Multicultural Training of Clinical and Counseling Psychology Doctoral Students: Ideals vs. Practice

The	  American	  Psychological	  Association	  (APA),	  which	  is	  the	  advocating	  body for	  the	  field	  of	  psychology,	  emphasizes	  the	  importance	  of	  multicultural	  competencies for	  researchers	  and	  clinicians	  (APA,	  2003;	  2010).	  Graduate	  students	  are	  the	  field’s future	  professionals.	  The	  multicultural	  training	  of	  doctoral	  level	  clinical	  and counseling	  psychology	  graduate	  students	  is	  integral	  to	  efforts	  to	  improve	  clinical services	  and	  the	  research	  that	  provides	  the	  foundation	  for	  those	  services.	  While	  the literature	  addresses	  issues	  of	  multicultural	  competence	  and	  training	  in	  a	  general way,	  few	  specifics	  regarding	  the	  methods	  employed	  by	  graduate	  programs	  to	  aid their	  students	  in	  the	  process	  of	  developing	  those	  competencies	  are	  explored. This	  study	  is	  a	  survey	  of	  doctoral	  programs.	  It	  was	  hypothesized	  that	  many training	  programs	  acknowledge	  the	  importance	  of	  multicultural	  training	  but	  fall	  far short	  in	  their	  efforts	  to	  provide	  students	  with	  sufficient	  training.	  Additionally,	  it	  was hypothesized	  that	  doctoral	  students	  who	  identified	  their	  programs	  as	  highlighting multicultural	  competence	  would	  have	  greater	  multicultural	  self-­‐efficacy.	  Graduate students’	  self-­‐perceived	  multicultural	  competence	  was	  associated	  with	  a	  number	  of program	  training	  methods.	  Although	  analyses	  yielded	  clear	  differences	  in	  guidelines and	  standards	  adherence	  between	  program	  types,	  all	  participating	  training	  directors reported	  that	  multicultural	  issues	  are	  incorporated	  into	  their	  program	  training methods.	  As	  anticipated,	  many	  programs	  did	  not	  directly	  address	  multiculturalism and	  diversity	  in	  their	  training	  materials.	  Descriptive	  information	  about	  multicultural training	  methods,	  reflection	  on	  exemplary	  training	  methods,	  and	  recommendations for	  training	  initiatives	  are	  provided.

for the field of psychology, emphasizes the importance of multicultural competencies for researchers and clinicians (APA, 2003;. Graduate students are the field's future professionals. The multicultural training of doctoral level clinical and counseling psychology graduate students is integral to efforts to improve clinical services and the research that provides the foundation of those services. While the literature addresses issues of multicultural competence and training, few specifics regarding the methods employed by graduate programs to aid their students in the process of developing those competencies are explored. This study is a survey of doctoral programs. It was hypothesized that many training programs acknowledge the importance of multicultural training but fall far short in their efforts to provide students with sufficient training. Additionally, it was hypothesized that doctoral students who identified their programs as highlighting multicultural competence would have greater multicultural self efficacy than those whose programs did not emphasize the importance of multicultural competence. Descriptive information about multicultural training methods, reflection on exemplary training methods, and recommendations for training initiatives are provided.

Major Assumptions
Among the major assumptions that serve as premises upon which this study is based are the following: 1. The United States is racially and ethnically diverse and clinical populations are reflective of this diversity (APA, 2003). As such it is necessary for those entering the field be thoroughly trained to provide culturally appropriate treatment for all clients and to engage in scholarly work regarding issues related to multiculturalism.
2. Multicultural psychology is not just a specialty area. It needs to be generalized across work with diverse clients and participant groups. According to Sue and Torino (2005), "Multicultural counseling and therapy can be defined as both a helping role and process that uses modalities and defines goals consistent with the life experiences and cultural values of clients, recognizes clients identities to include individual, group, and universal dimensions, advocates the use of universal and culture--specific strategies and roles in the healing process, and balances the importance of individualism and collectivism in the assessment, diagnosis, and treatment of client and client systems." 3. Included under the umbrella term, "multicultural" are factors including race, ethnicity, sexual orientation, gender, religion, physical ability, socioeconomic status, geographic region, and other individual differences that impact the human experience and as such are relevant to psychological functioning (Owens & Khalil, 2007).

