Cross-Cultural Supervision in Cognitive-Behavioral Therapy: A Case Study

Cross-Cultural Supervision in Cognitive-Behavioral Therapy: A Case Study

CBPRA-00703; No of Pages 10: 4C Available online at www.sciencedirect.com ScienceDirect Cognitive and Behavioral Practice xx (2018) xxx-xxx www.else...

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CBPRA-00703; No of Pages 10: 4C

Available online at www.sciencedirect.com

ScienceDirect Cognitive and Behavioral Practice xx (2018) xxx-xxx www.elsevier.com/locate/cabp

Cross-Cultural Supervision in Cognitive-Behavioral Therapy: A Case Study Yang Fahui, 1 Beijing Normal University Keith Dobson, Li Xiaomiao, Adam Hennebury, University of Calgary Gao Ying, Otto Von Guericke Universität Magdeburg Tang Xinfeng, University of Hong Kong Qi Le, City University of Macau 1

This article provides a thorough description of a representative case of online cross-cultural supervision by interviewing all parties involved in the supervision (the supervisor, the supervisee, and the translator). This study provides evidence about the benefits and challenges of online crosscultural supervision and the feasibility of such a training modality. A cross-cultural supervision competence model and culturally adapted treatment stage model are proposed, and the article provides suggestions for future supervisors, supervisees, and translators.

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is a principal foundation of clinical practice (Starr, Ciclitira, Marzano, Brunswick, & Costa, 2013). Although supervision has been historically a face-to-face interpersonal process, modern communication technologies mean that supervision is no longer restricted by geography, but can be provided to a variety of therapists in rural, remote, or underserved areas (Rousmaniere, Abbass, Frederickson, Henning, & Taubner, 2014). Long-distance online supervision also enables cross-cultural supervision, wherein the supervisor and the supervisee live in different countries, are of different cultural backgrounds, and may even speak different languages. During the past two decades, there has been a growing emphasis on cultural and international contexts for supervision (Forrest, 2010; Panos, 2005), as the practice of cross-cultural supervision may generate significant and unique considerations, as opposed to traditional non-cross-cultural supervision. In the sections that follow we present some of the major considerations that have been discussed in the literature. UPERVISION

Major Concerns Associated With Cross-cultural Training Cultural Awareness and Sensitivity Previous work has focused on both the content and format of cross-cultural supervision. Content considerations 1

include the awareness of cultural differences in the clients who are seen, the discussion of culture-related topics, and the potential influence of cultural differences on the process and outcome of supervision itself (Falender, Burnes, & Ellis, 2013; Falender, Shafranske, & Falicov, 2014). Some studies have reported outcome differences between culturally sensitive and culturally nonsensitive supervision, including enhanced supervisory working alliance when supervision included explicit discussion of culture variables (Gatmon, Jackson, Koshkarian, & Martos-Perry, 2001). Culturally responsive supervision has also been associated with supervisees who feel supported to explore cultural issues, which positively affected the supervisee, the supervision relationship, and client outcomes (Burkard et al., 2006). In contrast, without cultural sensitivity, cultural and language differences may contribute to supervisees’ increased self-doubt, stress, and less healing involvement (Taubner, Henning, Schwietring, & Kächele, 2013). Some studies suggest that culture awareness is sometimes not as strong as it should be. There has been a reported low rate of actual discussion of cultural variables in supervision, and a lack of initiation of these topics by supervisors (Gatmon et al., 2001). Moreover, supervisors sometimes did not view discussion of cultural differences as influential in supervision, in contrast to their supervisees (Toporek, Ortega-Villalobos, & Pope-Davis, 2004).

The two first authors share authorship equally.

The Use of Technology in Cross-Cultural Training Keywords: supervision; cross-cultural; cognitive-behavior therapy; case study

1077-7229/18/© 2018 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.

