Essay on Multicultural Competence and the Therapeutic Alliance

This essay delves into the crucial relationship between multicultural competence and the therapeutic alliance within the field of psychology. It highlights the significance of cultural knowledge and understanding in healthcare, particularly in mental health, emphasizing how cultural values and social structures influence beliefs and motivations. The essay examines the various phases of psychotherapy and underscores the impact of culture on worldviews and behaviors, illustrating how therapists must be culturally competent to effectively assist patients from diverse backgrounds. It explores the importance of establishing trust, using cultural analysis, and recognizing the three key components of a therapeutic alliance: working alliance, empathic resonance, and mutual affirmation. The essay references studies that demonstrate the positive effects of therapeutic alliance on treatment outcomes and the adverse consequences of weak alliances, including higher dropout rates. It also discusses the implications of generic versus specific cultural competence, the stigma associated with mental health in certain cultures, and the importance of adapting treatment plans to align with clients' cultural beliefs. Furthermore, it explores how language, migration, and client behavior influence the therapeutic alliance and the importance of therapist behavior in building trust and encouraging clients to open up. The essay concludes by acknowledging potential negative implications of therapeutic alliance, such as dependency and anxiety related to termination, and emphasizing the need for therapists to consider the complex and multidimensional nature of cultural identity in their practice.

Running head: PSYCHOLOGY
MULTICULTURAL COMPETENCE AND THE THERAPEUTIC ALLIANCE
Name of the Student
Name of the University
Author’s Note

1MULTICULTURAL COMPETENCE AND THE THERAPEUTIC ALLIANCE
Culture is complex and multidimensional. It is also an important factor that influences the
therapeutic alliance. Cultural knowledge has become an important part of practicing health care
and this includes mental health as well. The social structure and the cultural values are an
important guiding factor that plays a crucial role in determining personal beliefs and motivation.
The following essay explores the implication of multicultural competence and its relation with
therapeutic alliance.
The term therapeutic alliance refers to the relationship that exists between a patient and
their therapist. This correlation is an essential part of the treatment process and implicitly related
with the practice of cultural competence. When the therapist takes up a client they are required to
understand the client or patient's cultural background that may have influenced their current
state. Living in a heterogeneous society where there is confluence of various culture especially in
a country like Australia, a therapist needs to be culturally competent in their practice to ensure
they can help their patients within the framework of cultural practice (Lo et al, 2003). There are
several phases of psychotherapy which consists of the following phases that is pre-engagement,
engagement, assessment and feedback, treatment, and termination. These steps need to be carried
out so that a proper diagnosis and treatment plan can be achieved.
Culture influences our worldviews, behaviour and determines our general characteristics
(Lo et al, 2003). Culture is not merely representation of food, costume but a set of ideas that are
present in our guiding practices and influences our belief system and our perception. For
example, in certain cultures women have lesser roles as the society has a more patriarchal view
point as a result of which some clients may refuse a female therapist to help them. In other cases,
women may not feel comfortable talking about their issues with a male therapist owning to the
cultural beliefs that women should not interact with a man. These aspects are influenced by the

2MULTICULTURAL COMPETENCE AND THE THERAPEUTIC ALLIANCE
cultural structure that people have grown up with and find it difficult to let go and seek the help
they need. Furthermore, there are clients who want to seek help only from people of their
community someone who speaks their language and they can trust. Case in point the indigenous
people who have suffered from the effects of the stolen generation may distrust therapist who is
white because they associate their trauma and oppression with that culture and may want
someone who is indigenous. This is where the multicultural competence is an essential tool
which can enable a therapist to practice culturally competent treatment process. Assouad (2014)
studies show that when the patient is broached with the subject relating to his or her culture they
respond better to the treatment and it helps in therapeutic alliance. It is important to establish a
sense of trust and bond with the client, sometimes showing cultural naiveté allows the patient to
talk. Therapists will often use cultural analysis on patients which helps them to understand the
influence of culture on the patient, enables them to diagnose them better and helps them to create
a treatment plan that is relevant to the patient's cultural beliefs.
Therapeutic alliance needs to have the following three components that establishes a
clinician's credibility; they are working alliance, empathic resonance, and mutual affirmation.
Therapy is a process that needs the engagement of the patient considerably. When the patient is
unable to connect with their therapist they are not going to respond to the treatment procedure no
matter how good it is (Lo & Fung, 2003). Therapeutic alliance helps to set goals for the
assignment of tasks and the slow development of the bond. Therapist need to understand how
their client's feel and how the experience has effected them. Certain cases conventional method
of therapy may not be helpful for the patient such as open confrontation for an Asian client (Lo
& Fung, 2003). Thus when a therapist wants to implement this it may have adverse effect on the
client and they may want to terminate the treatment process. These kind of difference is common

