
culturally diverse clients, but developing a complex understanding
of every culture is challenging, if not impossible. It is unlikely that
a clinician will possess a high level of expertise on more than a few
cultural groups. Chu (2007) proposes the use of a cultural “approach†as a means for working with various cultural groups. The
model is essentially a general therapy framework that includes a
deliberate effort to “maximize the cultural exchange†(p. 39). The
author describes this exchange as ongoing attempts to challenge
assumptions and test cultural hypotheses. That is, there is a continual dialogue between the client and clinician regarding culture, cultural assumptions, and cultural interactions in therapy. Thus cultural
interaction is not an examination only of the client’s cultural background, but instead focuses on the discrepancy between the clinician’s
culture and the client’s, a sentiment that is illustrated in the following
vignette.
Maximizing Cultural Exchange: The Case of G
G. is a 54-year old Bosnian refugee who came to the United
States with his adult daughter to escape the war and strife in
Bosnia, to which he had lost his wife and many other friends and
198 FIELDS
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family members. G. came to therapy because of “suddenly waking
up†in the nighttime with feelings that something was wrong. G.
spoke almost no English despite living in the United States for 10
years, and all therapy was conducted through an interpreter that
would be present in the room for each session. Initial attempts to
understand G.’s symptoms were fruitless, only leading to general
descriptions of sudden waking and possibly some feelings of
anxiety. It seemed that G. was experiencing posttraumatic stress
disorder (PTSD) related to the war in his home country and the
tragic losses he experienced. However, using a typical treatment
approach for working with trauma seemed impossible. There was
virtually no therapeutic alliance, and G. appeared to be frustrated
at attempts by the therapist to talk about his symptoms. Rather than
fruitlessly press for more information, the therapist asked G.
whether there were psychologists in Bosnia. G. described himself
as a traditional man, stating that the concept of coming to a
therapist usually meant that one was “crazy.†He was concerned
that he would be perceived as crazy by the therapist. He was told
what PTSD was, and how a therapist in the United States would
view this as an anxiety disorder in reaction to experiencing tragedies like he had. The therapist reassured him that he was not crazy
and that the symptoms could be treated by talking about them. He
asked G. how he felt talking via an interpreter, and while G.
expressed understanding of the necessity of it, he admitted that it
made him feel inadequate that he could not communicate more
directly. G. shared that he has not spoken more than a few words
to anyone other than his daughter since he arrived in the United
States. This was because of feeling uncomfortable learning a new
language, yet it led to problems because his daughter was living
her adult life in the United States and did not have time to be there
for him always. He expressed a desire for social interactions, but
at this point felt foolish trying to initiate communication with
others. Through the course of therapy, G. described a desire to
have friends to play chess with, a game he felt he was very good
at. They explored ways that G. could develop friendships by
finding a small group of Bosnian immigrants through an organization the interpreter knew of. G. developed some friendships and
was able to learn more English over chess games with a friend at
a local coffee shop. His new friend had also lost loved ones in the
war, and they relied on each other as a source of support. At
termination of therapy, G. reported that he was sleeping soundly,
with no sudden awakenings.
In this case, addressing the cultural dynamics in the session
became more important than initiating a treatment plan. Never
during therapy did G. talk in detail about his trauma, work on
relaxation techniques, identify triggers, or take medication. The
cultural exchange in session helped G. get what he wanted most,
which was social support where he was able to address his PTSD
symptoms through channels that felt more natural to him than
therapy. Clinicians must be aware that addressing the cultural
exchange is not an addition to therapy, but rather a therapeutic
intervention on its own.
Chu (2007) argues that this cultural exchange approach can help
a clinician watch for what the author calls Type I and Type II
cultural errors. Analogous to hypothesis testing errors, the Type I
cultural error is the assumption that a clinical issue is cultural when
it is not. For example, a client who consistently arrives late for
therapy sessions may be viewed as doing so because of cultural
attitudes toward time or punctuality. In actuality, this may be an
important clinical issue that is unrelated to culture. The Type II
cultural error assumes an issue is not cultural when it is, such as
labeling a client who is acting out cultural beliefs concerning
respect toward authority figures as being passive and deferential
(Chu, 2007).
Type I Cultural Error: The Case of D
D. was a 20-year-old female Chinese international student who
had only been in the United States for a few weeks. She sought
therapy to address difficulties adjusting to U.S. culture, reduce
anxiety about choosing a major, and to have a safe place to ask
questions about university life. While her English was fluent, it
was limited enough that it still led to difficulties in expressing
some ideas, especially those related to feelings. Using a cultural
exchange approach, the therapist attempted to ask D. about how
she perceived talking about emotions in session. He assumed that
D. had a cultural value that led her to be less emotionally expressive, and he wanted to start a discussion about this to avoid making
culturally biased assumptions. When asked about how her culture
viewed emotions, D. expressed confusion about the question, and
the therapist attributed this to both the language barrier and the
notion that individuals from Asian cultures are less inclined than
Americans to express emotions openly with a stranger. Therapy
took on a problem-solving approach, with the therapist directing
D. to make use of international student resources on campus and
attempting to make friends as a means to practice her English. D.
often talked about classes and her desire to join professional clubs.
