Atlas›Domain III · Humanistic, existential & experiential›Guide 116
Guide III-116

Multicultural counselling

Sue, Arredondo, McDavis1992
A 36 · L 57 · M 733 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts, Singh, Nassar-McMillan, Butler & McCullough, 2015, endorsed by AMCD and ACA) as the organising frame, building on the original Multicultural Counseling Competencies (Sue, Arredondo & McDavis, 1992) as operationalised by Arredondo et al. (1996); operational tools taken from Day-Vines et al. (2007) broaching, the DSM-5 Cultural Formulation Interview (APA 2013; Lewis-Fernández et al. 2016 handbook), Hays's ADDRESSING framework and ten steps for culturally responsive CBT (Hays 2009), and the Multicultural Orientation (MCO) framework (Davis et al. 2018; Hook et al. cultural humility, 2nd ed. 2025).

Multicultural counselling is not a single therapy with its own manual. It is a competency framework and a stance that overlays whatever model you already practise (person-centred, CBT, psychodynamic, systemic). Its authors define it through what the counsellor must be aware of, know and do across four domains: counsellor self-awareness, client worldview, the counselling relationship, and counselling and advocacy interventions [source: Ratts et al. 2015]. The procedures below are the concrete clinical tools its authors and allied institutions describe; sequencing them into phases is my own [synthesis].

Core idea of change: clients' distress is shaped by their cultural identities and by power, privilege and oppression in their context, so change comes from (a) a relationship in which those identities and power dynamics can be named and explored safely, (b) a case conceptualisation built from the client's own explanatory model and worldview rather than imposed from the counsellor's culture, (c) interventions fitted to the client's values, strengths and supports, and (d) action at whichever level (individual, interpersonal, institutional, community, policy, global) actually maintains the problem, so the client stops blaming themselves for systemic harm [source: Ratts et al. 2015; Arredondo et al. 1996; Hays 2009; Day-Vines et al. 2007].

2. Framework

The sources give no fixed phases, session count or format: the MSJCC is organised by developmental domains, not session stages, and the CFI is designed to open every standard assessment [source: Ratts et al. 2015; Aggarwal et al. 2016]. The phase sequence below is my [synthesis] of how the published tools fit together in a course of individual therapy. Length and format follow your host model (weekly 50-minute individual sessions is typical; the framework also applies to couples, family and group work, e.g. via the ASGW Multicultural and Social Justice Principles of Group Work [source: Counseling Today MSJCC article]).

Phase 0. Counsellor preparation (before and alongside all cases)

  • Goal: know your own cultural identities, privileged and marginalised statuses, biases, communication style and limits of competence (MSJCC Domain I; MCC Domain I) [source: Ratts et al. 2015; Arredondo et al. 1996].
  • Activities: cultural self-assessment (ADDRESSING, cultural frames inventory), quadrant mapping for each new client, supervision/consultation, community immersion and ongoing training.
  • Moving on: never 'completed'; the MCO authors warn against treating cultural work as a finish line [source: Davis et al. 2018].

Phase 1. Engagement and cultural assessment (typically sessions 1–2)

  • Goals: orient the client to therapy and to the place culture may have in it; broach identity and the relationship early; elicit the client's explanatory model, identities, stressors (including discrimination), supports, coping and help-seeking history, and treatment expectations.
  • Tools: client orientation, broaching, core CFI (about 15–20 minutes as designed), CFI informant version and supplementary modules as needed, ADDRESSING review, strengths and supports inventory [source: Aggarwal et al. 2016; APA CFI supplementary modules; Hays 2009; Day-Vines et al. 2007].
  • Criteria to move on [synthesis]: you can state the problem in the client's own terms; you know which identities are salient to them (and which are not); you know what help they expect and any concerns about working with you; the client has heard that culture and identity are welcome topics at any time.

Phase 2. Collaborative cultural formulation and plan (sessions 2–4)

  • Goals: build the case conceptualisation with the client so their worldview shapes it; separate environmental from internal/cognitive contributors; choose the level(s) of intervention and whether advocacy is needed, and whether it is done with the client (self-advocacy) or on their behalf [source: Davis et al. 2018; Hays 2009; Ratts et al. 2015; ACA Advocacy Competencies as summarised in Counseling Today].
  • Format: present the conceptualisation in plain, jargon-free terms; share decision-making; agree goals and the role of family, community or spiritual figures [source: Davis et al. 2018].
  • Criteria to move on [synthesis]: the client recognises themselves in the formulation; there is an agreed split between 'what to change in me' and 'what to change around me'; any value conflicts have been noticed and taken to consultation.

Phase 3. Intervention (bulk of therapy)

  • Goals: deliver your host model's interventions adapted to the client's culture, plus socioecological work at the intrapersonal, interpersonal, institutional, community, public-policy and global levels as indicated [source: Ratts et al. 2015].
  • Ongoing: keep acting on cultural opportunities, monitor fit of interventions with client values, invite feedback on cultural ruptures, repair when they occur [source: Davis et al. 2018; Hook et al. 2025].
  • Criteria to review or shift level [synthesis]: if individual work stalls because the stressor is external and continuing, move toward environmental or advocacy work; if the client's self-blame for systemic harm reduces and skills grow, shift to self-advocacy and consolidation.