American Psychological Association Guidelines and Association for Multicultural Counseling and Development Standards
The American Psychological Association (APA) is often the vehicle through which practitioners and researchers collaborate to establish guidelines that aid psychologists in their work (APA, 2013). In 2002, the APA approved the Guidelines on Multicultural Education, Training, Research, Practice and Organizational Change for Psychologists. Contributors to the document established six multicultural guidelines for education, training, research, practice, and organizational change. The first guideline instructs psychologists to be aware of the influence that culture, attitudes, and beliefs have on interactions with people who are ethnically and racially different from themselves (Smith, et al. 2008). The second guideline highlights the importance of cultural sensitivity, responsiveness, knowledge and understanding about different ethnic and racial groups. The third guideline outlines the importance of incorporating multiculturalism and diversity into education. The fourth guideline suggests that psychologists conduct culture--centered and ethically based research practices among minority groups. The fifth guideline emphasizes the importance of culturally appropriate clinical skills. The sixth and final guideline encourages psychologists to actively pursue policy changes that increase the cultural sensitivity at the organizational level (APA, 2003).
The Association for Multicultural Counseling and Development (AMCD) has endorsed 31 specific competencies (see Appendix V) to aid psychotherapists in the provision of culturally sensitive services (Cartwright, et al., 2008). The 31 competencies are outlined under the following broad competency areas: 1) Counselor awareness of personal cultural values and biases, 2) Counselor awareness of client's worldview, and 3) culturally appropriate intervention strategies. Under the first two broad areas, specific competencies and objectives are provided under the headings of "attitudes and beliefs" and "knowledge." The third area (interventions) includes particular "skills" (Sue, et. al., 1992). Both the APA multicultural guidelines and the AMCD multicultural competencies and standards are especially relevant to this study. The perpetuation of high standards (if followed) that ensure the best care for clients and the solidity of empirical studies that inform clinical treatment depends on the quality of graduate training (Green, 1998).
Trainees who experience multicultural activities including personal experiences with diversity and exposure to people who are culturally different, report higher levels of multicultural awareness, knowledge, and skills (Carlson, et al., 1998). Additionally, multicultural training increases clinician's self report of multicultural competencies (Smith, et al. 2008). Despite the positive impact of personal experiences with diversity and multicultural training on self--perceived multicultural competence, Implicit bias has been evidenced by therapists in training who believe themselves to be multiculturally competent (Boysen & Vogel, 2008). These findings support the need for training that targets the first guideline, so that clinicians in training may engage in exploration of the role that their beliefs about others play in their therapeutic interactions.

Resistance to Multicultural Competence
Despite organizational support within the field of psychology, there is some resistance to the concept of multicultural competence. According Sue et al. (2009), resistance to cultural competence takes the form of four main arguments. The first argument is based on a concern that emphasizing multicultural competence encourages therapists (and those in training) to stereotype ethnic minority group members. From this perspective clinicians are discouraged from learning about specific groups and integrating that knowledge into treatment plans. However, research suggests that culture--centered practices help to reduce stereotypes (Fouad, 2006). Knowledge about cultural differences may be prevented from developing into stereotypes if it is coupled with an awareness of individual differences within groups and a sense of humility with regard to our limited capacity to know all things about those who are different from ourselves.
The second source of resistance to cultural competence is the belief that advocating for multicultural competence for ethnic minority groups results in the neglect of other aspects of diversity such as sexual orientation, gender, and social class (Sue et al., 2009). Multicultural competence requires addressing all aspects of identity. Culture and other aspects of client background are not mutually exclusive contexts for therapeutic work. Sue et al. (2009) identify the two remaining sources of resistance to cultural competence as concerns regarding overemphasis of external factors (e.g. racism) and the fear of creating hostility among groups by addressing multicultural issues.
Fulfilling this responsibility includes engaging in competent practices and training future clinicians and researchers to be multiculturally competent. There are innumerable race--based healthcare inequities; in the interest of justice, psychologists must provide the most appropriate treatment to clients from all cultural backgrounds (Sue et al., 2009). The diversity--related components of the APA Code of Ethics and Standards of Practice should in fact also be generalized to other marginalized populations based on individual factors outside of culture such as sexual orientation (APA Division 44, 2000). Clients must be treated as fully human; which requires honoring of all aspects of their identity.
The APA's Ethics Code Principle E (Respect for People's Rights and Dignity) associates respect with an appreciation for culture, and highlights the danger of failuring to competently address culture (APA, 2010). Similarly, the American Counseling Association (ACA) emphasizes the importance of understanding clients from diverse cultural backgrounds (ACA, 1995). The intent of the present study is to survey doctoral level counseling and clinical psychology programs that have been accredited by the APA to determine how they provide graduate students with multicultural training.

Defining and Demonstrating Multicultural Competence
The guidelines established by the APA broadly address areas of multicultural competencies. Cultural competence is an active process rather than a finite goal. It requires three specific but interrelated dimensions. Sue and Sue (2008) (Bell, 2006). I also found research that indicated that cultural contexts that should be considered when engaging in work with incarcerated adolescents include a) the client's family culture and home environment, b) demographic factors such as race, ethnicity, primary language, gender, socioeconomic status, sexual orientation, and religion (Harmon, Langley, & Ginsburg, 2006), (c) the client's family structure and role within that structure, d) the culture of the detention center, e) the client's self perception (Rodriguez, Umana--Taylor, Smith, & Johnson, 2009), f) the client's values and treatment goals, and g) the client's perception of the therapist and the therapeutic process. Additionally, the available literature noted that given differences in symptom expression between people of different backgrounds, the cultural context must be considered when treating diverse clients (Harmon, Langley, & Ginsburg, 2006;Langhinrichsen--Rohling, Friend, & Powell, 2009 Throughout the course of our 24 sessions, we were able to address the psychosocial factors that were related to his everyday stressors. Specifically, discussing racial and class--based inequities helped him to understand why "people in his neighborhood" were more likely to turn to illegal means of making money and more likely to be discovered and penalized for such behaviors. He was able to move from being angry about his situation to understanding the roots of his reality. He was able to establish goals for the future, as well as identify potential obstacles while working to develop contingency plans in preparation for his release from the juvenile detention center. Taking into account his cultural context facilitated our therapeutic alliance, allowing us to more fully understand his presenting problems, and to adapt my clinical skills to best meet his needs.