Much of the discussion of cross-cultural supervision has focused on the use of computer-based techniques (e.g., e-mails, teleconferencing, chat rooms), and whether and how those online communication methods affect the

Please cite this article as: Fahui et al., Cross-Cultural Supervision in Cognitive-Behavioral Therapy: A Case Study, Cognitive and Behavioral Practice (2018), https://doi.org/10.1016/j.cbpra.2017.12.004

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quality of interactions. These technologies diminished the capacity for subtle nonverbal communication, as even in the best case, the supervisor can only see the supervisees’ faces. This limitation may pose challenges to understand the issues being discussed, which may in turn negatively impact the supervisory working alliance (Olson, Russell, & White, 2002; Vaccaro & Lambie, 2007). Researchers have also pointed out that the limitations of online chatting may even exacerbate cultural misunderstandings between supervisors and supervisees (Panos, Panos, Cox, Roby, & Matheson, 2002; Powell & Migdole, 2012), especially when it is text-based and conducted in an asynchronous (i.e., not live) format. Others have also suggested that there might be a reduced effectiveness in the online supervision format as opposed to the traditional face-toface format. For example, Gainor and Constantine (2002) found out that although trainees’ multicultural case conceptualization ability increased with both in-person and Web-based peer group supervision formats, those who participated in in-person peer group multicultural supervision demonstrated greater multicultural case conceptualization ability than did trainees who participated in Web-based peer group multicultural supervision. Studies have shown that trainees generally preferred inperson supervision to videoconference supervision (e.g., Coker, Jones, Staples, & Harbach, 2002). Other Considerations in Cross-Cultural Training Distance supervision has been associated with other concerns. For example, technical issues can lead to dropped calls or poor Internet connectivity, which are outside the control of users and may result in a reduced amount and quality of communication (Rousmaniere et al., 2014). There may also be ethical considerations associated with online cross-cultural supervision. For instance, videoconference supervision usually involves the transmission of patient-protected health information through a central server, which may not be “secure” (Rousmaniere et al., 2014). Moreover, there may be issues related to informed consent, especially when the clients, supervisees, or supervisors do not fully understand the technologies being employed. Cross-cultural supervision may also limit the supervisors’ control over emergencies or crises. Supervisors may be unable to provide sufficient help to trainees because of timely access to information, or unfamiliarity with local laws and regulations in the location where the client is being seen (Abbass et al., 2011; Panos et al., 2002). Liability concerns associated with distance supervision are largely unknown at present. Yet another issue that may either facilitate or inhibit cross-cultural training is related to funding. In the current case, the supervisor worked in a salaried position, and had an inherent interest in cross-cultural training. Thus, while

the trainee insisted on providing an honorarium in the third year of the training program, this was the only funding, and the vast majority of the supervision was provided pro bono. Further, the face-to-face meetings that did take place all occurred while the supervisor was in China for another purpose, and so the trainee was not required to fund these interactions. Supervisors who work in settings where funding is required (e.g., private practice settings) would be less able to provide such intensive and protracted training. We do note that the translator was provided with an honoraria of approximately D20 USD for each translation session, in recognition of her important contributions to the training process. Given the many uncertainties about online crosscultural supervision, it is crucial to continue to examine its benefits and challenges, and to further explore ways to make the best out of it. To our knowledge, there is yet no formally published case study that has discussed the objective process and outcome of an online cross-cultural supervision, or explored and compared the evaluations of such supervision from the perspectives of all parties included (the supervisor, the supervisee, and the translator). Furthermore, most of the extant literature about online cross-cultural supervision has emphasized shortterm supervision (e.g., within 20 sessions) rather than long-term supervision. Therefore, it is necessary to examine the unique features of long-term supervision to gain a deeper understanding of the implications of such distance cross-cultural supervision. To fill the gap in the current literature, this article describes a specific longterm and distance cross-cultural supervision process, in the context of cognitive-behavioral therapy. Within this discussion we describe the nature of such long-term online cross-cultural supervision, the process of culturally sensitive case conceptualization and discussion, and the factors that were identified as beneficial and problematic by the supervisor, the supervisee, and the translator. We provide suggestions to support future supervisors, supervisees, as well as translators to work more effectively in such type of supervision.

The Supervision Process Prior to the current supervision, the first author (Mr. Y) was a psychiatrist with 13 years of experience working in a psychiatric hospital in Chong Qing, in the People’s Republic of China. At a cognitive behavioral therapy (CBT) supervision training held by Columbia University and Academy of Cognitive Therapy in Beijing, China, where the third author (Dr. D) was presenting, Mr. Y spoke with Dr. D and voiced his interest in learning the CBT model under Dr. D’s supervision. Dr. D felt him to be “forthright” and eager to learn the skills of CBT. Dr. D himself was interested at the time in encouraging the

