Language: ASPPB offers a French form of the EPPP (the FEPPP) where a licensing authority legally requires one. ASPPB has not yet published the competency statements in French, so our questions and cards are in English until it does.

5.C.2

Culturally attuned skills for building and keeping alliances

ASPPB's competency statement 5.C.2: Use culturally appropriate interpersonal skills (e.g., personal distance, use of language) to engage, establish, and maintain collaborative relationships and alliances

Culturally appropriate interpersonal skills are the concrete behaviors that make collaboration possible across cultures: how close to sit, which words to use, how to work through an interpreter, when and how to raise culture, and how to repair a misstep. None is a fixed rule for a group; each is tuned to the person, learned by watching and asking, and checked over time.

Key ideas

Personal distance: Hall's proxemics divides interpersonal space into intimate, personal, social and public zones, each suited to different kinds of interaction, and observed that preferred distances differ across cultures. Seating and room arrangement therefore send messages about formality and closeness.
The client's own words: "Thinking too much," an idiom of distress found worldwide, overlaps only partly with depression, anxiety and PTSD and should not be read as a gloss for a disorder. The DSM-5 Cultural Formulation Interview, found feasible and useful in an international field trial, elicits such explanations.
Interpreters: Professional interpreters are associated with better communication, use of services, clinical outcomes and satisfaction for patients with limited English proficiency than ad hoc interpreters, bringing care close to that of patients without a language barrier.
Broaching: Broaching is a counselor's effort to open meaningful conversation about a client's cultural identity. Among ethnic minority clients, indirect broaching was the most favorable approach overall, and avoiding cultural topics was consistently linked to poorer ratings on every therapy outcome measured.
Rupture and repair: A rupture is a breakdown in agreement on goals or tasks, or a strain in the bond. Across 11 studies, resolving ruptures was moderately related to good outcome (r = .29), so owning and repairing a cultural misstep is part of the work.

Worked example

Mrs. Rao, 58, is referred by her physician for depression. In the first session she says she is "not mental" and that her trouble is "thinking too much" since her husband's heart surgery. She answers questions politely but briefly.

Adopt her words: ask what "thinking too much" is like for her and use her phrase, rather than replacing it with "depression" at the outset.
Use Cultural Formulation Interview questions to learn her explanation: what she believes causes it, how her family would describe it and what help she would expect.
Broach culture indirectly and respectfully, for example by asking how people close to her view this kind of help, leaving her free to answer as she wishes.
If a misstep happens, such as naming a diagnosis too soon and seeing her withdraw, name it and repair it, since resolved ruptures go with better outcomes.

Shared language, invited cultural meaning and prompt repair are the working tools of a cross-cultural alliance.

Check yourself

In a study of ethnic minority clients, which therapist approach to cultural topics was most consistently linked with poorer therapy outcomes?

Practise 5.C.2

Sources

Hall (1966), The Hidden Dimension, Chapter 10, Distances in Man
Kaiser, Haroz, Kohrt, Bolton, Bass and Hinton (2015), "Thinking too much": a systematic review of a common idiom of distress, Social Science and Medicine (PMID 26584235), Abstract: overlap with psychiatric constructs; not a gloss for disorder
Lewis-Fernández and colleagues (2017), Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: mixed-methods results from the DSM-5 international field trial, British Journal of Psychiatry (PMID 28104738), Abstract: results and conclusions
American Psychiatric Association (2022), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, Section III, Culture and Psychiatric Diagnosis (Cultural Formulation Interview)
Karliner, Jacobs, Chen and Mutha (2007), Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature, Health Services Research (PMID 17362215), Abstract: principal findings and conclusions
Depauw, Van Hiel, De Clercq, Bracke and Van de Putte (2023), Addressing cultural topics during psychotherapy: evidence-based do's and don'ts from an ethnic minority perspective, Psychotherapy Research (PMID 36585951), Abstract: definition of broaching; results (indirect, direct and avoidant approaches)
Eubanks, Muran and Safran (2018), Alliance rupture repair: a meta-analysis, Psychotherapy (PMID 30335462), Abstract: definition of rupture; first meta-analysis (11 studies)