Population-Based Mental Health Facilitation (MHF): A Grassroots Strategy That Works

J. Scott Hinkle

Abstract: The World Health Organization (WHO) estimates that at least 450 million people worldwide live with unmet mental health problems. Additionally, one in four people will experience psychological distress and meet criteria for a diagnosable mental health disorder at some point in their lives. This data speaks to the need for accessible, effective and equitable global mental health care. Available mental health resources are inequitably distributed, with low- to middle-income countries showing significantly fewer mental health human resources than high-income countries. The need to proactively address this care-need gap has been identified by WHO and various national organizations, including NBCC International (NBCC-I). NBCC-I’s Mental Health Facilitator (MHF) program addresses the global need for community-based mental health training that can be adapted to reflect the social, cultural, economic and political climate of any population, nation or region.

Keywords: global, mental health, international, mental health facilitator, MHF, population, community, WHO

Pages 1–18

Developing and promoting mental health services at the grassroots level while also maintaining a global perspective is, to say the least, an overwhelming task. The National Board for Certified Counselors’ International division (NBCC-I) has responded to this task in two deliberate steps. Initially, NBCC-I collaborated with the World Health Organization’s (WHO) Department of Mental Health and Substance Abuse to establish the global Mental Health Facilitator (MHF) training program. The MHF program addresses the international need for population-based mental health training that can be adapted to reflect the social, cultural, economic and political realities of any country or region. Once the program was effectively addressed by WHO and NBCC-I as a viable strategy to reduce mental health issues on a global basis, NBCC-I independently developed a curriculum and implementation method that has begun to make a promising global impact (Hinkle, 2006, 2007, 2009, 2010a, 2010b, 2012a, 2012b, 2012c, 2013; Hinkle & Henderson, 2007; Hinkle & Schweiger, 2012; Schweiger & Hinkle, 2013).

For years the global burden of mental disorders on individuals, families, communities and health services has been considerably underestimated (Chisholm et al., 2000; Murray & López, 1996a, 1996b; Ustün & Sartorius, 1995). Resources for mental, neurological, and substance use disorders have been slow in development, insufficient, constrained, fragmented, inequitably distributed, and ineffectively implemented (Becker & Kleinman, 2013; Chen et al., 2004; Gulbenkian Global Mental Health Platform [GGMHP], 2013a; Hinkle & Saxena, 2006). While mental and neurological disorders comprise only 1% of deaths worldwide, they account for 8–28% of the disease burden (GGMHP, 2013a; Murray et al., 2012; Prince et al., 2007; WHO, 2004a), with the majority of these disorders occurring in low- to middle-income countries.

Mental Health: An International Problem

Most mental disorders are highly prevalent in all societies, remain largely undetected and untreated, and result in a substantial burden to families and communities. Although many mental disorders can be mitigated or are avoidable, they continue to be overlooked by the international community and produce significant economic and social hardship. Moreover, in all countries there is an enormous gap between the prevalence of mental disorders and the number of people receiving care (Becker & Kleinman, 2013; Saraceno et al., 2007; Weissman et al., 1994; Weissman et al., 1996; Weissman et al., 1997; WHO, 2010a, 2010b). In less-developed countries, more than 75% of persons with serious mental disorders do not receive treatment (Demyttenaere et al., 2004). Unfortunately, psychiatry’s best efforts at training physicians to provide mental health care within the global context are simply too small for such a large, global problem (Furtos, 2013; Hinkle, 2009, 2010b, 2012b, 2012c; Patel, 2013). The focus has been too long on medicine and not on local communities (Patel, 2013). In fact, every person’s health care is local (Unützer, 2013). The major issue with the current provision of care is, therefore, the limited size and training of the community health care workforce (Becker & Kleinman, 2013).