Please cite this article as: Fahui et al., Cross-Cultural Supervision in Cognitive-Behavioral Therapy: A Case Study, Cognitive and Behavioral Practice (2018), https://doi.org/10.1016/j.cbpra.2017.12.004

Cross-Culture Supervision spread of CBT in China and saw the supervision of Mr. Y as one way to further that goal, even while they both acknowledged the potential difficulties involved in a crosscultural supervisory relationship. Dr. D agreed to take on the role of supervisor, anticipating it to last for approximately 1 year. This professional relationship has persisted well into its seventh year, with their supervisory goals having evolved and changed over time. In order to address the language barrier between Mr. Y and Dr. D, supervision was conducted primarily through the use of a third-party translator. The fifth author, Ms. G, was a psychology student at the beginning of the supervision, and she has remained their translator throughout the supervisory relationship, even while she herself went on to graduate school in Germany. Ms. G translated both Mr. Y’s session scripts and was present during the online meetings, to facilitate discussion and to be both a literal and cultural translator, as needed. Settings Supervision was primarily conducted online via live prearranged two-way or three-way video or audio calls, using programs such as Skype and QQ International, the latter of which is the Chinese equivalent of Skype. To supplement these discussions, in-person meetings were carried out when possible and email correspondence was used. Online meetings occurred approximately every 2 to 3 weeks for about 1 hour, with timing and length varying as the needs and schedules of both the supervisor and supervisee varied. Supervisory Phases This supervision can be divided into roughly three phases. Phase one (the first 2 years) emphasized learning CBT and practicing CBT skills with clients. Since he knew very little about CBT at the beginning of the supervision, the supervisee reported that what he needed most was basic CBT knowledge, as well as the supervisor’s support and appreciation as cases were seen. During the second phase (the third to the fifth year), they mainly focused on how to use CBT to treat different types of disorders, namely, disorder-specific treatment. The teaching part of supervision gradually receded as Mr. Y’s knowledge and capability increased during this phase. During the third phase (the sixth to the seventh year), Dr. D and Mr. Y started to focus more on the discussions of different thoughts and perspectives from each other’s clinical experiences as well as cultural experiences. New treatment ideas were generated, and Mr. Y decided to develop a treatment model appropriate for Chinese patients. This third phase, elaborated below, was described by Mr. Y as the “intermingling phase” when culture perspectives were discussed and integrated.

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Culturally Sensitive Supervisory Style The supervisor’s approach was to try and manage the supervisor-supervisee relationship in much the same way as for the counsellor-client relationship. It was essential to seek clarification if a cultural issue was suspected, until both had an adequate understanding of each other. Dr. D also sought to expose himself to Chinese culture in order to enhance his own understanding and appreciation of it. This exposure included actual time spent in China, although other means such as the study of history and popular Chinese media were also seen as helpful. Mr. Y considered Dr. D’s culturally sensitive supervisory style to be very important. He was impressed by Dr. D’s approach, including: (a) creating a warm and supportive environment; (b) providing a combination of both intellectual and emotional support (e.g., sending research papers to Mr. Y immediately after the supervision to assist his learning); (c) respecting the supervisee’s opinions and ideas; (d) expressing curiosity about different perspectives and behaviors shaped by culture; (e) a strength-focused and nonjudgmental stance (e.g., always giving praise to the supervisee); and (f) a pleasant personality (e.g., easygoing and humorous). Mr. Y also identified several factors that were of upmost importance when there were cultural differences: (a) a trusted supervisory relationship; (b) mutual respect; (c) professional guidance from the supervisor (e.g., citing reliable evidence to support one’s opinion); (d) flexibility in supervisory style according to the needs of the supervisee. From Ms. G’s perspective, a culturally sensitive supervision style means that both the supervisor and supervisee should be free to ask direct questions for clarification whenever they encounter potential cultural misunderstandings. The culture contents should be discussed in an open and honest manner. “Too much politeness” (e.g., not expressing one’s real opinions when disagreeing with the other person’s opinions) may impair the effectiveness of the supervision process. Translation Issues Dr. D and Mr. Y considered the use of a translator as essential to the success of their supervision. From a linguistic perspective, both of them valued the precision of translation, without the addition of personal interpretation. Beyond linguistic issues, there was concern that Chinese cultural concepts (e.g., concepts in Buddhism/ Taoism) were precisely translated and correctly understood. As the translator, Ms. G felt that the translation process was not as troublesome as she had previously thought. During the online meetings, time was always taken to explain any confusing concepts (e.g., culturebased concepts without direct terminology in the other language) and made them clear enough to each other.