Training Models from the Existing Literature
An urban counseling psychology department training model. Since the publication of the 2003 APA guidelines, there has been extensive discussion of multicultural competencies. However, there continues to be a relative lack of literature focusing on the role of training programs (Green, 1998). In one of the few attempts to evaluate multicultural training, Fouad (2006)  Fouad's program requires all students to engage in clinical work with ethnically diverse clientele and has practicum placements at a number of community mental health centers. The program provides required proseminars to infuse diversity into all aspects of their curriculum, meeting weekly and covering topics such as diagnosis, interviewing, specific therapy modalities, and psychotherapy research. These proseminars address issues of culture that are related to each topic area. While the program infuses culture--centered approaches into core courses, there is no examination of foundation and research courses for multicultural content.
The program does require students to provide annual self--evaluation of multicultural skills. Specifically students are required to outline clinical accomplishments with diverse clients, and multicultural knowledge is measured by preliminary exams and supervisor evaluations. Nevertheless, as Fouad notes that neither student cultural awareness nor cultural competence of supervisors is assessed.

Strengths and limitations.
As the Director of Training, Fouad is invested in the reputation of her program so her role in the program may limit the objectivity of the report. On the other hand a program a Training Director may having the most intimate knowledge of a program be in the most appropriate position to summarize and evaluate its training methods. Additionally, Fouad highlights both the successes and limitations of the program's multicultural training efforts. Despite the admitted limitations it would seem that in terms of prioritizing multiculturalism, infusing it into the curriculum, and providing practical experiences for graduate students, this program is exemplary. The self--reflective nature of Fouad's article is a model for other programs. It is important for programs to model the self--awareness that they encourage in graduate trainees.
The brookline community mental health center multicultural training model. Although many gradate students will be exposed to a great diversity in client population during practicum placements at community mental health centers, there are not many generalizable multicultural training models employed at fieldwork Although the program seems to be a comprehensive means of facilitating the development of multicultural competence, some limitations including sample size (N=19) are apparent. For example, failure to group students by level of awareness in terms of the diversity teams may result in frustration on the part of those who are more culturally aware. The pilot assessment revealed that at least one graduate student of color felt burdened by the fact that participants in the training experience were at "very different places." Supervisor and client ratings of multicultural competence before and after graduate students complete their training process would help to evaluate the model's effectiveness.

Multicultural Competence
Despite psychologists whose names were furnished by the APA Research Office. The first goal of the study was to explore the relationship between commonly held practitioner beliefs and level of multicultural competency. The second was to determine whether doctoral level psychologists engage in culturally responsive professional behaviors. Participants completed a demographic questionnaire, the Multicultural Practices and Beliefs Questionnaire (Hansen, 2006), and the Multicultural Social Desirability Scale (Sodowsky, et al., 1998 discrepancies between beliefs about the importance of multicultural factors and actual practices were found. Half of the participants reported that they rarely prepared a culturally informed DSM--IV--TR diagnosis. Moreover, participating psychologists infrequently made efforts to improve multicultural competencies using the following methods: a) implementing a specific plan, b) seeking consultation, c) augmenting treatment with literature, translators, or indigenous healers, d) referring clients to more qualified providers, or e) using sensitive data gathering techniques.
While seasoned professionals stated that they learned the most from practical experience, early career psychologists felt that they developed multicultural competencies best as a result of supervision and didactic experiences. In the present study, there is an exploration of the self--perceived level of multicultural competence of doctoral students relative to their articulation of the aforementioned aspects of was used to recruit participants. E--mail addresses for training directors were retrieved from program webpages. E--mails requesting participation were sent at three different time--points. All Training directors received the first e--mail to solicit participation in the study. One month later, those who did not reply to the first e--mail were sent a second request to participate. Finally those who did not respond to either the first or second e--mails were sent a third solicitation e--mail one month after the second e--mail had been sent. Training directors and students who chose to participate completed a consent form indicating their understanding of the process and purpose of the present study and their willingness to participate (Appendix I).
All program directors were asked to complete relevant questionnaires and to forward the survey link to their trainees. Participating students and programs were assigned random identification numbers. Participants were not asked to provide their names or the name of the program with which they were affiliated.

Data Cleaning Process
Participants who consented, identified themselves as either a training director or graduate student, but did not complete any other portions of the survey were eliminated (1 training director and 73 students). As a result of the data cleaning process, the final sample for this study consists of 169 graduate students, 38 Training Directors, and 307 training programs.
Training directors ranged in age from 38 to 72 years of age. The majority of the training directors (89.5% n =34) identified as White or European American, 5.3% (n=2) as Hispanic/Latino or Hispanic/Latino American, 2.6% (n=1) as Black or African American, and one training director chose not to endorse any racial or ethnic background (See Figure 1). Figure 1 reflects the racial/ethnic composition of Training directors participant group. Doctoral students. The graduate student group was more diverse than that of the training directors. The graduate student participants were overwhelmingly female (89%, n=151), 10% being male (n=17), and 1 participant chose not to endorse a gender. Students ranged in age from 20 to 43 with a mean age of 26.73.

