Cultural Humility: Measuring Openness to Culturally Diverse Clients

Cultural Humility: Measuring Openness to Culturally Diverse Clients
Joshua N. Hook University of North Texas
Don E. Davis Georgia State University
Jesse Owen University of Louisville
Everett L. Worthington Jr. and Shawn O. Utsey Virginia Commonwealth University
Building on recent theory stressing multicultural orientation, as well as the development of virtues and dispositions associated with multicultural values, we introduce the construct of cultural humility, defined as having an interpersonal stance that is other-oriented rather than self-focused, characterized by respect and lack of superiority toward an individual’s cultural background and experience. In 4 studies, we provide evidence for the estimated reliability and construct validity of a client-rated measure of a therapist’s cultural humility, and we demonstrate that client perceptions of their therapist’s cultural humility are positively associated with developing a strong working alliance. Furthermore, client perceptions of their therapist’s cultural humility were positively associated with improvement in therapy, and this relationship was mediated by a strong working alliance. We consider implications for research, practice, and training.
Keywords: humility, multicultural orientation, outcome
In recent years, psychologists have recognized the importance of developing multicultural competencies (MCCs) in the areas of education, training, research, and practice (American Psychologi- cal Association [APA], 2003). There are three main components of MCCs: attitudes/beliefs, knowledge, and skills (D. W. Sue, Arre- dondo, & McDavis, 1992; D. W. Sue et al., 1982). APA MCCs guidelines encourage psychologists to (a) develop an understand- ing of their own cultural background and the ways that their cultural background influences their personal attitudes, values, and beliefs (i.e., attitudes/beliefs); (b) develop understanding and knowledge of the worldviews of individuals from diverse cultural backgrounds (i.e., knowledge); and (c) use culturally appropriate interventions (i.e., skills). This tripartite model has greatly influ- enced the research, practice, and training of psychologists.
Although the field of MCCs has received increasing research attention over the past 30 years, researchers have called for (a) innovations in the measurement of MCCs and (b) increased re-
search linking MCCs to actual client improvement (Worthington, Soth-McNett, & Moreno, 2007). Measurement concerns in this field include (a) reliance on therapist-report measures (Worthing- ton et al., 2007); (b) lack of association between therapist-reported MCCs, client-reported MCCs, and observer-rated MCCs (Con- stantine, 2001; Fuertes et al., 2006; Worthington, Mobley, Franks, & Tan, 2000); and (c) conflation of therapist-report measures of MCCs and therapist efficacy for conducting culturally sensitive counseling (Constantine & Ladany, 2001).
Some researchers have suggested a shift from measuring ther- apists’ MCCs to measuring therapists’ multicultural orientation (MCO; Owen, Tao, Leach, & Rodolfa, 2011). Whereas MCCs might assess how well a therapist has mastered specific knowledge or skills for working with a culturally diverse client, MCO might assess a therapist’s “way of being” with the client, guided by the therapist’s philosophy or values about the salience of cultural factors in the lives of therapists and clients. In contrast to MCO, MCCs can be conceptualized as “ways of doing” that assess how competent a therapist is at implementing cultural awareness, knowledge, and skills into therapy (Owen et al., 2011). Related to this shift from competencies to orientation, others have identified virtues or dispositions for therapists that align with the values of diversity in the field of counseling psychology (Winterowd, Ad- ams, Miville, & Mintz, 2009). For example, Fowers and Davidov (2006) argued that the primary virtue necessary for multicultural- ism is openness to the other.
This multicultural focus on openness to the other is closely related to the concept of humility. In their review of definitions of humility, Davis, Worthington, and Hook (2010) noted that defini- tions of humility generally included both intrapersonal and inter- personal components. On the intrapersonal dimension, humble individuals have an accurate view of self. On the interpersonal
This article was published Online First May 6, 2013. Joshua N. Hook, Department of Psychology, University of North Texas;
Don E. Davis, Department of Counseling and Psychological Services, Georgia State University; Jesse Owen, Department of Educational and Counseling Psychology, University of Louisville; Everett L. Worthington Jr. and Shawn O. Utsey, Department of Psychology, Virginia Common- wealth University.