Phase 4. Consolidation and ending [synthesis]

  • Goals: review what the client attributes change to, in their own cultural terms; strengthen identity-affirming networks and community supports that will outlast therapy; check whether the patient–clinician relationship worked for them (CFI Patient–Clinician Relationship module can be revisited across sessions) [source for module: APA CFI supplementary modules].

3. Guiding principles

  • Cultural self-awareness is the starting point. Practical meaning: before formulating, ask how your own identities, privilege and biases may be shaping what you see [source: Ratts et al. 2015; Arredondo et al. 1996].
  • Everyone has privileged and marginalised identities; the dyad has a power configuration. Locate each relationship in one of the four MSJCC quadrants (privileged/marginalised counsellor × privileged/marginalised client), knowing it may shift by which identity is in play [source: Counseling Today MSJCC article].
  • Intersectionality and within-group difference. Do not treat any group as monolithic; the identity that matters most is the one the client says matters [source: Ratts et al. 2015; Day-Vines et al. 2007].
  • Power, privilege and oppression belong in the formulation. Ask how history, current events and power dynamics contribute to the presenting problem [source: Ratts et al. 2015].
  • The counsellor initiates. Do not wait for the client to raise race or culture; broach early and keep the invitation open throughout [source: Day-Vines et al. 2007].
  • Broaching is continuous, not a one-off box. A single early mention then silence is the 'isolating' style the authors warn against [source: Day-Vines et al. 2007].
  • Cultural humility over expertise. Be other-oriented, aware of your limits, curious, not superior; treat each client as teaching you their culture [source: Davis et al. 2018; Hook et al. 2025].
  • Use cultural opportunities. Treat moments when identity, values or beliefs surface as openings, entered smoothly from what the client just said [source: Davis et al. 2018].
  • Cultivate cultural comfort. Notice and regulate your own discomfort so you can stay present in cultural conversations; some discomfort is useful information [source: Davis et al. 2018].
  • Client's explanatory model first. Elicit the problem in the client's own words and idioms and plan treatment around them; there are no right or wrong answers [source: Aggarwal et al. 2016].
  • Validate reports of oppression. Accept the client's account of discrimination rather than testing it [source: Hays 2009].
  • Separate environment from cognition. Not every negative belief is a distortion; some reflect real conditions that need environmental change [source: Hays 2009].
  • Question helpfulness, not validity; leave core cultural beliefs alone. In cognitive work ask whether a thought helps the client, and do not dispute core cultural or religious beliefs [source: Hays 2009].
  • Collaboration over confrontation; shared decision-making. Share power in goal setting and planning [source: Hays 2009; Davis et al. 2018].
  • Build on cultural strengths and supports. Identify and use the client's culturally based resources [source: Hays 2009].
  • Counselling is culture-, class- and language-bound. Adjust helping style, language and assessment instruments rather than expecting the client to adjust [source: Arredondo et al. 1996].
  • Respect indigenous helping and spiritual practices. Consult traditional healers and religious leaders when appropriate [source: Arredondo et al. 1996].
  • Individual counselling and systems advocacy are both legitimate tools. Decide which the problem needs, and whether to advocate with or for the client [source: Ratts et al. 2015].
  • Help clients avoid self-blame for systemic problems. Help the client assess whether a difficulty stems from bias in others [source: Arredondo et al. 1996; Day-Vines et al. 2007].
  • Know and own your limits. Seek consultation, training or referral; seek accurate feedback because people overestimate their expertise [source: Arredondo et al. 1996; Davis et al. 2018].
  • Competence is lifelong and aspirational. The MSJCC calls its competencies aspirational; build them through training, immersion and reflection [source: Ratts et al. 2015].

4. Intervention inventory

Grouped as: A. counsellor preparation; B. engagement and cultural assessment; C. culturally responsive treatment (adapting your host model); D. socioecological and advocacy interventions; E. relationship maintenance and repair. Sources per item. Example language is my own (illustrative) unless quoted and cited.

A. Counsellor preparation

A1. Cultural self-assessment (ADDRESSING / cultural frames inventory)

  • Purpose: make your own identities, privileges, biases and blind spots explicit before they act on the client (MSJCC Domain I; MCC Domain I) [source: Ratts et al. 2015; Arredondo et al. 1996; Tao 2025].
  • When: at the start of practice, repeated periodically and whenever a client stirs strong reactions.
  • Steps: (1) Write your position on each ADDRESSING dimension: Age and generational influences, Developmental disabilities, Disabilities acquired later in life, Religion and spiritual orientation, Ethnic and racial identity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, Gender [source: Hays, Addressing Cultural Complexities; letter meanings partly confirmed on Hays workshop page, the two D categories from the book (details [uncertain])]. (2) Mark each as privileged or marginalised in your current context. (3) Note where you have had little contact or hold stereotypes. (4) Note how your communication style (directness, eye contact, use of time) reflects your culture [source: Ratts et al. 2015]. (5) Bring the result to supervision; plan learning (training, reading, community immersion).
  • Example language (illustrative, self-talk): 'Where am I on the power map with this person, and what might I not be seeing because of it?'
  • Watch for: an inventory that lists only marginalised identities and skips privilege; working 'on' the client's culture without examining your own. Working when you can name specific biases and a concrete learning plan.