Please cite this article as: Fahui et al., Cross-Cultural Supervision in Cognitive-Behavioral Therapy: A Case Study, Cognitive and Behavioral Practice (2018), https://doi.org/10.1016/j.cbpra.2017.12.004

Fahui et al.

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Ms. G identified three important issues for the translation of cross-cultural supervision: (a) be a precise information transmitter; (b) be familiar with both the content of discussion and the general knowledge of this field; (c) maintain a good relationship with your listeners. Representative Cases In this section we describe selected case examples from this supervision. The goal here is not to provide a comprehensive case review or thorough discussion, but to highlight some of the cross-cultural issues that emerged in the current context. We note that all clients provided informed consent for their treatment, and for the crosscultural supervision by Dr. D. Case 1: Social Anxiety Disorder In this and other early cases, Dr. D’s supervision focused on coaching the supervisee to best provide “pure CBT.” Meetings were conducted more regularly and the focus was on Mr. Y’s use of CBT methods and skills (e.g., setting the agenda, Socratic questioning, role-playing, and homework assignment). Transcripts were made of sessions, and Dr. D would read the transcript and make notes of areas to explore. Whenever possible, supervision occurred prior to the next session to ensure appropriate and timely feedback had been given. Discussions about cross-cultural issues were integrated as needed. For example, the mother of the client (a young woman with social anxiety) had a strong desire that her daughter should work in a specific company after graduation. However, this expectation was against the wish of the client. From Mr. Y’s perspective, it is common in China for Chinese parents to have a strong wish to “protect” and to “pave a safe way” for their children. The idea “listening to your parents” came from the client’s concepts of “filial piety” and “respect the elderly,” which are core values in Chinese culture. A widely cited saying used by Chinese parents to educate their children is, “If you don’t listen to old people’s words, you are doomed to fail,” which reflects a collective belief that older people are also wiser. From Dr. D’s perspective, although filial piety and respect are important pillars of a civil society, it is rare in Western cultures for parents to make career decisions for their children. As a consequence, the intervention approach should differ between a Western and a Chinese client. A Western approach may emphasize the independence of the young woman, and may focus on exploration of self-needs, taking action, and being responsible for personal choices. In contrast, a culturally adapted approach for a Chinese young woman might emphasize enhanced effective communication with her mother, how to involve the father in the decision-making process, how to consider and balance each person’s opinions, and how to maintain good relationships in times

of disagreements, as well as issues of personal choice and responsibility. Case 2: Borderline Personality Disorder As the supervisory relationship progressed, Mr. Y sought to adopt a more eclectic approach, in part due to his interest in combining a Jungian psychological approach with traditional CBT. This issue emerged during a case that was diagnosed with borderline personality disorder, and it led to the need to reevaluate the goal of the supervisory relationship. As stated before, respectful yet direct discussions were needed to balance initial learning goals with Mr. Y’s interest in other potentially culture-adapted methods. Rather than making these initial goals a matter of disagreement and turmoil, the focus was maintained on the effectiveness of what was being tried in the therapy room, and on how to improve the therapeutic relationship and treatment methods between Mr. Y and his clients, when progress was not evident. Mr. Y reported a number of challenges, and some frustration with the use of traditional CBT methods with this client, because she “never listened” to him. It seemed that she could not use CBT’s structure to guide herself. Quite the opposite, she expressed concern about being controlled by methods such as identifying thoughts and behavioral activation, and would subtly critique the therapist for these methods. From a CBT perspective, these structures help borderline clients to regulate their emotions and behaviors, and indeed, after about 30 sessions, Mr. Y had successfully achieved the goals of treatment, including more emotional stability, prevention of suicide attempts, and better daily functioning. However, Mr. Y had the sense that this client might need more therapy than the traditional CBT could give, such as stronger emotional connection, as is consistent with the collectivist value of Chinese culture. As a result, Mr. Y began to “follow this patient’s emotional flow” and provided more empathy and understanding to achieve a state of “being with her.” The contents of Mr. Y and the client’s discussions became focused on the client’s ideas, such as Confucianism, Taoism, Buddhism, mythological images, death, early traumas, and objective relationships. Sometimes Mr. Y would tell the client that he was uncertain what to do and allowed the patient guiding him. They would then share feelings with each other after Mr. Y followed the “instructions” of the client. This case ultimately lasted for 63 sessions, and it encouraged Mr. Y to integrate CBT, Jungian analysis, and culture understandings to treat his Chinese clients, as he came to believe that this approach might be more culturally adaptive. Ethical Considerations A healthy supervisory relationship, but with professional boundaries, was foundational to a positive supervisory