Figure 1: Training director racial/ethnic backgrounds
Asian or Asian Americans comprised 7.1% (n=12) of the participating students, 5.9%    A major goal of this study was to determine the extent to which training program methods are consistent with APA guidelines and AMCD standards, as well as with the literature regarding multicultural competencies. The hypotheses of this study are as follows: 1. Inconsistency is anticipated between the areas outlined in APA and AMCD guidelines and standards and the areas of multiculturalism addressed by training programs.
2. Graduate students from programs that emphasize APA and AMDC guidelines are expected to exhibit higher levels of self--perceived multicultural competencies.
3. There will be group differences between graduate students of different racial and ethnic backgrounds.
Puerto Rico a. Those of color being expected to perceive themselves as being more multiculturally competent than their white counterparts.
4. There will be a positive relationship between the duration of time that a program has been accredited and the extent to which it focuses on multicultural training.

Procedure
Training directors were contacted and asked to complete an electronic survey regarding multicultural training efforts in their programs. They were also asked to disseminate an e--mail, describing the study, requesting participation, and providing the link to the electronic survey to graduate student. There was also a review of available program materials including mission statements, handbooks, curriculum/course requirement descriptions, and training goals (See Appendix VIII for the web pages from which information about training methods was retrieved).

Measures
Demographic questionnaire. Participating graduate students were asked to complete a brief demographic questionnaire (Appendix II). The questionnaire contains seven items regarding students' backgrounds and years of training. They were asked to indicate their age, gender, religion, race, sexual orientation, highest level of education, and number of years completed in their current programs. Program material review. A content analysis of available program materials including web pages served as the primary means of identifying efforts to produce multiculturally competent graduates. Programs were given one point for specifically addressing each of the 31 AMCD and 6 APA guidelines. For example, identification of training methods that require students to explore their own cultural heritage and related attitudes, values, and biases about psychological processes (AMCD Strategies IA1 and IA2) would be given 2 points. On the other hand, programs were not given points for merely including the guidelines and standards documents in their program materials, they were only given credit for explicit articulation of training efforts related to those guidelines. Total training program scores were calculated by 29 incorporating two additional items; the first was based on the number of required multicultural courses (one point for each course) and the second was one point given to programs that mentioned multiculturalism in any form in their program materials.

Hypotheses Based on Training Director Reports of Training Methods
Hypothesis 1. It was expected that training directors' would report that their programs value multicultural issues and endorse aspects of the guidelines and standards. To address this hypothesis the responses of training directors to the following items were assessed: incorporation of multiculturalism into training practices, perceived importance of multicultural issues, and perceived importance of multiculturalism for clinical skills. All participating training directors reported that their programs integrated multiculturalism into training practices (N = 38).
Similarly, 97.4% of faculty members responsible for overseeing program training practices reported that multicultural considerations were either very important (n=30) or important (n=8) in the development of clinical skills. While the majority of training directors indicated that multicultural competence was considered in student evaluations (86.8%, n = 33) a very small portion of respondents reported that their programs directly assess multicultural competence (13.2%, n = 5).

Hypothesis Related to Graduate Student Variables
Hypothesis 1. There was an expectation that there would be group differences in level of multicultural competence between graduate students of different racial and ethnic backgrounds. To address this hypothesis an analysis of variance (ANOVA) was performed. Students' self--identified race/ethnicity served as the independent variable and MAKSS--CE--R scores were used as the dependent variable. As the individual groups of students from different backgrounds were not numerically substantial (in some cases n = <2) and graduate students who identified as White were overrepresented in the sample (n=132), the demographic variables were collapsed into a White/graduate student of color (n= 35) dichotomy for the purpose of this analysis. The results were not significant (F (1, 165) = 1.574, p = .211) and did not support this hypothesis such an analysis provides some insight into possible group differences, it was not the preferred method as it fails to account for the heterogeneity within groups. Other possible confounding variables are explored in the discussion section.
Hypothesis 2. Graduate students who reported that their training program emphasizes aspects of the APA and AMDC guidelines were expected to exhibit higher levels of self--perceived multicultural competencies. A bivariate Pearson correlation analyses was run to determine whether self--perceived multicultural competence (MAKSS--CE--R score) was associated with the following variables: students' age, current enrollment in a multicultural course, number of multicultural courses completed, number of clients (and years) working with those whose background differs from their own, and perceived importance of multicultural considerations.
Additionally, there was an assessment of correlations between students--self perceived multicultural competence and their report of the following training program variables: program type, whether multicultural competence was assessed, whether students were encouraged to include multicultural considerations in research projects, whether there was a requirement of a multicultural course, and whether programs integrate multicultural issues into training practices.
The analysis was one--tailed and an alpha level of .05 was used for the analysis. Significant correlations were found between self--perceived multicultural competence and the following student variables: age (r = .267, p < .001), number of multicultural courses completed (r = .188, p < .01), number of years working with culturally different clients (r = .296, p <.01), number of culturally different clients, (r = .250, p <.01), students' perception of the importance of cultural considerations in clinical work (r = .183, p < .01). Significant relationships between self--perceived multicultural competences and students' perceptions of the following program variables were also found: whether programs' assess multicultural competence (r = .161, p < .05), and whether programs have a multicultural course requirement (r = .132, p < .05) (The results are depicted in Figure 5).  Figure 5 represent the student and program variables that are positively associated with doctoral students' self--identified multicultural competence. Counseling psychology Ph.D. programs scored the highest with a mean score of 2.28  Notably, these means are affected by the significant proportion of programs in each category type that achieved program total and guidelines and standard scores of 0.
Hypothesis 2. It was anticipated that there would be differences among program types. A one--way ANOVA (alpha = .05) was employed to determine whether there were differences between types of training programs and level of adherence to APA guidelines and AMCD standards. The analysis yielded significant results; group differences in both program total scores F(3, 306) = 5.009, p < .01 and group differences in program guidelines and standards scores F(3, 306) = 5.302, p < .01 (See Table 2).   Table 2 indicates significant differences in program total scores among programs. The lower portion reflects significant differences in endorsement of guidelines and standards among the four program types.