A2. Quadrant mapping of the dyad

  • Purpose: anticipate power dynamics in the relationship [source: Counseling Today MSJCC article; Ratts et al. 2015].
  • Steps: (1) For each salient identity, place the dyad in Quadrant I (privileged counsellor, marginalised client), II (both privileged), III (marginalised counsellor, privileged client) or IV (both marginalised). (2) Note that the same dyad can sit in several quadrants at once depending on identity, e.g. shared racial marginalisation but differing gender or sexual-orientation privilege. (3) For each quadrant, predict likely risks (I: unintended replication of oppression; III: client bias toward counsellor; IV: over-assuming shared experience) [risk examples: synthesis]. (4) Use this to plan your broaching statement (B2).
  • Watch for: assuming a single quadrant; assuming shared identity equals shared experience.

A3. Session-by-session reflection questions

  • Purpose: keep cultural awareness active and build cultural comfort [source: Tao 2025, MCO training deck].
  • Steps: after each session, note: what you noticed about identity or culture; what you were curious about and why; which of your identities might shape that curiosity; what you did not do or ask and why; what body cues you noticed in yourself. Bring patterns to supervision; supervisors can use the same questions.
  • Watch for: repeated 'what I didn't ask' about the same topic, a sign of avoidance (see E2).

A4. Consultation, training and referral; owning limits

  • Purpose: practise within competence and keep growing [source: Arredondo et al. 1996; Davis et al. 2018; Day-Vines et al. 2007].
  • Steps: (1) Identify gaps (a population, language or practice you know little about). (2) Seek consultation, preferably including people whose values or identities differ from yours. (3) Seek training and community involvement outside the counselling room. (4) Refer when the gap is too great for safe work (e.g. language), explaining the reason to the client. (5) Ask supervisors for honest feedback rather than hiding weaknesses.
  • Watch for: defensiveness in supervision; using referral to avoid discomfort rather than because of a real competence gap [synthesis].

B. Engagement and cultural assessment

B1. Orienting the client to counselling and to culture

  • Purpose: explain the process (goals, expectations, legal rights, your orientation) and signal that culture is welcome in the room [source: Arredondo et al. 1996; Davis et al. 2018].
  • Steps: (1) In session 1, describe what therapy involves, confidentiality and its limits, and how you work. (2) Ask what the client expects of a helper; check expectations from their culture or past help-seeking. (3) Say explicitly that their background, identities and experiences of being treated unfairly are relevant and can be raised at any time. (4) Ask early how they would like you to handle it if you get something wrong (links to E3).
  • Example language (illustrative): 'People's background, faith, family and experiences of how they're treated often matter a lot in what brings them here. You're welcome to bring any of that in, and I may sometimes ask about it.'
  • Watch for: a client who expects a more directive or advice-giving helper; adjust format rather than pathologising the expectation [synthesis].

B2. Broaching the counselling relationship (intracounselling)

  • Purpose: open discussion of how differences or similarities between you and the client may affect the work; builds safety and the working alliance [source: Day-Vines et al. 2007; Cogan et al. 2024].
  • When: early (first or second session), when the client's presentation suggests identity is relevant, and later whenever the relationship seems affected. The residents' framework notes some moments are unsuitable, e.g. an acutely decompensated patient [source: Cogan et al. 2024].
  • Steps (four-stage preparation from Cogan et al. 2024, built on Day-Vines): (1) Know the broaching strategies (B2, B3). (2) Prepare: reflect on your own position and biases (A1, A2). (3) Set an intention: why you are raising it now. (4) Compose the statement with the specific context or form of oppression in mind. In session: (5) Make the statement warmly and tentatively. (6) Paraphrase and validate the response. (7) Leave the door open for later.
  • Example language: Day-Vines et al. offer an example of a White European American woman counsellor asking how the client feels about working with her (paraphrased). Illustrative: 'I'm a White woman and you've told me about being one of very few Black staff at your firm. I wonder what it's like to talk about this with me, and I want you to know you can tell me if I'm missing something.'
  • Watch for: client reactions mapped by Day-Vines et al.: low racial salience (client says race is irrelevant; respect it, explore what identities do matter); anger (do not personalise; it may be directed at oppression rather than you). Working when the client brings cultural material spontaneously in later sessions.

B3. Broaching across the four dimensions

  • Purpose: explore culture beyond the dyad [source: Cogan et al. 2024, drawing on Day-Vines].
  • Steps: choose the dimension that fits the client's material: (a) intracounselling (B2); (b) intraindividual: how overlapping identities (race, gender, sexuality, class) shape this experience; (c) intra-racial/ethnic/cultural: tensions within the client's own community, e.g. differing values or expectations; (d) inter-racial/ethnic/cultural: effects of racism, discrimination or oppression from outside. Then paraphrase, validate, and keep the topic open.
  • Example language (illustrative): (b) 'You're a first-generation student, a woman, and from a working-class family. Which of those feels most present in this?' (c) 'Are there expectations from your family or community that pull against what you want?' (d) 'Has the way people respond to your race or accent played a part in what happened at work?'
  • Watch for: the 'continuing/incongruent' pattern, broaching repeatedly but through stereotypes or without linking culture to the presenting problem [source: Day-Vines et al. 2007].

