Professional Psychology: Research and Practice © 2012 American Psychological Association

2012, Vol. 43, No. 3, 165–174 0735-7028/12/$12.00 DOI: 10.1037/a0025783

Individual and Systemic Factors in Clinicians’ Self-Perceived

Cultural Competence

Pratyusha Tummala–Narra, Rachel Singer, Jessica Esposito

and Zhushan Li Columbia University
Boston College

Sarah E. Ash
Boston College
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Although research supports the critical need for cultural competence in clinical practice, few studies have
This document is copyrighted by the American Psychological Association or one of its allied publishers.

addressed practitioners’ perspectives on their psychotherapeutic practices with ethnic minority clients.
This study examined whether personal orientation to diversity (universal-diverse orientation or UDO),
perceived access to institutional resources, and multicultural training were associated with self-perceived
cultural competence among 196 licensed clinicians. We also explored differences in self-perceived
cultural competence across clinicians identified with specific theoretical orientations. Multiple regression
analyses indicated a positive association between UDO and clinicians’ self-perceived cultural compe-
tence, and a positive association between access to institutional resources and self-perceived cultural
competence. The extent to which multicultural training was thought to be helpful was also associated
with self-perceived cultural competence. Analysis of variance and post hoc analyses revealed mixed
findings with respect to differences on self-perceived cultural competence across theoretical orientation.
Implications of these findings for research, practice, and training are discussed.

Keywords: cultural competence, psychotherapy, clinicians, ethnic minorities

It is well documented in the research and clinical literature that
many ethnic minority communities struggle with accessing cultur-
ally competent mental health services. Several barriers to adequate
treatment and advocacy have been identified within the counseling
relationship, such as misdiagnosis, lack of credibility of the pro-
vider, and bias and/or discrimination (Alegrı́a et al., 2008; Sue,
1998). Despite evidence supporting an association between mul-
ticultural competence and positive therapeutic outcomes (Barnett,
2009; Worthington, Soth–McNett, & Moreno, 2007), research
examining clinicians’ perspectives and practices in psychotherapy
with ethnic minority clients has received little attention.
The purpose of this study was to examine individual and sys-
temic factors that may be associated with clinicians’ perceptions of
competence in working with ethnic minority clients in psychother-
apy. Because clinicians provide psychotherapy to ethnic minority
clients in a variety of settings, we were interested in the perspec-
tives of clinicians across disciplines (e.g., psychologists, social
workers, psychiatrists) and treatment settings (e.g., independent
practice, community health centers, hospitals, college counseling
centers, schools). In the present study, we examined whether
clinicians’ personal orientation to diversity, perceived access to
institutional resources, and multicultural training are associated
with clinicians’ perceived cultural competence. We were also
interested in whether there are any differences in self-perceived
cultural competence among clinicians identified with different
theoretical orientations. We begin by reviewing existing literature

Editor’s Note. This is one of 13 accepted articles received in response to
an open call for submissions on Multicultural Practice in Professional
Psychology.—MCR
PRATYUSHA (USHA) TUMMALA–NARRA received her PhD in clinical psy-
chology from Michigan State University. She is former Director of the
Asian Mental Health Clinic at the Cambridge Health Alliance/Harvard
Medical School. She is an Assistant Professor in the Department of
Counseling, Developmental, and Educational Psychology at Boston Col-
lege. Her areas of interest include multicultural psychology, immigration,
trauma, and psychodynamic psychotherapy.
RACHEL SINGER is a doctoral student in Counseling Psychology at Boston College.
She is a predoctoral intern at St. John’s Child and Family Center in Santa Monica.
Her research interests include multicultural competence, relational health, intimate
partner violence, and factors that impact immigrants’ mental health.
ZHUSHAN LI received her PhD from the University of Illinois at Urbana-
Champaign. She is an Assistant Professor in the Department of Educational
Research, Measurement, and Evaluation at Boston College. Her research
interests include categorical data analysis, latent variable modeling as well
as research methodology development and application for education, psy-
chology, and health fields.
JESSICA ESPOSITO received her Master’s in Counseling Psychology from
Boston College. She is a doctoral student in Counseling Psychology in
Teachers College at Columbia University. Her research interests in-
clude marginalized populations, multiculturalism, and health psycho-
logy.
SARAH E. ASH is a doctoral student in Counseling Psychology at Boston
College, where she received her Masters in Counseling Psychology. Her
areas of professional interest include community-based interventions with
low income and diverse populations as well as interventions aimed to
improve children’s social and emotional wellbeing.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Praty-
usha Tummala–Narra, 319 Campion Hall, 140 Commonwealth Avenue,
Chestnut Hill, MA 02467. E-mail: tummalan@bc.edu

