Journal of Consulting and Clinical Psychology 1991, Vol. 59, No.

6,799-812

Copyright 1991 by the American Psychological Association. Inc. 0022-006X/91/S3.00

Cultural Diversity and Treatment of Children

Roland G. Tharp University of California, Santa Cruz

The increasing cultural diversity of child clients has produced a cascade of new issues and concerns for psychological practice, theory, and research. Available evidence and pertinent theory are reviewed on such topics as the predictive utility and treatment consequences of ethnic membership, whether treatments should be generic or specific to cultural groups, the degree of privilege that should be accorded to same-culture therapists, and the relative desirability of different modalities of treatment for children of different cultural groups. The concept of cultural compatibility of treatment is explored and evaluated. A broad agenda of hypotheses for research and development is suggested, and some guidelines for clinical practice and policy are proposed. It is concluded that insofar as possible, treatment for all children should be contextualized in their family's and community's structure of meanings, relationships, and language.

The culturally diverse society that our nation has become provides a challenge to our politics, our schools, our science, and our profession. As reiterated by concerned commissions, agencies, professional organizations, and review articles including the current Guidelines for Providers of Psychological Services to Ethnic andCulturatty Diverse Populations (American Psychological Association, 1990), we are instructed that "Psychologists should recognize ethnicity and culture as significant parameters in understanding psychological processes" (p. 4) before delivering services. What will be necessary to satisfy this new imperative? Self-examination? New specialized training? Anthropological indoctrination, religious and spiritual relativism, multilingualism, "politically correct" thought? And most to the point, what are the required practical clinical actions? In discussing these questions, Pedersen and Marsella (1982) conclude that to know all and do all that a psychologist should is a goal that accelerates beyond us. The task is to bring some order out of this cascade of new issues and concerns, in the light of available research evidence and pertinent theory. I will suggest here that some broad outlines for strategy are emerging, with enough clarity at least to pose an agenda of hypotheses for research and development, and possibly even to provide an initial set of guidelines for clinical practice and policy. These strategies can be stated clearly enough to allow them to be tested by both formal evaluation and clinical experience. Not to overpromise, it should be said that research on cultural issues in clinical treatment is scant, particularly research addressing such issues with children. We must rely on evidence from other age groups and look to related literatures (family and community) where child treatment is discussed. Cultural issues in the education of children is a field somewhat more mature, and if considered cautiously, evidence from that field can serve by analogy. Other disciplines, notably anthropology and linguistics, have a longer history with the study of ethnic and

cultural diversity, and psychology can anticipate from their experience. In attempting to discern the figure in this ground, we can fit some of these diverse tesserae into the beginning of a mosaic. Still, there are more spaces than tiles.

Basic Questions
Concerns arising from both theory and practice converge on four basic questions about the implications of cultural membership for the treatment of children. First, is there a useful level of developmental analysis, which I will call here ethnogenetic, that accounts for important current features of a childls psychology in terms of the historical forces operating on his or her ancestors in a time frame of hundreds to thousands of years? That is, does ethnogenesis, which lies in the dimension of time between phylogenesis and ontogenesis, provide critical elements for understanding and treating the child's present condition? Second, are there present in cultures psychosocial features so widely shared that membership is a useful guide for prescription of clinical services? Or, conversely, does membership as a guide result in stereotypical overgeneralization, and are more conventional individual and family descriptors to be preferred? Third, are there forms of treatmenteither potential or actualthat are specifically or uniquely suited for the treatment of children of different cultures? It is important to differentiate specific from unique. Although one or another form of therapy may be specifically suited for members of one culture, that does not mean that the modality is exclusively suited to them; family therapy, for example, might prove to be the treatment of choice of members of several cultures, whereas the sweat lodge might be uniquely suited to those of only one. Fourth, are culture members privileged in the capacity to treat or to investigate the treatment of children of their own culture? Although the literature has not necessarily developed in response to them, these questions may be borne in mind as the available knowledge is reviewed.

Cultural Differences in Diagnosis and Treatment

Correspondence concerning this article should be addressed to Roland G. Tharp, Merrill College, University of California, Santa Cruz, California 95064.

Cultural Differences in Pathology

Some childhood disorders are of particular frequency in certain cultural groups, because of either characteristic social
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ROLAND G. THARP ture" (Krener & Sabin, 1985, p. 457). These authors decry the practice of applying the diagnostic scheme of one culture to child patients from another. Among indigenous minorities, there are also characteristic child problems. Because of high rates of death and displacement, Crow Indian children objectively experience repeated and traumatic loss; they suffer a chronic condition of mourning and depression (Long, 1983). The common plight of the actingout, depressed, poor, alienated Black male adolescent is another example of a disorder so frequent in that group as to require a psychocultural category. Paster (1985) provides a discussion of this syndrome, emphasizing the way that political, historical, societal, economic, interpersonal, and intrapsychic factors may be seen as intertwined and reciprocally reinforcing; the article is an example of how ethnogenetic, ontogenetic, and microgenetk levels of analysis integrate. When such integrated-genetic analyses are performed, it is difficult to discount cultural factors. The case can be made that not only in minorities are cultural, ethnogenetic features present in psychopathology. The overwhelming evidence of cultural psychiatric literature. . . is that cultural factors are a substantial part of every disorder and not a descriptive, picturesque component.. . . What is lacking in the [DSM-III] system, from a Latin-American perspective, is the explicit recognition of psychocultural categories or cultural criteriaor bothto aid in the identification of crucial categories and in the description of clusters of symptoms. (Alarcon, 1983, p. 104) The even stronger case is made by Marsella and Higgenbotham (1984), who argue that reserving the term culture-specific for exotic disorders merely delays the awareness that all disorders are culture-specific, and so is all treatment.

problems or psychosocial structures. Weisz, Suwanlert, Chaiyasit, and Walter (1987) consider psychosocial differences by contrasting Thailand, a Buddhist nation, which discourages children's aggression and encourages inhibition, peacefulness, politeness, and deference, with the United States, where independence, competitiveness, and differentiation from the family as the goal of socialization is widespread. In Thailand, children and adolescents are referred for clinic treatment more often for "overcontrolled syndrome" (fearfillness, sleep problems, somaticizing), whereas in the United States referred children and adolescents are reported more often with "undercontrolled syndrome" (disobedience, fighting, arguing). The same general pattern is discernible in an epidemiological study, although the culturally consistent trends are more marked in parents' decisions to refer for treatment than in their general ratings of their children (Weisz, Suwanlert, Chaiyasit, Weiss, et at, 1987). Another "overcontrolled" society (Jamaican) has produced similar results (Lambert, Weisz, & Knight, 1989). Many describe minority status itself as a stressor, because it is often associated with hostility and prejudice. According to Moritsugu and Sue (1983) minority status also often is associated with a lack of effective support during crises and the danger of developing ineffective cognitive coping styles. The status of all minorities, however, is not the same, and neither are their characteristic stressors nor responses to them. In the field of minority education, the nature of stress and the responses to it are often differentiated for the children of voluntary immigrant groups versus those of "involuntary" minority children. Children of the latter (such as African Americans and Native Americans) learn that education does not lead to economic improvement, and they become withdrawn and hostile in school. Children of recent minority groups, however, may feel the stress of difference, but see that their people prosper through education, and they may respond in school by striving. Gibson and Ogbu (1991), with whose names this analysis is associated, are now attempting to further differentiate among minority groups as to the specific defenses and coping mechanisms used. As an example of disorders in response to culturally characteristic stressors, Indochinese refugee children treated in California were recovering from such severe stress that application of categories from the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., DSM-III, 1980, American Psychiatric Association) was confounded (Krener & Sabin, 1985). The pattern is found with Central American refugee children as well (Arredondo, Orjuela, & Moore, 1989). "For every one of our patients, Axis I DSM-III diagnoses could be reached on the basis of the patient's fulfilling the criteria, but the diagnosis was felt to be incompletely descriptive or fundamentally wrong" (Krener & Sabin, 1985, p. 457). The issue does not derive only from specific stress; their Indochinese child patients revealed cross-cultural child-rearing differences and their potential misconstruing as psychopathology. For example, the American concept of mourning includes a sequencing of stages and a time limitation. Indochinese, who believe that the dead live after bodily death, may be seen as manifesting pathological or incomplete grief. "Particular DSM-III diagnostic categories. . . break down when we attempt to apply them cross-culturally, and . . . may have only qualified validity within our own cul-