The therapist viewed her as a hardworking student who did not
seem interested in her personal life. Five weeks into therapy, D.’s
interactions with American students had increased and her English
was noticeably better. The therapist pointed out that they were able
to converse more directly. He again asked D. about expression of
emotions in her culture. She explained that she believed many
Chinese people did not share emotions, except with close relatives
or friends. However, she stated that she was not typical of her
culture, because she considers herself more emotional and enjoys
talking about her feelings, something she had been enjoying with
her new American friends. It turned out that D. simply did not
know the English version for some of the words being used in
therapy, such as assertive and rejection. After teaching her some of
the words, the therapist was able to learn that D. desperately
wanted to have friends at school, but was unsure about how to
initiate conversations with others. In addition, D. was having
difficulty with her roommate but was afraid of being offensive
by raising her concerns to her roommate. From here they were
able to work on assertive communication skills and to role-play
initiating social conversations. The therapeutic alliance also
became stronger as D. delighted in sharing stories about her
hometown in China. She also expressed a desire to come to the
United States because she did not feel her values fit well with
some common Chinese values.
This case shows how the assumptions a therapist makes about
other cultures may blind him or her to the heterogeneity within
cultures. The therapist had assumed from her lack of responding
that D. did not consider it appropriate to discuss emotions, when in
fact it had been a misunderstanding based on the language barrier.
While a cultural exchange approach serves to enhance understanding of dynamics for both the therapist and client, it can be easy to
MULTICULTURAL ISSUES 199
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overassume the impact of culture. The culturally competent therapist is aware of within group variability as well as shared variance
across cultures.
Type II Cultural Error: The Case of R
R. was a 30-year-old Columbian male who had lived in the
United States for 5 years. He was seeking therapy for symptoms of
depression related to insecurities in his relationship with his girlfriend. R. stated that he would become anxious about his physical
appearance, including his weight and acne, and was afraid that his
girlfriend would decide that he was not good enough for her and
leave him. He interpreted benign behaviors, such as her desire to
go to the mall with her mother, as her rejection of him. R. also
reported fears of abandonment early in life back in Columbia,
recalling throwing temper tantrums when his mother would leave
the house to go to the store. During therapy sessions, R. would
often focus on recent events where he felt insecure and wished his
girlfriend would behave differently to reduce his anxieties. The
therapist made many attempts to help R. examine how his insecurities may stem from early childhood events he seemed unwilling
to explore. Because the therapist was unfamiliar with Columbian
culture, he asked R. about his values about disclosing personal
information in therapy. R. shared that his culture valued “machismo†in men, referring to acting in an assertive or even aggressive manner, being unemotional, providing for his family, and
other traits that one might equate with a traditional masculine
gender role. R. expressed a reluctance to talk about his past,
because this was an emotional topic, and he did not want to express
vulnerable emotions in front of a male therapist out of fear that he
would be humiliated and demasculinized. The therapist informed
R. that this is similar to what happens in the United States, where
men struggle to be emotionally open based on gender role expectations. R. rejected the notion that these were similar, because he
did not feel the pressure was as great for American men. In fact, he
even expressed a desire to date American women out of a belief
that they would not require him to adhere to such a strict masculine
code. R.’s attendance at therapy following this session was sporadic and superficial. The therapist suggested that R. was resistant
to the therapy process because it involved talking about emotional
material. R. often agreed with this notion but did not engage in
therapy further. R. suggested they terminate therapy, and during
the termination session the therapist admitted that he had made an
error in assuming that R.’s experiences were similar to what
American men experience. R. stated that he felt belittled and
misunderstood, like his identity as a man was being challenged at
the expense of understanding his background. At this discovery the
therapist and R. engaged in sharing how gender roles were viewed
in Columbian and U.S. culture. R. enthusiastically described the
cultural norms in his family. R. later shared how being able to talk
about his culture to a naı¨ve therapist made him feel intelligent and
worthwhile in a therapy relationship that initially made him feel
weak and stupid. It was through this discussion that R. revealed
that early in life his father had left him and his mother for another
woman. R. believed that his father no longer desired to be a family
man who provided for his wife and child, and instead sought out
relationships with younger women. The feelings of abandonment
were intimately tied to confusion about his own role as a man, one
he continued to struggle with in his adult life.
Only through a cultural exchange was the therapist able to
establish a therapeutic relationship with the client. Without previous knowledge of machismo, one may simply interpret that the
client is defensive. Through the cultural exchange, the therapist
enabled the client to feel competent and capable, allowing him to
engage in the work of therapy. These exchanges also increase the
cultural competence of the therapist for identifying similar issues
in future clients. Working with every therapy client using a cultural
exchange approach can improve the therapy relationship and open
doors of exploration for the therapist and client.
Conclusions
This article reviewed current thinking and research regarding
cultural interactions with mental illness. It was argued that definitions of culture are variable and research findings from the WHO
and other cross-cultural studies warrant careful examination of the
interaction between mental illness and culture. Although studies
suggest that a phenomenon called depression likely exists to some
similar extent across cultures, caution must be used in understanding cultural nuances. Research on cross-validation of depression
measures was examined, and current findings suggest that many
translated measures of depression show promise; however, the
methods used to establish cross-cultural validity are inadequate. It
was also argued that the increased use of CFA is warranted to test
specific hypotheses regarding a scale’s behavior in other cultural
settings or with diverse clients.
Of utmost importance is examination of culture as an exchange
between two people in a clinical setting, rather than merely looking
at a particular client’s cultural beliefs and values. Case vignettes
were presented to illustrate some of the complexities of the cultural
exchange approach. It was argued that competence extends beyond
cultural sensitivity or knowledge and includes a comprehensive
approach to clinical work, research, teaching, and policy-making.
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Received October 13, 2008
Revision received July 15, 2009
Accepted September 1, 2009
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