165
 166 TUMMALA–NARRA, SINGER, LI, ESPOSITO, AND ASH
on the definition of cultural competence in clinical practice, the
clinician’s orientation to diversity and theoretical approach, insti-
tutional factors, and multicultural training, all of which bear rele-
vance to clinical practice with ethnic minority clients.
Defining Cultural Competence
Cultural competency has been viewed as a process-oriented
concept (Maxie, Arnold, & Stephenson, 2006), involving three
broad dimensions: therapist’s cultural knowledge, therapist’s atti-
tudes and beliefs toward culturally different clients and self-
understanding, and the therapist’s skills and use of culturally
appropriate interventions (Helms & Cook, 1999; Sue, Arredondo,
& McDavis, 1992). In accordance with the American Psycholog-
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
ical Association (APA) Guidelines for the Providers of Psycho-
logical Services to Ethnic, Linguistic, and Culturally Diverse Pop-
ulations (APA, 2003), cultural competence includes the
assessment of cultural identity, acculturation, family dynamics,
and explanatory models of illness and healing, which then guides
the implementation of culturally sensitive interventions. Other
professional associations have also noted the importance of cul-
turally competent clinical practice. For example, the American
Psychiatric Association (2000) has called attention to culture-
bound syndromes and the use of the cultural formulation (Diag-
nostic and Statistical Manual of Mental Disorders, 4th edition, text
revision [DSM–IV–TR]; Lewis-Fernández & Diaz, 2002) in clini-
cal assessment, diagnosis, and treatment.
In the present study, we view cultural competence as involving
the therapist’s attitudes and practices across the three broad di-
mensions delineated in previous literature (knowledge, awareness
of beliefs and attitudes, skills and interventions). While recogniz-
ing that general case conceptualization skills and multicultural
case conceptualization skills are both distinct and overlapping sets
of skills (Lee & Tracey, 2008), we focused on multicultural case
conceptualization. We define self-perceived cultural competence
as including clinicians’ perceptions of both their general cultural
competence and specific multicultural practices with ethnic mi-
nority clients. Self-perceived cultural competence is a particularly
important aspect of therapeutic practice since therapists’ attitudes
and beliefs concerning ethnic minority clients and awareness of
biases can influence their efforts toward cultural competence in
interactions with clients (Helms & Cook, 1999; Hansen et al.,
2006).
Therapist’s Worldview: Diversity Orientation and
Theoretical Approach
Therapists’ personal factors, such as racist attitudes, empathy,
and ethnic tolerance have been found to predict cultural compe-
tence (Constantine & Gushue, 2003; Constantine, 2001; Lee
& Tracy, 2008). Although a number of individual factors may
contribute to a clinician’s perceptions of his or her cultural com-
petence, in the present study, we were interested in whether the
personal worldviews of the therapist, including his or her orienta-
tion to diversity and theoretical orientation, are associated with
self-perceived cultural competence. The awareness and apprecia-
tion of similarities and differences between oneself and others is
relevant to effective client-therapist interactions (Miville et al.,
1999). The construct, universal-diverse orientation (UDO), has
been described as “an awareness and potential acceptance of
both similarities and differences in others that is characterized
by interrelated cognitive, behavioral, and affective compo-
nents” (Fuertes, Miville, Mohr, Sedlacek, & Gretchen, 2000, p.
158). This type of orientation encompasses an individual’s
appreciation of self and others, efforts in seeking diversity of
contact with others, and a sense of connection with larger
society. The UDO has been associated with positive well-being,
self-efficacy, and problem-focused coping (Miville et al.,
1999). In light of previous research that highlights the role of
diversity orientation in the therapeutic process (Munley, Thi-
agarajan, Carney, Preacco, & Lidderdale, 2007), we expected in
the present study that therapists’ acceptance of similarities and
differences among people would be positively associated with
self-perceived cultural competence in psychotherapy.
In addition to clinicians’ orientation to diversity, we were inter-
ested in differences in self-perceived cultural competence across
clinicians’ theoretical orientations. Scholars from a number of
theoretical orientations, including cognitive– behavioral, psy-
chodynamic, humanistic, and integrative perspectives, have es-
poused the value of diversity and the significance of social context
in the practice of psychotherapy (Newman, 2010; Sarnat, 2010).
The few studies that have examined theoretical orientation and
cultural competence have yielded mixed findings. Some research
has suggested that an integrative orientation to psychotherapy is
associated with increased cultural competence and multicultural
case conceptualization skills (Constantine, 2001). However, in a
more recent study of discussions on social difference between
therapists and clients (Maxie, Arnold, & Stephenson, 2006), psy-
chodynamic, psychoanalytic, humanistic, and integrative thera-
pists reported having more discussions concerning difference than
eclectic and cognitive– behavioral therapists, although there were
no group differences on discussions that were initiated by the
therapist. In the present study, we extended previous inquiry on
theoretical orientation by exploring differences in self-perceived
cultural competence across clinicians’ theoretical orientations
(psychodynamic, cognitive– behavioral, integrative).
Institutional Factors
Various systemic barriers may play a role in the discrepancy
between attitudes and practices concerning cultural competence
noted in previous research (Hansen et al., 2006). The access to
ongoing multicultural training, for example, may be limited in
various clinical settings and training programs (Sehgal et al.,
2005). Other systemic factors can potentially influence clinical
practice. Clinicians may feel constrained by managed care require-
ments, and may not be in a position to seek feedback from
colleagues and supervisors about culturally competent practices,
seek consultation, prepare a cultural formulation, or access rele-
vant literature to inform practice (Hansen et al., 2006). Research
on cultural competence has not yet focused on the role of institu-
tional resources in clinicians’ perceived cultural competence, al-
though scholars have noted the importance of attending to sys-
temic barriers (Sue, 1998). In the present study, we were interested
in examining the role of resources available to therapists (e.g.,
having access to colleagues with whom therapists could consult,
having access to ongoing multicultural training) that may promote
culturally competent practices. We expected that greater access to
 SELF-PERCEIVED CULTURAL COMPETENCE