B4. Core Cultural Formulation Interview (DSM-5)

  • Purpose: a brief semi-structured interview eliciting the client's own view of the problem, its causes and context, coping and help-seeking, and treatment expectations; designed for all patients in all settings, not only minorities [source: Aggarwal et al. 2016].
  • When: at the start of the initial assessment; designed to take about 15–20 minutes [source: Aggarwal et al. 2016].
  • Steps (structure only; obtain the official form from the APA): (1) Introduce it by saying you want to understand the problem in the client's own words, that there are no right or wrong answers, and that their view may differ from a biomedical one. (2) Domain 1, cultural definition of the problem (3 questions): what brings them, how they would describe it to people close to them, what troubles them most. (3) Domain 2, perceived cause, context and support (7 questions): their explanation of cause, their own term for the problem (then use that term in place of 'the problem' in later questions), what family and friends think, supports and stressors, and which cultural identities matter to them and how. (4) Domain 3, self-coping and past help-seeking (3 questions): what they do to cope, help sought inside and outside medicine, past barriers. (5) Domain 4, current help-seeking (3 questions): what help they want now, what people close to them think would help, and any concerns about differences between you and them. (6) Use answers to tailor the plan, gauge social impairment, identify the most relevant social group, plan around barriers and resources, and address relationship concerns.
  • Example language (illustrative): 'You called it “nerves”. What do you think has been causing your nerves?'
  • Watch for: rushing it as a form; ignoring the final question about clinician differences. Working when you can restate the problem in the client's idiom and they agree.

B5. CFI Informant Version

  • Purpose: gather a key informant's cultural view (spouse, relative, friend) [source: Aggarwal et al. 2016].
  • When: client cannot give a coherent history; history vague or contradictory; informant central to decisions or care; client wants them involved; difficulties arise later in treatment.
  • Steps: (1) Get the client's consent and respect privacy and autonomy first. (2) Choose timing and which informant, using all or part of the instrument. (3) If client and informant views differ, present both non-judgementally alongside the clinical view, negotiate a shared understanding where possible, and otherwise document the differences.
  • Watch for: informant views overriding the client's; confidentiality breaches.

B6. CFI supplementary modules

  • Purpose: deepen specific domains; 12 modules can be used with the core CFI or alone [source: APA CFI supplementary modules].
  • Modules and when to use: Explanatory Model (detailed causes and mechanisms); Level of Functioning (daily life impact; can pair with a standard disability measure); Social Network (how others respond, whether to involve them); Psychosocial Stressors (sensitive stressors including discrimination, when the client may be reluctant to raise them); Spirituality, Religion and Moral Traditions (use the client's own names for their traditions); Cultural Identity (background, language, migration, gender, sexuality, religion); Coping and Help-Seeking (self, family, spiritual, medical, alternative help); Patient–Clinician Relationship (expectations of clinicians; repeat across sessions as rapport develops); School-Age Children and Adolescents (with a parent addendum); Older Adults (aging, comorbidity, ageism); Immigrants and Refugees (migration history, losses, legal status; use accurate interpretation and allow time for trust); Caregivers (caregiver's role and expectations, or when the person cannot answer).
  • Watch for: over-assessment at intake; spread modules across sessions as relevant [synthesis].

B7. ADDRESSING assessment of the client

  • Purpose: a checklist to consider all major cultural influences and their intersections so none is assumed or missed [source: Hays; book details [uncertain]; letters confirmed on Hays workshop page].
  • Steps: (1) After intake, review each ADDRESSING dimension for the client, noting what you know, what you are assuming and what to ask. (2) Note which identities are privileged or marginalised in the client's context. (3) Ask, rather than infer, about dimensions not yet discussed (e.g. religion), as the MCO authors illustrate with a therapist who wrongly assumed a client from Tennessee was Christian [source: Davis et al. 2018]. (4) Note intersections that shape the presenting problem.
  • Example language (illustrative): 'I don't want to assume. Is faith or spirituality part of your life, and if so, how?'
  • Watch for: using the checklist as a substitute for the client's own account of what matters.

B8. Assessing culturally related strengths and supports

  • Purpose: identify the client's cultural resources for later use in intervention (Hays step 2) [source: Hays 2009]. Hays names a 'Personal Strengths Inventory' tool; its content is not drawn on here [uncertain].
  • Steps: (1) Ask about strengths linked to each salient identity (e.g. bilingualism, faith, survival of migration, extended family, community roles, cultural pride, humour). (2) Ask about supports: people, places, practices and institutions. (3) Record them in the client's words; review them when building plans and replacement thoughts (C4). Treat bilingualism as a strength, not a barrier [source: Arredondo et al. 1996].
  • Example language (illustrative): 'What has your background given you that helps you get through hard times?'
  • Watch for: clients who were taught to see their culture as a deficit; it may take several sessions to name strengths.

C. Culturally responsive treatment

C1. Collaborative cultural conceptualisation and shared planning

  • Purpose: let the client's worldview shape the formulation and plan, sharing power [source: Davis et al. 2018].
  • Steps: (1) Draft a formulation that includes cultural identity development in context, stressors including discrimination, the client's explanatory model (B4) and strengths (B8). (2) Present it in plain, jargon-free language and ask what fits and what does not. (3) Revise with the client. (4) Agree goals and methods, asking about preferences (e.g. directive vs exploratory, individual vs family sessions, involvement of spiritual figures). (5) Monitor whether chosen interventions still fit the client's values. (6) If you hold a privileged identity, check the plan does not repeat patterns of oppression (e.g. you deciding what is 'healthy' for them); if you hold a marginalised identity, notice when it becomes salient.
  • Example language (illustrative): 'Here's how I'm putting it together so far. Tell me where it sounds right and where it sounds like my way of seeing things rather than yours.'
  • Watch for: agreement given out of deference to authority [synthesis]; ask for disagreement explicitly.

