Journal of Marital and Family Therapy 42(1): 123–138 doi: 10.1111/jmft.12115 © 2015 American Association for Marriage and Family Therapy

STRATEGIES USED BY FOREIGN-BORN FAMILY THERAPISTS TO CONNECT ACROSS CULTURAL DIFFERENCES: A THEMATIC ANALYSIS Alba Ni~ no Alliant International University

Karni Kissil Private Practice

Maureen P. Davey Drexel University

With the growing diversity in the United States among both clinicians and clients, many therapeutic encounters are cross-cultural, requiring providers to connect across cultural differences. Foreign-born therapists have many areas of differences to work through. Thus, exploring how foreign-born family therapists in the United States connect to their clients can uncover helpful strategies that all therapists can use to establish stronger cross-cultural therapeutic connections. A thematic analysis was conducted to understand strategies 13 foreignborn therapists used during therapeutic encounters. Four themes were identified: making therapy a human-to-human connection, dealing with stereotypes, what really matters, and flexibility. Findings suggest that developing a deep therapeutic connection using emotional attunement and human-to-human engagement is crucial for successful cross-cultural therapy. Clinical and training implications are provided. Societal changes and technological advancements are altering the landscape of human relations. Now more than ever, we are exposed to individuals and groups from different backgrounds. For example, developments in technology and transportation have facilitated more geographic mobility, migration, and communication (Platt & Laszloffy, 2013). This is especially true for the United States, a country that continues to have one of the highest levels of net migration in the world (World Bank, 2014). Also, a growing awareness of social barriers such as racial and economic discrimination is now making it possible for diverse groups that have historically remained mutually invisible or segregated, to start seeing and relating to each other. These global demographic trends and growing awareness are also experienced during therapeutic encounters between therapists and clients (Vasquez, 2007). Thus, as family therapists, we will likely work with an increasingly diverse clientele. This will require the development of successful clinical strategies that help to establish strong therapeutic relationships with clients who are culturally different from us regarding culture of origin, family composition, sexual orientation, religious affiliation, and other salient contextual variables. Providers need to learn how to connect across cultural differences to become culturally sensitive. Even though this has been recognized and accepted in extant literature (please see review below), studies that specifically describe

Alba Ni~ no, PhD, LCMFT, Couple and Family Therapy Program, Alliant International University; Karni Kissil, PhD, LMFT, Private Practice; Maureen P. Davey, PhD, LMFT, Department of Couple and Family Therapy, Drexel University. We want to express our appreciation to the 13 foreign-born therapists who very generously shared their stories of struggle and success as therapists who are clinically active in the United States. Their ingenuity, creativity and perseverance made this paper possible. Address correspondence to Alba Ni~ no, Couple and Family Therapy Program, Alliant International University, 10455 Pomerado Road, DH-206A, San Diego, California 92131; E-mail: [email protected]

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successful strategies therapists use to establish cross-cultural connections with clients continue to be sparse. Among the groups of providers who more drastically face the challenge of connecting across differences are therapists who were born and raised in a country different from where they practice. For these clinicians, not learning how to connect across differences with their clients can mean perishing professionally. The ingenuity that foreign-born therapists in the United States have displayed to overcome this challenge makes them a privileged group from whom to learn. Many authors agree that every therapeutic encounter is a cross-cultural experience (Collins & Arthur, 2010; Hardy & Laszloffy, 2002). All therapists need to find effective ways to connect across differences to build strong therapeutic relationships with clients. Therefore, we believe the strategies described in this article can be useful to many family therapists. In this article, we describe a thematic analysis of interviews with 13 foreign-born family therapists who are currently practicing in the United States. The purpose of this article was to describe successful clinical strategies they used to build strong therapeutic relationships with their clients in the United States. First, we briefly summarize general trends in the literature describing cross-cultural connections in therapy. Then, we describe the strategies reported by the 13 foreign-born family therapists, followed by a discussion of these findings. We conclude by describing future research, clinical and training implications.

CROSS-CULTURAL CONNECTIONS Before we describe some general trends in the literature addressing cross-cultural connections in therapy, we want to make some clarifications about terminology. In this article, we chose the word “connection” as a general term to describe the therapeutic relationship, therapeutic bond, or therapeutic engagement. We chose this term because the latter terms have specific definitions in the literature and denote particular aspects of interactions between therapists and clients. The descriptions provided by participants in this study do not adhere to these specific definitions, as their descriptions were more experiential and less theoretically based. Additionally, we used the Qureshi and Collazos (2011) definition of cultural difference as dissimilarities in social locations that not only refer to ethnicity, but also to other variables such as race, religion, or sexual orientation. From Cultural Literacy to Cultural Competence According to Dyche and Zayas (1995, 2001), cultural literacy is a prominent framework in the literature on cross-cultural connections in therapy. This literature can help therapists better prepare for their work with clients who have different cultural backgrounds. This framework is also referred to as the cross-comparative perspective (Seedall, Holtrop, & Parra-Cardona, 2014). Many volumes (Boyd-Franklin, 2003; Falicov, 1998; Sue & Sue, 2013), edited books (McGoldrick, Giordano, & Garcia-Preto, 2005; Pedersen, Draguns, Lonner, & Trimble, 2008), articles, and trainings have been offered to improve therapists’ knowledge about particular groups’ histories, traditions, values, and relational styles. These resources also offer helpful suggestions for how to work with diverse clients (Vargas & Wilson, 2011). The contribution of this literature to the field of Couple and Family Therapy (CFT) has been significant. It has expanded our definitions of family, relationships and normalcy. It has also made us more aware of how Euro-centered and heteronormative our theories and interventions have been in mental health. According to Dyche and Zayas (1995), there are many drawbacks in the cultural literacy approach. First, the emphasis on the acquisition of information makes this training task impractical because many groups and subgroups would need to be studied. Second, learning about specific groups or populations increases the possibility of overgeneralizing, where group similarities are emphasized and intragroup variability is overlooked. A third drawback is the possibility of reinforcing stereotypes, which in turn can negatively affect therapeutic relationships by privileging the abstract and the conceptual over the immediate experience of the client (Dyche & Zayas, 1995). This focus has slowly expanded from the initial push to acquire specific knowledge about particular groups to the development of cultural competence (Sue & Sue, 2013). In addition to the acquisition of knowledge about clients’ cultures and worldviews, cultural competence also involves 124