institutional resources would be associated with higher levels of
self-perceived cultural competence.
Multicultural Training
Research on the impact of multicultural training on clinical
practice indicates that multicultural training is associated with
self-perceived cultural competence (Lee & Tracey, 2008; Sehgal et
al., 2011; Worthington, Soth–McNett, & Moreno, 2007). In a
study of multicultural beliefs and practices (Hansen et al., 2006),
psychologists were asked to rate how often they engaged in spe-
cific culturally relevant behaviors when they worked with clients
who are racially/ethnically different from themselves, and then rate
the importance of the same behavior to competent professional
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practice. Findings of this study indicated a significant discrepancy,
with participants not always practicing what they believed to be
important for effective practice. However, personal experience and
multicultural supervision and training were reported as important
activities that promoted cultural competence. The mixed findings
concerning the effects of multicultural training on attitudes and
practices among clinicians may indicate that the mere presence of
multicultural training is not sufficient to promote cultural compe-
tence (Hansen et al., 2006). In the present study, we examined
whether both exposure to multicultural training (e.g., coursework,
discussions in supervision, and workshops/seminars) and the ex-
tent to which multicultural training was experienced as helpful are
associated with self-perceived cultural competence. We expected
that greater exposure to multicultural training and a higher degree
of satisfaction with multicultural training would be associated with
higher levels of clinicians’ self-perceived cultural competence in
psychotherapy.
Methods
Participants
A total of 196 participants completed all of the surveys through
the Qualtrics online survey program. The average age of these
participants was 47.6 years of age (standard deviation [SD] ⫽
11.90). A majority of the participants were female (75%) and
White (64.3%). Participants also identified as African American
(8.7%), Latino (10.7%), Asian (4.1%), Asian Indian (2.6%), Jew-
ish (4.6%), Middle Eastern (1.0%), and biracial (4.1%). When
asked to identify their highest degree or diploma, 77% indicated
that they had received a PhD in clinical or counseling psychology.
Other psychologists (7.1%) reported a doctorate in another field,
such as educational, professional, school, or health psychology.
Other participants had received a Masters degree in one of the
following disciplines: social work (8.2%), clinical and counseling
psychology (5.1%), marriage and family therapy (0.5%), and other
(0.5%). Participants’ clinical experience ranged from 1 year to 52
years (mean [M]⫽ 15.17).
With regard to theoretical orientation, 23.5% of participants
described their orientation as psychodynamic, 20.9% as cognitive–
behavioral, 33.2% as integrative, 4.6% as family systems, 3.6% as
humanistic– existential, 1.5% as biological/medical, and 12.7% as
other (e.g., Buddhist, ecological, interpersonal). A majority of
participants reported completing multicultural coursework
(67.9%), and receiving clinical supervision that included discus-
167
sions of multicultural issues (83.7%) during graduate study, and
attending ongoing workshops and training on multicultural issues
(89.3%) after completing their graduate education.
The settings in which clinicians worked included independent
practice (46.9%), university or college counseling (14.8%),
community-based outpatient clinic (10.2%), hospital-based outpa-
tient clinic (8.7%), inpatient psychiatric facility (5.6%), school
(2.0%), and partial hospital or day treatment center (0.5%). Some
of the participants (10.2%) reported working in churches, Veter-
ans’ Administration hospitals, prisons, and forensic settings.
Procedure
Licensed clinicians from a number of different disciplines (psy-
chology, social work, psychiatry) were recruited to participate in
the present study through e-mail messages sent to various mental
health agencies, such as outpatient clinics in hospitals, community
health centers, and college counseling centers. Participants were
also recruited through list serves of professional associations, such
as the APA, state associations, and psychology, psychiatry, and
social work training associations. For example, e-mail invitations
to participate in the study were sent to the listservs of practice-
focused Divisions of the APA (e.g., Divisions 12, 17, 35, 39, 42,
44, 45), Presidents of 45 State Psychological Associations, and
Directors of Training at APA-accredited internship sites.
The recruitment letter sent via e-mail included a link to the
online consent form and survey. Participants were told that they
would be eligible to enter a drawing for one of three gift certifi-
cates in the amount of $75 for Amazon.com upon completion of
the surveys. If they were interested in entering the drawing, they
were asked to send their contact information to an e-mail account
that was maintained separately to ensure the anonymity of their
responses on the survey. At the completion of data collection, three
participant names were randomly drawn by the first author who
then sent the gift certificates to the winners of the drawing. As we
sent the recruitment letter primarily to directors of training, direc-
tors of mental health care settings (e.g., counseling centers, com-
munity mental health centers), and leaders of professional associ-
ations, we cannot estimate the number of clinicians who forwarded
the invitation to other licensed clinicians, nor the number of
clinicians who read the e-mail invitation and then declined to
participate in the study. Of the 284 clinicians who initiated their
participation online in this study, 196 completed all of the surveys.
Measures
Participants completed a background information form that in-
cluded questions about age, racial/ethnic background, gender,
practice setting, theoretical orientation, involvement with multi-
cultural training during graduate study (coursework and supervi-
sion that included discussions of multicultural issues), involve-
ment with multicultural workshops/seminars after graduate study,
and the extent to which they found these multicultural workshops/
seminars (after graduate study) to be helpful. In addition to the
demographic form, participants completed several measures aimed
to assess orientation to diversity, access to institutional resources,
and self-perceived cultural competence in psychotherapy.
Orientation to diversity. The Miville–Guzman Universality-
Diversity Scale Short Form (M-GUDS; Fuertes, Miville, Mohr,
 168 TUMMALA–NARRA, SINGER, LI, ESPOSITO, AND ASH
Sedlacek, & Gretchen, 2000), a 15-item survey, was used to
measure clinicians’ orientation to diversity. This measure assesses
attitudes concerning similarities and differences in others, includ-
ing cognitive, behavioral, and affective components of UDO.
These components include a relativistic appreciation of oneself