Sum of
The results of the post -hoc Tukey HSD for program total scores indicate significant differences between counseling Ph.D. and clinical Ph.D. programs Counseling Ph.D. programs have significantly higher mean scores (program total score mean =4 guidelines and standards mean score = 2.28) than clinical Ph.D.
programs (program total score mean =2.73 guidelines and standards mean score = 36 1.31), clinical Psy.D. programs (program total score mean =2.85 guidelines and standards mean score = 1.15), and counseling Psy. D. programs (program total score mean =2.6 guidelines and standards mean score = 0.40). Notably, program total scores and guidelines and standards scores were relatively similar between programs located in the West, Mid--West, South, and Northeast. Programs located in Canada had substantially lower program total scores and Guidelines and standards scores than other programs. The one program located in the North--East Caribbean had program total and guidelines and standards scores that exceeded the means of programs in other geographic regions. See Figure 6 for a comparison of Guideline and Standard Scores and Program total scores between program types and Figure 7 for comparisons of mean scores by location.  "…to train students who can work with people across the lifespan and present with a broad spectrum of issues and severity of psychological conditions; who can provide counseling, assessment, and educational services to individuals, couples, families, and groups in a variety of settings; and who can collaborate with other professionals in their community and region." (Radford University, 2013).
The program material posits that the above mentioned goals are to be achieved, then ethical and socially conscious students must be trained to attend to the needs of the underserved, including rural and frontier Americans. Program materials indicate that issues of poverty, unemployment, inadequate insurance, limited healthcare access, and availability of service providers significantly impact the experiences of most individuals living in rural Virginia (Radford University, 2013). Accordingly, doctoral students provide much needed services to the local community, receive didactic training on rural practice, and have the opportunity to collaborate with campus organizations such as the Appalachian Regional Studies Center.
Cultural diversity is also addressed by the involvement of faculty in the campus and community organizations such as the Center for Gender Studies, Radford University Safe Zones, and the Women's Resource Center of the New River Valley. Radford students are also exposed to issues of social justice including

Meeting Trainees' Multicultural Training Needs
The results of the analyses of the self reports of graduate students' suggest that the extent to which training programs manifest a valuing of multiculturalism significantly impacts their perceptions of professional competence. Specifically, when programs require didactic training on multicultural issues, and assess related competencies students are more likely to feel adequately prepared to deal with issues of diversity. Similarly, the personal valuing of multicultural issues by students was also positively associated with feeling competent. Additionally, the increased exposure of students to clients who are different from themselves has positive implications for their multicultural competence. The training methods outlined in the exemplary practices section address the aspects of training which can also lead students to feel more competent.
Counseling Ph.D. programs address the APA guidelines and AMCD standards significantly more often than other types of programs. This may reflect increased valuing of multiculturalism in the field of counseling psychology and a related emphasis dealing with diversity issues in training. This has implications for both the consumers of training and those who receive psychological services or are research participants.
However, it is important to note that despite the significant differences between training program types, all types fared poorly in their available literature regarding multicultural training. Out of a possible 37 points, the average program received 1.47 points and guidelines and standards scores ranged from 0 to 13. This suggests that doctoral training programs in both clinical and counseling psychology would benefit from closer adherence to suggested guidelines and standards. The field's governing and accrediting bodies, the available literature, and logic dictate that training programs must put forth a better effort in preparing future professionals to address the needs of an increasingly diverse population. It is particularly troubling that nearly half of the accredited programs do not even mention any of the guidelines or standards in their materials. While training materials do not necessarily reflect all of a program's practices, the failure to incorporate any content relating to any of the guidelines or standards at this point in history is unconscionable.

Limitations
There are several limitations of this study design. Respondent groups for both graduate trainees and training directors may be biased toward supporting multicultural competences. As discussed earlier, many professionals within the field are resistant to multicultural competencies (Sue, Zane, Hall, & Berger, 2009). Those who have little professional and personal investment in multicultural issues may have chosen not to participate in the study. While many training directors were contacted to participate in this study, and many stated that they would participate and encourage their students to participate as well, the final sample size of both groups were relatively small. This suggests that many training program members read the solicitation e--mail and simply chose not to participate. Moreover, some training directors did not even reply to e--mail solicitations.
On the other hand, individuals who chose to participate may reflect a subset of training directors and students who are especially invested in multicultural issues, and as a result, spent considerable time and effort studying and developing their competences. If this is the case, the sample may be skewed in favor of multicultural training, so the generalizability of the results is limited. The inclusion of the program material review was aimed at compensating for the aforementioned concern.
Nevertheless many hypotheses gained some support; findings from the program review have very important implications. Much "lip service" and little tangible training was evidenced supporting the hypothesis that ideals and practices in the field are vastly different.
Finally, it is important to acknowledge the possible effect of social desirability in this study. Doctoral program materials emphasize program strengths. Training directors are invested in the reputation of their programs and as a result, may over report the quality of their training methods. Students and training directors alike are aware that it "looks better" to report the valuing of diversity. Program materials should be developed to provide both perspective and current students, accrediting bodies, as well as the general public with an accurate overview of training practices.
It is hoped that such material emphasizes the multicultural aspects of training accurately.
To lessen the impact of social desirability on training director reports, they were not asked to identify the programs in which they serve. Similarly, students were not asked to identify their training programs, as the request to do so also had the potential to influence their responses. A consequence of this study's consideration of social desirability and acknowledgement of the importance of participant anonymity to elicit honest feedback, the design does not provide a direct link between the results of the program material review and responses from training directors or graduate students. As such, this study is a broad report on the state of the field's training programs from three perspectives: program materials, training directors, and students consumers. While direct relationships between responses and training program affiliation would have provided more insight into training methods outcomes, this study may serve as an important first step in improving training methods.