Please cite this article as: Fahui et al., Cross-Cultural Supervision in Cognitive-Behavioral Therapy: A Case Study, Cognitive and Behavioral Practice (2018), https://doi.org/10.1016/j.cbpra.2017.12.004

Cross-Culture Supervision experience. Considerations were made about the balance between “the endeavour to feel close to each other when the distance is long” and “the effort to not be too warm to the extent that a clear boundary be impaired.” Given the infrequent face-to-face meetings between Dr. D and Mr. Y (six times in 7 years), both thought that it was important to retain certain normal social interactions (e.g., informal chat about recent events, bringing small gifts to each other). In fact, such interactions helped to build a closer relationship between the two, and for each to feel more genuine in their relationships. However, these social interactions were not so often as to turn the supervisory relationship into a pure friendship. As the actual clients who were treated resided in China, another ethical consideration was given to the local laws and ethical rules that were in force there. Wherever ethical questions arose, such as informed consent, Dr. D. gave deference to the local laws and practices, even while he shared North American practices to give an alternative perspective.

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between Mr. Y and his clients. Dr. D only had access to abridged, translated transcripts of the therapy sessions rather than the audio/video recording or the in-person supervision that would be available in a typical supervisory relationship. This meant that Dr. D had to also rely heavily on Mr. Y’s memory and verbal description of the sessions, which left room for the supervisee to neglect or simply be unaware of areas that needed more attention. It also meant that neither therapist-client therapeutic relationship, nor the “homework” completed by the client were directly observable. This dynamic thus required a strong degree of honesty from the supervisee, and trust between the supervisor and supervisee, to make this cross-cultural supervision process as effective as its traditional counterpart. Relatedly, the lack of direct observation or recordings meant that there was no objective evaluation of the skill improvement of Mr. Y. While some objective assessment of clients’ symptom reductions or overall outcomes was possible, the lack of specific measures for use in China also precluded more formal clinical outcome assessment, as might have been useful.

Outcome Evaluation Mr. Y reported that his achievements far exceeded his initial expectations. First, he learned the theory of CBT and basic CBT skills such as case conceptualization, setting agendas, Socratic questioning, and behavioral experiments. Second, he learned how to apply these skills in a manner that was receptive to client needs (e.g., how to build a good therapeutic alliance, how to clarify vague problems, how to use the skills in a nondidactic way). Third, he applied CBT to clients with different disorders and successfully treated seven cases. (All cases completed Chinese adaptations of validated scales and assessments questionnaires. These data are not provided here, as the focus is not on the clients’ clinical outcomes, but all cases reported improvements in functioning and reduced symptomatology over the course of treatment.) Fourth, he gained a better understanding of what culturally adapted CBT might look like as well as how to flexibly use the strategies according to the needs of different clients. His personal, culturally sensitive therapeutic theory and methods were also formed through this process. Fifth, he became the first person in Mainland China to be certified by the Academy of Cognitive Therapy as both a CBT diplomate (2011) and a CBT supervisor (2016). Sixth (at the time of this writing), he is pursuing a doctoral degree in applied psychology at the City University of Macau, China, and will most likely graduate in 2017. The translator, Ms. G, benefited from this supervision as well. She is currently a doctoral student in Germany. Limitations of Supervision One limitation in the current supervisory process was the lack of direct observation of the therapy sessions