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therapists’ self-awareness of their own culturally informed values and attitudes, and the development of relational skills for culturally sensitive interventions. Thus, knowledge, self-awareness, and skills are recognized as the three essential domains of cultural competence (Sue & Sue, 2013). Adding Complexity: Intersectionality and Social Justice Power differentials and power dynamics have been recognized as intrinsic aspects of all crosscultural relationships in CFT. The recognition of power in all relationships, and the commitment to questioning the status quo to facilitate transformation are the main goals of the social justice approach to diversity in CFT (Seedall et al., 2014). Literary sources in this area have highlighted not only the social realities of oppression and discrimination that many clients face (KnudsonMartin et al., 2014; McGoldrick & Hardy, 2008), but also the dynamics of power during clinical encounters (Ward & Knudson-Martin, 2012). Additionally, literature on cross-cultural relationships and diversity has brought attention to intersectionality. Intersectionality describes how multiple dimensions of power such as race, sexual orientation, or religious affiliation interact with each other and affect individuals, couples, families, and communities (Seedall et al., 2014). Authors have suggested taking into consideration intersectionality when understanding family relations (Bograd, 1999) and establishing the therapeutic relationship (Watts-Jones, 2010). A recent content analysis of family therapy journals by Seedall et al. (2014) reported that social justice and intersectionality are important approaches to diversity in CFT, representing 48.1% and 17.6% respectively of all diversity articles published in the main family therapy journals from 2004 to 2011. These authors mentioned, however, that articles using a cross-comparative approach (e.g., articles that highlight differences and similarities of groups to promote a better understanding) are still a significant portion of published articles on diversity. Cultural Differences as a Drawback Some of the literature on cross-cultural therapeutic encounters emphasizes the potential for misunderstandings, biases, and discomfort (Tang & Gardner, 1999). In fact, some authors ascribe to an almost fatalistic view, asserting that differences in cross-cultural therapeutic pairings can “undermine communication and the development of the therapeutic relationship, as each participant will undoubtedly view the other with confusion, if not unfavorably” (Qureshi & Collazos, 2011, italics added). Thus, the very presence of cultural differences between therapists and clients is viewed as problematic regardless of their particular clinical issues (Tang & Gardner, 1999). Additionally, similarities between therapists and clients in social demographic characteristics (e.g., race, ethnicity, or sexual orientation) are often assumed as a source of mutual understanding that contributes to the initial formation of a stronger therapeutic alliance (Gelso & Mohr, 2001). The assumption that differences between therapists and clients lead to confusion and matching between therapists and clients facilitate better therapeutic connections has partial support in research. Yet, uncritically embracing these assumptions can lead to a focus on the difficulties associated with cross-cultural encounters and promote the idea that similarities with our clients guarantee a mutual understanding. Research on Cross-Cultural Connections Prior research examining the effects of client/therapist demographic matching is inconclusive (Sparks & Duncan, 2010). On the one hand, there is evidence that demographic similarities between therapists and clients are associated with better therapeutic alliances and clinical outcomes. Variables that seem to be positively affected by client/therapist demographic matching are the number of sessions attended, treatment utilization, and therapy satisfaction (Johnson & Caldwell, 2011; Zane, Hall, Sue, Young, & Nunez, 2004). Recent meta-analyses, however, report no significant associations between matched or discordant client–therapist backgrounds and the quality of the therapeutic relationship and therapy outcomes (Gaztambide, 2012; Zane et al., 2004). Factors such as therapist’s warmth and empathy, therapist’s competence, therapist’s cultural sensitivity, and therapist/client congruence in values have been found to be more important for therapeutic outcomes than the social locations of clients and therapists (Lee, 2011; Sparks & Duncan, 2010; Zane et al., 2004). January 2016

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In a review of research on psychotherapy with culturally diverse populations, Zane et al. (2004) reported that racial and ethnic minority clients may prefer working with therapists from similar backgrounds. Yet, other variables besides racial and ethnic similarity significantly mediate these preferences, including stage of minority identity development (stages individuals from ethnic minority groups go through while developing their racial/ethnic identities; Sue & Sue, 2013), level of acculturation (extent to which an individual from one group embraces the beliefs and behaviors of another group after prolonged contact), and level of English proficiency (for immigrant clients whose primary language is not English; Akhtar, 2006). More recently, cross-cultural therapy researchers and scholars have focused on studying the therapeutic alliance. Given that weaker therapeutic alliances are associated with higher attrition, identifying salient factors that strengthen or weaken the therapeutic relationship can help to reduce dropout rates during cross-cultural clinical encounters (Gaztambide, 2012). For example, the unintentional bias that has been identified during cross-cultural relationships in the general public also affects cross-cultural therapeutic relationships and contributes to their erosion (Vasquez, 2007). A strong therapeutic relationship can serve as a buffer for the negative effects of intentional or unintentional micro-aggressions that occur during cross-cultural therapeutic relationships (Gaztambide, 2012). Lee (2011) asserted that developing cross-cultural competence leads to positive therapeutic outcomes by strengthening the therapeutic alliance. Cross-cultural competence describes a therapist’s ability to attune to the client’s culturally embedded lived experience (Lee, 2011). This can foster closeness between the therapist and client, transform strangers into working partners, and be an antidote to intercultural misperceptions. Similarly, Dyche and Zayas (2001), Roysincar, Hubbell, and Gard (2003), or Sue (2006) recommended the development of cross-cultural empathy, ethnotherapeutic empathy, or cultural attunement, respectively, to help transcend cultural differences in the therapeutic relationship. In addition, Dyche and Zayas (1995) highlight cultural naivete and respectful curiosity as two important stances in cross-cultural therapy. Although there is always the possibility of misunderstanding and miscommunication during any cross-cultural therapeutic encounter, clear strategies for how to overcome them are seldom offered or are too vague and difficult to put into practice. Some notable exceptions were recently published. In a grounded theory study of relationship building efforts during crosscultural therapy among 22 recently graduated MFTs, Vargas and Wilson (2011) described the following five categories: (a) self-supervision: therapist’s awareness and attentiveness to assumptions, possible biases, and experienced discomforts; (b) client-to-therapist cultural education: the client takes the role of the expert and provides culturally related information to the therapist; (c) therapist-to-client cultural education: therapist teaches the client about his or her own culture; (d) therapist self-education using case consultation, review of literature, workshops, etc.; and (e) empathy: therapist puts himself or herself in the place of the clients to understand and validate their experiences. These five categories describe not only participants’ reports of what they did in therapy, but also what they believe should be done during crosscultural therapeutic encounters. Tsang, Bogo, and Lee (2011) conducted a narrative analysis of the first sessions of nine cases to identify what facilitated cross-cultural clinical engagement. Two main patterns were identified: (a) therapist’s recognition of the client’s primary needs, communication of that recognition to the client, and definition of consensual goals based on this mutual understanding; and (b) therapist’s emotional attunement to the client. Both patterns require careful listening, close attention to misunderstandings, and addressing relational ruptures. The second pattern seems to be a decisive factor because it was reported that the lack of emotional attunement was the common denominator in all cases with the worst clinical outcomes in this study. The authors concluded that even though the multicultural counseling competence literature has focused on awareness, knowledge, and skills, their findings suggest emotional attunement between therapists and clients is the essential ingredient for therapeutic success (Tsang et al., 2011). Collins and Arthur (2010) concur with this view that knowledge, awareness, and skills are not the only essential elements of cultural competence. They suggest that developing a positive therapeutic alliance should be an organizing principle to guide interventions and techniques in cross-cultural therapy. 126