Cultural Differences

in Treatment

Do clients of all cultures receive equal mental health services? Meta-analyses of research conclude that the issue is not clear (Atkinson, 1985; Sue & Zane, 1987) because of the usual research problems of nonuniformity of treatment goals, inaccessibility of records, inappropriate analog designs, and absence of any process research. However, to illustrate the issue, we may consider a set of data that appear to make the optimistic case, that clients are offered about the same services according to diagnosis and prognosis, without regard for ethnicity. Sue, Allen, and Conaway (1978) studied 13,450 clients and found no evidence that Hispanic or Native-American clients in community mental health facilities were offered inferior or discriminatory services in either diagnosis, assigned personnel, or type of treatment. However, Hispanic and Native American clients frequently did not return after the initial treatment session. In these facilities, the dropout rates were Hispanic 42%, Indian 55%, Black 52%, Asian-American 52%, and Anglo clients only 30%. Why are these rates so high for minority culture clients? The authors indict not only the fit of the assigned type of service, but the quality of the professional interaction. Thus the same service is not necessarily responsive service, and in its effects, identical is not necessarily equal. Techniques that are of demonstrated utility in one culture may not operate in the same way for others. In a study con-

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ducted by Lieh-Mak, Lee, & Luk (1984), Hong Kong Chinese parents were trained to be mediators of behavior therapy for their own children, but the therapists reported severe culturally based reluctance, arising from patterns of traditional family structure and interaction. These parents found it difficult to play with their children or respond contingently with praise or ignoring, because this violated their accustomed mode of child rearing, their beliefs about childhood problems, and their attitudes about the proper role of doctors. Thus Lieh-Mak, Lee, & Luk warn against the ethnocentric bias involved in importing treatment modalities from one culture to another.

Cultural Differences

in Knowledge

The core of the problem, according to King, Moody, Thompson, & Bennett (1983), is that mental health intellectual and institutional constructions
reflect the orientations of educators, researchers, and therapists who too often make judgments about and define programs for Black persons and communities with insufficient data on the nature of these persons and communities, their beliefs, values or their abilities and resources. We have almost developed an incapacity to shift from our Anglo-American perceptions, to change our attitudes and to foster real change. (King et al., 1983, p. 5)

This perception of establishment ignorance and nonresponsiveness is not limited to African-American psychologists.
Although non-Indian psychologists are becoming increasingly involved in mental health service delivery to American Indians, they are, unfortunately, typically not prepared to work effectively with Indian clientele. The non-Indian psychologist may not be aware of the cultural values, life-styles, family practices, developmental progressions, and needs of their American Indian clients. This lack of cultural awareness typically results in conflicts and frustrations for both the psychologist and his or her Indian clients; ultimately, American Indian children and families may not receive appropriate mental health services. (Everett, Proctor, & Cartmell, 1983, p. 588)

the degree to which children should submit to adult dominance. The authors suggest that ignorance of these differential norms will lead to mistreatment of some parents by ethnocentric social workers. It should be noted that the potential for misunderstanding of one another's parenting conventions across all ethnic groups is high, and not restricted to EuroAmericans. However, the institutionalization of Euro-American norms into professional assumptions is a hazard to advances in psychocultural understanding and to the just perception of parents' behaviors within other cultures. A source book on ethnic child socialization is Phinney and Rotheram (1987), on cultural approaches to parenting is Bernstein (1991), and an analysis of the use of such information in understanding child abuse and neglect is Korbin (1980). Much of the research and professional literature in culture and mental health attempts to provide enough information to sensitize psychologists to cultural issues in diagnosis and treatment. Several journals have published special issues on culture and mental health, and edited books on the topic are the most typical medium of communication. The typical pattern of these publications is to have several chapters on specific cultures, book-ended by introductory and summary chapters that attempt more general discussions.' This construction well communicates the state of analysis of the issues. The field suffers from a shortage of empirical studies of program or variable evaluation, and there are virtually no studies of process in cross-cultural treatment. Nevertheless, this literature can sensitize the therapist to some issues that may be present for culturally unfamiliar clients.2 Differences Within Cultures

Not only is the individual client harmed, but child workers who devalue native culture may actually intensify social disorganization in Indian communities (Sullivan, 1983).
The single most important explanation for the problems in service delivery involves the inability of therapists to provide culturally responsive forms of treatment.. . .Most therapists are not familiar with the cultural backgrounds and life-styles of various ethnicminority groups and have received training primarily developed for Anglo, or mainstream, Americans. . . [and ] are often unable to devise culturally appropriate forms of treatment, and ethnicminority clients frequently find mental health services strange, foreign, or unhelpful. (Sue & Zane, 1987, p. 37)

This general approachto learn as much about cultures as possibleis frustrated by significant differences among subgroups and individuals within cultures. Everett, Proctor, and Cartmell (1983) point out the vast intertribal, interclan, urbantraditional, and individual differences among American Indian clients. Isomura, Fine, and Lin (1987) discuss the differences in offering services to Japanese immigrant families of the first, second, and third generations. Hispanic cultures differentiate among themselves; Cuban-, Mexican-, and Puerto RicanAmericans celebrate their distinctions as well as their common causes. Although clients expect respect and understanding of

Many mental health professionals find clients of some cultures strange and unhelpful, or even harmful, for example in the area of child abuse/neglect. Gray and Cosgrove (1985) interviewed Mexican, Samoan, Vietnamese, Filipino, Japanese, and Blackfoot as to their culturally normative child rearing values and practices. The researchers then examined these practices for the likelihood of their being misunderstood as "abuse" or "neglect" by child-protective professionals. That potential for misunderstanding is very high, particularly around two basic topics: the degree of responsibility delegated to children and

See, e.g, Atkinson, Morton, and Sue (1989); Pedersen, Sartorius, and Marsella (1984); Chunn, Dunston, and Ross-Sheriff (1983). 2 Notable journals include a special issue of Psychotherapy titled "Psychotherapy with Ethnic Minorities." There is a special issue of the American Journal of Social Psychiatry on psychiatric care of minority groups, ftmily therapy with immigrant families is treated in Journal of Strategic and Systemic Therapies, and Journal of Drug Issues has a special issue on "Alcohol Problems and Minority Youth." A useful compilation of orientations to family structure and function, with implications for family treatment, is discussed for 20 different cultural groups in McColdrick, Pearce, & Giordano (1982), and more recently by Ho (1987,1990), who presents useful tabular comparisons of familytherapy relevant dimensions by culture. For child treatment, the most useful volumes of this sort are Children of Color: Psychological Interventions With Minority Youth (Gibbs & Huang, 1989) and Ethnic Issues in Adolescent Mental Health (Stiffman & Davis, 1990).