Globally, one in four people will experience psychological distress and meet criteria for a diagnosable mental disorder at some point in their lives (WHO, 2005). This ominous data speaks to the need for accessible, effective and socially equitable mental health care (Hinkle & Saxena, 2006). WHO estimates that more than 450 million people worldwide live with mental health problems; these numbers are no doubt bleak. More specifically, WHO estimates that globally more than 154 million people suffer from depression, 100 million are affected by alcohol use disorders, 25 million have schizophrenia, 15 million experience drug abuse, and nearly one million people die each year by suicide (Saraceno et al., 2007). Depending on the source, unipolar depression has been estimated to be in the top four causes of loss of disability-adjusted life years across the six socially diverse continents (Murray & López, 1996a, 1996b; Vos et al., 2012).

Furthermore, it has been estimated that as many as 25% of all primary care consultations have a mental health component (Goldberg & Huxley, 1992; Warner & Ford, 1998; WHO, 2006a). Mental disorders are related to a range of problems, from poverty, marginalization, and social disadvantage, to relationship issues such as divorce, physical conditions such as heart disease, reductions in economic productivity, and interruption of child and adolescent educational processes (see Alonso, Chatterji, He, & Kessler, 2013; Breslau et al., 2013). At the developmental level, at least 10% of children are considered to have mental health problems, but pediatricians and general medical practitioners are not typically equipped to provide effective treatment (Craft, 2005). With mental disorders contributing to an average of 20% of disabilities at the societal level, the evidence is clear that these disorders pose a major challenge to global health (Alonso, Chatterji, et al., 2013; Alonso, Petukhova, et al., 2013). Moreover, the associated economic burden exceeds that of the top four non-communicable diseases (i.e., diabetes, cardiovascular, respiratory and cancer; Bloom et al., 2011).

Unfortunately, most international mental health systems are dominated by custodial psychiatric hospitals that deplete resources for treatments with little efficacy (WHO, 2005). In contrast, governments and nongovernmental organizations (NGOs) should scale up services for community mental health with programs that reflect credible evidence of effectiveness (see Patel, 2013; Patel, Araya, et al., 2007). Murthy (2006) has indicated that there is no global community mental health blueprint to achieve universal mental health access, and that effective community workforce strategies need to be matched to each country’s unique situation. It is an ecological fallacy to try to understand people and mental health issues outside the environments in which they exist (Galea, 2013). Thus, a radical shift is urgently needed in the way mental disorders are managed, and this clearly includes community-based care that can be effectively implemented via non-health as well as health sectors (GGMHP, 2013a, 2013b; Hinkle, 2012b).

Global Community Mental Health

Serious mental disorders are generally associated with substantial role disability within the community. About 35–50% of mental health cases in developed countries and approximately 75–85% in less-developed countries have received no treatment in the 12 months preceding a clinical interview. Due to the high prevalence of mild and sub-threshold cases, the number of untreated cases is estimated to be even larger. These milder cases, which can be found in communities all over the world, require careful consideration because they are prone to progress to serious mental disorders (WHO, 2010a, 2010b; WHO World Mental Health Survey Consortium, 2004).

It is important to note that in most low- to middle-income countries, community workers are often the people’s first line of contact with the health care system (Anand & Bärnighausen, 2004; Hongoro & McPake, 2004). However, there is a long history of issues with the sustainability of community programs (Walt, 1988), and the lack of community service providers with the necessary competencies to address needs remains the most significant barrier to the provision of mental health services. Although human resources are the crucial core of health systems, they have been a neglected developmental component (Hongoro & McPake, 2004), particularly in the field of mental health. WHO’s “Mental Health Atlas” (2005) specifies a critical global shortage of mental health professionals (e.g., psychiatrists, psychiatric nurses, psychologists, social workers, neurologists). Similarly, an informal international survey of clinical mental health, school, and career and work counselors by NBCC-I indicated that the professional counselor workforce has yet to be adequately identified on a global scale (Hinkle, 2010b). Moreover, extant mental health services are inequitably distributed; lower-income countries, where behavioral risk factors tend to cluster among people of lower socioeconomic status, have significantly fewer mental health human resources than higher-income countries (Coups, Gaba, & Orleans, 2004; WHO, 2005; WHO World Mental Health Survey Consortium, 2004).