Discussion Challenges and Benefits of Online Cross-Cultural Supervision Although there have been concerns about the quality of online cross-cultural supervision (e.g., Powell & Migdole, 2012; Rousmaniere et al., 2014), the 7-year supervision between Mr. Y and Dr. D has demonstrated that long-distance online cross-cultural supervision can successfully improve the quality and competence of the supervisee. From the supervisee’s perspective, the most important benefit of this supervision was not the saved traveling time and costs, but the opportunity to receive high-quality supervision that a local supervisor may not be able to provide. In addition, Chinese clients welcome foreign supervisors to be involved in their treatment, as they generally believe that foreign supervisors can help the therapist to provide better care. Therefore, the crosscultural supervision may have actually enhanced, at least to some extent, the working alliance between Mr. Y and his clients. Several challenges exist for online cross-cultural supervision, including computer-related issues. One of the issues with the online supervision format was some difficulty figuring out how to use the online chatting software (reported by Mr. Y). Due to a somewhat low level of computer skill at the start of supervision, it took Mr. Y nearly 2 months to learn how to use Skype (including how to obtain an account, how to log in, how to add Dr. D as a contact in the system). Sometimes, due to the time differences, Mr. Y did not receive Dr. D’s email replies in a timely manner, which caused some anxiety and worry.

Please cite this article as: Fahui et al., Cross-Cultural Supervision in Cognitive-Behavioral Therapy: A Case Study, Cognitive and Behavioral Practice (2018), https://doi.org/10.1016/j.cbpra.2017.12.004

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Fahui et al.

A second challenge for supervision was arranging an appropriate time to meet. Because of their different time zones and personal schedules, a three-way meeting proved to be complicated, and the situation became even more complicated when Ms. G moved to Germany. The supervision times are now set at approximately 8:00 A.M. in Canada, 11:00 P.M. in China, and 5:00 P.M. in Germany, although Daylight Savings Time necessities seasonal adjustments. A third challenge, especially with when three countries were involved, was poor Internet connectivity. Dropped or delayed calls were encountered during many sessions (often once or twice per session), which were usually quickly repaired. Indeed, this issue occurred more often with video connections, likely due to the higher amount of data streaming required than for audio calls, and so audio was more frequently employed. Though this issue wasted some time during the supervision meetings, neither Mr. Y nor Dr. D considered it to be a significant barrier to their supervision progress and relationship building. Mr. Y did prefer face-to-face supervision, because he could see the real person in front of him. Similarly, Dr. D held the opinion that it was crucial to have some face-to-face meetings to know the supervisee better. However, neither identified any impairments to closeness as a result of the online format. A fourth consideration for distance cross-cultural supervision is translation. A qualified translator is key to the success of experiences such as described here. Further, a high level of trust in the translator is needed, particularly regarding the precision of translation, the protection of client confidentiality, and the extent to which the translator might influence the dynamic of the supervision. In many respects, the issues that arise in the use of a translator in cross-cultural supervision are similar to the issues that arise in the use of translators in other mental health contexts (Searight & Armock, 2013), but, given the abstract concepts and technical language employed in the training and supervision of psychotherapy, we would argue that cross-cultural supervision presents even greater complexity. Mr. Y also reported certain benefits of the online format. For example, he reported less anxiety with the online format because he could rely more on the translator when communicating with Dr. D; in contrast, during the face-to-face meetings, he often felt that it was more socially appropriate for him to speak English directly to Dr. D. Although he understood that it was not necessary for him to speak English, such a pressure might be associated with face-to-face interaction. Another advantage of the online format reported by Mr. Y was that it gave them an opportunity to focus mainly on thought exchange (e.g., pure discussions of therapeutic contents), rather than talking about social topics or issues that were

unrelated to treatment. Thus, although neither party considered the lack of face-to-face interaction to be a major hindrance to their working alliance, as others have proposed (Dickens, 2010; Walther, 1995), they maintained that more face-to-face communications could have strengthened their working alliance. Cross-Cultural Supervision Competency: Four Key Domains Cross-cultural supervision presents a good opportunity for Chinese therapists to learn psychotherapy, including CBT. Although local supervisors share the same cultural background as the supervisee, some may lack advanced competency in specific models of psychotherapy and supervision. For Western supervisors who have these skills, and who can successfully engage in cross-cultural supervision, supervision in China can be a rewarding and enriching experience. The key points that were identified as cross-cultural supervision competencies in this article can be categorized into the four domains of mutual respect, culture knowledge, open discussions, and role modeling (see Figure 1). Mutual respect provides a foundation for good supervisory rapport, and provides the space for supervisees to freely express themselves. Previous studies have shown that acceptance and support from the supervisor and supervisory safety contribute to a positive supervision process (e.g., Starr et al., 2013). Cultural knowledge has also been benchmarked as one of the core areas in clinical supervision (Falender & Shafranske, 2007; Fouad et al., 2009). Research has shown that such knowledge can significantly affect the quality of supervision (Arthur & Collins, 2009; Inman, 2006). Open discussion is not only another important factor in multicultural competency, but it enhances both respect and culture-related knowledge. Open discussion corrects culture-related misunderstandings and confusion. “Too much politeness” may lead to unexpressed opinions, which may in turn lead to more misunderstanding and confusion. The fact that Mr. Y reported that Dr. D acted as a role model is consistent with previous work that underscores that supervision is largely a modeling and mentoring process (Hernández, Taylor, & McDowell, 2009). A mentoring approach to supervision can be especially effective with Asian trainees, as a reflection of Confucius’ influence on the teacher– student relationship (Gong, Chen, & Lee, 2011). The mentoring approach also works to improve respect and open discussions with the supervisee. For example, being passive and reserved due to one’s cultural upbringing could create difficulty in interactions with the supervisor in both individual and group supervision (Wong, Wong, & Ishiyama, 2013). The role-modeling of openness and honesty from the supervisor may be gradually reciprocated