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METHODOLOGY Most literature on cross-cultural relationships is based on anecdotal or clinical experience, rather than empirical research (Collins & Arthur, 2010; Lee, 2011; Tsang et al., 2011). This qualitative study filled a gap by describing strategies used by 13 foreign-born family therapists to develop therapeutic relationships with clients during cross-cultural clinical encounters. Thematic analysis was the qualitative method used to identify, analyze, interpret, and report patterns and themes (Braun & Clarke, 2006). The interviews were originally conducted in a phenomenological dissertation study (Ni~ no, 2013). Data The data consisted of verbatim transcriptions of individual in-depth interviews with 13 foreign-born couple and family therapists. The interviews were conducted by the first author between August 2012 and February 2013. Interviews lasted between 1 and 2.5 hr. To preserve the anonymity of participants, all transcripts were de-identified by the first author. A nonprobabilistic sampling strategy combining criterion and snowball sampling (Newman, 2003; Patton, 2002) was used to recruit participants. Couple and family therapists qualified for this study if they (a) were born and raised in a country different from the United States, (b) immigrated to the United States after the age of 18, and (c) were clinically active in the United States when the interview took place. A recruitment flier was distributed to key informants (e.g., couple and family therapists, CFT professors, and CFT program directors) to share with potential participants. Once an interested participant contacted the first author, inclusion criteria were first verified, and then, the interview was scheduled. The semi-structured interview covered the following topics: (a) general aspects about being foreign-born CFT, (b) clinical experience, (c) relationships with clients, (d) language, and (e) context of the therapeutic work in the United States. Participants The sample included 13 foreign-born couple and family therapists (10 females and 3 males) who were clinically active in the United States. Participants’ ages ranged from 31 to 70 and all selfidentified as heterosexual. Ten were married, two were single and one was divorced at the time of the interview. Regarding race, six self-identified as White or Caucasian, two as Black, one as Asian, one as Hispanic, one as mixed race, and one as White/Semitic. Race was not reported by one participant. Participants represented six regions and eight countries. Six participants were from South America, two from Northern Europe, two from Southern Asia, and the remaining three were from Eastern Asia, Eastern Europe, and Western Africa, respectively. Participants reported living in the United States from 2 to 35 years, and their age of arrival ranged from 20 to 45. English was the primary language for three participants and a second language for the remaining 10. Participants’ clinical experience ranged from 2 to 35 years, with a mean of 13 years. Some reported previous experiences in mental health before moving to the United States and/or becoming couple and family therapists. The amount of clinical work therapists reported doing ranged from 4 to 45 hr per week. Most participants (n = 8) were licensed MFTs in the state where they practiced. Regarding education, all participants reported getting formally trained as MFTs in the United States; however, some reported learning and practicing some marriage and family therapy theories and models in their countries of origin. The formal training as MFTs was achieved in master’s programs (n = 6), post-master’s training (n = 3), or PhD programs (n = 3). Information about whether these programs were COAMFTE-accredited was not collected. A fuller description of the sample is provided in the larger phenomenological dissertation study (Ni~ no, 2013) to help readers make informed decisions about the transferability of the findings (Lincoln & Guba, 1985). Data analysis After receiving approval for this study from the Institutional Review Board at the first author’s institution, a thematic analysis was conducted. To increase the trustworthiness of findings (Lincoln & Guba, 1985), two researchers independently carried out the data analysis: (a) the first

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author, who collected and analyzed the data for the original phenomenological dissertation study, and (b) the second author, a researcher not involved in the data collection and initial phenomenological analysis. The thematic analysis was conducted in the following three stages. The first stage was carried out independently by each researcher. Each individual read the transcripts to become familiar with the data and to identify any content relevant to the study. Then, each researcher coded the transcripts by assigning short labels to meaningful pieces of information. These codes were then clustered into larger themes and subthemes according to similarities and patterns of meaning. During the final step of the first stage, each researcher developed a document with a provisional list of themes, subthemes, and codes. This document included brief descriptions for each theme and subtheme, definitions of the codes, and illustrative quotes from transcripts exemplifying each code. The researchers then shared their provisional lists with each other to prepare for the second stage. The second stage of the thematic analysis involved discussing the two provisional lists to create a consensual list. The researchers looked for commonalities in the codes and definitions. Codes that were present in the two lists were included in the consensual list, with their corresponding definitions and illustrative quotes. When a code was only in one list, a case could be made for its inclusion in the consensual list, and if the two researchers agreed, it was included. The clustering of codes was also discussed until consensus was reached about specific themes and subthemes. The end result of the second stage was a consensual list that included a definition of themes and subthemes, the list of codes belonging to each subtheme, and definitions and illustrative quotes for each code. During the final stage of data analysis, the researchers re-read the transcripts and counted the number of participants who mentioned each theme in the consensual list. Themes that were mentioned by more than seven participants (more than half) were considered major themes and remained in the list. The final list describing the major themes, subthemes, and codes was used to outline the findings (Hsieh & Shannon, 2005; Newman, 2003). All steps of this process were documented, generating an audit trail that is open to scrutiny (Lincoln & Guba, 1985).

FINDINGS Four major themes emerged: (a) making therapy a human-to-human connection, (b) dealing with stereotypes, (c) what really matters, and (d) flexibility. Below we describe these four themes using illustrative quotes from participants. Note that some illustrative quotes have grammatical errors because English is a second language for most participants. Making Therapy a Human-to-Human Connection The first major theme, making a human-to-human connection, was mentioned by all participants. They described how they tried to become more human in the eyes of their clients, and to validate their clients’ humanity. This made therapy more of an interaction between human beings, and less like a distant professional/client interaction. This theme includes the following two subthemes: (1) using differences to connect and (2) using similarities to connect. Using Differences to Connect Participants described how they accepted their own foreignness, and the limitations that come with it, such as language difficulties or not knowing some culturally bound ideas. This acceptance helped them find ways to use their foreignness to improve their therapeutic relationships. As one participant said, “I have come to a point to believe and to accept that I will never speak perfect English, and I do not need perfect English to be a good therapist.” Another participant said: When I came here, I had to realize that I was not an expert on anything, maybe of my own experience, and if I was able to go kind of down to that level, and just let it be, and be at a human level, human being level, more down to earth, even more concrete, I think it was through that, that I learned this – and I came up to be who I am as a therapist. Through the experience of working with clients from different cultures, participants became more aware of the culturally bound nature of their own values and worldviews. They described