C2. Separating environmental from cognitive or internal problems (Hays steps 3–4)

  • Purpose: distinguish problems located mainly in the environment (discrimination, poverty, unsafe housing, hostile workplace) from those mainly in the client's thinking or behaviour, and address environmental problems directly [source: Hays 2009].
  • Steps: (1) List the problem's components with the client. (2) For each, ask: is this mostly about what is happening around them, or about how they are interpreting or responding to it? Consider cultural influences on both. (3) For environmental components, work on reducing stressors, building supports and strengths, and developing skills to deal with the social and physical environment (problem-solving, referral, advocacy: see D). (4) Reserve cognitive restructuring (C4) for genuinely internal components.
  • Example language (illustrative): 'Some of this sounds like it's really happening to you at work, and some sounds like the voice in your head afterwards. Shall we sort which is which, because they need different tools?'
  • Watch for: treating a realistic perception of discrimination as a distortion.

C3. Validating experiences of oppression; appraising bias ('healthy paranoia')

  • Purpose: accept the client's account of oppression (Hays step 5) and help them judge whether a problem stems from bias in others so they do not wrongly blame themselves [source: Hays 2009; Arredondo et al. 1996, which uses the short phrase "healthy paranoia"].
  • Steps: (1) When the client reports discrimination, reflect and validate before exploring. (2) Do not interrogate whether it 'really' was bias. (3) Help the client weigh the situation: what happened, patterns over time, others' experiences, institutional context. (4) Explicitly name systemic contributors and the client's non-responsibility for them. (5) Explore the impact (anger, despair, exhaustion) and coping.
  • Example language (illustrative): 'That sounds unfair and exhausting. It makes sense you'd be wary after the pattern you've described.'
  • Watch for: the counsellor 'balancing' with alternative explanations too soon; Day-Vines et al. describe a case in which ignoring a client's account of racism damaged trust and risked dropout [source: Day-Vines et al. 2007].

C4. Culturally responsive cognitive restructuring (Hays steps 6–9)

  • Purpose: adapt cognitive work so it respects the client's worldview [source: Hays 2009].
  • Steps: (1) Favour collaboration over confrontation; attend to differences between you and the client. (2) Identify thoughts that are unhelpful to the client (by their own standard). (3) Test helpfulness rather than truth: ask what the thought does for them and what it costs. (4) Do not challenge core cultural or religious beliefs; work around or within them. (5) Build replacement thoughts using the client's own cultural strengths and supports list (B8), e.g. a family saying, a faith teaching, a role model from their community.
  • Example language (illustrative): 'When you tell yourself you've shamed your family, how does that thought affect what you do next? Is there something your grandmother would say to you that might help more?'
  • Watch for: the client's relief or energy when a replacement thought is in their own idiom; defensiveness suggests you have touched a core belief.
  • Note: Hays's workshop materials also name tools called 'Compassion Voice', 'Wise Elder' and 'Most Generous Interpretation Technique'; their procedures are not described here [uncertain].

C5. Culturally congruent, client-directed homework (Hays step 10)

  • Purpose: make between-session tasks fit the client's culture and life [source: Hays 2009].
  • Steps: (1) Ask the client to propose or shape the task. (2) Check it against their obligations (family, work, religious practice), resources (time, privacy, literacy, money) and values. (3) Use culturally familiar forms where possible (prayer, conversation with an elder, community activity, oral rather than written practice). (4) Review next session without blame; redesign rather than label non-completion [synthesis for 3–4].
  • Example language (illustrative): 'What would be realistic this week, given everything at home? What form would feel natural to you?'

C6. Adapting helping style and communication

  • Purpose: use a range of verbal and nonverbal helping responses, send and read messages accurately, and modify a culturally limited style [source: Arredondo et al. 1996; Ratts et al. 2015].
  • Steps: (1) Notice the client's communication style: high- vs low-context, use of eye contact, silence, directness, time orientation, use of space [source: Ratts et al. 2015]. (2) Adjust pace, directness, self-disclosure and structure accordingly. (3) Check understanding explicitly when styles differ. (4) Consider sharing your own cultural identities where it helps, as the MSJCC application article suggests at the intrapersonal level [source: Counseling Today MSJCC article].
  • Example language (illustrative): 'I tend to ask a lot of direct questions. Tell me if it would be better for me to slow down or say more about myself.'
  • Watch for: misreading reduced eye contact, indirectness or silence as resistance or symptoms [synthesis].

C7. Working in the client's language; interpreters and bilingual referral

  • Purpose: provide service in the client's requested language [source: Arredondo et al. 1996].
  • Steps: (1) Ask preferred language for therapy and for emotional topics. (2) If you cannot provide it, use a translator with suitable cultural knowledge and professional background, or refer to a competent bilingual counsellor. (3) For refugees and immigrants, use accurate interpretation and allow time for trust [source: APA CFI supplementary modules]. (4) [synthesis] Brief the interpreter before sessions on confidentiality and verbatim rendering, avoid family members (especially children) as interpreters, speak to the client not the interpreter, debrief afterwards.
  • Watch for: an interpreter from a group the client distrusts; ask the client [synthesis].

