The author finds group therapy to be an underutilized tool in the realm of psychotherapy. First, a meta-analysis conducted by Burlingame and colleagues (2016) stated that individual and group therapy for clients produced treatment outcomes that were equivalent to one another. Meaning, those who went to therapy when dosage, patients, and treatments were equal, the therapy produced equivalent therapeutic outcomes. Furthermore, there were no differences found between treatment responses and dropout rates. Second, group therapy can be found to be more easily accessible due to cost effectiveness with different disorders (Otto, Pollack, & Maki, 2000; Roberge, Marchand, Reinharz, & Savard, 2008). When comparing groups to both individual and medication therapy, the clients who attended group saved the most money compared to individual and medication respectively (Otto et al, 2008). Third, group psychotherapy has been found to be effective across multiple dimensions of psychopathology, including: mood disorders, anxiety disorders, eating disorders, substance-related disorders, trauma-related disorders, schizophrenia, personality disorders, and even within medical settings (Burlingame & Jensen, 2017).
In sum, there are many benefits to the use of psychotherapy groups that can provide important outcomes for clients and clinicians. However, what research has been done to examine the benefits of facilitation within group therapy? Specifically, how have group leaders been trained in multicultural oriented groups? What must group leaders do to become effective facilitators within this context? Thus, the focus of this paper and article one will be to stress the importance of group leadership and how the use of Multicultural Orientation (MCO) is important not only within group settings but also for the group facilitators themselves. Next, this paper will also address the previous research surrounding MCO and the combination of this orientation within group dynamics, the void in the literature that can be addressed through this upcoming research, and what research questions and hypotheses the author finds important. Finally, this paper will address why the author is choosing to do a continued study beyond the previous paper called “Construction and Validation of the Multicultural Orientation Inventory-Group Version” which was conducted by his advisor and colleagues at the University of Iowa.
Multiculturalism Within Psychotherapy
In terms of group facilitation, the author has examined the literature regarding multiculturalism in conjunction with group leadership. There has been a substantial contribution to the academic literature surrounding multiculturalism. For example, one of the most poignant phenomenon within counseling psychology is the idea of multicultural competence. This was a tripartite model developed by Sue and colleagues (1982). It stressed that therapists should approach multiculturalism with a knowledge to develop and understand their own cultural backgrounds, identities, and worldview. By doing so, they gain knowledge of individuals from different backgrounds of their own, implement culturally appropriate interventions, and understand in what ways their own group membership impacts their clients. From this model, several important measures have been developed to identify how counselors are conducting therapy that is competent. Moreover, the Cross-Cultural Counseling Inventory (CCCI-R) developed by LaFromboise and colleagues (1991) was designed to measure the attitudes, beliefs, knowledge, and flexibility surrounding culture and the effectiveness of the counselor’s skills implementing them. This was then measured by the client’s observations of that counselor (LaFromboise et al., 1991).
Over time, studies have provided key examples of ways therapists can increase their competency beyond the tripartite model. For example, the Colorblind-Racial-Attitudes Scale, or CoBRAS was designed to gage how individuals maintain color-blind ideology. In one particular study, the CoBRAS scale was used to identify counselors who had a higher level of color-blindness. These results suggested that counselors who maintained a color-blind belief had lower levels of multicultural competencies (Burkard & Knox, 2004; Spanierman, Poteat, Oh, & Wang, 2008). Thus, the CoBRAS scale may be used as an individual examination to not only look at internal biases, but as a tool to help counselors increase their own competence. Additionally, Iverson (2012) posits how therapists can expand their awareness, knowledge, and skills in building off Sue’s framework. For example, Iverson expressed the importance of doing social justice work to better understand the limitations of the multicultural competency framework itself. Iverson argues that it is not enough to only know about the identities and human differences of our clients, but it is also important to fight and dismantle the many forms of oppression which impacts the clients themselves. Iverson states that this can be done by becoming more equity minded, advocating for social justice, and developing critical consciousness. Moreover, therapists should be actively engaged in not only their own cultural processes but to work in social justice areas that benefit the lives of others beyond their own.
Additionally, Conron and colleagues noted the importance of understanding how the interactions between racial, ethnic, religious, gender, sexual, and other identities can have an enormous impact on health disparities and mental health outcomes (2010). Furthermore, the American Counseling Association endorsed the Association for Multicultural Counseling and Development (AMCD) to revise and update the competencies of multiculturalism outlined by the work done by Sue and colleagues in 2015. This revision is now titled the Multicultural and Social Justice Competencies (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015).