In low- to middle-income countries, human resources are clearly limited, and the quality and productivity of the existing workforce is often challenged. Investment in human resources for community mental health care is insufficient in absolute terms as well as in distribution (Hongoro & McPake, 2004). For instance, the global average for physicians is 170 per 100,000 people, but in Nepal and Papua New Guinea there have been as few as five doctors for this ratio (WHO, 2004a). In 2003, approximately 36% of doctors’ posts and 18% of nurses’ posts were unfilled around the world (Bach, 2004). Moreover, general practitioners are not typically adept at providing mental health care, including detection, referral and management of mental disorders (Chisholm et al., 2000). Therefore, partnerships between formal primary and informal community health care systems need to be more prevalent, effective and integrated.

Two facets for integrating mental health into primary care are (a) financial and human resources and (b) collaboration with non-health sectors. NGOs, community workers and volunteers can play a significant role in supporting formal primary care systems for mental health. For example, village health workers in Argentina, India and the Islamic Republic of Iran have been trained to identify and refer people for medical assistance. Even countries that have adequate services, like Australia, use local informal services to support mental health patients (see WHO, 2006b). Because psychiatric hospital beds are extremely limited, the demand for mental health services within communities becomes even more critical (Forchuk, Martin, Chan, & Jensen, 2005). Furthermore, early detection and treatment of mental disorders and co-occurring emotional and behavioral problems not only decreases the chance of lower physical health later in life, but also associated costly hospitalizations (Alonso, Chatterji, et al., 2013; Alonso, Petukhova, et al., 2013; Scott et al., 2013).

An urgent, radical change in the way mental disorders are managed and monitored—one that moves away from lengthy institutional hospitalizations and toward population-based mental health care in the community—is needed (GGMHP, 2013a, 2013b; Hinkle, 2009). The need to proactively address this care-need gap from a praxis, or practical, rather than a theoretical approach has been repeatedly identified by WHO and various national and international organizations, including NBCC-I (Hinkle & Schweiger, 2012). Communities in developing countries have historically lacked opportunities for mental health training, skill development, and capacity building (Abarquez & Murshed, 2004); however, long years of training are not necessary for learning how to provide fundamental help for people who are emotionally distressed.

Volunteer community workers are a large untapped community resource of potential service providers for people suffering from problems associated with mental health (Hoff, Hallisey, & Hoff, 2009). Chan (2010) has reported that “there is a widely shared but mistaken idea that improvements in mental health require sophisticated and expensive technologies and highly specialized staff. The reality is that most of the mental, neurological and substance use conditions that result in high morbidity and mortality can be managed by non-specialist health-care providers” (p. iii). The research has substantiated that it is feasible to deliver psychosocial-type interventions in non-specialized health care settings (WHO, 2010a, 2010b). Enhancing basic community mental health services, both informally and formally, is a viable way to assist the never-served. The MHF program is part of a grassroots implementation trend that has already begun in communities around the globe (e.g., Canada, Europe, Africa, Asia, United States; see Hinkle, 2007, 2013; Hoff, 1993; Hoff et al., 2009; Marks & Scott, 1990; McKee, Ferlie, & Hyde, 2008; Mosher & Burti, 1994; Patel, 2013; Rachlis & Kushner, 1994).

A Brief Review of Grassroots Community Mental Health Approaches

Unfortunately, governmental psychiatric hospitals have a long history of human rights violations and poor clinical outcomes (Hinkle, 2010b). They also are costly and consume a disproportionate amount of mental health care monies. In contrast, informal community caregivers are not generally part of the formal health care system; examples include traditional healers, professionals such as teachers, police and various community workers, NGOs, consumer and family associations, as well as laypeople. Informal care is typically accessible because it is an integral part of the community. However informal, this care should not replace the core of formal mental health service provision (Saraceno et al., 2007; WHO, 2010a, 2010b), but serve as a grassroots, adjunctive care system.