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how they began to challenge their own values, and the universality of their beliefs and convictions. For example, one participant said: I had the opportunity to be exposed to different kind of living arrangements, different kind of ways of maintaining relationships, and how people survived those, and they become an everyday routine. So, it’s like those kinds of things that come constantly when you work with clients from different cultures. And I think that that stimulation and the constant challenge really helped me to put my values to minimum, because you’re constantly being challenged with everything. It’s like the thing that you are so used to, is not the norm, so you really have to find the way to put your norms and your values aside, and just force yourself to enter every therapeutic relationship as a new baby. You have to enter it with fresh eyes. Additionally, participants described how they intentionally used the differences between themselves and their clients to facilitate therapeutic connections. For example, most used their language difficulties and/or accent to facilitate the alliance in the following five ways: (a) as a conversation starter; (b) joking about it to lighten up the mood; (c) answering questions about it as a way of bonding; (d) talking to clients about difficulties with language and definitions; and (e) showing their own vulnerability or imperfection by taking a one-down position. For example, one participant shared: Often clients are very intrigued by my accent, so sometimes they’ll share with me, “Oh, there was something you said, and it was so terribly [language of origin], and I really loved that” and things like that. So I think, yeah, it’s just been another kind of way of talking about something that’s not necessarily the counseling process or their problems but that just helps us to kind of be people with each other. Another way they used differences to connect to their clients was described as being the “curious stranger.” Because they were foreigners, they asked more questions for clarification and regularly checked in with their clients. Also, participants reported they had more leeway to not know salient points without being considered ignorant or unprofessional. This stance was useful both to convey an interest in clients’ experiences and to challenge clients’ taken for granted assumptions. For example, two participants shared the following: I think I have the possibility and the opportunity to exercise a stance of curiosity easier than other people because I’m not from here. So, my curiosity is genuine. But also I think people grant me somehow the opportunity to be more curious because I’m not from here. I think that’s really valuable, because it allows me to really tease out things in a lot of detail and it’s not seen as intrusive. So, that stance of curiosity, because I am a foreigner, and people see it; I think it’s helpful. I’m not always in their kind of cultural experiences or in some of the experiences they’ve had at school or whatever. But like, it does free me up to be able to kind of check things out and challenge in ways that if I had grown up in America with some of the same experiences, I may not have been able to do. And, I’m not too sure why, but that’s often the feeling that I’m left with, that there’s some distancing in some ways that frees me up to be able to do that. Curiosity was a mutual experience; participants described using their clients’ curiosity about them to break the ice and to allow clients to experience them on a more human level. Participants reported answering many questions from their clients regarding their own personal lives, countries of origin, immigration experiences and opinions about the United States. One participant said: Often [clients are] kind of intrigued by my accent, by how I got over here. And in some ways, it has been a way of kind of breaking the ice, of being able to acknowledge cultural differences, particularly if I’m working with any ethnic minorities here. In lots of ways, I think it’s been a strength in my relationship with people because I think it’s been just another way of kind of joining with them.

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Another participant described how responding to personal questions from clients helped to better connect them to each other and build the necessary bond for future interventions: For me, it’s a plus because if I tell my story, I’m using my story as a connecting point. If there’s anything to act as an icebreaker as something to help me to join, and if my story is going to help me join quicker, then I’m ready to make sure the story is told right there so that if it opens up for me to do the intervention, I got it. Another way participants reported using cross-cultural differences to connect to their clients was using their own foreignness to level the hierarchy in the therapy room. Participants made comments about how being different, having flaws and imperfections, or having a minority status put them in a less hierarchical/expert position in relation to their clients and help to reduce the power differential. Related to this, one participant stated: [Speaking about grammar errors and a foreign accent] That levels the hierarchy; that makes me a real person. I am no longer this expert who comes in to tell them that “you screw up your kids, you did this wrong.” Right? I am someone who is real. You know? Sometimes we laugh about my mistakes or my accent. So, it makes a real relationship, is that making mistakes and not having to be perfect. The last strategy using differences to connect to clients was putting the difference on the table by talking about being a foreigner at the beginning of therapy, and being nonnative English speakers or having a foreign accent. This included giving their clients permission to ask for clarifications, as needed. One participant explained: I have personally put it out there that “if I say anything that is unclear to you, you have the permission to ask me to clarify because my goal is to help you understand what I’m saying”. So, I put it out there that “You have the permission. If I say something that’s unclear to you, please make sure it’s clear.” Another participant shared: Sometimes I feel like it helps to say ‘if I say something wrong and you don’t understand me because I speak another language it’s more justified’. Or ‘I tend to laugh; I think that’s how I cope with stress’. So, I tell them, ‘If I laugh at something and you take it the wrong way, I apologize’ . . . so I try to put the things that some people may take in a wrong way out there so they are aware that I may relate in a different way. Using similarities to connect In addition to how participants used cultural differences to connect, they also found ways to connect through their similarities. Participants reported looking for common experiences with their clients to help them better understand their clients, which facilitated clients being heard and understood. These experiences included parenting, being people of faith, being immigrants, moving and relocating, dealing with educational and health systems, being a minority, and more. One participant commented: I connected with them as women, in their struggles as women, a little bit of self-disclosure, “I’m a mother too. I understand what it’s like.” I do a lot of “Oh, we women are very good at taking care of other people” kind of thing. Another participant said: Right now I’m not seeing anyone from my religion. But just being and just having faith is something that I use a lot, and that I have in common with the majority of the families that I work with. The religion might be different but the beliefs are the same. And I use that a lot, and it really helps me connect as well. Participants also talked about their belief in a shared humanity. They described having shared emotional and personal experiences with clients, despite differences in their countries of origin, first

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Journal of Marital and Family Therapy 42(1): 123–138 doi: 10.1111/jmft.12115 © 2015 American Association for Marriage and Family Therapy

STRATEGIES USED BY FOREIGN-BORN FAMILY THERAPISTS TO CONNECT ACROSS CULTURAL DIFFERENCES: A THEMATIC ANALYSIS Alba Ni~ no Alliant International University