and others, seeking diversity of contact with others, and a sense of
connection with the larger society or humanity as a whole. Previ-
ous studies analyzing the internal consistency and test–retest reli-
ability of the M-GUDS yielded scores in the 0.89 to 0.95 range
(Fuertes et al., 2000). Convergent validity for the M-GUDS mea-
sure has been demonstrated through comparisons to other similar
measures and through confirmatory factor analyses (Fuertes et al.,
2000). Since we were interested in clinicians’ overall diversity
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orientation (acceptance of similarities and differences in others) in
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the present study, the total scale score was used for data analyses.
The internal consistency of the M-GUDS in the present study was
adequate (␣ ⫽ .77).
Access to institutional resources. The resource checklist
was designed for the purpose of the present study to assess
access to resources that exist within the clinician’s institution,
agency, or practice setting thought to promote the provision of
culturally competent care with ethnic minority clients. A pilot
study with 10 clinicians with at least 5 years of clinical expe-
rience, practicing in different settings (e.g., community mental
health center, independent practice), from different disciplines
(psychology, social work, psychiatry), was conducted to de-
velop this measure. These clinicians provided written responses
to the following open ended question: “What do you consider to
be the resources available to you in your practice setting(s) that
help you to work effectively with ethnic minority clients in
psychotherapy?” The final 12-item resource checklist (␣ ⫽ .67)
was developed based on the responses of the clinicians in the
pilot study and a review of relevant literature on multicultural
competence (Hansen et al., 2006; Park–Taylor et al., 2009). The
resources that were identified by two or more clinicians and
resources thought to be of particular importance to the delivery
of culturally competent services in the existing literature were
included in the final survey. For example, several clinicians in
the pilot study identified having access to ongoing training in
working with diverse populations as helpful to their work with
ethnic minority clients. This resource has also been noted in the
multicultural competence literature (Hansen et al., 2006). The
final resource checklist included questions about whether or not
participants had access to various resources in their practice
settings such as access to supervisors and/or consultants, ongo-
ing training in working with diverse populations, access to
literature related to clinical practice with diverse populations,
working in a setting with colleagues from culturally diverse
backgrounds, access to interpreters, and working in a setting
that values and prioritizes issues of diversity.
Self-perceived cultural competence. Two different mea-
sures were used to assess self-perceived cultural competence. The
first measure was the California Brief Multicultural Competence
Scale (CBMCS; Gamst et al., 2004). This 21-item Likert-type
scale assesses self-reported mental health practitioner cultural
competency. Sample items in this scale include “I am aware that
counselors frequently impose their own cultural values on minority
clients,” and “I am aware of how my cultural background and
experiences have influenced my attitudes about psychological pro-
cesses.” Gamst et al. (2004) found strong levels of reliability for
the CBMCS, with scores ranging from 0.75 to 0.90 for the various
subscales. In the present study, reliability was similarly strong,
with a Cronbach’s alpha of 0.83. The CBMCS has demonstrated
strong construct validity through high levels of convergent validity
with similar measures (Gamst, Liang, & Der–Karabetian, 2011).
While the CBMCS was used to assess clinicians’ general self-
perceived cultural competence, a second measure, the Clinicians’
Multicultural Practices in Psychotherapy Scale (CMPPS), was
developed in the present study to assess clinicians’ self-perceived
implementation of multicultural practices in psychotherapy with a
specific ethnic minority client. We believe that examining self-
perceived cultural competence through both measures can offer
more information about how clinicians view their engagement
with culturally competent practice more generally and in the
context of a specific psychotherapy experience. In the second
measure (CMPPS), participants are asked to think of an ethnic
minority client whose background is different from their own, with
whom they have worked in psychotherapy for at least two months,
and indicate the client’s racial/ethnic background on the survey.
The racial/ethnic backgrounds of the clients identified by the
participants included African American (44.9%), Asian American
(19.3%), Latino/a American (17.9%), Biracial (9.2%); Afro-
Caribbean (2.6%), Middle Eastern American (2.6%), American
Indian (1.5%), and Other (2.0%).
Participants then indicated on a 4-point Likert scale how
often (from not at all [1], sometimes [2], often [3], to always
[4]) they engaged in specific multicultural practices during the
course of psychotherapy with this particular client. The initial
67 items for this survey were constructed by the first author, an
Asian American psychologist who has practiced psychotherapy
with ethnic minority clients for over 15 years. The items were
developed through a review of the multicultural competence
literature (APA, 2003; Hansen et al., 2006; Maxie, Arnold, &
Stephenson, 2006), and included an emphasis on knowledge,
self-awareness, skills, and therapeutic process. Although some
items on the survey concern different aspects of diversity, such
as religion and spirituality, the survey focused on the dimen-
sions of race and culture. The initial 67 items were discussed
among the authors of the present study and then reviewed by
three senior expert psychologists, all of whom have extensive
experience in the field of multicultural psychology and identify
as ethnic minority (African American, Latino American, Amer-
ican Indian) psychologists.
The final list of items in the survey was revised based on
discussions among authors and feedback provided by the senior
experts. The final CMPPS (␣ ⫽ .95) included 51 items (See Table
1), such as “Sought information about my client’s racial, ethnic
and/or religious background and sociopolitical history through
reading either mental health or other literature that concerns his or
her background,” “Communicated with leaders (e.g., social, reli-
gious) or trusted members of my client’s community,” and “Asked
my client what he or she thinks is the diagnosis or problem from
his or her cultural perspective.” A factor analysis using a principal-
component extraction method did not yield sufficient evidence to
support separate subscales, the total score of the survey was used
as a measure of clinicians’ multicultural practices.
 SELF-PERCEIVED CULTURAL COMPETENCE 169