3MULTICULTURAL COMPETENCE AND THE THERAPEUTIC ALLIANCE
occurrence and can be reduced through cultural competent practices. Studies show that
therapeutic alliance can have a positive impact on the outcome of the treatment. It also pointed
that the opposite may happen when there is a weak therapeutic alliance or no therapeutic
alliance. In such a scenario the patient dropout rate from the treatment plan is higher. The study
also pointed out that this dropout rate was influenced by the social structure of the patient. This
shows that the cultural influences impacts the treatment process and therapeutic alliance
considerably.
Startup et al, (2006) conducted a study on understanding the therapeutic alliance on
patients suffering from acute case of psychosis. They employed the use of cognitive-behavioural
therapy (CBT) in the treatment of the patients who suffered from acute psychotic issues. The
study contained the sample of 43 clients from diverse cultural backgrounds who were assigned to
a control group randomly and used the cognitive behaviour therapy and their treatment plan. The
objective of the study was to understand the influence of therapeutic alliance in the
responsiveness of the client towards the treatment plan. The results showed that the groups
which failed to establish a client therapist bond resulted in a higher dropout rate and the groups
which were successful in establishing a therapeutic alliance completed their treatment plan and
showed less dropout rates (Startup et al, 2006). The main conclusion from the study was the
attitude and behaviour of the therapist involved. When the therapists practiced culturally
competent behaviour they were able to ensure their group members were engaged and invested
in the treatment procedure it yielded better and positive result (Startup et al, 2006).
Behaviour of the counsellor or therapist is a determining factor in most client therapist
relationship. According to studies, when dealing with a diverse cultural client groups,
counsellors who display positive cultural competent behaviour tend to make progress with their

4MULTICULTURAL COMPETENCE AND THE THERAPEUTIC ALLIANCE
clients (Sao et al, 2016). Generic cultural competence and specific cultural competence differ
slightly from each other. Generic therapeutic knowledge is effective while dealing with cross
cultural encounters whereas specific cultural competent knowledge helps to address the issues
pertaining to a specific ethnic community (Sao et al, 2016). In some cases specific cultural
knowledge influences the client behaviour for example, in aboriginal communities the society is
treated as family and hence any recommendation coming from an elder is taken positively rather
than coming from an outside source. Mental health issues is considered a subject of stigma and is
frowned, this cultural attitude prevents individuals from seeking help (Martin et al, 2019).
Treating a patient can be difficult for a therapist or counsellor who is not aware of the cultural
implication that affects the client. The cultural differences can create misunderstandings and
prevent from forming a therapeutic alliance. For example, it is perfectly normal for a client from
an indigenous background to involve a family member during the counselling session. This
situation might be difficult for a therapist who may feel that the client therapist relationship to be
confidential. Client confidentiality is one of the foremost rules that all counsellors and therapists
must adhere to, however this is where cultural knowledge becomes important. Families are open
and very closely knit in an indigenous context and it is often natural for a family member to be
present with the client during the counselling session (Martin et al, 2019). The therapist must
understand that the general concepts often may not apply to certain ethnic community and
therefore must not impose their ideologies on their client, instead must adapt the treatment plan
according to the cultural beliefs of the client.
This acceptance is the first step in creating a therapeutic alliance with the patient. When a
client feels they are accepted and not judged they are likely to be more open to the treatment
procedure. Research shows that the engaging in certain behaviour such asking questions, talking

5MULTICULTURAL COMPETENCE AND THE THERAPEUTIC ALLIANCE
about the client's feelings, encouraging the client to talk and giving validation to the client's
experience can be very positive in building therapeutic alliance. In the initial counselling stage it
is recommended that the therapist must show positive body language to encourage or assure the
client by maintaining eye contact, showing positive behaviour such as smiling, nodding or giving
verbal signs such as "please continue", "I see", asking relevant questions from time to time
(Dynes, 2018). These kind of behaviour helps to establish that the therapist is interested in
whatever the client has to say. Therapist behaviour and encouragement often helps the client to
build trust and open more about their personal experience (Dynes, 2018). In some cultures,
therapists are viewed as someone who is wiser and knowledgeable and therefore they do no
appreciate therapists asking many questions. In such cases it is best not to make stereotypical
judgement instead should always have an open attitude while making appropriate enquiries about
the patient. Therapist must understand the cultural dynamics of the patient instead of conforming
to the general concept and ideas.
As mentioned above, there is a stigma attached to the mental health issues. People who
seek help from psychologist are not regarded positively in many societies. In such case too,
sometimes patients prefer therapist who are not a member of their ethnic community so that they
can maintain confidentiality (Martin et al, 2019). In other words, therapeutic alliance can be
achieved even with non-conformity with a particular community or group. It shows that the
attitude and personal belief of the client is a determining factor in achieving therapeutic alliance.
Cultural identity is a complex and multidimensional subject where individuals are influenced to
conform to certain behavioural patterns or ideologies and this subsequently effects their
perception of mental wellness. For example, in the western civilisation there is greater
acceptance for a scientific explanation for mental illness. Indigenous perspective tends to view