Conclusions, Recommendations, and Future Directions
In keeping with the literature that suggests its efficacy, an awareness, knowledge, and skills based approach to engaging in culturally competent clinical work is recommended. Cultural competences are not merely applicable to clients from underrepresented and underserved groups but to all clinical populations; all treatment should take place within the context of cultural awareness, knowledge, and skills. Dominant group values are woven throughout typical research and treatment practices. This standardization of dominant group values serves to disadvantage clients whose cultures differ from the culture around which methods were based. As such, applying evidence--based practices without consideration of culture is both unethical and unjust (APA, 2010).
Graduate programs are encouraged to have both faculty and students engage in the self--reflective practices such as those discussed by Fouad (2006). Evaluation of the successes and shortcomings of a program with regard to multicultural training 51 should be an ongoing process. Programs may use preparation for accreditation site visits as an opportunity to engage in such reflection. However, it is recommended that programs engage more regularly in exploration of their multicultural training methods. Graduate students and the consumers of graduate student services as well, should be included in this review process.
Programs may also facilitate the development of multicultural competence by Consent Form for Research You are being invited to take part in a research project described below. If you have questions regarding the study aims or processes you may contact, Bryana White, M.A. the person mainly responsible for this study at, bryana_white@my.uri.edu. You must be at least 18 years old to be in this research project.

Description of the project:
You have been asked to take part in the study that explores the multicultural training methods of clinical and counseling psychology doctoral programs and graduate trainee's self perceived multicultural competence. What will be done: If you decide to take part in this study here is what will happen: You will complete the following questionnaires online. The completion of these questionnaires will take approximately 25 minutes.

Risks or discomfort:
The risk for discomfort resulting from your participation in this study is minimal.

Benefits of this study:
Although there will be no direct benefit to you for taking part in this study, the researcher may learn more about the relationship between doctoral programs' multicultural training methods and graduate trainee's sense of multicultural self-efficacy.

Confidentiality:
Your part in this study is confidential. You will not be asked to identify yourself by name rather you will complete the survey measures anonymously online. All records will be kept in an encrypted electronic document. The document will only be accessible by the researcher. Data for this study will be discussed in aggregate.

Decision to quit at any time:
The decision to take part in this study is up to you. You do not have to participate. If you decide to take part in the study, you may quit at any time. Whatever you decide will in no way negatively affect your course grade. If you wish to quit, simply close your browser window or inform the researcher, Bryana White via e--mail (bryana_White@my.uri.edu) of your decision.

Rights and Complaints:
If you are not satisfied with the way that this study is performed, you may discuss your complaints with Bryana White, anonymously, if you choose. In addition, you may contact the office of the Vice President for Research, 70 Lower College Road, Suite 2, University of Rhode Island, Kingston, Rhode Island, telephone: (401) 874--4328. You are at least 18 years old. You have read the consent form and your questions have been answered to your satisfaction. Your filling out the survey implies your consent to participate in this study.

APPENDIX II Demographic Questionnaire
Instructions: Please answer the following questions about your background. This survey is designed to obtain information on the educational needs of counselor trainees. It is not a test. No grade will be given as a result of completing this survey.
Please complete the demographic items listed below.
Following the demographic section, you will find a list of statements and/or questions related to a variety of issues related to the field of multicultural counseling. Please read each statement/question carefully. From the available choices, circle the one that best fits your reaction to each statement/question. Thank you for your participation. 3. Culturally skilled counselors are able to recognize the limits of their multicultural competency and expertise. 4. Culturally skilled counselors recognize their sources of discomfort with differences that exist between themselves and clients in terms of race, ethnicity and culture. B. Knowledge 1. Culturally skilled counselors have specific knowledge about their own racial and cultural heritage and how it personally and professionally affects their definitions and biases of normality/abnormality and the process of counseling. 2. Culturally skilled counselors possess knowledge and understanding about how oppression, racism, discrimination, and stereotyping affect them personally and in their work. This allows individuals to acknowledge their own racist attitudes, beliefs, and feelings. Although this standard applies to all groups, for White counselors it may mean that they understand how they may have directly or indirectly benefited from individual, institutional, and cultural racism as outlined in White identity development models. 3. Culturally skilled counselors possess knowledge about their social impact upon others. They are knowledgeable about communication style differences, how their style may clash with or foster the counseling process with persons of color or others different from themselves based on the A, B and C, Dimensions ,and how to anticipate the impact it may have on others. C. Skills 1. Culturally skilled counselors seek out educational, consultative, and training experiences to improve their understanding and effectiveness in working with culturally different populations. Being able to recognize the limits of their competencies, they (a) seek consultation, (b) seek further training or education, (c) refer out to more qualified individuals or resources, or (d) engage in a combination of these. 2. Culturally skilled counselors are constantly seeking to understand themselves as racial and cultural beings and are actively seeking a non racist identity.