Importance of Group Leadership
Previous research posits the importance of group leaders within group psychology. For example, group leaders have the unique responsibility to facilitate and navigate discussion with group members (Mahon & Leszcz, 2017). Without guidance from these leaders, group members will struggle to enter the next stages of the group process. Specifically in groups where interpersonal group process is the theoretical model, clients in the beginning stages will consist of group members talking more to the group leader. Without the facilitators direction during this key period, group members might not ever enter a stage that creates feedback from members in the here and now. Moreover, leaders help establish the goals for the group, focus on the therapeutic alliance to strengthen the autonomy of participants, contribute to concrete tasks for members, and create an atmosphere of healing (Mahon & Lecsz, 2017). Additionally, starting a group for the first time can be a very intimidating and worrisome process. Therefore, group leaders are valuable in the process of pre-screening members to make sure they understand clearly what the group is designed to do. Logistic pieces come into play as well. The pre-screening process helps clients understand information surrounding location, time of the group, size, duration, sessions, and policies (Bernard, 2008).
Furthermore, the guidelines that therapists set are crucial in how the clients observe the facilitators. Previous literature has expressed how important the beginning of sessions are for clients (Bernard, 2008). Specifically, how consistent the group leaders stay on task to their proposed guidelines are important for the group member in not only believing the therapists credibility, but also modeling those norms as well. When these norms are established the facilitator’s work is not done. Specifically, therapeutic factors are important in assessing the progress of the group, its members, and its facilitators (Yalom & Leszcz, 2005). The biggest example of this is the therapeutic factor called cohesion. Cohesion is a foundational piece in the therapeutic relationship for not only the group leaders and members, but also within member to member interactions, and finally towards the group as a whole (Bernard, 2008). Moreover, if therapists are unable to facilitate a cohesive environment amongst the group, members are likely to lack a sense of belonging, acceptance, commitment, and allegiance to the group (Yalom & Leszcz, 2005). Additionally, Bernard and colleagues stress the importance for group leaders to create a healthy climate by way of three models: facilitating the group intrapersonally, intra-group, and interpersonally (Bernard, 2008). Thus, the therapeutic relationship has become so important throughout all groups that a set of instruments for group facilitators to use in psychotherapy has been created (Burlingame, 2006) In sum, group cannot perform its intended purposes without the contribution of many dynamics interwoven throughout group psychotherapy; a very important one being the group leaders.
Introduction to MCO
Now that the importance of multiculturalism and group leadership has been discussed, it is key to introduce the important topics related to article one. With the advancement of multicultural competency, there has been a significant push from the literature to explore multiculturalism in an alternate way (Owen, Tao et al., 2011; Hook et al., 2013). Furthermore, an article published in 2010 by Burnes and Ross highlighted the significance and need for group psychologists to address multiculturalism due to it being absent in traditional group theory. Moreover, there is call from clinicians within the literature who suggest that group psychologists should invest time in developing ways to incorporate social justice models into group based theory (Fambrough & Comerford, 2008). Through this lens, the author sees great potential in the framework of multicultural orientation. With this framework, Owen et al. (2013) distinguished several differences between multicultural competence and multicultural orientation (MCO). Specifically, he suggested that future assessment should focus on the therapists’ multicultural orientation in contrast to their multicultural competence. Multicultural orientation is viewed as a way of being with the client (Owen, Tao et al., 2011). This is different to the previous conceptualizations of multicultural competence which was described as ‘ways of doing’. These ways of doing assess how competent a therapist is at implementing cultural awareness, knowledge, and skills into therapy (Hook et al., 2013). Further, Owen, Tao et al. (2011) contend that it is possible that previous studies attempting to assess therapists’ multicultural competence were more closely assessing therapists’ multicultural orientation.
MCO has had several implications in the multiculturalism domain. Previous research has focused on how microagressions can severely impact the therapeutic relationship (Constantine, 2007). In this study, the author examined how perceived microagressions change the working alliance and the counseling satisfaction. Although multicultural competence can still be obtained, racism is often manifested in unconscious processes and can negatively effect the client. Therefore, MCO research has been important in understanding why multicultural competence is important, but how it is not enough. Another recent study conducted by Owen and colleagues have looked at how the perceived microagressions of a client can cause interference with the therapeutic process (Owen, Tao, Imel, Wampold, & Radolfa, 2014), detecting microagressions in session (Owen et al., 2018), and using cultural humility as an effective, yet non superior approach to addressing cultural differences (Owen, 2013). Moreover, Owen and colleagues (2011) examined how to repair cultural ruptures in therapy.
In expanding upon this non-superior ideology, Owen and colleagues suggest that there are three tenets to address difficult circumstances that arrive in therapy, how to be actively engaged in a multicultural manner, and to achieve better therapeutic outcomes. The first is cultural humility. Not only is this approach humbling, but it approaches the client from a place of curiosity rather than all-knowing (Owen, 2013). It was found that clients’ perceptions of their therapist’s cultural humility positively associated with therapy outcomes and negatively associated to microagressions. Second, cultural opportunities are described as moments during a session when the cultural content is presented and has the potential to be explored more in depth. An example of this might be cultural heritage. When a client’s heritage was accounted for in session, the therapeutic outcomes increased. Last, cultural comfort is the ease to which culturally salient interactions are had. Owen and colleagues found that racial-ethnic therapy outcome disparities within caseloads were partly due to the cultural comfort of the therapist. In summary, there has been substantial research regarding individual competency ranging from Sue’s tripartite model to the Multicultural and Social Justice Competencies and even a multicultural orientation. However, there has been scant research addressing the multicultural facilitation process of a leader within psychotherapy groups that discuss multicultural dialogue. Thus, it is important to address the needs for future research and the implications for article one.