C8. Culturally fair use of assessment instruments

  • Purpose: use tests for the client's benefit while recognising cultural limitations and bias [source: Arredondo et al. 1996].
  • Steps: (1) Check whether norms and validation include the client's group and language. (2) Interpret scores cautiously and in light of the CFI and cultural idioms of distress. (3) Identify and remove bias and discriminatory contexts in evaluation (racism, sexism, heterosexism, elitism). (4) Explain results in the client's terms.
  • Watch for: diagnosing culturally normative experiences as pathology; Day-Vines et al. stress distinguishing culture-specific behaviour from unhealthy functioning [source: Day-Vines et al. 2007].

C9. Involving family, traditional healers and religious or spiritual leaders

  • Purpose: respect indigenous helping practices and community support networks; consult traditional healers and spiritual leaders when appropriate [source: Arredondo et al. 1996; Davis et al. 2018].
  • Steps: (1) Ask (CFI Domain 3 and Coping and Help-Seeking module) what other help the client uses or wants. (2) With written consent, contact or invite the helper. (3) Agree roles and how approaches complement each other. (4) Respect taboos and spiritual beliefs in the plan.
  • Example language (illustrative): 'Would it help if I spoke with your pastor, or if your mother came to one session? Only if you want that.'
  • Watch for: safety conflicts (e.g. a practice that delays urgent medical care); handle openly and in consultation [synthesis].

C10. Navigating value conflicts

  • Purpose: handle clashes between your values and the client's without imposing yours [source: Davis et al. 2018; Hook et al. 2025].
  • Steps: (1) Name the conflicting values and who they affect (e.g. your egalitarian values vs a couple's wish for traditional gender roles). (2) Moral foundations theory can be used to structure the analysis [source: Davis et al. 2018]. (3) Take it to consultation or supervision, ideally with people whose values differ from yours. (4) Decide whether and how to raise it with the client. (5) Support the client's goals unless there is a safety or ethical issue; Hook et al. describe a dialectical balance between reducing cultural arrogance and affirming your own boundaries.
  • Watch for: subtle steering through which topics you reflect and which you ignore [synthesis].

D. Socioecological and advocacy interventions (MSJCC Domain IV)

For each, first decide with the client whether to work collaboratively (building their self-advocacy) or act on their behalf, and at micro, meso or macro level (ACA Advocacy Competencies, as summarised in Counseling Today). Always get informed consent before any contact outside the session [synthesis for consent detail].

D1. Intrapersonal: critical consciousness and empowerment

  • Purpose: address internalised privilege or oppression; help clients develop critical consciousness of racism, sexism, ableism, classism, homophobia, transphobia and other oppressions; build self-advocacy [source: Ratts et al. 2015; Counseling Today MSJCC article].
  • Steps: (1) Assess how history, current issues and power contribute to the problem. (2) Explore internalised messages (e.g. 'people like me don't belong here') and trace where they came from. (3) Link personal experience to wider patterns, using language that connects the client's social status to their concerns. (4) Use empowerment-based techniques so the client can express anger or despair arising from discrimination. (5) Build self-advocacy skills (naming bias, requesting accommodations, documenting incidents) [examples in 5: synthesis].
  • Example language (illustrative): 'Where did you first learn that your accent made you sound less capable? Whose voice is that?'
  • Watch for: shifting from self-blame to anger is often a sign of progress, not deterioration [synthesis]. For privileged clients, the target is unlearning privilege.

D2. Interpersonal: family, peers and identity-affirming networks

  • Purpose: strengthen relationships that support the client and reduce those that undermine them; build connection with others who share their identities [source: Ratts et al. 2015; Counseling Today MSJCC article].
  • Steps: (1) Map relationships that support or obstruct progress and how identity plays into each. (2) With permission, talk with supportive family, friends, colleagues or community members, possibly outside the office. (3) Help the client find groups that share their identity (e.g. a student association), or for a privileged client an anti-racism group; the MSJCC article suggests counsellors may consider attending with the client. (4) Rehearse conversations about power and oppression with significant others. (5) Use evidence-based interventions that fit the client's culture.
  • Example language (illustrative): 'Who in your life gets this without you having to explain it?'
  • Watch for: boundary and dual-relationship issues when attending events with clients; discuss in supervision [synthesis].

D3. Institutional: climate exploration, allies and systemic advocacy

  • Purpose: assess and change how schools, workplaces, churches and organisations support or obstruct the client [source: Ratts et al. 2015; Counseling Today MSJCC article].
  • Steps: (1) Ask about the institutional climate (the MSJCC article's example asks what it is like to be the only Latina woman in a predominantly White workplace). (2) Consider a needs assessment or climate survey with the client. (3) Identify and connect the client with allies inside the institution. (4) Where indicated and consented to, advocate for systemic change (e.g. a school counsellor pushing for automatic doors and less crowded corridors for a wheelchair user; a clinician attending a workplace meeting as an ally). (5) Balance individual counselling with systems work.
  • Watch for: retaliation risk to the client; plan for it before acting [synthesis].