Please cite this article as: Fahui et al., Cross-Cultural Supervision in Cognitive-Behavioral Therapy: A Case Study, Cognitive and Behavioral Practice (2018), https://doi.org/10.1016/j.cbpra.2017.12.004

Cross-Culture Supervision

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Figure 1. Cross-culture supervision competence model

by the supervisee, and thus enhance mutual openness and honesty. Long-Term Supervisory Phases—From Culturally Sensitive to Culturally Integrated There are consistent references in the literature to the administrative, educative, and supportive functions of supervision (O’Donoghue & Tsui, 2013). Many studies suggest that the goal of supervision is to enhance supervisees’ professional knowledge, practice skills, and social functioning, and to enhance the quality of professional service that is provided to the clients (Lambert & Ogles, 1997; Vaccaro & Lambie, 2007; Wampold & Holloway, 1997). However, the emphasis on these goals may decrease as the supervisee gradually gains experience and independence over time. In the same vein, clinical supervision is defined as a collaborative process between a more experienced and skilled supervisor and a novice or apprentice supervisee who seeks to develop the competencies necessary for successful clinical practice (Barnett, 2011). However, the content and focus of this collaborative process may change inevitably across years. After Mr. Y had received Dr. D’s supervision for 2 years, his intentions shifted from “learning and practicing skills” to “gaining independency and forming his own therapeutic styles.” Thus, having a consultant and obtaining support became more important in this later phase than

guiding and teaching. A great deal of discussion occurred about different case conceptualization, including explicit consideration of cultural perspectives and what intervention strategies could be attempted to test a culturally adaptive approach. When a therapy is developed and then implemented within a single cultural context, there is no need for cultural considerations (see Figure 2). When cross-cultural training begins, however, cultural issues are often discussed on a technical level (e.g., applying different therapeutic skills and assigning different home-

Figure 2. Culturally adapted treatment stage model

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work to clients in a culturally sensitive manner). In the final phase of supervision, cultural beliefs and phenomena were considered more from a theoretical level and provide a more rich and complex way to integrate crosscultural factors into treatment. In other words, the cultural aspects need to be integrated into the theoretical foundations of those already well-formed psychotherapy modalities. Overall, the long-term supervision experience revealed a shift of deepness of treatment, from a “culturally sensitive” stage (focused on choosing different intervention methods to fit the need of the patients of different cultures) towards a “culturally integrated” stage (focused on merging culture aspects into the theory of the original treatment model; see Figure 2). In many respects, the shift from a focus on technical skills to one of broader conceptualization and cultural adaptation was analogous to the type of shift that has been identified in psychotherapy training, from a supervision to a consultant role (Gold, 2006). In the former role, the supervisor has recognized expertise and some authority to direct the activities of the supervisee, whereas the consultant role is more of a peer who discusses issues and presents alternatives, but then provides the support for the consultee to choose and implement his/her own decisions.

reactions (Sue & Sue, 1990). Such culture contact therefore leads to the question of where to draw a line between “changing my intervention to adapt to the other culture” and “letting others change as a sign of successful intervention.” Studies of cross-cultural supervision report that some supervisees were able to “experience personal growth through negative experiences” (Wong et al., 2013), whereas in other cases, supervisors’ assertive or confrontational interpersonal styles created difficulty for ethnic minorities (Daniels, D’Andrea, & Kim, 1999). In the supervision of Mr. Y and Dr. D, Mr. Y reported that he acquired a deeper understanding of the strengths and weaknesses of his own culture by learning the perspectives of another culture from Dr. D. Dr. D also expressed a deepened and profound respect for other cultures in general, and Chinese culture and traditions in particular. The same situation may also happen in cross-cultural treatment where certain degrees of adherence to the “pure” CBT rules may lead to patients’ reflections on their own patterns, and, as a consequence, more insights and personal growth may be gained through the experience of cross-cultural contact and even potential “conflict.” Therefore, cross-cultural supervision and therapy should consider both what to change or adapt, but also what to maintain in order to maximize the benefits of supervisees and clients.