Table 1
Clinicians’ Multicultural Practices in Psychotherapy Scale (CMPPS)

1. Asked my client about his/her level of comfort in talking with me in counseling or psychotherapy
2. Sought consultation with other mental health professionals who have more knowledge and experience
3. Sought information about my client’s racial, ethnic, and/or religious background and sociopolitical history through reading either mental health or
other literature that concerns his/her background
4. Watched documentaries or read materials that provide information about my client’s sociohistorical background
5. Attended to my client’s need for an interpreter if my client’s language was a language other than my first language
6. Understood my client’s verbal and nonverbal communication styles
7. Considered my client’s first language and acculturation during initial assessment and/or psychological testing
8. Used my knowledge of my client’s acculturation level to inform the counseling or psychotherapy process
9. Communicated with leaders (e.g. social, religious) or trusted members of my client’s community
10. Asked my client what he/she thinks is the diagnosis or problem from his/her cultural perspective
11. Explored my client’s bicultural or multicultural identity
12. Talked with my client about intergenerational relationships and/or conflicts within his/her family
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13. Felt that I was able to find appropriate ways to ask my client questions about his/her social background
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14. Felt that I emotionally connected with my client’s experiences of being an ethnic minority person
15. Observed my client’s culture specific nonverbal communication in our work together
16. Explored difficult emotions such as anger, guilt, shame, embarrassment that the client may have experienced
17. Felt that I established a trusting relationship with my client
18. Asked my client about his/her perspective on how one heals from psychological distress
19. Considered the client’s sociocultural context in forming a diagnosis
20. Talked with my client about his/her feelings about physical features specific to his/her racial group
21. Talked with my client about his/her feelings about his/her cultural group(s)
22. Thought about including family members or members of my client’s community as a part of information gathering and assessment or in the course
of psychotherapy or counseling.
23. Considered culture-bound syndromes (DSM) as possible diagnoses when assessing my client
24. Asked my client about his/her religious and/or spiritual beliefs and practices
25. Felt comfortable with assessing and providing meaningful spiritual interventions
26. Learned more about different cultural beliefs, values, and traditions when working with my client
27. Asked my client about his/her sources of support within his/her racial/ethnic/religious community
28. Explored my client’s use of alternative healing practices (e.g. traditional healing, herbal medicine, acupuncture)
29. Wondered about how my client perceived my racial or cultural background
30. Asked my client about his/her physical symptoms or bodily experiences of psychological distress
31. Talked with my client about social differences (racial, ethnic, linguistic, gender, social class, sexual orientation and identity, physical disability)
that may exist between my client and myself
32. Felt that I was able to help my client talk about his/her experience of being an ethnic minority person
33. Talked with my client about differences and similarities in cultural values and beliefs held by me and my client
34. Felt that I was able to integrate my theoretical orientation with my client’s sociocultural experiences
35. Explored my client’s experience of discrimination and racism
36. Asked my client about his/her expectations of psychotherapy or counseling
37. Talked openly about difficulties or conflicts I had in communicating with my client
38. Discussed my client’s experiences with psychopharmacological treatment
39. Explored transference and countertransference issues related to race, culture, religion, sexual orientation, social class, or physical ability with my
client
40. Modified my theoretical ideas on therapeutic boundaries when they differed from those of my client
41. Explored my client’s racial identity
42. Explored my cultural and religious identity outside of the counseling or psychotherapy office
43. Explored my racial identity outside of the counseling or psychotherapy office
44. Felt that I was able to help my client understand my cultural perspective
45. Asked my client about his/her family structure and roles
46. Shared information about my own cultural history or background in the course of working with my client
47. Discussed immigration or visa status with my client if he/she is an immigrant
48. Asked my client about stigma possibly associated with seeking psychotherapy or counseling
49. Worked with my agency or institution to remove barriers to treatment for my client
50. Explored my client’s experiences of his/her social class, and how these experiences may have changed over time
51. Was aware of my own biases and the potential impact of these biases in my work with my client