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their culture and values, all will resent being seen merely as a representative of a cultural central tendency. Issues of culture and treatment exist today in a context of tempestuous intercultural relations in the political and economic arena, putting us in hazard of using cultural membership as no more than stereotypical overgeneralization. A part of the research agenda must therefore be to unpack the cultural variable (Whiting, 1976) so that differentiating characteristics within culture can be understood for clinical implications for individuals. In this way culture can be analyzed for its variable influence on individuals, in contrast to approaches that assign an equal value to culture for all members of a group. I am unaware of such work within mental health disciplines, but an idea of the strategy is given by work in culture and education (e.g., Weisner, Gallimore, & Jordan, 1988). Gallimore, Reese, Balzano, Benson, and Goldenberg (1991), in investigating the correlates of academic success for children of Mexican immigrants, found that the domestic variable with the strongest relationship to child school success is whether the father uses skills of literacy/numeracy in his employment (not the level of father's education). This kind of finer grained analysis of cultural and community life would allow us accurately to perceive the dynamics of culture in the daily life of the individual child in the consulting chair. Faced with these contradictions, confusions, similarities, and differences, mental health professionals have advocated every position on the continuum. Some writers bundle all "children of color" together and believe their cause is common. Other writers call for culturally derived diversity of treatments, and others insist on a universality of the form of treatment, although of course purified by a correction of racist attitudes. Psychological science is now searching for a system of understanding, and some theoretical guidance that
goes beyond a study of exotic populations from different cultures and examines guidelines for excellence for mental health as a whole. . .the case for emphasizing cultural context in the understanding, treatment, and prevention of mental disorders has been made extensively and persuasively. . .The problem we face, however is going from general knowledge about culture traditions to specific mental health practices. This is where the disagreements, debates, and arguments begin and where the pragmatists frequently lose interest. (Sartorius, Pedersen, & Marsella, 1984, p. 282)

ity, or Euro-American, culture; the second type includes those cultures whose students typically experience problems in schools, who are by-and-large children of color, less industrialized, urbanized, or western acculturated, and who thus share crucial incompatibilities with standard mental health practices. In this position, effective treatment strategies for children of color would not be critically different from one another. This position is more salient in social work (e.g., Lum, 1986) than in psychology. The null form of the cultural compatibility hypothesis is the universalistic argument that effective treatments will follow the same course for all cultures. This is the default hypothesis of clinical psychology, in that the unreflective proceed as though there are no significant differences. However, many universalists agree that there are some variant subroutines that make minority children and their families more comfortable and are willing to engage in the search for these accommodations. The challenge faced by all is to balance universality and pluralism, preserving an authentic responsiveness to individual differences while avoiding an impractically large number of kinds of treatments (Huang & Gibbs, 1989). The obstacles are several, but they include pervasive psychological theory that lacks concepts crucial to the solution, and in which culture itself plays almost no role as a variable. Proponents of all three positions appear to be moderately satisfied with the existing monolith of treatment, as derived from, practiced by, and practiced for Europeans and EuroAmericans. Whether their hypotheses call for erecting many other treatment structures, as in the culturally specific position; or creating one other alternate for children of color, as in the two-type hypothesis; or only for modifying and polishing the universalist structure, there is no systematic understanding that the serious examination of the issues of culture and treatment may well call for a restructuring of the monolith itself, even for children of its own. Approaches to Culturally Compatible Treatment Each of these hypotheses operates in the same arena and takes its different positions on certain salient issues. These include modifying professional role behaviors, assigning sameethnicity professionals, and searching for the process details that will create or modify compatible procedures. Modified Professional Roles in Cross-Cultural Treatment Jenkins (1985), in discussing Afro-American clients, suggests that they should be approached in a down-to-earth and egalitarian manner that reduces status differences. In this way a positive affective response is made more likely, and early treatment attrition is reduced. By contrast, it is not uncommon that a more authoritative, formal, and concrete therapist role is recommended for Japanese clients (e.g, Isomura, Fine, & Lin, 1987). Hong (1988) recommends that a psychologist dealing with an Asian-American clientele operate in a context of general family practice as a primary care provider, similar to the traditional family doctor who provides treatment for clients and their families, thus assessing the strong and traditional role of the family, minimizing client families' inhibition against

The Cultural Compatibility Hypothesis The hypothesis of cultural compatibility suggests that treatment is more effective when compatible with client culture patterns. The hypothesis has a more mature theoretical and research base in child education (Tharp, 1989) than in child mental health, but the issues may be argued in substantially the same terms. Three forms of this hypothesis exist. The strong form, or culturally specific version, suggests that the most effective interventions for different cultures will be different and specific (if not unique) to cultures. Proponents are associated with the effort to derive culturally based modalities or variations of treatment. A weaker form is the two-type hypothesis, which suggests that there are two types of cultures, and therefore two types of most-effective clinical interventions. The first type is the major-

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seeking mental health services, and taking advantage of the Asian-American's respect and deference to doctors. Juarez (198S) recommends a firm, instructing, professional demeanor when working with the Hispanic client, as do most who write from the Latino perspective. However, consider this quotation from Montijo (1985):
Any therapeutic model that strives to serve poor Puerto Ricans or poor people in general cannot. . .enhance the control and hierarchical superiority of the therapist at the cost of the greater sense of self-esteem produced by the assumption of greater autonomy, assertiveness, and responsibility by patients, (p. 439)

This contradiction is consistent with differences that flow from economic class, as well as differences in opinion as to whether mental health treatment should be seen first as an instrumentality that feeds and is fed by an existing social order. Furthermore, as in all efforts to match treatment to culture, there are wide individual and subgroup/acculturation differences in client preferences for therapist roles (Sue & Zane, 1987). Even if there were agreement on recommendations for professional role stances toward members of different cultures, problems remain, including the difficulty for any therapist of manifesting flexible role behaviors and maintaining authenticity. More fundamentally, many forms of treatment have theoretical requirements for specific role characteristics of the therapist. How much cultural variation in therapist behavior could be allowed without wounding the core of client-centered therapy, or psychoanalysis, or any theory driven treatment?

Ethnicity ofTherapists: The Question of Privileged Status When there are pervasive social attitudes from one culture toward another, are they likely to infiltrate the therapeutic relationship? Spurlock (1985) and Sykes (1987) both recommend an early and frank discussion of the comfort of the client in Black/ White cross-cultural treatment, thus assisting both parties to understand racially based attitudes. Greene (1985), following Kupers (1981), articulates four general stances that are expressions of racism, and for which White therapists are enjoined to self-examination. They are (a) bigotry, "a conscious or unconscious belief in White supremacy and as a consequence, the feeling that the Black patient's problems are an outgrowth of the patient's inferiority"; (b) color blindness, which "may represent the therapist's resistance to confronting the meaning of the color difference'1, (c) paternalism, which "involves the attribution of all of the patient's problems to society and the effects of racism. To do this will fail to help patients to understand any role they may have in their dilemma"; and (d), "often a result of the therapist's racial guilt, is the unquestioning compliance with the rhetoric of Black power . . . [which] can result in a failure or reluctance to set appropriate limits or interpret acting-out." The Black patient may consciously or unconsciously put the White therapist to a series of tests to determine the acceptance as an individual. "It remains, however, the therapist's responsibility to be familiar with the Black patient's culture to some extent, and with his or her own personal feelings and motivations for and about working with Black patients" (Greene, 1985; all quotations in this paragraph are from pp.