Merger of MCO and Group Therapy: Future Implications
Most recently, one study has attempted to measure multicultural constructs of group therapy (Kivlighan III et al 2018). Specifically, Kivlighan III and colleagues hypothesized that a tripartite model consisting of three MCO tenets could be adapted into a measure for group psychotherapy. Moreover, this group measure was adapted from three scales existing of the Cultural Humility Scale, Cultural Comfort Scale, and Cultural Missed Opportunities. Results supported an internal and psychometric consistent MCO inventory measure designed for group psychotherapy. The authors hypothesis was supported that this was the best fitting model for a client-rated measure of MCO. This states that the group therapeutic factor is significantly associated with other group therapy process outcomes like the Patient’s Estimate of Improvement (PEI), and the Therapeutic Factor Inventory (TFI). Moreover, this study provided support that subscales within the MCO such as Cultural Humility and Cultural Missed Opportunities were strongly associated with the participant’s therapeutic outcomes within PEI and TFI. Additionally, the Multicultural Orientation Inventory – Group Version (MCO-G) measured client’s perceptions of multicultural orientation within these three scales and results supported that there was an association with a therapeutic factor: the group therapeutic factor.
Several strengths arose from this research. First, group psychologists now have an opportunity to utilize a measure that can assess how discussions are conducted over culture. Second, group programs can stress the importance of MCO-G in relation to its therapeutic outcomes for participants in psychotherapy. Finally, group psychologists need measures to assess how cultural discussions are facilitated, offered, and structured in group therapy.
However, the limitations of the study were that a cross-sectional, correlational design was used. To expand the results from the multicultural orientation of group psychotherapy, future research should look to conduct longitudinal analyses of MCO-G over time in order to understand the processes of MCO amongst members, facilitators, and the group overall. This will provide the authors different time points into how multicultural orientation develops throughout group work. Additionally, another limitation of this study was that group leaders were not assessed. It is possible that group facilitators provide a strong factor in the establishment of multicultural group orientation. Therefore, future studies would do well to address this void in group research by examining how the Multicultural Orientation (MCO) model could be an effective measurement of how group leaders facilitate therapy groups.
Now that previous research has been summarized, limitations have been addressed, and future implications have been noted, the author looks to describe his research purpose statement, the design of the present study, and hypotheses. Against this backdrop, the current study will build off previous literature surrounding group psychotherapy by (a) expanding on the MCO-G measure of group therapy assessing cultural humility, cultural missed opportunity, and cultural comfort within group therapy; (b) go beyond a cross sectional design and assess the changes of MCO throughout different time points in therapy; (c) MCO-G will be applied to group leaders facilitating each group by asking members to fill out the measure assessing their facilitators’ multicultural orientation throughout group; (d) assess how the MCO-G contributes to therapeutic process and outcomes; and (e) the MCO-G will be distributed online through a data collection software titled Qualtrics.
In order to carry out the design the author will need to contact fifteen different counseling centers across the country to produce the desired sampled size for this study (N > 100). The author will ask the same centers that distributed the survey for the preliminary analysis of the MCO-G if they would be willing to participate in an additional study. However, the author is solely in charge of distributing the surveys now that they can be given online. With the intended modifications in mind, the online survey, assessment of group leaders, and distribution will be conducted through Qualtrics. The author will contact each participant with an individualized link to fill out the questionnaire through the online system. Once contacted, the members will have the opportunity to fill out the demographic and consent forms. Once completed, participants will be asked to assess their group through several measures: The Patient’s Estimate of Improvement, Group Climate Questionnaire, Racial Microaggressions in Counseling Scale, Therapeutic Factors Inventory, Group Interactivity Measure, Outcome Rating Scale, and Group Session Rating Scale. These eight measures will all be assigned to understand the process and outcomes within the group and how MCO-G contributed to these outcomes.
With this design in mind, the author has several hypotheses. One, the author hypothesizes that the multicultural orientation will be reliably measured amongst group members at different time points. Specifically, members’ assessment of MCO will have strengthened at the end of group more than after the 3rd session. Second, individual leaders will have a relationship with MCO and the group. Moreover, members who rate their therapists highly on the MCO scale will strengthen the overall MCO rating of the group. Finally, the author hypothesizes that group members’ therapeutic outcomes will improve across time when associated with MCO. Specifically, as the rating of MCO increases for the group, so will the individual members’ therapeutic outcomes. Additionally, if group leaders are reported as having high levels of MCO, this will correlate to higher therapeutic outcomes amongst group members.