Note. DSM ⫽ Diagnostic and Statistical Manual of Mental Disorders.

Results general cultural competence) and the CMPPS (self-perceived mul-

Orientation to Diversity and Institutional Resources
In separate regression models, clinicians’ orientation to diversity
based on the M-GUDS and access to institutional resources based
on the resource checklist were used to predict self-perceived
cultural competence as measured by the CBMCS (self-perceived
ticultural practices in psychotherapy with a specific client).
The UDO (both overall scale scores and individual subscale
scores) was positively associated with self-perceived general cul-
tural competence (B ⫽ 0.44, standard error [SE] ⫽ 0.06, p ⬍ .001),
and with clinician’s self-perceived multicultural practices in work-
ing with an ethnic minority client (B ⫽ 0.47, SE ⫽ 0.20, p ⬍ .001).
 170 TUMMALA–NARRA, SINGER, LI, ESPOSITO, AND ASH
Additionally, greater access to institutional resources was associ-
ated with higher levels of self-perceived general cultural compe-
tence (B ⫽ 0.16, SE ⫽ 0.09, p ⬍ .05) and self-perceived multi-
cultural practices (B ⫽ 0.18, SE ⫽ 0.33, p ⬍ .05; see Table 2).
Post hoc power analyses indicated that with a sample size of
196, ␣ at the .05 level, and the corresponding effect sizes, the
statistical power reached 1.0 in two of the regression models—
predicting self-perceived multicultural competence as measured by
both the CBMCS and the CMPPS with clinicians’ orientation to
diversity. Statistical power was 0.61 when using access to institu-
tional resources to predict general multicultural competence as
measured by the CBMCS, and 0.70 for using access to institutional
resources to predict self-perceived multicultural competence as
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measured by the CMPPS.
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Multicultural Coursework, Supervision, and
Workshop Experiences
Similarly, separate regression analyses were conducted to pre-
dict clinicians’ self-perceived cultural competence as measured by
the CBMCS and the CMPPS. Independent variables included
whether the participant completed coursework and supervision
(during graduate study), workshops on multicultural issues (after
graduate study), and the extent to which they found multicultural
workshops (after graduate study) helpful. These independent vari-
ables were entered into the models one at a time.
Table 3 presents the results from these regression analyses. The
associations between the extent to which participants found mul-
ticultural workshops helpful and self-perceived cultural compe-
tence as measured by the CBMCS and the CMPPS were statisti-
cally significant. The results indicated that a greater degree of
satisfaction with multicultural workshops (after graduate study)
was associated with higher levels of self-perceived general cultural
competence (B ⫽ 0.15, SE ⫽ 0.64, p ⬍ .05) and self-perceived
multicultural practices in psychotherapy (B ⫽ 0.29, SE ⫽ 2.31,
p ⬍ .001). There were no significant associations between partic-
ipation in multicultural coursework (during graduate study), su-
pervision (during graduate study), multicultural workshops (after
graduate study), and self-perceived cultural competence.
Self-Perceived Cultural Competence Across
Theoretical Orientation
Due to limited size of the sample of participants who identified
with humanistic, biological, family systems, and other theoretical
Table 2
Regression Analyses to Determine if Orientation to Diversity and Institutional Resources are
Associated With General Multicultural Competence and Multicultural Practices With Ethnic
Minority Client (N ⫽ 196)
Multicultural practices with ethnic minority client general multicultural
B SE
Orientation to diversity 0.47 0.20
Institutional resources 0.18 0.33
ⴱ ⴱⴱ
p ⬍ .05. p ⬍ .001.
orientations, we examined differences in self-perceived cultural
competence across only the participants who identified with psy-
chodynamic, cognitive– behavioral, or integrative orientations.
Based on results from one-way analyses of variance (ANOVAs),
participants who identified with these three different theoretical
orientations (psychodynamic, cognitive– behavioral, integrative)
were not found to differ significantly on self-perceived general
cultural competence as measured by the CBMCS, F(2, N ⫽
152) ⫽ 1.95, p ⫽ .15 or on multicultural practices in psychother-
apy with an ethnic minority client (CMPPS), F(2, N ⫽ 152) ⫽
2.96, p ⫽ .06. However, post hoc tests on multicultural practices
with ethnic minority clients indicated a significant difference be-
tween participants whose theoretical orientations were psychody-
namic and participants whose theoretical orientations were
cognitive– behavioral. Cognitive– behavioral clinicians scored
higher (M ⫽ 136, SD ⫽ 24.93) on the CMPPS when compared
with psychodynamic clinicians (M ⫽ 124, SD ⫽ 20.06). Integra-
tive clinicians (M ⫽ 130, SD ⫽ 22.53) scored in between on this
scale and were not significantly different from either cognitive–
behavioral or psychodynamic clinicians with respect to self-
perceived multicultural practices.
Discussion
While some previous research has examined attitudes and prac-
tices related to cultural competence among clinicians (Hansen et
al., 2006; Maxie, Arnold, & Stephenson, 2006), the role of per-
sonal and systemic factors in clinicians’ perceptions of their cul-
tural competence has received little attention. An important
strength of the present study is the examination of both individual
and institutional factors and their relationship with self-perceived
cultural competence. Keeping in mind the discrepancies between
clinicians’ multicultural attitudes and practices noted in prior re-
search, we were interested in assessing both general attitudes
concerning cultural competence and more specific multicultural
practices. As such, we assessed clinicians’ self-perceived general
cultural competence using the CBMCS and a newly developed
measure (CMPPS) that focused on assessing multicultural prac-
tices with a specific ethnic minority client in psychotherapy. The
present study included a more racially and ethnically diverse
sample who practice in a broader range of practice settings (e.g.,
independent practice, university counseling, community based
clinics, hospital clinics) as compared with previous studies in
which over 90% of participants are White clinicians, most of
whom practiced psychotherapy in independent practice (Hansen et
competence
t B SE t
ⴱⴱ
7.46 0.44 0.06 6.89ⴱⴱ
2.50ⴱ 0.16 0.09 2.23ⴱ
 SELF-PERCEIVED CULTURAL COMPETENCE
Table 3
Regression Analyses to Determine if Multicultural Coursework, Supervision, and Workshops are
Associated With General Multicultural Competence and Multicultural Practices With Ethnic
Minority Client (N ⫽ 196)
Multicultural practices with ethnic minority client general
B SE
Multicultural coursework ⫺0.04
Multicultural supervision 0.06
Multicultural workshops (participation) 0.14
Multicultural workshops (helpfulness) 0.29
ⴱ ⴱⴱ
p ⬍ .05. p ⬍ .001.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
al., 2006; Maxie et al., 2006). In the following sections, we
describe the implications of our findings concerning clinicians’
worldviews (e.g., orientation to diversity, theoretical orientation),
multicultural training, and access to resources for research, prac-
tice, and training.
Therapist’s Worldview and Cultural Competence
In recent years, the therapist has been thought to be responsible
for ongoing dialogue with the client about racially and culturally
based assumptions, interactions and impasses in psychotherapy
(Fields, 2010; Helms & Cook, 1999; Tummala–Narra, 2007). The
therapist has been conceptualized as a “cultural being” (Fields,
2010), emphasizing the importance of self-awareness and reflec-
tion on his or her own cultural beliefs and attitudes. Indeed, the
therapist’s psychological experience of race and culture has been
found to play an important role in clinical case conceptualization