392-393). Is there any acceptable stance? Or are same-ethnicity therapists privileged in knowledge and attitude and thus in power of effectiveness? College youths have clear preferences for counselors who are like themselvesin many dimensions, not only ethnicity Samples give somewhat different results, depending on geographical location, but by and large students prefer counselors who are well educated and of the same ethnicity and gender and who share their attitudes and values; by and large students report themselves more likely to use counseling services when their preferences are met (Atkinson, Furlong, & Poston, 1986; Atkinson, Poston, Furlong, & Mercado, 1989; Haviland, Horswill, (JConnell, & Dynneson, 1983; Ponterotto, Alexander, & Hinkston. 1988). Preference is not the same as effectiveness. In a discussion of counseling with Mexican-American youth, DeBlassie (1976) insists that a therapist need not be Hispanic to be effective. Rather, common humanity is sufficient, and if solid counseling skills and correct, generous counselor attitudes are present, so too will be effectiveness. However, this author goes on to report many areas of values and beliefs that are arguably specific to Mexican-American youth, knowledge of which is critical to empathic understanding (DeBlassie. 1976). Sue (1988), who has labored long in the field of culture and treatment, reviews the literature on ethnic matching of therapist and client in psychotherapy and finds contradictory and inconclusive evidence as to whether matching is superior. He distinguishes between ethnic membership (which emphasizes national or geographic origin of ancestors) and cultural membership (which emphasizes current identifications with the group or groups, and their commonalities of values, attitudes, motives, etc.). Although concluding that ethnic matching is irrelevant, whereas cultural matching is likely to be an authentic distal variable affecting outcome, Sue urges researchers to consider more proximal variables, such as how cultural knowledge is translated into particular therapeutic behaviors and decisions. This position emphasizes the therapist's capacity for correct understanding and for comfortable communication.
The issue is not whether patients are treated more effectively by same-race, same-class, or same-sex therapists, but whether the therapists' interpretation of the clients' cultural experience creates the ambience that is necessary to establish rapport and an empathic bond which facilitates the therapeutic process. (Juarez, 1985, p. 441)

This resolution is similar to that espoused for cultural research by the Cuban-American anthropologist Dominguez (1985; 1986), who has worked both as "member" and "outsider" in cultural research. Her position is that "native" members' accounts of their own situation may well be privileged, because of their intimate, subjective, and empathic knowledge. This does not excuse native anthropologists' accounts from the disciplines of their scholarship and profession and does not invalidate the outsider anthropologist's account, over which in terms of objectivity the native account is not ipso facto privileged. By analogy, it appears that psychological treatment, relying so heavily on both subjective and objective accuracy of perception, must attempt to maximize that accuracy in a variety of ways. Ethnic matching may contribute, but as a matter of practicality it is not an available strategy, and were it to be adopted, it would

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exclude minority-culture therapists from treating most clients. Are there other ways?

Culturally Specific Treatment Modalities

Many writers (e.g^ da Silva, 1984) urge therapists to become aware of ethnogenetically determined patterns of help-seeking. For example, folk healers may be approached for folk diseases and scientific healers sought for infectious diseases, wounds, and refractory emotional disorders. These patterns for some Hispanic Americans are discussed in Tharp and Meadow (1973). Among urban Colorado Hispanic-American women, 20% had visited a curandero (folk healer) for treatment, and 12% had taken one or more of their children for treatment (Rivera, 1988). These treatments are far from conventional psychological treatments in form, and they may involve prayers, rest, ritual, and the ingestion of herbs. Many progressive treatment centers provide for cooperative work among scientific and folk practitioners. More than specific forms, there are presumptions and metaprocesses in the traditional treatment practices of many cultures that are drastically different from values inherent in European and American mental health treatment. LaFromboise, Trimble, and Mohatt (1990) provide an excellent description of American Indian healing processes, in which "religion, physiology, and psychology intertwine" (p. 632) and where traditional healing encourages the client to transcend the ego by experiencing self as embedded in and expressive of community. Traditional ceremonies reinforce adherence to cultural values and remind participants of the importance of family and community networks. Indeed, the family, kin, and friends coalesce into an interlocking network to observe and understand and to integrate the individual back into the social life of the group. Unlike conventional psychological treatments, American Indian healing ceremonies and procedures usually involve the client's family and community members along with the healer and client. This collective treatment of the entire network "heals" not only the individual, but reaffirms the norms and solidarity of the entire group (Kaplan & Johnson, 1964). A third route toward cultural compatibility is to specifically design treatment modalities on and for members of specific cultures. An excellent example is cuento therapy, developed for Puerto Rican children by Costantino, Malgady, and Rogler (1986), but no doubt equally appropriate for other Hispanic groups for whom cuentos (cautionary folktales) are familiar socialization devices. In this technique, cuentos that were either traditional or adapted to reflect current conflicts in American life were read to high-risk kindergarten through third-grade children by their (bilingual, bicultural) therapists and their mothers, and a discussion was then fostered exploring the meaning of the tale. Results indicated that cuento therapy significantly reduced children's trait anxiety relative to traditional therapy and to no intervention, and this trend was stable over 1 year. Cuento therapy also increased Wechsler Intelligence Test for Children-revised (WISC-R) Comprehension subtest scores. The authors discuss this technique as a modeling therapy, which is attractive to the children because of the cultural familiarity of the story characters, and as a cognitive development task, useful because of the familiarity of the story-telling

modality itself. They also point out the relevance of the literature on cognitive and social development of disadvantaged minority children, who respond well to fairy-tale, story-telling formats in classroom contexts. We should also note that the involvement of the mothers is another feature highly recommended by most students of Latin-American child treatment, regardless of treatment modality.

Choice of Treatment Levels and Modalities: Compatibility Through Context

However desirable specific-culture treatments are held to be, it must be noted that very few have been designed and reported, although the issue of cultural compatibility has been with us for nearly 40 years. The history of the cultural compatibility movement in education has a similar pattern. In spite of heroic efforts, almost no culturally "invented" specific educational modalities have been designed to survive the practicalities of schools. In the culture and education movement, most compatibilities have been established through choosing established modalities that per se allow for greater influence of the child's culture, or at least do not demand incompatible child behavior. The majority of mental health programs for minority children in the literature appear to be using that same tactic: By electing modalities that naturally include family and community members and settings, some compatibility is assured by the objective introduction of the cultural context. I will discuss those modalities in an order that represents a rough progression from lesser toward greater contextualization in the client's culture. Psychotherapy In the eyes of the public, individually conducted talking treatment conducted by a professional is the paradigmatic treatment form. Many clients of many cultures insist on receiving it because they have been convinced of its primacy and are well aware of its elevated status. Indeed psychotherapy is not per se ineffective for any culture (Sue, 1988); it can be made to work for clients. For example, Paster (1985) makes a heroic argument for the adaptations needed to psychodynamic psychotherapy so that it can be used with depressed, acting-out Black male adolescents. Tyler, Sussewell, and Williams-McCoy (1985) address the issue of providing culturally sensitive services by an attempt to preserve the basic structure and concepts of psychotherapy while reconciling the universalist and particularist positions into a "transcendist" perspective of an "ethnic validity model" that stresses that "persons from different ethnic/racial backgrounds are psychosocially different but that under some circumstances those differences can be transcended in therapy" (p. 312). With what reliability and regularity can therapists expect to establish that transcendence? It appears to this writer that, because of two basic conditions, importing culture into individual child psychotherapy is heavy freight indeed. First, individual psychotherapy is a culturally specific form of treatment, just as surely as is the sweat lodge or the herbalism of the curandero; and second, of all the modalities at the command of the mental health professions, individual psychotherapy most rigidly ex-