Karni Kissil Private Practice

Maureen P. Davey Drexel University

With the growing diversity in the United States among both clinicians and clients, many therapeutic encounters are cross-cultural, requiring providers to connect across cultural differences. Foreign-born therapists have many areas of differences to work through. Thus, exploring how foreign-born family therapists in the United States connect to their clients can uncover helpful strategies that all therapists can use to establish stronger cross-cultural therapeutic connections. A thematic analysis was conducted to understand strategies 13 foreignborn therapists used during therapeutic encounters. Four themes were identified: making therapy a human-to-human connection, dealing with stereotypes, what really matters, and flexibility. Findings suggest that developing a deep therapeutic connection using emotional attunement and human-to-human engagement is crucial for successful cross-cultural therapy. Clinical and training implications are provided. Societal changes and technological advancements are altering the landscape of human relations. Now more than ever, we are exposed to individuals and groups from different backgrounds. For example, developments in technology and transportation have facilitated more geographic mobility, migration, and communication (Platt & Laszloffy, 2013). This is especially true for the United States, a country that continues to have one of the highest levels of net migration in the world (World Bank, 2014). Also, a growing awareness of social barriers such as racial and economic discrimination is now making it possible for diverse groups that have historically remained mutually invisible or segregated, to start seeing and relating to each other. These global demographic trends and growing awareness are also experienced during therapeutic encounters between therapists and clients (Vasquez, 2007). Thus, as family therapists, we will likely work with an increasingly diverse clientele. This will require the development of successful clinical strategies that help to establish strong therapeutic relationships with clients who are culturally different from us regarding culture of origin, family composition, sexual orientation, religious affiliation, and other salient contextual variables. Providers need to learn how to connect across cultural differences to become culturally sensitive. Even though this has been recognized and accepted in extant literature (please see review below), studies that specifically describe

Alba Ni~ no, PhD, LCMFT, Couple and Family Therapy Program, Alliant International University; Karni Kissil, PhD, LMFT, Private Practice; Maureen P. Davey, PhD, LMFT, Department of Couple and Family Therapy, Drexel University. We want to express our appreciation to the 13 foreign-born therapists who very generously shared their stories of struggle and success as therapists who are clinically active in the United States. Their ingenuity, creativity and perseverance made this paper possible. Address correspondence to Alba Ni~ no, Couple and Family Therapy Program, Alliant International University, 10455 Pomerado Road, DH-206A, San Diego, California 92131; E-mail: [email protected]

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Furthermore, participants talked about cultural differences being one of many possible differences between them and their clients in addition to age, gender, sexual orientation, or marital status. They reported believing that attributing difficulties in therapy to only cultural differences is problematic because it could mask other explanations. One participant talked about this problem of “culturalizing” therapy: I cannot accept the notion that sometimes we want to totally wrap the whole therapy session in the cultural context because sometimes if both sides fail, they have a good excuse. I have seen so many white therapists who have claimed, “we have not been able to work with this family; I think that’s a cultural issue.” So they can dismiss themselves. To me, that wasn’t a cultural issue; to me that was a humanistic problem. He or she was not able to authentically engage with the family. Another participant said: “So you’re not a man, so you don’t understand a man’s experience.” People can label you and categorize you in many, many different ways. And then growing up from a different country, and speak not very perfect English is just one of the many. But it’s just that for us, we are more self-aware. So, if your client drops out other therapists who speak perfect English will just say “the client is not ready for change”, or “I’m too young”, or “I am this and that”, or “I am too expensive.” But they can find different reasons. But for us, our first assumption to explain the dropping out is “maybe [it is because] I am from a different country.” Dealing With Stereotypes The third major theme, dealing with stereotypes, was mentioned by 12 of the 13 participants. They reported being the target of discriminatory statements and actions against them, and some clients assuming they were not clinically competent. They reported being prepared for clients perceiving them less favorably compared to U.S.-born therapists. Below are examples described by two participants regarding clients’ assumptions because of their foreign accents: I have to prove to every single client of mine that I have the ability to understand you and to help you. And I think that’s something that I learned as a non-English speaker, I have to prove that, because I will always speak with an accent, so people will always assume that I am not as smart or that I am not as competent. When you don’t speak the language at the level that other people do, the perception of you is as ignorant. You don’t speak English like they do, therefore you’re an ignorant person. Not being able to conjugate verbs at the same speed, you know, makes you being perceived as ignorant. Participants reported working to debunk clients’ negative stereotypes about them or about people from their countries of origin, in general. Through their engagement in the therapeutic relationship, participants were able to challenge these stereotypes either directly by making specific statements or indirectly by interacting in a way that contradicts these stereotypes. Sometimes when I work with couples, they joke about that. When I challenge the husband and he’s a Caucasian, upper class guy, and I’m challenging him about equality and “how could you do this with your wife?” they say, “What? You look like someone who should be really oppressed, and won’t know anything about women’s rights. What are you talking about, telling me how I am and not being very egalitarian in my relationship?” So it has been fun, a lot of fun working with people and challenging their perception of who I’m supposed to be. Another participant talked about how he responds to clients’ stereotypes during clinical encounters: I stay with it and I ask them what they mean and then I talk about how that’s a prejudice and what it means in terms of a therapeutic relationship. What I do with that, it’s 132

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basically, you know, directly but delicately bring it into the open and have a discussion about what that means to them, what it means in therapy, and if there’s something that needs to be clarified because it’s not true, it’s wrong. I do that. Participants reported that because they could be perceived negatively (e.g., clients initially assume they will not understand them because of language difficulties or a lack of familiarity with their culture), in the beginning they have to work harder to prove themselves as competent clinicians. One participant said: “there are times that you have to work extra hard because nothing comes easy, you have to earn everything.” Thus, participants perceived that their foreignness presented some extra hurdles that put them at a disadvantage in comparison with U.S.-born therapists, and that required from them to work harder to compensate. Another participant said: Because you have something that is not working for you, you have to compensate and become good at something else. So, I’ve been able to work on my clinical skills way more, because I don’t have anything else going for me, so I’d better have good clinical skills and I’d better be helpful. So, over time I’ve been able to build a practice and part of it is about being clinically good. The other part is “let me show you that all of your stereotypes are wrong.” The hard work of proving themselves begins during the first session. Participants reported putting a strong emphasis on the first session, doing their best to engage their clients early, making a positive connection, and showing that they can be effective and helpful. One participant explained: This is my motto now, is that you have your first session to prove yourself to your client. I mean, even now that I feel much better about my therapy work, I still do that, I still believe that the first session is the one time chance your client gives to you to prove that you’re worth coming back for. Another way to deal with clients’ stereotypes was to see them as part of a larger system of oppression and marginalization. This helped participants to not take stereotypes personally. Consequently, they were able to engage and join with clients and invest in the therapeutic relationship, without developing feelings of anger or resentment. I think I go into the families knowing, so to speak, that it is out there. In other words, I live in a country [the U.S.] that the issue of racism, and the issue of classism, and the issue of gender are prevalent. So you don’t have to be surprised going into these families and see those things on display. I know that about the culture. I don’t get too surprised when I experience it in the families. One of the things that I also tell myself is that these are families who have called for help. So, my goal as a family therapist is to go offer the help that I can give. Another participant stated: I have no problem with that because I can empathize with that client. I mean, when I see a white client, some of them living in a remote area, the only channel that they do have access to is Fox News. Watching Fox News for 24/7, the information they get, the connection that they have with their surroundings, of course, even if I was in their shoes I would have the same perception about my country perhaps. So, I do not personalize that. Flexibility The fourth and final major theme was flexibility. Eight of 13 participants made statements about flexibility. They noted that because they are foreigners, they had more freedom and flexibility in their clinical work. They described having a broader perspective about what therapy is, more flexible boundaries regarding scheduling and session length, and more fluidity and freedom in their therapeutic relationships. One participant said: I prefer to see the family every two weeks or three weeks and have sessions of two hours. I think that works better. Sometimes I have meetings with kids who are just half an hour January 2016