and the psychotherapy process (Kelly & Greene, 2010; Jernigan,
Green, Helms, Perez–Gualdron, & Henze, 2010). The findings in
the present study support the importance of the therapist’s personal
attitudes toward diversity, and specifically his or her awareness
and acceptance of both similarities and differences of others
(UDO), in his or her attitudes and practices in psychotherapy. The
positive association between UDO and self-perceived cultural
competence in the present study suggests that clinicians who hold
more open and positive attitudes concerning diversity are likely to
report engaging in culturally competent practices.
This finding may be especially relevant to the clinician’s per-
sonal and professional identity development, consistent with other
studies that indicate a relationship between UDO and well-being
(Miville, Romans, Johnson, & Lone, 2004). For example, a clini-
cian’s personal exploration of his or her own and others’ racial and
cultural backgrounds is an important aspect of both personal
diversity orientation and to professional identity as a culturally
competent practitioner. Clinicians who revisit and examine their
own beliefs about their own and others’ worldviews routinely may
be less likely to inappropriately impose their own beliefs in prac-
tice (Stuart, 2004). Fields (2010) has pointed out that since it is
impossible for clinicians to develop an in-depth understanding of
every culture, dialogue and exchange concerning their own and
their clients’ assumptions about race and culture may be best
suited for culturally competent practice. At the same time, clini-
cians who seek out their own personal experiences that advance
171
multicultural competence
t B SE t
3.53 ⫺0.05 0.03 0.96 0.37
4.52 0.86 0.01 1.23 0.16
5.28 1.94 0.12 1.44 1.69
2.31 4.01ⴱⴱ 0.15 0.64 2.03ⴱ
and deepen their knowledge about their own cultural groups and
that of other groups may feel more comfortable in engaging in this
type of dialogue with their clients.
In addition to personal orientation to diversity, we examined
differences in self-perceived competence among clinicians identi-
fying with one of three different theoretical orientations (psy-
chodynamic, cognitive– behavioral, or integrative). Contrary to
findings in previous research (Constantine, 2001; Maxie et al.,
2006), there were no differences across theoretical orientation on
the CBMCS, a general measure of self-perceived cultural compe-
tence. There were also no differences on self-perceived compe-
tence as measured by the CMPPS between integrative clinicians
and clinicians from the other two theoretical orientations. While
our findings indicate that cognitive– behavioral clinicians report
higher self-perceived cultural competence on the CMPPS when
compared with psychodynamic clinicians, we are not suggesting
that identifying with any specific theoretical orientation contrib-
utes to culturally competent practice.
Rather, we note the discrepancy in findings on theoretical ori-
entation and self-perceived cultural competence across the two
measures (CBMCS and CMPPS) in the present study. It is possible
that the CBMCS more broadly assesses clinicians’ value of issues
of diversity, which seems to be of equal importance to clinicians of
all three theoretical orientations. Specific culturally competent
practices in psychotherapy, as measured by the CMPPS, may be
endorsed at higher levels by cognitive– behavioral clinicians when
compared with psychodynamic clinicians for two potential rea-
sons. First, cognitive– behavioral approaches in recent years have
emphasized the importance of cultural competency and consulta-
tion with colleagues (Hays, 2009; Newman, 2010), which may
contribute to an increased attention to multicultural practices
among CBT clinicians in the present study. Second, although the
therapeutic relationship is central to all contemporary psychother-
apeutic approaches, cognitive– behavioral and psychodynamic per-
spectives in particular approach the therapeutic relationship in
distinct ways. For example, a core competency of psychodynamic
practice involves attending to unconscious processes, and partic-
ularly the interpretation of unconscious conflict and related de-
fenses thought to serve both adaptive and pathological functions
for an individual (McWilliams, 1999; Sarnat, 2010). A core com-
petency of cognitive– behavioral practice is a focus on the here and
now, conscious thoughts, and behavioral change (Hays, 2009;
 172 TUMMALA–NARRA, SINGER, LI, ESPOSITO, AND ASH
Newman, 2010). The interactions between clients and therapists
likely reflect these theoretical distinctions, as cognitive–
behavioral therapists may be trained to adopt a more directive and
self-disclosing position while psychodynamic therapists may be
trained to adopt a more nondirective and neutral position.
Bearing in mind fundamental differences across these two the-
oretical perspectives, we suggest that future research address the
ways in which clinicians construct cultural competency practices
within their particular theoretical orientations. For example, a
culturally competent cognitive– behavioral framework may in-
volve the consideration of the client’s cultural context when con-
ceptualizing dysfunctional thought patterns (Hays, 2009). A psy-
chodynamic perspective, on the other hand, may focus on the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
racial dynamics in the therapeutic dyad through the analysis of the
This document is copyrighted by the American Psychological Association or one of its allied publishers.
client’s transference and the therapist’s countertransference
(Comas–Dı́az & Jacobsen, 1995; Tummala–Narra, 2007). As both
cognitive– behavioral therapy and psychodynamic therapy have
been found to be efficacious as psychotherapeutic treatments
(Newman, 2010; Shedler, 2010), it is especially important for
future studies to deconstruct the unique ways in which therapists of
each theoretical orientation (e.g., psychodynamic, cognitive–
behavioral, humanistic– existential, integrative) conceptualize and
implement culturally competent practices, and how they may mod-
ify existing theory when working with clients of culturally and
racially diverse backgrounds.
The Role of Multicultural Training and
Systemic Factors
Training in multicultural issues has been thought to play an
important role in culturally competent practice. Previous research
has suggested that the presence of this training has the potential to
enhance clinicians’ general clinical skills and multicultural con-
ceptualization skills (Hansen et al., 2006; Lee & Tracey, 2008;
Maxie et al., 2006) while simultaneously enhancing clients’ usage
of mental health services (Worthington et al., 2007). In the present
study, our hypothesis that exposure to multicultural training would
be associated with clinicians’ self-perceived cultural competence
was not supported. However, the extent to which ongoing multi-
cultural training (postgraduate study) was experienced as helpful
was associated with self-perceived cultural competence. These
findings highlight the potential benefits of multicultural training
that is tailored to clinicians’ particular needs concerning cultural
competence. For example, for some clinicians, involvement in
experiential activities may be more effective than didactic training
on diversity, and for other clinicians, some combination of expe-
riential and didactic training may provide most benefits. The
nature of training may also be modified based on the experience
level of the clinician (Hansen et al., 2006).
It is worth noting that the majority of clinicians in the present
study completed multicultural training at the graduate and post-
graduate levels, and it is possible that these clinicians may have
chosen to participate in the study due to specific interests in the
area of diversity or cultural competence. Additionally, the present
study included clinicians from a relatively broad range of clinical
experience. In considering research that has highlighted the gen-