D4. Community: norms and stereotypes

  • Purpose: explore how spoken and unspoken community norms help or hinder the client and advocate against oppressive norms [source: Ratts et al. 2015].
  • Steps: (1) Explore how the client thinks others perceive them and which stereotypes they believe society holds. (2) Explore the wider societal views involved (the MSJCC article's example: a non-traditional female medical student having to prove herself to male peers). (3) Offer information, connection to resources, or broader social advocacy; draw on research on reducing negative attitudes.
  • Example language (illustrative): 'What do you think people in that department assume about you before you open your mouth?'

D5. Public policy

  • Purpose: identify and change laws and policies that disadvantage the client's group [source: Ratts et al. 2015; Counseling Today MSJCC article].
  • Steps: (1) Discuss with the client how specific policies affect them and how they could influence policy. (2) Research the policy's effects. (3) Take or support action: e.g. for a transgender client required to use a restroom matching their birth certificate, advocating with city officials or working with professional organisations and legislators on non-discriminatory policy. (4) Advocate outside the office for fair access to employment, healthcare and education.
  • Watch for: the client's wishes about public visibility; never make them a case example without consent [synthesis].

D6. International and global affairs

  • Purpose: stay informed about world events that affect clients' wellbeing [source: Ratts et al. 2015].
  • Steps: (1) Track events likely to affect clients (the MSJCC article cites how a terrorist attack abroad may raise discrimination against Middle Eastern clients). (2) Seek training on the political and historical context. (3) Check in with affected clients proactively. (4) Work with community leaders on prevention programmes where relevant.
  • Example language (illustrative): 'With what's been in the news this week, I wondered how you and your family have been.'

E. Relationship maintenance and repair

E1. Noticing and acting on cultural opportunities

  • Purpose: use moments where the client's beliefs, values or identities surface to deepen the work [source: Davis et al. 2018; Hook et al. 2025; Tao 2025].
  • Steps: (1) Listen through a cultural as well as diagnostic lens. (2) When identity material appears, choose whether to follow it now; enter smoothly from the client's own words. (3) Name your curiosity, e.g. that a topic keeps recurring, and ask what it means to them. (4) If a subject seems hard, invite it at the client's pace; cultural themes can be approached indirectly. (5) Remember avoidance also communicates: it can signal the identity is unimportant to you.
  • Example language (illustrative): 'You've mentioned your church three times today. What part does it play in all this?'
  • Watch for: missed opportunities spotted in session review (A3).

E2. Building cultural comfort

  • Purpose: be at ease enough to stay curious in cultural conversations [source: Davis et al. 2018; Hook et al. 2025; Tao 2025].
  • Steps: (1) Track your thoughts, feelings and body sensations before, during and after cultural conversations. (2) Tolerate discomfort rather than rushing to resolve it; admit what you don't know. (3) Use mindfulness, self-affirmation, self-compassion or a here-and-now focus to settle anxiety about getting it wrong. (4) Build comfort through experiences outside the therapy room too. (5) Take persistent discomfort with a group to consultation.
  • Watch for: perfectionism and fear of evaluation, which drive avoidance.

E3. Inviting feedback on cultural fit and offences

  • Purpose: surface cultural ruptures that clients rarely volunteer; the MCO review notes microaggressions in therapy are commonly reported and often disclosed late or never [source: Davis et al. 2018].
  • Steps: (1) Early on, say you may make cultural mistakes and how you would like to hear about them. (2) Periodically check whether the work fits their values and background. (3) Revisit the CFI Patient–Clinician Relationship module across sessions [source: APA CFI supplementary modules].
  • Example language (illustrative): 'Has anything I've said or assumed about your background felt off? I'd genuinely rather know.'

E4. Repairing cultural ruptures and microaggressions

  • Purpose: restore trust after a cultural offence [source: Davis et al. 2018; Hook et al. 2025, ch. 7].
  • Steps: (1) Understand: invite the client's account without defending. (2) Validate the impact regardless of your intent. (3) Make amends in a way meaningful to this client, which can include a sincere apology. (4) [synthesis, from Tao 2025 themes] Name the moment explicitly, ask what they need from you now, reflect on your part (including what you did not do), and check in again next session. (5) Take it to supervision.
  • Example language (illustrative): 'I assumed your partner was a man, and that wasn't fair to you. I'm sorry. How did that land?'
  • Watch for: over-apologising that makes the client caretake your guilt [synthesis]; working when the client raises later concerns more readily.