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because they cannot stand it anymore. That’s fine with me, too. So, time for me is kind of to use, and the flexibility about treatment. Who said that treatment has to be “you just start, you assess, you treat, and then you finish”? Who said that’s the way it’s going to be? I don’t see it that way. I see that sometimes my clients will see me for something, then they go and they come back later and we do something different. Another participant shared a story exemplifying her flexibility about the boundaries of therapy: I don’t follow rules easily not being from here and that can get me in trouble a lot of times . . . I am less constricted . . . I’ve been working with the family in the school and my identified client is a little boy, a six-year-old boy, who is just having some anxiety. The boy also has a 20-year-old sister with kids of her own and she was going through a domestic violence relationship and she wanted to get out. My therapeutic contract, the one that I signed is for this six-year-old boy but I couldn’t say no to helping this 20-year-old desperate girl. Then I realized it might not have been the smartest thing to do but I jumped, I jumped in to help her without thinking what might be the liability, consequences might have been for me . . . I think that if I would have been from here I would have never agreed to help this 20 year old girl because she was not my client. Another therapist saw flexibility as an antidote to the rigidity that can often get in the way of establishing a closer connection to clients. She shared: I feel like sometimes people put so many boundaries around the therapy and maintaining the professional boundaries. That to me is kind of strange. I don’t know. I feel like you’re a person and for your clients you are a person. You are a human being, too. One participant talked about a client she saw after this client’s oldest son’s suicide. She saw the client and her other children for a while and then they dropped out of therapy. After several months, the mother came back for a few more sessions and then dropped out again. The therapist called the client at Christmas to check in with her. The therapist said: I called her and I said, “I just needed to talk to you and see how you were,” and she said, “Okay, I want to see you,” and I’m okay with that, because I know this is just overwhelming. So she will disappear for some time, and I’ll call not to get her back into therapy, but just to see how she’s doing . . . And it’s that kind of flexibility. And I don’t know if I were from here if I had that kind of flexibility, that it’s not about getting her back into therapy because I think that she needs it. It’s about keeping that connection with her, because probably I need to see how she’s doing, and it just happens that she’s okay with me, so she confides.

DISCUSSION The primary aim of this thematic analysis was to explore the strategies foreign-born family therapists use to connect across differences during therapeutic encounters with clients in the United States. Participants described successful strategies that helped them develop stronger therapeutic relationships with clients. Despite their dissimilar backgrounds, they transformed their cultural differences into therapeutic assets. The findings support and add to prior literature on this topic. A common assumption in the field of psychotherapy is that dissimilarities in the backgrounds of therapists and clients are an obstacle or impediment for successful therapy (Gelso & Mohr, 2001; Qureshi & Collazos, 2011; Worthingon, Soth-McNett, & Moreno, 2007; Zane et al., 2004). Given that development of the therapeutic alliance is more complex when therapists and clients come from dissimilar backgrounds, therapists will need to make concerted efforts to cultivate the alliance. Our findings support this assumption. Foreign-born family therapists in our study stated that because they are culturally different from their clients, they faced many more challenges developing a strong therapeutic alliance. In particular, they reported being perceived less favorably compared to U.S.-born therapists (e.g., clients asking to be transferred after one session, clients canceling their appointment after hearing their accent). Consequently, they had to work harder

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especially at the beginning of therapy, connecting during the first session, and by continuously honing their clinical skills. Even though all participants expected this would be a clinical disadvantage, they also stated that once the therapeutic relationship was firmly established, their foreignness became secondary. What mattered most was how emotionally attuned they were to their clients and whether they were able to help them feel understood and validated. They described various strategies that helped them be more emotionally attuned to their clients’ internal states, feel their clients’ pain and help them feel heard and validated. These findings support previous studies that examined the importance of emotional attunement during cross-cultural clinical encounters (Keenan, Tsang, Bogo, & George, 2005; Tsang et al., 2011; Vasquez, 2007; Zane et al., 2004). Foreignness: From Difficulty to Asset Participants described how they shifted their views about their foreignness. Initially they believed it was an obstacle and expected to struggle during clinical encounters in the United States. Yet, gradually they reframed these anticipated limitations (e.g., not speaking perfect English, not knowing the culture). They became more comfortable with themselves, and began to realize they could still be effective therapists in the United States. Thus, they went beyond acceptance and were able to use those setbacks as assets in their clinical work. Additionally, participants reported several ways to use their foreignness to better connect to clients in the United States. For example, they used their language difficulties to help level the hierarchy and to decrease power differentials. Participants also capitalized on their foreignness by assuming the stance of a “curious stranger.” They had the freedom to not know, could be genuinely curious about their clients, and ask questions that U.S.-born therapists may feel uncomfortable asking. In a previous article (Kissil, Ni~ no, & Davey, 2013), we suggested, based on our clinical experiences as foreign-born therapists and review of the literature, that one of the advantages of being a foreign-born therapist was the ability to be genuinely curious. Findings from this study provide empirical support for our clinical experiences and theoretical review. Immigrant therapists such as Salvador Minuchin and Celia Falicov have also described how they capitalize on their foreignness in their clinical work. Minuchin, for example, has mentioned that clients are more prone to accept his irreverence because he is internationally born and has a foreign accent. Falicov has shared how she has used her own experiences of immigration to validate the pain and longing of her immigrant clients (Falicov, 1998). Dyche and Zayas (1995) reported that “the work of healing with clients whose backgrounds are different from therapists’ will proceed well when therapists develop the discipline to acknowledge their inevitable naivete about another person’s life and to use the compass of a respectful curiosity” (p. 390, italics added). Similarly, participants in our study described a state of respectful naivete used for the benefit of their clients in the United States. Participants also described being flexible and having more freedom to do what was best for their clients. Most reported that because they were foreigners, they felt less constricted by rules in the United States regarding what therapy should conform to (e.g., length of sessions), and were able to be more client-centered and use their humanity while making clinical judgments. One paradox of therapy is that to be professionally effective, we have to be personally present. Participants reported their ability to be more of a “person” and less like a detached professional facilitated deeper connections to their clients; being flexible was an important factor in making this possible. Findings from this study are useful for all clinicians, not just those who are foreign-born. Considering the increasing diversity in the United States and the assumption that every clinical encounter is cross-cultural, all therapists should find effective ways to connect across differences. Our findings suggest creating a deep therapeutic connection is crucial for successful therapy and the best way to achieve it is through emotional attunement and human-to-human engagement. Our findings also highlight that even though establishing cross-cultural therapeutic connections requires hard work especially at the beginning of therapy, differences between therapists and clients are not an impediment and can be transformed into clinical assets. Finally, our findings support the body of research that identified the quality of the therapeutic relationships as an important common factor in the therapeutic process (Norcross, 2010). Our study confirms the work of authors such as Fife, Whiting, Bradford, and Davis (2014), Karam, January 2016