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eludes family or community members who might in feet import the cultural context. In any event, the preponderance of writers propose forms of treatment for minority children that structurally involve participants who are themselves culture carriers. Group Therapy Kahn, Lewis, and Galvez (1974) reported a counseling program for miscreant Papago Indian youth. The authors quickly moved from an individual to a group therapy format, although they improvised a number of changes to the usual confessionaland-problem-sharing approach:
The cultural truth that Papagos are very reluctant to reveal personal and intimate details to others, particularly in a setting with their peers, appeared to be a major hurdle in developing much group [therapy] interaction. It appeared that the main thing sustaining the group in early sessions was the money being paid for attendance . . . [then] the therapists selected what they judged would be a relevant problem or topic for these boys. The first part of the sessions [was] given to formal presentations.. . . How to meet girls, venereal disease, homosexuality, drinking and alcoholism, the role of the male in the family, etc.. . . The boys would talk about subjects or ask questions in the abstract or in terms of a third person." (Kahn, Lewis, & Galvez, p. 239-240)

values awareness and enhances self-esteem and a sense of selfpower through increasing abilities for stress reduction, decision making, and behavioral alternatives such as assertiveness, refusal skills, and social competency. Even minority youths in effective social training groups for alcoholism prevention are concerned with problem drinking by their family members. Edwards and Edwards (1988) urge that Indian families be involved, including nondrinking members and the extended family

Family Therapy Family therapy is often recommended by therapists and theorists who are concerned to establish more compatible and more effective treatment. Several considerations enter into this broad-based recommendation. For example, consider that tangle of racial attitudes, transferences, countertransferences, and guilt that Greene (1985) cautions against in White treatment of Black adolescents. Sykes (1987) recommends structured family therapy (short-term, goal-directed) as a way of avoiding those tangles, because the presence of the family establishes a Black context in which the White therapist is a facilitator and in which immediate problem solving is the focus. The emphasis on extended family and on the individual as part of a family in Asian culture is discussed by Chin (1983).
The Western view of family is more restrictive and based on the nuclear family with the ultimate goal of a separation from the family. The emphasis on nuclear family boundaries and individual "privacy" in Western families, when imposed on Asian-American families, often fails to appreciate the supportive networks, social cohesiveness, and sense of affiliation of the extended family. The diagnostic process needs to examine the indusiveness and interdependence of kinship relationships in terms of how they might facilitate the therapeutic process." (p. 107)

The boys also confronted the [non-Indian] therapists about their motivations and real reasons for working with them on the reservation. They did develop regular attendance and much improved arrest and school truancy rates. Recourse to group treatment of children of cultures unfamiliar to the therapist can have many advantages, including the socialization of new clients into an unfamiliar process, as well as providing a socialization of the therapist into the client culture. Spurlock (1985) presents an instructive case in which a White resident treats Black adolescents in just such a situation. Problem Solving and Social Skills Training Many writers recommend for Native American clients a structured, problem-solving, skill-training approach, which teaches through modeling and rehearsing those everyday skills that are useful to Indian adolescents in adaptive living (e.g, Long, 1983; Kahn et al, 1974; LaFromboise & Low, 1989; LaFromboise & Rowe, 1983; LaFromboise et al, 1990). Such programs have been successfully applied with Indian adolescents to reduce substance abuse (Bobo, Cvetkovich, Gilchrist, Trimble, & Schinke, 1987; Schinke et al, 1988), and adolescent suicide (LaFromboise & BigFoot, 1988). Globetti (1988) has reviewed alcohol education programs for minority youth and concludes that similar programs are suited for African-American and Hispanic youth as well. He does not avoid the question of whether such an approach can be effective without corresponding changes in family and neighborhood conditions or without correction of the feelings of anomie, feelings of oppression, marginal status, and the unemployment of minority poverty. However, among Black, Hispanic, and Indian minority communities, there are resources available for community treatment, including a strong abstinence sentiment especially among women and youth. A psychosocial skills approach reaches youth before they enter the age where drinking patterns and attitudes become rigid. This approach emphasizes

Because family therapy brings kin into the process itself, they are less likely to be overlooked in the diagnostic process. In the same way, family therapy mobilizes the available family resources for impact on the situation of the child. Kim (1985) endorses structured family therapy as the presumptive treatment for children of Asian Americans and provides a valuable discussion of the issues likely to arise in Asian families; merely to resort to family treatment is no final escape for the therapist from the need for cultural knowledge. Structured family therapy was recommended by Inclan (1985) for Puerto Rican and other Hispanic clients. Structural family therapy was found to protect the integrity of the family at 1-year follow-up, more than did psychodynamic child therapy, although the two treatments were apparently equal and superior to control conditions for 69 six- to twelve-year-old Hispanic boys (Szapocznik, Rio, Murray, & Cohen, 1989). Family therapy is recommended for Latin-American school children by Vazquez-Nuttal, Avila-Vivas, and Morales-Barreto (1984) because of the strong Hispanic emphasis on the family. These authors recommend that the therapist explore the importance of ethnic values and traditions to the family, the strain between traditional family values and contemporaneous American life, intergenerational strains that are likely loci of these value conflicts, and the extent to which the family relies on neighborhood and school institutions.

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ROLAND G. THARP temic interaction with those of the network members. Network therapy is held to combat the depersonalization of the acculturating, urban environment; and because it mobilizes the strength of the support network, it contextualizes treatment directly in the cultural nexus of family and community members. Network therapy has been discussed as a specific culturally consistent treatment and prevention approach for American Indian communities (LaFromboise et al, 1990). In Native Hawaiian communities, the entire network of family and support participants are involved in a traditional process of healing and reconciliation called hob'ponopono; Mokuau (1990) has reported on the practice and its implications and possibilities for the treatment of children. Community Intervention Contextuality may be seen as extending from family to extended family to community to the entire ecocultural niche. Culturally oriented writers consistently call for an ecologically oriented, contextualized analysis of psychological phenomena and consequently a diagnosis and treatment scheme that locates the child in the sociocultural nexusand indeed recognizes that the intervention target for some child problems lies in family, school, or community (Huang & Gibbs, 1989). Illustrating that critical difference, under new environmental conditions of migration, displacement, or community change, the family and the school themselves may become sources of stress for the child and lose their value as social support networks (Canino, Earley, & Rogler, 1980). Ramirez (1980) discusses the complexity of family and community as problem/support units among urban Mexican Americans. His study found that the propinquity and size of extended family was positively related to mental health status among Mexican Americans in Detroit. But nearness in time to Mexico and markers of traditional culture were negatively related to mental health status. Apparently an effective support structure develops slowly, postmigration. It appears that as a family migrates, it slowly develops a network, gains education, and improves in mental health status. Furthermore, family support is a structural phenomenon that operates in a mundane, solid, and workaday manner: The presence of someone in the network who offers "emotional understanding" and such "counselorlike" qualities is unrelated to mental health status. Assisting a referred child in a recent immigrant community may require assisting a family, group of families, or entire community to organize for mutual assistance. An example of a developmentally oriented community psychology program is that of OTJonnell and Tharp (1990), which is based on the principles of neo-Vygotskian socio-historical theory. In their analyses, the real client of the consultation is the social system that produces or maintains the problem. No permanent improvement in a child's condition can be expected unless the sustaining context is also assisted to change. The consultant must locate the levers of influence that can bring about some reorganization. The ultimate goal of the consultant is to empower and to increase the self-assistance of the community and thus the growth or development of its members, particularly the referred child or children. The route to that goal is through reorganization of activity settings. Through the pro-