We would like to acknowledge the generous financial support of John Templeton Foundation, Grant No. 14979 (Relational Humility: An Inter- disciplinary Approach to the Study of Humility) and the University of North Texas (Research Initiation Grant).
Correspondence concerning this article should be addressed to Joshua N. Hook, Department of Psychology, University of North Texas, 1155 Union Circle #311280, Denton, TX 76210. E-mail:
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Journal of Counseling Psychology © 2013 American Psychological Association 2013, Vol. 60, No. 3, 353–366 0022-0167/13/$12.00 DOI: 10.1037/a0032595

dimension, humble individuals are able to maintain an interper- sonal stance that is other-oriented rather than self-focused, char- acterized by respect for others and a lack of superiority (Davis et al., 2011). In the present study, we focus on the interpersonal dimension, which we view as potentially more relevant to the therapy relationship and better able to be accurately perceived (and rated) by the client (Funder, 1995; Vazire, 2010). Furthermore, humility may be especially important in order to develop a strong bond in a situation in which relationship partners may have a strong tendency to value their own perspective (e.g., cultural differences; Davis et al., 2013). We posit that for a therapist to develop a strong working relationship and conduct effective coun- seling with a client who is culturally different, the therapist must be able to overcome the natural tendency to view one’s own beliefs, values, and worldview as superior, and instead be open to the beliefs, values, and worldview of the diverse client.
The purpose of the present studies was to develop a client-rated measure of cultural humility as a component of MCO. Namely, we were interested in the degree to which clients perceived their therapists as expressing humility in regard to central aspects of cultural identity such as gender, race/ethnicity, sexual orientation, or religion/spirituality. Therapists have their own beliefs, values, and worldviews that likely guide how they understand psycholog- ical distress and how people make changes in their lives. Thera- pists who do not create a therapeutic environment that is open to different beliefs, values, and worldviews may struggle to work effectively with diverse clients. Cultural humility may help coun- teract and regulate the sense of superiority that may occur when cultural differences arise in therapy. As such, cultural humility involves the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client. Cultural humility is especially apparent when a therapist is able express respect and a lack of superiority even when cultural differences threaten to weaken the therapy alliance. Culturally humble thera- pists rarely assume competence (i.e., letting prior experience and even expertise lead to overconfidence) for working with clients just based on their prior experience working with a particular group. Rather, therapists who are more culturally humble approach clients with respectful openness and work collaboratively with clients to understand the unique intersection of clients’ various aspects of identities and how that affects the developing therapy alliance.
The concept of cultural humility is not entirely new. Tervalon and Murray-Garcia (1998) contrasted the concept of cultural hu- mility with MCCs in the field of health care. They noted that whereas MCCs have traditionally focused on building knowledge of multicultural content areas, cultural humility requires practitio- ners to engage in self-reflection and self-critique as lifelong learn- ers. Similarly, S. Sue (1998) has encouraged therapists to develop scientific mindedness when working with clients from diverse backgrounds. Thus, therapists should make hypotheses rather than jump to premature conclusions when working with clients from diverse backgrounds. Ridley, Mendoze, Kanitz, Angermeier, and Zenk (1994) have encouraged therapists to develop cultural sen- sitivity, which involves seeking out, perceiving, and interpreting cultural information from clients. Ridley et al. note that it is impossible to understand an individual on the basis of his or her cultural background alone. Rather, therapists should accept their
naiveté in regard to their assumptions about clients from diverse backgrounds.
Thus, although the idea of cultural humility has been previously discussed, models on the development of MCCs (and the existing instruments) have focused primarily on helping therapists build and develop competencies (i.e., self-awareness, knowledge, and skills). Rather than focusing on specific competencies, our con- ceptualization of cultural humility can be categorized as a virtue…