6MULTICULTURAL COMPETENCE AND THE THERAPEUTIC ALLIANCE
the subject of mental health and wellness from a holistic point of view which is very attached to
the community health and wellness as well. However, the members of these groups may not
conform to the general ideologies of their respective community (Martin et al, 2019).
Migration may happen due to economic situation, political situation or it may be forced
migration such in the case of flesh trade. The immigrant clients are different than the mainstream
demographic, therapists often use the clients' socio political history to analyse the source of their
trauma. To form a therapeutic alliance in these cases is very essential. In most cases immigrants
try their best to assimilate with the demographic. It is extremely difficult for some to open up
about their trauma, the struggle they might face at work. Knowledge about the client's spiritual
belief and ethnic community can help in the healing process. Therapists need explore the client's
acculturation strategy and regard the case in the way that suits the needs of the clients (Delara,
2016). Language is another aspect that influences the therapeutic alliance; bilingual therapists
have noticed that in certain cases people tend to feel free to express certain aspects such as
sexual health in the common language such as English rather than their mother tongue (Jongen et
al, 2018).
Certain studies point that while therapeutic alliance is important there is a negative
implication of it as well. A research showed that clients who were afflicted with severe social
anxiety, therapeutic alliance promoted a severe dependency on the therapists (Zimmermann et al,
2019). While the treatment procedure helped the client the client often feared a negative
evaluation from their therapist. They also showed extreme anxiety when the treatment was
terminated (Zimmermann et al, 2019). This has a cultural interpretation as well in some culture,
termination of the procedure may be interpreted negatively and in some cases abandonment
(Zimmermann et al, 2019). Establishing effective communication through using client's language

7MULTICULTURAL COMPETENCE AND THE THERAPEUTIC ALLIANCE
can help considerably (Smith, 2017). This practice may help to ease the client's doubts and
anxiety to a great extent. This practice has led many therapist to reinvent the term of termination
which is usually the last step of the treatment instead they chose to maintain a link with their
patients and give them the opportunity to ask for help when they need it.
In conclusion, it can be understood that multicultural competence is an essential
component of therapeutic alliance. Therapist and psychologist need to understand that their
cultural knowledge and personal attitude plays an important role in the patient care system. Often
cultural practice may not affirm to the general concept and ideologies. However, this knowledge
allows a therapist to establish a successful therapeutic alliance and contributes to the treatment
process.

8MULTICULTURAL COMPETENCE AND THE THERAPEUTIC ALLIANCE
Reference
Assouad, J. P. (2014). The effects of acknowledging cultural differences on therapeutic alliance
in cross-cultural therapy.
Delara, M. (2016). Social determinants of immigrant women’s mental health. Advances in
Public Health, 2016.
Dynes, R. (2018). Positive Interaction Skills: A Group Therapy Manual. Routledge.
Jongen, C., McCalman, J., Bainbridge, R., & Clifford, A. (2018). Services and Programs to
Improve Cultural Competency. In Cultural Competence in Health (pp. 75-97). Springer,
Singapore.
Lo, H. T., & Fung, K. P. (2003). Culturally competent psychotherapy. The Canadian Journal of
Psychiatry, 48(3), 161-170.
Martin, J. M., White, J., Roberts, S., Haussegger, Z., Greenwood, E., Grant, K., & Haines, T.
(2019). Aboriginal Wellbeing: A Culturally Safe, Trauma-Informed Framework for
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Sao Xiong, Y., Vue, T., & Yang, P. (2016). Hmong Mental Health and Alcohol and Other Drug
Abuse: An Analysis of Focus Group Findings.
Smith, L. (2017). Communication and Mental Health. ABC of Clinical Communication, 49.
Startup, M., Wilding, N., & Startup, S. (2006). Patient treatment adherence in cognitive
behaviour therapy for acute psychosis: the role of recovery style and working alliance.
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Zimmermann, D., Lutz, W., Reiser, M., Boyle, K., Schwartz, B., Schilling, V. N., ... & Rubel, J.
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