As Falicov and Brudner-White (1983) have discussed, the acceptance of the extended family as the unit of analysis reveals vulnerabilities and sources of growth enhancement that are not dreamed of in nuclear-family-based treatment tactics and theories. Black families, even those of the stereotypical father-absent, unemployed-mother pattern, often have strengths and resources in extended family and social networks that are completely overlooked by the therapist with a narrow view of "family" (Spurlock, 1985). Juarez (1985) also discusses the best fit for Hispanic children and recommends family therapy, but also a form of megafamily treatment, "network therapy," a collaborative involvement of all significant members of the child's social world. Home-Based Treatment Home-based programs embed treatment in a cultural surround and thus are far less insulated from the influences of home, family, and community. "The most well-documented, effective therapeutic treatment with lower socioeconomic class Blacks has been home-visiting programs aimed at supporting and counseling mothers of young children" (Thomas & Dansby, 1985, p. 400), particularly those such as described in Gray and Ruttle (1980), that have positive effects on child language development and a sustained improvement in mothers' teaching styles. These criteria are well met by the carefully evaluated home-visiting programs of Roberts and his associates, working principally with Native Hawaiians (Roberts, Wasik, Casto, & Ramey, 1991; Roberts & Magrab, 1991). These authors rightly urge that culturally compatible programs must be continually vitalized by a staff committed to the principle of compatibility and influenced by community participation. Even more deeply embedded in context is the Homebuilders program, which trains, places, and supports professional workers who become temporarily resident or quasi-resident in the homes of their children clients, most of whom have already been targeted for placement outside of the home (Kinney, Haapala, & Booth, 1991). Although home-maintenance success rates are impressive for all categories of children, children of color had a significantly higher chance of remaining at home during and after Homebuilders treatment than did their White, non-Hispanic counterparts (Fraser, Pecora, & Haapala, 1991). These data are consistent with the view that contextualization of service is particularly critical for minority children. Network Treatment Network therapy (see Schoenfeld, Halevy-Martini, HemleyVan der Velden, & Ruhf, 198 5,1986, for descriptions and evaluations) involves a group of family, relatives, and friends who are organized into a network. It is informal in operation. The therapist's role is to catalyze and conduct the process, but the forces of healing and correction are those of the support system of the network itself. Ordinarily conducted in the home, it can include 50 people or more. Network therapy can be used for solving a common or shared problem of the clan, family, or community, or the network can be mobilized in response to the problem of a single child or adolescent. Even in the latter case, the patient's behaviors, experiences, and goals are understood in their sys-

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cesses of interaction and assisted performance in activity settings, the targeted community members gain greater competence, skill level, and solidarity. The basic task of intervention is to design new or changed activity settings in which that growth and development can occur. The influence of the consultant is used to generate or organize the resources necessary to produce those activity settings. The consultant, working in the triadic model (Tharp & Note, 1988; Tharp & Wetzel, 1969), exercises the consulting effects through mediators who are themselves members of the settings or of the community context. A fine example of such a program is that for prevention of drug abuse by American Indian youth by the Indian Drug Prevention Program (IDPP) of Washington State (Bobo et al, 1987). The consultants established an all-Indian advisory board, worked with members to establish goals and guidelines, developed together a curriculum of skills training (modeling, instructing, and practicing), contacted gatekeepers of services in six different communities, located venues and activity settings in which the program could be operated, trained and cooperated with local schools and other agencies, and left the communities competent to carry out the positively evaluated program. Other examples of similar community programs are available in Edwards and Edwards (1988). The IDPP operates primarily in schools. The movement toward integrated mental health services in schools is particularly important for cultural minorities. Red Horse (1982) described a short-lived but well-conceived program that operated for Indian public school adolescent girls in Minnesota. It included credit-bearing social skills training and psychosocial developmental materials, cultural enrichment materials provided by Indian elders, pregnancy prevention, group counseling, and a professional staif of counselors who assisted the girls to bridge and build extended family relationships both in the city and on the nearby reservation. The creation of new activity settings and the mobilization of resourcesof the family and community to assist the performance of the adolescent girls is a model of community program design. Another exemplary program is a school psychology program for Hispanics that involves "systems networking among the nuclear and extended family, compadres, church personnel, indigenous support systems, and school [which] affords pooling of human, informational, and mental health resources for more effective, efficient, and ethnospecific services for Hispanics" (Rosado, 1986, p. 196). Status of the Evidence for the Cultural Compatibility Hypotheses As we have now seen, there is virtual unanimity among writers that some degree of compatibility between culture and treatment is necessary. That unanimity, however, does not conclude the case. A useful understanding of compatibility requires evidence that will allow unpacking the concept into its potent and inert components. The necessary breadth of that evidence is not yet present in the child-treatment literature. The absence can be felt especially in the paucity of process studies of child treatment, where interactions could be examined by charting flows and glitches against the culturally based repertoires of participants. Evidence of that sort is present to a greater degree in the

study of child education. Although these parallel data can be taken only as suggestive, they can help to formulate hypotheses for research in the clinical and consulting context. In education research on children, there is a substantial body of evidence demonstrating cultural diversities in at least four domains that make a difference in educational process and outcome: in linguistics and sociolinguistics, cognition, motivation (state and trait), and social organizational proclivities (reviewed in Tharp, 1989). As an illustration of the consequences for schooling, effective monocultural classrooms for Native Indian children have been shown to be markedly different from those for Native Hawaiian children, in social organization, in patterns of child control, in management of gender interaction, and in the patterns of the teaching conversation between and among children and teacher. As one example of an "unpacked" cultural variable, sociolinguistic studies have demonstrated crucial differences in the courtesies and conventions of conversation for different ethnic groups, differences that have strong emotional effects on children and condition the child's reaction to instruction, from willing engagement to hostile withdrawal. Although this might be taken as evidence for the "strong" cultural compatibility solution of designing classrooms for specific cultures, specific-culture classrooms are largely impractical. The typical classroom of our nation today is mwft/cultural.3 Of course, clinical services are not, and a variety of specific culturally compatible services might be feasible within existing service delivery institutional structures. Before leaping to recommendations, however, we must note in that same review of culture-and-education research (Tharp, 1989) considerable evidence for the weak or "two-type" form of the hypothesisthat the children of all those cultures who typically underachieve in schools share the requirement for a modified kind of education that is not the same as that provided by the majority-oriented schools. The educational research evidence speaks for two conditions shared by successful classrooms for children of underachieving minorities: (a) contextualization of learning activities into settings and topics that are meaningful in the children's daily life and (b) assisting children in developing the language of instruction, the latter assuring the child of adequate participation in the learning activities. These two factors are consistent with the evidence for child treatment reviewed in this article: Contextualization of treatment in the meanings and processes of cultural life is the most insistent urging of all who work in child culture and mental health. And logic dictates that treatment cannot be effective unless it is delivered in a language the child and the family can understand and use. However, the universalist position does not lack evidence either. For example, just as in the clinical domain, specific educational "treatments" growing from the institutions of specific cultures have not emerged in any great number and in general

3 Certainly there are monocultural classrooms present in society, and these have been of great interest to researchers in culture and education because they allow cultural processes in teaching and learning to emerge clearly. Likewise, investigating both process and outcome studies of various treatment modalities within a single culture is a research strategy of promise.