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Blow, Sprenkle, and Davis (2014) and Karam, Sprenkle, and Davis (2014) who have urged CFT to incorporate this important common factor in our training programs to increase clinical effectiveness. Next, we describe study limitations and areas for future research and provide recommendations for therapists and training programs. Limitations One limitation of this study is the relative homogeneity of the sample in relation to variables such as sexual orientation (all participants self-identified as heterosexual), marital status (10 participants were married), age at arrival (10 participants arrived at the United States in their 20s), and region of origin (six participants came from South America). Participants, however, had a high degree of variability in terms of age, length of time in the United States, years of clinical experience, and type of clinical setting. When assessing the transferability of findings (Lincoln & Guba, 1985), readers are advised to consider the demographic characteristics of our participants when applying the findings to other groups of therapists. Future Research The findings described in this article were part of a larger phenomenological study that examined the clinical experiences of foreign-born couple and family therapists currently practicing in the United States (Ni~ no, 2013). Strategies to connect across differences were not the main focus of that original study. Future studies on cross-cultural therapeutic connections should ask participants how they specifically overcome differences to establish strong therapeutic relationships with clients. In addition, this study described strategies used by foreign-born couple and family therapists. Yet, they are not the only therapists devising strategies to connect cross-culturally. Studies on other types of therapists connecting with clients different from themselves are also encouraged (e.g., urban-raised therapists working in rural areas; civilian therapists working with military families). Finally, other methods and sources of information should be included in future studies. Following the example of Tsang et al. (2011), studies could examine actual cross-cultural therapy sessions. Also, clients are invaluable informants who can describe the salient factors that helped them feel more connected to their therapists. Participants in this study reported coping with clients’ stereotypes as one of the tasks they performed to connect with their clients in the United States. Even though a few participants mentioned stereotypes they had about clients in the United States and how they challenged them, this theme was not salient in our study. For a more thorough understanding of cross-cultural connections between therapists and clients, it is important to also understand how therapists deal with their own stereotypes about clients. Future research in this area is recommended. Clinical and training implications When sociodemographic differences exist between therapists and clients, the tendency in the field has been to consider them hindrances for achieving therapeutic connections and optimal clinical outcomes. The field of psychotherapy can benefit from debunking this myth. Differences do require a higher investment, especially at the beginning of therapy, in establishing a therapeutic relationship. As clinicians and trainers, however, we need to teach our students that recognizing and validating differences needs to be complemented with finding the common ground, especially our common humanity (Aponte et al., 2009). When highlighting differences contributes to stereotyping or overgeneralizing, the therapeutic relationship can be compromised. Karam, Sprenkle, and Davis (2014) affirmed that developing a strong therapeutic relationship is something that can be improved through training. We agree with this statement and believe that training to help providers develop stronger therapeutic relationships should be informed by studies that, like this one, identify strategies that have been used by family therapists in the field. Additionally, participants reported using their own personal experiences to find points of connection with diverse clients. Thus, programs and classes that train family therapists should help them become more familiar with their own experiences, and use their vulnerability as a therapeutic tool. Therefore, we direct the attention of the reader to the Person-of-the-Therapist Training (POTT) program (Aponte & Winter, 2012; Aponte et al., 2009) which trains therapists to acknowledge their personal issues, accept them, and then use them to connect, assess, and intervene with their clients. 136

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REFERENCES Akhtar, S. (2006). Technical challenges faced by the immigrant psychoanalyst. The Psychoanalytic Quarterly, 75, 21– 43. Aponte, H. J., Powell, F. D., Brooks, S., Watson, M. F., Litzke, C., Lawless, J., et al. (2009). Training the person of the therapist in an academic setting. Journal of Marital and Family Therapy, 35, 381–394. doi:10.1111/j.17520606.2009.00123.x Aponte, H. J., & Winter, J. E. (2012). The person and practice of the therapist: Treatment and training. In M. Baldwin (Ed.), The use of self in therapy (3rd edn, pp. 141–165). New York, NY: Routledge. Bograd, M. (1999). Strengthening domestic violence theories: Intersections of race, class, sexual orientation, and gender. Journal of Marital and Family Therapy, 25, 275–289. doi:10.1111/j.1752-0606.1999.tb00248.x Boyd-Franklin, N. (2003). Black families in therapy: Understanding the African American experience (2nd edn). New York, NY: Guilford. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. doi:10.1191/1478088706qp063oa Collins, S., & Arthur, N. (2010). Culture-infused counselling: A fresh look at a classic framework of multicultural counselling competences. Counselling Psychology Quarterly, 23, 203–216. doi:10.1080/09515071003798204 Dyche, L., & Zayas, L. H. (1995). The value of curiosity and naivete for the cross-cultural psychotherapist. Family Process, 34, 389–399. Dyche, L., & Zayas, L. H. (2001). Cross-cultural empathy and training the contemporary psychotherapist. Clinical Social Work Journal, 29, 245–258. Falicov, C. J. (1998). Latino families in therapy. New York, NY: Guilford Press. Fife, S. T., Whiting, J. B., Bradford, K., & Davis, S. (2014). The therapeutic pyramid: A common factors synthesis of techniques, alliance, and way of being. Journal of Marital and Family Therapy, 40, 20–33. doi:10.1111/ jmft.12015 Gaztambide, D. J. (2012). Addressing cultural impasses with rupture resolution strategies: A proposal and recommendations. Professional Psychology: Research and Practice, 43, 183–189. doi:10.1037/a0026911 Gelso, C. J., & Mohr, J. J. (2001). The working alliance and the transference/countertransference relationship: Their manifestation with racial/ethnic and sexual orientation minority clients and therapists. Applied and Preventive Psychology, 10, 51–68. doi:0962-1849/01 Hardy, K. V., & Laszloffy, T. A. (2002). Couple therapy using a multicultural perspective. In A. S. Gurman & N. S. Jacobsen (Eds.), Clinical handbook of couple therapy (pp. 569–593). New York, NY: The Guilford Press. Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277–1288. doi:10.1177/1049732305276687 Johnson, L. A., & Caldwell, B. E. (2011). Race, gender, and therapist confidence: Effects on satisfaction with the therapeutic relationship in MFT. The American Journal of Family Therapy, 39, 307–324. doi:10.1080/ 01926187.2010.532012 Karam, E. A., Blow, A. J., Sprenkle, D. H., & Davis, S. D. (2014). Strengthening the systemic ties that bind: Integrating common factors into marriage and family therapy curricula. Journal of Marital and Family Therapy, doi:10.1111/jmft.12096 Karam, E. A., Sprenkle, D. H., & Davis, S. D. (2014). Targeting threats to the therapeutic alliance: A primer for marriage and family therapy training. Journal of Marital and Family Therapy, doi:10.1111/jmft.12097 Keenan, E. K., Tsang, A. K. T., Bogo, M., & George, U. (2005). Micro ruptures and repairs in the beginning phase of cross-cultural psychotherapy. Clinical Social Work Journal, 33(3), 271–289. Knudson-Martin, C., Huenergardt, D., Lafontant, K., Bishop, L., Schaepper, J., & Wells, M. (2014). Competencies for addressing gender and power in couple therapy: A socio emotional approach. Journal of Marital and Family Therapy, doi:10.1111/jmft.12068 Kissil, K., Niño, A., & Davey, M. (2013). Doing therapy in a foreign land: When the therapist is “not from here”. American Journal of Family Therapy, 41, 134–147. doi:10.1080/01926187.2011.641441 Lee, E. (2011). Clinical significance of crosscultural competencies (CCC) in social work practice. Journal of Social Work Practice, 25, 185–203. doi:10.1080/02650533.2011.573654 Lincoln, Y. S., & Guba, E. (1985). Naturalistic inquiry. Newbury Park, CA: Sage. McGoldrick, M., Giordano, J., & Garcia-Preto, N. (Eds.) (2005). Ethnicity and family therapy (3rd edn). New York, NY: Guilford. McGoldrick, M., & Hardy, K. V. (2008). Re-visioning family therapy. Race, culture and gender in clinical practice. New York, NY: Guildford Press. Newman, W. L. (2003). Social research methods: Qualitative and quantitative approaches. Boston, MA: Allyn and Bacon.