II. Counselor Awareness of Client's Worldview
A. Attitudes and Beliefs 1. Culturally skilled counselors are aware of their negative and positive emotional reactions toward other racial and ethnic groups that may prove detrimental to the counseling relationship. They are willing to contrast their own beliefs and attitudes with those of their culturally different clients in a nonjudgmental fashion. 2. Culturally skilled counselors are aware of their stereotypes and preconceived notions that they may hold toward other racial and ethnic minority groups. B. Knowledge 1. Culturally skilled counselors possess specific knowledge and information about the particular group with which they are working. They are aware of the life experiences, cultural heritage, and historical background of their culturally different clients. This particular competency is strongly linked to the "minority identity development models" available in the literature. 2. Culturally skilled counselors understand how race, culture, ethnicity, and so forth may affect personality formation, vocational choices, manifestation of psychological disorders, help seeking behavior, and the appropriateness or inappropriateness of counseling approaches. 3. Culturally skilled counselors understand and have knowledge about sociopolitical influences that impinge upon the life of racial and ethnic minorities. Immigration issues, poverty, racism, stereotyping, and powerlessness may impact self esteem and self concept in the counseling process. C. Skills 1. Culturally skilled counselors should familiarize themselves with relevant research and the latest findings regarding mental health and mental disorders that affect various ethnic and racial groups. They should actively seek out educational experiences that enrich their knowledge, understanding, and cross--cultural skills for more effective counseling behavior. 2. Culturally skilled counselors become actively involved with minority individuals outside the counseling setting (e.g., community events, social and political functions, celebrations, friendships, neighborhood groups, and so forth) so that their perspective of minorities is more than an academic or helping exercise.

III. Culturally Appropriate Intervention Strategies
A. Beliefs and Attitudes 1. Culturally skilled counselors respect clients' religious and/ or spiritual beliefs and values, including attributions and taboos, because they affect worldview, psychosocial functioning, and expressions of distress. 2. Culturally skilled counselors respect indigenous helping practices and respect help~iving networks among communities of color. 3. Culturally skilled counselors value bilingualism and do not view another language as an impediment to counseling (monolingualism may be the culprit). B. Knowledge 1. Culturally skilled counselors have a clear and explicit knowledge and understanding of the generic characteristics of counseling and therapy (culture bound, class bound, and monolingual) and how they may clash with the cultural values of various cultural groups. 2. Culturally skilled counselors are aware of institutional barriers that prevent minorities from using mental health services. 3. Culturally skilled counselors have knowledge of the potential bias in assessment instruments and use procedures and interpret findings keeping in mind the cultural and linguistic characteristics of the clients. 4. Culturally skilled counselors have knowledge of family structures, hierarchies, values, and beliefs from various cultural perspectives. They are knowledgeable about the community where a particular cultural group may reside and the resources in the community. 5. Culturally skilled counselors should be aware of relevant discriminatory practices at the social and community level that may be affecting the psychological welfare of the population being served.
C. Skills 1. Culturally skilled counselors are able to engage in a variety of verbal and nonverbal helping responses. They are able to send and receive both verbal and nonverbal messages accurately and appropriately. They are not tied down to only one method or approach to helping, but recognize that helping styles and approaches may be culture bound. When they sense that their helping style is limited and potentially inappropriate, they can anticipate and modify it. 2. Culturally skilled counselors are able to exercise institutional intervention skills on behalf of their clients. They can help clients determine whether a "problem" stems from racism or bias in others (the concept of healthy paranoia) so that clients do not inappropriately personalize problems. 3. Culturally skilled counselors are not averse to seeking consultation with traditional healers or religious and spiritual leaders and practitioners in the treatment of culturally different clients when appropriate. 4. Culturally skilled counselors take responsibility for interacting in the language requested by the client and, if not feasible, make appropriate referrals. A serious problem arises when the linguistic skills of the counselor do not match the language of the client. This being the case, counselors should (a) seek a translator with cultural knowledge and appropriate professional background or (b) refer to a knowledgeable and competent bilingual counselor. 5. Culturally skilled counselors have training and expertise in the use of traditional assessment and testing instruments. They not only understand the technical aspects of the instruments but are also aware of the cultural limitations. This allows them to use test instruments for the welfare of culturally different clients. 6. Culturally skilled counselors should attend to as well as work to eliminate biases, prejudices, and discriminatory contexts in conducting evaluations and providing interventions, and should develop sensitivity to issues of oppression, sexism, heterosexism, elitism and racism. 7. Culturally skilled counselors take responsibility for educating their clients to the processes of psychological intervention, such as goals, expectations, legal rights, and the counselor's orientation. Arredondo, P., Toporek, M. S., Brown, S., Jones, J., Locke, D. C., Sanchez, J. and Stadler, H. (1996) Operationalization of the Multicultural Counseling Competencies. AMCD: Alexandria, VA APPENDIX VI American Psychological Association Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Guideline #1: Psychologists are encouraged to recognize that, as cultural beings, they may hold attitudes and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are ethnically and racially different from themselves. Guideline #2: Psychologists are encouraged to recognize the importance of multicultural sensitivity/responsiveness, knowledge, and understanding about ethnically and racially different individuals. Guideline #3: As educators, psychologists are encouraged to employ the constructs of multiculturalism and diversity in psychological education. Guideline #4: Culturally sensitive psychological researchers are encouraged to recognize the importance of conducting culture-centered and ethical psychological research among persons from ethnic, linguistic, and racial minority backgrounds. Guideline #5: Psychologists strive to apply culturally-appropriate skills in clinical and other applied psychological practices. Guideline #6: Psychologists are encouraged to use organizational change processes to support culturally informed organizational (policy) development and practices.