For example, beginning as early as 1963, the work of Rioch et al. portrayed community paraprofessionals serving as in- and out-patient “therapists.” Similarly, as far back as 50 years, Albee (1967) reported that the dearth of manpower in mental health services could be lessened by the use of paraprofessionals who could arrange for neighborhood outreach and basic psychiatric evaluations (Hines, 1970).

Likewise, in 1969 Vidaver suggested the development of mental health technicians with generalist skills for lateral and vertical mental health employment mobility. Vidaver (1969) further commented that community colleges were able to train local community helpers for a variety of informal roles in mental health services without years of higher education. Interviewing (i.e., communication), consultation, and community liaison techniques (i.e., referral) were depicted by Vidaver as important general skills for community helpers. One year later, Lynch and Gardner (1970) developed a training program with the goal of training laypeople to be “helpers in a psychiatric setting” (p. 1476), emphasizing communication skills training with a focus on the “front line of operation” (p. 1475) provided by paraprofessionals and professionals providing backup services.

Also in 1970, the U.S. military addressed mental health manpower shortages by increasing the use of paraprofessional specialists who were taught entry-level skills to help soldiers in need (Nolan & Cooke, 1970). Training included conducting interviews, collecting historical, situational and observational data, and developing referral skills to connect the soldier with professional mental health resources. Identifying common mental health problems and relating to problems in a realistic way were included in the training. Program evaluations indicated that trainees “quickly and confidently transpose their course-acquired skills to the job situation” (Nolan & Cooke, 1970, p. 79).

More recently, basic psychological first aid programs have been effective in Bangladesh, where psychosocial support is used in emergency situations (Kabir, 2011). As well, nurses and health care staff have been trained as mental health facilitators in the United Kingdom to recognize depression, anxiety, stress, drug and alcohol problems, grief reactions, and domestic violence; make referrals; and provide support and aftercare. These nurses also assist people with co-occurring disorders and provid mental health promotion in the schools. Furthermore, the nursing profession in the United Kingdom has noted that community mental health care is a particular problem area, resulting in the development of the mental health assistant practitioner as a creative practice strategy to reduce the costs of services as well as improve multi-professional communication based on local needs (Warner & Ford, 1998; Warne & McAndrew, 2004).

Although implementing such grassroots community mental health programs is not easy, global health care organizations have demonstrated greater need to develop innovative uses of informal mental health assistants and facilitators to establish community mental health services (Warne & McAndrew, 2004). In the long run, if the gap in mental health services is sufficiently closed, it must include the use of non-specialists to deliver care (Eaton, 2013; Eaton et al., 2011; Hinkle, 2006, 2009). Such non-specialized workers will have received novel training in identifying mental stress, distress and disorders; providing fundamental care; monitoring strategies; and making appropriate referrals (see Becker & Kleinman, 2013; Hinkle & Schweiger, 2012; Hinkle, Kutcher, & Chehil, 2006; Jorm, 2012; Saraceno et al., 2007).

The Mental Health Facilitator Training Program

Existing data speaks loudly to the need for accessible, effective and equitable global mental health care. However, a common barrier to mental health care is a lack of providers who have the necessary competencies to address basic community psychosocial needs. This barrier has been clearly identified by WHO and various national and international organizations, including NBCC-I (Eaton, 2013; Hinkle, 2006, 2009, 2012c; Hinkle & Saxena, 2006; Patel, 2013; WHO World Mental Health Survey Consortium, 2004; WHO, 2005, 2010a, 2010b).