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ROLAND G. THARP translators also served as cultural informants, explaining to the therapists the meaning of some of the client's topics in therapy. There is a danger, however, as pointed out by Lappin (1983), in having a "house ethnic," often a paraprofessional, who is called in to translate. Many individuals and cultural groups want a professional regardless of race. In fact, there is a danger in using any translator, who becomes a switchboard, a distorter, and an additional principal in an already complex interaction. Therapists must be cautious in using the most bilingual family member as translator for all, particularly when this is the child, who, while most flexible in language use may also be most psychologically vulnerable to the dynamic forces of family and therapist interaction. Nevertheless, there is evidence that provision of Spanish language opportunities in clinic programs does increase utilization rates in Hispanic communities (Rogler, Malgady, Costantino, & Blumenthal, 1987). However, it is not simply language code proficiency that creates misunderstandings and frustrations in cross-cultural service delivery Differing Sociolinguistic and paralinguistic patterns are barriers to communication. For example, Michaels (1984) has shown that children of different cultures tell their stories in different ways, with startling audience effects. In her study, White children were topic-centered in their narratives, with thematic cohesion and a temporal reference. Black children used a topic-associating style consisting of a series of implicitly associated anecdotal segments with no explicit statement of an overall theme or point. White adults criticized the topic-associating style as incoherent, but Black adults found it interesting with lots of detail and description. It is apparent that this cultural difference in basic language structure can lead to quite different judgments and predictions in the treatment room. Process studies of cross-cultural treatment of children are lacking. Again we must look to culture-and-education, where such research is growing. A recent review (Tharp, 1989) reveals that in determining relationship, learning, and satisfaction in cross-cultural settings, there is enormous weight in variables of the courtesies and conventions ofcomersation, such as the length of pause between speakers (wait-time), rhythm of speech and event, and participation structures (the patterns and conditions for speaking and listening). When Sociolinguistic school/home compatibilities are present, children are more comfortable, and they participate and display their abilities appropriately As one example, Black migrant children, whose schools view them as below grade level and unresponsive, speak and behave with complexity and competence in home settings. In addition, they exhibit full competence and full participation at church. The similarities of Sociolinguistic and behavioral conventions between church and home offer an example to schools of how formal institutions can engage their young by compatibilities of expectations with child repertoires (Lein, 1975). Many strategies have been devised for achieving linguistic compatibility for children in schools. Because schooling is so heavily language dependent, a first-order goal for effective education is to provide adequate language development. This goal is very likely parallel to child treatment, which is also a learning modality heavily dependent on language exchanges. To the degree that treatment does occur through language, we may expect that special attention will be required to ensure linguistic

have not survived the realities and necessities of schooling. Rather, the cultural-compatibility movement in education appears to have settled on the least-change principle (Tharp et al., 1984), which calls not for inventing entire new pedagogies or teaching modalities, but for the careful selection of modalities of demonstrated effectiveness in real schools and by working teachers. The selection of such modalities may be quite different for children of different cultures, and it is certain that the instantiation of the modalities will be modified by contextualizing them in the experience and language of the children's daily lives. This appears to be entirely consistent with the experience of the more youthful culture-and-treatment movement. Few specific treatment modalities have been offered. Certain modalities, however, are overwhelmingly preferred by therapists knowledgeable of certain cultures; and each instantiation is recommended to be conditioned by the culture. Thus, family therapy is repeatedly recommended for Hispanic children, but the recommendation is equally strong that the family must be treated in ways that reflect that family's composition, values, and language. On the basis of this discussion, it appears that the most viable hypothesis is a universalist one, but not the "unrversalist" hypothesis as previously understood. That is, clinical service for everyone must be contextualized in the values, processes, and language of the clients' culture, and that is the universalist principle. Existing services are already contextualized for majority, English-speaking culture members because treatment procedures grew out of that culture and language. Were it not so, prescription would have to see to it. When the strong, the weak, and the null forms of a hypothesis are all verified, we know the question needs rephrasing. Evidence and inference suggest the following as the best next direction for investigation. Cultural compatibility, rather than an accommodation needed for certain subsets of people, should be understood as an aspect of a universally required contextualization of services. The appropriate question would then become: How can therapists, program developers, and researchers develop heuristics for assuring the conditions of context uality and language accessibility? Some previous inquiry is available to that question.

Linguistic and Sociolinguistic Accessibility of Services The problem of assessing and providing treatment across a language barrier is central in the provision of services to children of diverse cultures. This issue is most familiar to psychology as an issue in testing: English-language interaction, in bilingual children, is not a clear window through which cognitive functioning can be estimated. And the problems associated with attempting treatment when the therapist is not competent in the basic language of the clients are formidable indeed. In an effort to increase the linguistic accessibility, bilingual and bicultural staff may be incorporated into the staff of mental health facilities, as advocated early by Scott and Delgado (1979). Acosta and Cristo (1981) describe a clinic for Hispanics that recruited community members to serve as translators for the English-speaking professional staff. Training was provided in the basic concepts and vocabulary of psychotherapy. These

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and sociolinguistic compatibilities. This makes cross-cultural psychotherapy particularly problematic for both therapist and client. In the dimension of language, it seems clear that culture members are indeed privileged, and same-language therapists are advantageous to clients. However, when therapists do serve clients of a different language, compensatory strategies are available, the most powerful of which is to contextualize treatment in the culture of the client. By importing other family and community members into the treatment itself, familiar language becomes a part of the treatment context.

apy depends more than any other modality on shared values, semiotics, habits, and expectations between therapist and client. When these are not present, resources of commonality have to be provided by expanding to family/network/community interventions, even for majority culture members. It appears that the conclusions available from the culture and treatment literature are not restricted to strategies for exotic culture members. As we should have expected, an expanded range of observations leads to a more comprehensive universalism. It is paradoxical but welcome, that facing the problems of treating others is teaching us how better to treat ourselves.