The Boundaries of “Culture-Adaptation” There has been an ongoing discussion about whether or not a therapy such as CBT, which was developed largely in a North American context, can adequately address the concerns of another cultural context, such as China (Naeem & Kingdon, 2012). The current supervisory experience clearly suggests that when due attention is given to cultural issues, differences between North American and Chinese culture do not preclude fruitful sharing of ideas and experience in the supervisory context. The success of this supervisory relationship and Mr. Y’s success working with patients demonstrates the applicability of CBT in the Chinese context. In fact, the theoretical concept of CBT has a lot in common with some concepts within Chinese culture. For example, one Chinese philosopher, militarist, and educator in the Ming Dynasty, Wang Yangming, proposed the “Yangming theory,” which emphasized the integrated and inseparable nature of “knowing” and “acting”: “knowing” must lead to “acting,” and no “acting” implies no “real knowing.” This idea is perfectly consistent with the cognitive and behavioral interventions within CBT. On the other hand, cultural differences are unavoidable in almost all kinds of cross-cultural interactions. By definition, cross-cultural supervision entails different cultures, which represent diverse worldviews, values, and belief systems, and which affect one’s perceptions and

Future Directions This article provides a single and extensive discussion of a specific cross-cultural supervision process, and both the processes and outcomes of the supervisory process described here cannot be necessarily generalized to other circumstances and cultures. As such, the current processes raise questions that should be examined in other studies. Quantitative data are needed to explore the outcomes of cross-cultural supervision. More systematic and objective evaluation could include the assessment of the characteristics and skills of the supervisor, the quality of the supervisory relationships, the progress of the supervisee (e.g., skill improvement), client progress (e.g., symptom reduction), and the quality of the therapeutic relationship between the supervisee and his/her patients. Direct monitoring of the sessions between the supervisee and patients (e.g., watching video clips with translated subtitles) may be a better way to yield more objective evaluations of the real treatment processes. Second, this study is based on the retrospective memories of the supervisor, supervisee, and translator. The reported results may be subject to memory bias. Future studies can be conducted prospectively, and with more participants to increase the generalizability of the conclusions. Further, comparison between cross-cultural and non-

Please cite this article as: Fahui et al., Cross-Cultural Supervision in Cognitive-Behavioral Therapy: A Case Study, Cognitive and Behavioral Practice (2018), https://doi.org/10.1016/j.cbpra.2017.12.004

Cross-Culture Supervision cross-cultural supervision may provide further information about the benefits and limitations of different forms of supervision. Third, guidelines may be needed in order to better regulate or assist the supervisor, the supervisee, and the translator to conduct more efficient and effective crosscultural supervision, and to avoid potential ethical issues. Cross-cultural competence training models or benchmarks for future supervisors could also be established to ensure the high-quality supervision for supervisees in remote or underserved areas. Finally, when it comes to cultural adaptation, it may be important to differentiate whether the treatment elements are due to cultural considerations or the nature of the disorder itself. For example, CBT has experienced the third-wave movement in recent decades and new treatment modalities continue to emerge (Dobson & Dozois, in press). Some of these models even draw upon concepts from other cultures, such as mindfulness (e.g., MindfulnessBased Cognitive Therapy for depression relapse; Segal, Williams, & Teasdale, 2002). How can the field know if the success of such a method is due to cultural adaptation or due to the beneficial effect of mindfulness itself? Future theory needs to differentiate whether a treatment is culturally adapted, an evolution of an existing treatment, or a new school of treatment.

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Please cite this article as: Fahui et al., Cross-Cultural Supervision in Cognitive-Behavioral Therapy: A Case Study, Cognitive and Behavioral Practice (2018), https://doi.org/10.1016/j.cbpra.2017.12.004