erational gaps in multicultural training between senior clinicians
and early career clinicians (Sherry, Whilde, & Patton, 2005) and
differential experiences of multicultural training across ethnic mi-
nority clinicians and White clinicians (Butler–Byrd, 2010; Dick-
son, Argus–Calvo, & Tafoya, 2010), it is possible that training
may be experienced uniquely across these different subgroups of
practitioners.
Clinical training that focuses on racial and cultural dynamics
may also be received differentially based on structure of institu-
tions and dynamics of power among clinicians holding different
positions and ranks (trainees, supervisors, administrators;
Tummala–Narra, 2004). The climate of the institution, including
the provision of ongoing continuing education and a supportive
learning atmosphere, can affect the multicultural development of
clinicians (Park–Taylor et al., 2009). Culturally competent practice
relies on institutional commitment to systematic integration of
diversity issues in practice. Institutional commitment further
adopts a view of “culture as a central treatment factor” (Schwartz,
Rodriguez, Santiago–Rivera, Arredondo, & Field, 2010, p. 211).
The findings of our study support the central role of institutional
support in the implementation of culturally competent practices.
Clinicians who reported having access to institutional resources or
supports were likely to report a higher level of self-perceived
cultural competence as measured by both the CBMCS and
CMPPS.
While previous literature has emphasized the importance of the
practice institution in cultural competence, this is the first study of
which we are aware that examines the relationship between insti-
tutional support specific to cultural competence and clinicians’
self-perceived cultural competence. Our findings suggest that in-
stitutional supports, such as having access to colleagues and su-
pervisors to discuss issues of race and culture, ongoing multicul-
tural training, and having access to multicultural literature, may
play an important role in culturally competent clinical practice.
The findings call attention to recently developed multicultural
training models used in community based mental health services
emphasizing ongoing multicultural education that involves reflec-
tion, experiential learning, and interpersonal relationships (Del-
phin & Rowe, 2008; Park–Taylor et al., 2009). In training insti-
tutions, it would be especially important for supervisors to provide
a safe space for clinicians to engage in discussions and address
difficult interpersonal dynamics concerning race and culture
(Jernigan et al., 2010). Future research can further address the
unique resources most beneficial to clinicians practicing within
specific settings, such as community health centers, outpatient
clinics in hospitals, college counseling centers, and independent
practice.
Limitations and Future Directions
Several limitations of the present study are worth noting.
Though we attempted to recruit participants from a broad range of
clinical settings and professional associations through listservs and
e-mail messages, we were not able to ascertain how many clini-
cians actually received and read the recruitment letter. Addition-
ally, the issue of self-selection may be relevant in interpreting the
findings, as clinicians who participated in the study may view
multicultural competence as important. As such, we cannot assume
that our sample is representative of licensed clinicians. Further, our
study assessed clinicians’ cultural competence through the use of
self-report surveys, which may have yielded responses influenced
by social desirability. On the CMPPS, participants were asked to
 SELF-PERCEIVED CULTURAL COMPETENCE
think of one specific ethnic minority client while responding to the
survey questions. While this approach allowed us to learn about
clinicians’ perspectives on their practices with this single client
more in depth, it limited our ability to assess clinicians’ percep-
tions of their cultural competence in their work with other clients
with whom they may have felt more or less effective.
The two new measures developed for this study (resource
checklist and CMPPS) need additional study to establish further
validity and reliability, and, as such, the interpretation of the
findings in the present study should be qualified. More broadly, the
use of self-report surveys with clinicians limited our knowledge of
the client’s experience of the psychotherapeutic work. Future
research can examine therapeutic dyads, with a focus on the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
client’s and clinician’s perspectives on cultural competence. We
This document is copyrighted by the American Psychological Association or one of its allied publishers.
examined UDO and theoretical orientation as two dimensions of
personal world view. Future research can examine the role of other
individual factors, such as racial identity and ethnic identity, in
cultural competence. Additionally, the CMPPS included items
focused primarily on race and culture, rather than various dimen-
sions of diversity (e.g., sexual orientation, gender, dis/ability).
Kelly and Greene (2010) pointed out that although the literature on
cultural competence has suggested the need for clinicians to raise
their awareness of social identity differences in clients, identities
tend not to be explored in the “intersecting and interconnected way
that clients experience them” (p. 196). Future research on cultural
competence should address the multiple intersections of identity of
clients and clinicians and how these intersections may influence
the therapeutic process.
Despite these limitations, the findings of the present study
expand existing understandings of clinicians’ perceptions of cul-
tural competence, an important factor in improving access to and
utilization of mental health services for ethnic minority clients. A
clinician’s perceptions of cultural competence in working with
ethnic minority clients can contribute to an understanding of the
clinician’s strengths and limitations and overall effectiveness in
working with clients. The present study is one of few that ad-
dresses clinicians’ beliefs concerning their cultural competence,
which are thought to shape their interactions with their clients.
The findings underscore the importance of some individual and
systemic factors associated with self-perceived cultural compe-
tence and suggest the need for future research that addresses the
interaction between clinicians’ personal orientation and the access
and use of resources in practice settings. Whereas previous re-
search has focused on individual factors, such as years of clinical
experience, the present study draws attention to the ways in which
training and systemic factors can play a role in culturally compe-
tent practice. Settings that promote the development of the UDO
orientation, self-reflection, and interpersonal learning, for exam-
ple, can improve their service provision for ethnic minority clients
(Delphin & Rowe, 2008). Graduate and postgraduate training
programs can also promote such learning environments. In partic-
ular, programs can advance knowledge of psychological theories,
such as psychodynamic, cognitive– behavioral, humanistic–
existential, and integrative perspectives that include a conceptual-
ization of race, culture, gender, sexual orientation, social class,
dis/ability. Our findings concerning multicultural training suggest
that an individualized approach to training may be beneficial in
supporting cultural competence. Perhaps such trainings can in-
clude how sociocultural context is conceptualized in existing psy-
173
chological theories and how existing theories can be modified
based on knowledge of this context. Such an approach can then
help with developing relevant interventions in psychotherapy.
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Received June 5, 2011
Revision received August 18, 2011
Accepted August 19, 2011 䡲