Contextuality of Treatment
Sue and Zane (1987) observe that therapist/client cultural matching is a distal variable and that efficacy lies in the proximal issues of how well the therapist is able to (a) meet the client's conceptualization of the problem, (b) require acceptable behaviors as means for problem resolution, and (c) share goals for treatment. The literature considered here suggests that the probability of those proximal conditions being achieved is limited by the degree to which social, linguistic, and other process variables are congruent. There seems little doubt that all else being equal, culturally matched psychologists and clients are more likely to achieve that congruence and those conditions. Most therapists can have little hope of sufficient detailed knowledge of many (if any) cultures other than their natal one and almost no hope of mastering a variety of linguistic and sociolinguistic codes. This leads us to consider the probability of achieving process congruence and the Sue and Zane conditions as a function of the modality of treatment. Treatment modalities for children may be arrayed on a continuum of inclusiveness or social contextuality, from individual psychotherapy to group therapy to family therapy to network therapy to community intervention. Historically, these modalities developed in roughly that order. Thus therapists of my own (senior) cohort were trained, by and large, in the individual model, with less intense training in groups, less still on families, and little direct experience of network or community methods, that is, with a decreasing emphasis on the expanding continuum of social contextuality Although that pattern has eased in many training programs during the past 30 years, there is perhaps a residual tropism toward the individual end of the continuum in the prescriptive inclinations of our field. If the reading of the literature offered here is correct, a reversal of that strategy is indicated. That is, for a therapist facing a client across a cultural chasm, the treatment of first consideration should be community intervention; that of second consideration, network therapy; that of third, family treatment; fourth, group treatment; and last of all, individual treatment. The work of therapy is potent when the therapist and child share so much that the therapist can presume a thorough knowledge of the workings of the child's family and community and can teach the youngster knowingly, confidently, and credibly Because Euro-American culture has produced most therapists and most clients, most clients and therapists have been matched in culture and language. Insulated within a common culture, we have not recognized cultural contextuality as a variable because it has not varied. We have not noticed the basic condition that because it is decontextualized, individual ther-

Implications for Research and Theoretical Programs

Humanity has a common base, provided by evolutionary processes; but over long periods of historical time, ethnogenetic processes have put our common humanity through different filters. To recover our common features, we must study those filters and come to know how historical processes have created differing psychological and behavioral realities for different peoples. These differences are not trivial, and they are not surface. They include differences in motivation, cognition, social organizational principles, communication patterns, values, and semiotic structures, as well as accustomed ways of teaching and learning. Further research into ethnogenetic processes is a necessity for advances in culture-and-treatment and also holds promise for the discovery of a broader range of fundamental processes of psychology and sociology. This agendum falls within the program of the sociohistorical theoretical movement (e.g., Cole, 1985; Tharp & Gallimore, 1988; Vygotsky, 1929,1978; Wertsch, 1985). On the other hand, just because we have been blind to "culture," we must not now be blinded by it. Each culture member has also had a different life history and accumulation of learning. Thus ethnogenetic effects are filtered and conditioned by ontogenetic and microgenetic processes; and in our rush to solve problems of treatment arising from cultural differences, we must not overlook the resulting wide range of variance within cultures. Indeed the definitions and boundaries of ethnicities are under constant negotiation and redefinition (Dominguez, 1986). Psychology comes to the porch of cultural studies just as the volatility of the concept of ethnicity is coming into focus, and although belated, our arrival may well be welcomed by the house of social science. Individuals define themselves in and out of ethnic identities, and that psychological identification is of more moment in treatment issues than is that of race. Psychologists have the means to understand those processes and how they operate in and through psychological treatment. Another major research need lies within the field of clinical and consulting psychology itself. The paucity of process studies in the treatment of different culture members, particularly in a variety of modalities, is the greatest single need for evidence. Critical data and its analysis will require methods of investigation less familiar to psychology than they might be, methods such as ethnography, microethnography, and discourse analysis. Expanding our range of research operations need not await major retooling of psychologists' methodology. Research partnerships made with scientists of other appropriate disciplines,

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ROLAND G. THARP health and people of color: Curriculum development and change. Washington, DC: Howani University Press. Cole, M. (1985). The zone of proximal development: Where culture and cognition create each other. In J. V Wertsch (Ed.), Culture, communication, and cognition: Vygotskian perspectives (pp. 146-161). New York: Cambridge University Press. Costantino, G., Malgady, R. G., & Rogler, L. H. (1986). Cuento therapy: A culturally sensitive modality for Puerto Rican children. Journal of Consulting and Clinical Psychology, 54, 639-645. da Silva, G. C. (1984). Awareness of Hispanic cultural issues in the health care setting. Children's Health Care, 13, 4-10. DeBlassie, R. R. (1976). Counseling with Mexican American youth: Preconceptions and processes. Austin, TX: Learning Concepts, Inc. Dominguez, V (1985). Intended and unintended messages: The scholarly defense of onels own "people." Nieuwe West-lndischeGids, 209222. Dominguez, V (1986). White by definition. New Brunswick, NJ: Rutgers University Press. Edwards, E. D, & Edwards, M. E. (1988). Alcoholism prevention/treatment and Native American youth: A community approach. Journal of Drug Issues, 18(1), 103-114. Everett, E, Proctor, N., & Cartmell, B. (1983). Providing psychological services to American Indian children and families. Professional Psychology: Research and Practice, 14, 588-603. Falicos C. J., &. Brudner-White, L. (1983). The shifting family triangle: The issue of cultural and contextual relativity. In J. C. Hansen & C.}. Falicov (Eds.), Cultural perspectives in family therapy (pp. 51-67). Rockville, MD: Aspen. [Family therapy with immigrant families], (1989). Journal of Strategic and Systemic Therapies, ^(Summer). Fraser, M. W, Pecora, P. J., & Haapala, D. A. (1991). Familiesin crisis: The impact of intensive family preservation services. Hawthorne, NY: Aldine de Gruyter. Gallimore, R., Reese, L. J., Balzano, S., Benson, C, & Goldenberg, C. (1991, April). Ecocultural sources of early literacy experiences: Job-reauired literacy, home literacy environments, and school reading. Paper read at the Annual Meeting of the American Educational Research Association, Chicago. Gibbs, J. T, Huang, L. N.,& Associates (Eds.). (1989). Children of color: Psychological intervention with minority youth. San Francisco: Jossey-Bass. Gibson, M., &Ogbu, J. (Eds.). (1991). Minority status and schooling: A comparative study of immigrant and involuntary minorities. New York: Garland Press. Globetti, G. (1988). Alcohol education programs and minority youth. Journal of Drug Issues, 18,115-129. Gray, E., & Cosgrove, J. (1985). Ethnocentric perception of child-rearing practices in protective services. Child Abuse and Neglect, 9,389396. Gray, S. W, & Ruttle, K. (1980). The family-oriented home visiting program: A longitudinal study Genetic Psychology Monographs, 102, 299-316. Greene, B. A. (1985). Considerations in the treatment of black patients by white therapists. Psychotherapy, 22, 389-393. Haviland, M. G., Horswill, R. K., O'Connell, J. J., & Dynneson, V Y (1983). Native American college students' preference for counselor race and sex and the likelihood of their use of a counseling center. Journal ofCounseling Psychology, 30, 267-270. Ho, M. K. (1987). Family therapy with ethnic minorities. Newbury Park, CA: Sage. Ho, M. K. (1990). Intermarried couples in therapy. Springfield, IL: Charles C Thomas. Hong, G. K. (1988). A general family practitioner approach for AsianAmerican mental health services. Professional Psychology: Research and Practice, 19, 600-605.

such as sociolinguistics, anthropology, or community development, could allow an immediate infusion of data that reveal cultural processes in their immediacy and at their points of impactin the situations and communications of treatment itself.4 Are there immediate, imperative, specific hypotheses for investigation? Certainly all conclusions offered above have the status of hypothesis. As much as on direct evidence, this analysis perforce relied on reasoning and analogy. My strategy was to suggest the figure in the ground by putting those tiles in the mosaic as placeholders, pending the arrival of more direct evidence drawn from the treatment of children. About the figure that will eventually be clear, there is one thing that now appears certain. These cultures meeting in the consulting room will clarify not only the processes of the cultures themselves, but will bring to our notice things about treatment that we do not yet suspect.

4 As an example of how this strategy was used in the culture-andeducational domain, see Tharp et al. (1984).

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