APPENDIX VII Counseling Psychology Model Training Values Statement Addressing Diversity 1
Respect for diversity and for values different from one's own is a central value of counseling psychology training programs. The valuing of diversity is also consistent with the profession of psychology as mandated by the American Psychological Association's Ethical Principles and Code of Conduct (2002) and as discussed in the Guidelines and Principles of Programs in Professional Psychology (APA, 2005). More recently there has been a call for counseling psychologists to actively work and advocate for social justice and prevent further oppression in society. Counseling psychologists provide services, teach, and/or engage in research with or pertaining to members of social groups that have often been devalued, viewed as deficient, or otherwise marginalized in the larger society. Academic training programs, internships that employ counseling psychologists and espouse counseling values, and post--doc training programs (herein "training programs") in counseling psychology exist within multicultural communities that contain people of diverse racial, ethnic, and class backgrounds; national origins; religious, spiritual and political beliefs; physical abilities; ages; genders; gender identities, sexual orientations, and physical appearance. Counseling psychologists believe that training communities are enriched by members' openness to learning about others who are different than them as well as acceptance of others. Internship trainers, professors, practicum supervisors (herein "trainers") and students and interns (herein "trainees") agree to work together to create training environments that are characterized by respect, safety, and trust. Further, trainers and trainees are expected to be respectful and supportive of all individuals, including, but not limited to clients, staff, peers, and research participants. Trainers recognize that no individual is completely free from all forms of bias and prejudice. Furthermore, it is expected that each training community will evidence a range of attitudes, beliefs, and behaviors. Nonetheless, trainees and trainers in counseling psychology training programs are expected to be committed to the social values of respect for diversity, inclusion, and equity. Further, trainees and trainers are expected to be committed to critical thinking and the process of self-examination so that such prejudices or biases (and the assumptions on which they are based) may be evaluated in the light of available scientific data, standards of the profession, and traditions of cooperation and mutual respect. Thus, trainees and trainers are asked to demonstrate a genuine desire to examine their own attitudes, assumptions, behaviors, and values and to learn to work effectively with "cultural, individual, and role differences including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status" (APA Ethics Code, 2002, Principle E, p. 1063). Stated simply, both trainers and trainees are expected to demonstrate a willingness to examine their personal values, and to acquire and utilize professionally relevant knowledge and skills regardless of their beliefs, attitudes, and values. Trainers will engage trainees in a manner inclusive and respectful of their multiple cultural identities. Trainers will examine their own biases and prejudices in the course of their interactions with trainees so as to model and facilitate this process for their trainees. Trainers will provide equal access, opportunity, and encouragement for trainees inclusive of their multiple cultural identities. Where appropriate, trainers will also model the processes of personal introspection in which they desire trainees to engage. As such, trainers will engage in and model appropriate self--disclosure and introspection with their trainees. This can include discussions about personal life experiences, attitudes, beliefs, opinions, feelings, and personal histories. Assuming no one is free from biases and prejudices, trainers will remain open to appropriate challenges from trainees to their held biases and prejudices. Trainers are committed to lifelong learning relative to multicultural competence. Counseling psychology training programs believe providing experiences that call for trainees to self--disclose and personally introspect about personal life experiences is an essential component of the training program. Specifically, while in the program trainees will be expected to engage in self--reflection and introspection on their attitudes, beliefs, opinions, feelings and personal history. Trainees will be expected to examine and attempt to resolve any of the above to eliminate potential negative impact on their ability to perform the functions of a psychologist, including but not limited to providing effective services to individuals from cultures and with beliefs different from their own and in accordance with APA guidelines and principles. Members of the training community are committed to educating each other on the existence and effects of racism, sexism, ageism, heterosexism, religious intolerance, and other forms of invidious prejudice. Evidence of bias, stereotyped thinking, and prejudicial beliefs and attitudes will not go unchallenged, even when such behavior is rationalized as being a function of ignorance, joking, cultural differences, or substance abuse. When these actions result in physical or psychological abuse, harassment, intimidation, substandard psychological services or research, or violence against persons or property, members of the training community will intervene appropriately.
In summary, all members of counseling psychology training communities are committed to a training process that facilitates the development of professionally relevant knowledge and skills focused on working effectively with all individuals inclusive of demographics, beliefs, attitudes, and values. Members agree to engage in a mutually supportive process that examines the effects of one's beliefs, attitudes, and values on one's work with all clients. Such training processes are