5. Handling problems

  • Client says race or culture is irrelevant / declines broaching. Day-Vines et al. note clients with low racial salience may reject broaching because other identities (religion, occupation) matter more. Respond: accept it, ask which parts of who they are do matter, keep the door open, and do not press [source: Day-Vines et al. 2007]. [synthesis] Revisit only if the material later points to it; record the response so you don't repeatedly re-broach the same identity.
  • Client responds to broaching with anger or mistrust. Do not personalise; it may reflect opposition to oppression rather than you. Validate, stay non-defensive, and acknowledge real reasons for mistrust of helpers from your group [source: Day-Vines et al. 2007]. [synthesis] Ask what would help them judge whether you are safe to work with; offer referral to a counsellor who shares their identity if they want it, without treating that as failure.
  • Mismatch in identity development between counsellor and client. Day-Vines et al., drawing on Helms and Cook, note that a counsellor at a less developed racial-identity status than the client risks mistrust and early dropout, and when both are low sessions stay superficial. Respond with your own identity work in supervision (A1, A4) [source: Day-Vines et al. 2007].
  • Your own avoidance or fear of 'getting it wrong'. Common among trainees; authenticity can offset it [source: Cogan et al. 2024]. Use cultural comfort strategies (E2), session reflection (A3) and consultation; aim for genuine, imperfect broaching over silence [source: Davis et al. 2018].
  • 'Isolating' or tokenistic broaching. If you raised culture once at intake and never again, return to it when material arises (E1) and link it to the presenting problem [source: Day-Vines et al. 2007].
  • Stereotyping or over-generalising. If you notice you are explaining the client by their group, ask instead; check within-group difference and intersections [source: Ratts et al. 2015; Day-Vines et al. 2007].
  • Rupture after a microaggression. Follow E4: understand, validate, make amends meaningfully, apologise sincerely when warranted [source: Davis et al. 2018]. [synthesis] If the client goes quiet or misses sessions after a sensitive exchange, raise it directly rather than waiting.
  • Value conflict you cannot set aside. Follow C10; consult; if the conflict impairs your ability to serve the client's goals, refer with care and explanation [source: Davis et al. 2018; Arredondo et al. 1996]. [synthesis] Check your professional code: refusing a client solely because of their identity or values may itself be an ethical breach.
  • Marginalised counsellor, client expresses bias toward you (Quadrant III). Hook et al. describe a dialectical balance in which sometimes the right response is to set boundaries and affirm your own cultural position rather than only reduce arrogance [source: Hook et al. 2025]. [synthesis] Decide in the moment whether to name the comment, how it affects the work, and seek supervisor support afterwards; you are not obliged to absorb abuse.
  • Client blames self for systemic harm; therapy 'stuck' despite effort. Reassess with C2: the stuck point may be a continuing environmental stressor. Shift to environmental problem-solving or advocacy (D1–D5) [source: Hays 2009; Ratts et al. 2015].
  • Overwhelm from discrimination or race-based trauma. [synthesis] Slow pace, use grounding and here-and-now focus (MCO and Tao note somatic tracking), prioritise safety and supports, and separate validation (C3) from detailed re-telling. Screen for trauma symptoms and offer trauma-focused treatment within your competence.
  • Homework non-completion. Check cultural and practical fit before attributing it to resistance; redesign with the client (C5) [source: Hays 2009; synthesis for redesign].
  • Client and family disagree about the problem or treatment. Present both views non-judgementally alongside the clinical view, negotiate shared understanding where possible, otherwise document the differences; respect the client's privacy and autonomy first [source: Aggarwal et al. 2016].
  • Client wants an advice-giving or directive helper. Adapt your style (C6) rather than interpret as dependency [synthesis, consistent with Arredondo et al. 1996 on modifying culturally limited helping styles].
  • Language barrier. Use a culturally knowledgeable interpreter or refer to a bilingual counsellor (C7) [source: Arredondo et al. 1996].
  • Advocacy risks: boundaries, confidentiality, retaliation. [synthesis] Obtain explicit, specific consent for any contact outside sessions; agree what will be disclosed; plan for retaliation risk; prefer building the client's self-advocacy where possible; discuss attending community events with clients in supervision.
  • Client burdened with educating you. [synthesis] Ask, but also do your own learning outside sessions (MSJCC Action items); acknowledge when the client is teaching you and thank them, without making it their job.
  • Suicide or self-harm risk. [synthesis] Follow your standard risk-assessment protocol; add cultural factors: the client's meaning of suicide and help-seeking in their culture and faith, discrimination as a stressor, protective cultural and religious factors, family involvement preferences, and stigma. Use lethal-means counselling (safe storage and removal) as standard.
  • Cultural humility becomes self-focused. The MCO authors caution against treating cultural work as a finish line or a performance; keep the focus on the client's needs [source: Davis et al. 2018].

Sources

Sources:

Further reading (not drawn on): books and articles cited

  • Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling & Development, 70, 477–486.
  • Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996). Operationalization of the multicultural counseling competencies. AMCD.
  • Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and Social Justice Counseling Competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28–48.
  • Lewis-Fernández, R., Aggarwal, N. K., Hinton, L., Hinton, D. E., & Kirmayer, L. J. (Eds.) (2016). DSM-5 Handbook on the Cultural Formulation Interview. American Psychiatric Publishing.
  • Hays, P. A. (2009). Integrating evidence-based practice, cognitive-behavior therapy, and multicultural therapy: Ten steps for culturally competent practice. Professional Psychology: Research and Practice, 40, 354–360.
  • Hays, P. A. Addressing Cultural Complexities in Counseling and Clinical Practice: An Intersectional Approach (4th ed.). APA. [not drawn on; ADDRESSING letter meanings [uncertain]]
  • Hook, J. N., Davis, D., Owen, J., & DeBlaere, C. (2025). Cultural Humility: Engaging Diverse Identities in Therapy (2nd ed.). APA.
  • Sue, D. W., Sue, D., Neville, H. A., & Smith, L. Counseling the Culturally Diverse: Theory and Practice. Wiley. [standard textbook; not used for specific claims]
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