January 2016

JOURNAL OF MARITAL AND FAMILY THERAPY

137

Norcross, J. C. (2010). The therapeutic relationship. In B. L. Duncan, S. D. Miller, B. E. Wampold & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (pp. 113–141). Washington, DC: American Psychological Association. Niño, A. (2013). Experiences of immigrant couple and family therapists clinically active in the United States: A phenomenological study. Doctoral dissertation. Available from ProQuest Dissertations and Theses database (Order No. 3567165, Drexel University). Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd edn). Thousand Oaks, CA: Sage. Pedersen, P. B., Draguns, J. G., Lonner, W. J., & Trimble, J. E. (Eds.) (2008). Counseling across cultures (6th ed.). Thousand Oaks, CA: Sage. Platt, J. J., & Laszloffy, L. A. (2013). Critical patriotism: Incorporating nationality into MFT education and training. Journal of Marital and Family Therapy, 39, 441–456. doi:10.1111/j.1752-0606.2012.00325.x Qureshi, A., & Collazos, F. (2011). The intercultural and interracial therapeutic relationship: Challenges and recommendations. International Review of Psychiatry, 23, 10–19. doi:10.3109/09540261.2010.544643 Roysincar, G., Hubbell, R., & Gard, G. (2003). Multicultural research on counselor and client variables: A relational perspective. In D. B. Pope-Davis, H. L. K. Coleman, W. M. Liu & R. L. Toporek (Eds.), Handbook of multicultural competencies in counseling and psychology (pp. 247–266). Thousand Oaks, CA: Sage. Seedall, R. B., Holtrop, K., & Parra-Cardona, J. R. (2014). Diversity, social justice, and intersectionality trends in C/ MFT: A content analysis of three family therapy journals, 2004–2011. Journal of Marital and Family Therapy, 40, 139–151. doi:10.1111/jmft.12015 Sparks, J. A., & Duncan, B. L. (2010). Common factors in couple and family therapy: Must all have prizes? In B. L. Duncan, S. D. Miller, B. E. Wampold & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (pp. 257–391). Washington, DC: American Psychological Association. Sue, S. (2006). Cultural competency: From philosophy to research and practice. Journal of Community Psychology, 34, 237–245. doi:10.1002/jcop.20095 Sue, D. W., & Sue, D. (2013). Counseling the culturally diverse: Theory and practice (6th edn). New York, NY: Wiley. Tang, N. M., & Gardner, J. (1999). Race, culture and psychotherapy: Transference to minority therapist. The Psychoanalytic Quarterly, 68, 1–20. Tsang, A. K. T., Bogo, M., & Lee, E. (2011). Engagement in cross-cultural clinical practice: Narrative analysis of first sessions. Clinical Social Work Journal, 39, 79–90. doi:10.1007/s10615-010-0265-6 Vargas, H. L., & Wilson, C. M. (2011). Managing worldview influences: Self-awareness and self-supervision in a cross-cultural therapeutic relationship. Journal of Family Psychotherapy, 22, 97–113. doi:10.1080/ 08975353.2011.577684 Vasquez, M. J. (2007). Cultural difference and the therapeutic alliance: An evidence-based analysis. American Psychologist, 62, 878–885. Ward, A., & Knudson-Martin, C. (2012). The impact of therapist actions on the balance of power within the couple system: A qualitative analysis of therapy sessions. Journal of Couple and Relationship Therapy, 11, 221–237. Watts-Jones, D. (2010). Location of self: Opening the door to dialogue on intersectionality in the therapy process. Family Process, 49, 405–420. World Bank (2014). Net Migration. Retrieved March 30, 2014, from http://data.worldbank.org/indicator/SM.POP.NETM/countries?display=map Worthingon, R., Soth-McNett, A. M., & Moreno, M. V. (2007). Multicultural counseling competencies research: A 20-year content analysis. Journal of Counseling Psychology, 54, 351–361. doi:10.1037/0022-0167.54.4.351 Zane, N., Hall, G. C., Sue, S., Young, K., & Nunez, J. (2004). Research on psychotherapy with culturally diverse populations. In M. J. Lambert (Ed.), Bergin and Garfield’s Handbook of psychotherapy and behavioral change (pp. 767–804). New York, NY: Wiley.

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JOURNAL OF MARITAL AND FAMILY THERAPY

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