General MHF Background Information and Rationale

In 2005, officers from NBCC-I met with the director of the WHO Department of Mental Health and Substance Abuse to discuss the challenges of international mental health care. As a result of these meetings, WHO selected 32 international mental health professionals to evaluate NBCC-I’s proposed MHF program, with almost 100% supporting its development. Subsequently, the curriculum and master training guide were completed by NBCC-I in 2007. Drafts of the curriculum and proposed teaching methods were piloted on two occasions in Mexico City with mental health professionals from Europe, the Caribbean, Africa and the United States. Additional subject matter experts facilitating pilot development included mental health professionals from Malaysia, Canada, Trinidad, St. Lucia, Turkey, India, Mexico, Botswana, Romania and Venezuela.

The resulting MHF training program draws on a variety of competencies derived from related disciplines, including but not limited to psychiatry, psychology, social work, psychiatric nursing, and counseling. Its eclectic programming and international composition allowed for a flexible training model with expertise drawn from global practices. Because MHF training is transdisciplinary, traditional professional helping silos are not reinforced; skills and competencies are linked instead to population-based mental health needs rather than professional ideologies. Thus, individuals with MHF training (MHFs) can effectively identify and meet community mental health needs in a standardized manner, regardless of where these needs are manifested and how they are interpreted. Mental health and the process of facilitating it is based on developing community relationships that promote a state of well-being, enabling individuals to realize their abilities, cope with the normal and less-than-normal stresses of life, work productively, and make a contribution to their communities.

The MHF training program was first taught in Lilongwe, Malawi in 2008 and has since been taught approximately 108 times by 435 trainers, including 181 master trainers in 20 countries. The MHF program recently expanded to provide mental health assistance in more established countries, as manifested in the program’s current popularity in the United States (Schweiger & Hinkle, 2013). This expansion also marks the completion of an educators’ edition of the MHF curriculum for use in schools with a focus on students, teachers and schooling.

To date, the MHF training program has been implemented globally to enhance mental health care at various levels. At the formal, primary health care level, general medical practitioners provide acute and long-term treatment to individuals with a variety of mental disorders, supplemented by the efforts of individuals with MHF training. MHFs also augment specialized services by functioning within a mental health care team to provide support, targeted assistance, referral and follow-up monitoring (Paredes, Schweiger, Hinkle, Kutcher, & Chehil, 2008). Likewise, informal community care is characterized by community members without formal mental health education or training providing much-needed services. At this level, nonclinical forms of mental health care such as psychological support or strategic problem solving by community leaders, family groups, and local elders (including indigenous healers) are emphasized. MHF training has been used to bridge the gap between formal and informal mental health care where MHFs work within both systems and do so simultaneously (Hinkle, Kutcher, & Chehil, 2006). With due respect to horizontal and vertical considerations, MHFs have augmented traditional, formal inpatient services by working with mental health teams to provide family support and education, monitor follow-ups, and provide practical “in the trenches” assistance (see Figure 1). This is where informal care, including self-care, becomes critical (Murthy, 2006).

Contextualizing the MHF Program

Most importantly, it is ill-advised to attempt to understand people outside their environments; people must be considered within the characteristics of their respective populations (Galea, 2013). The MHF program is designed to be flexible so local experts can modify components of the training to reflect the realities of their situation. Local stakeholders then identify and include specific competencies in their MHF trainings. As a consequence, consumers and policymakers ensure that MHF trainings provide culturally relevant services to the local population. Furthermore, the MHF training curriculum was conceived as a dynamic document and is revised once each year based on input from local institutions and individuals who provide MHF training. This contextual, organic approach grounds the MHF program in the principle that mental health care is a combination of both universally applicable and context-specific knowledge and skills (Furtos, 2013; Hinkle, 2012a; Paredes et al., 2008). The program consists of integrated knowledge ranging from basic mental health information and promotion to specific, local, culturally relevant helping strategies. The global MHF program

Figure 1. Modified WHO Pyramid Framework: MHF (Hinkle, 2013b)

provides equitable access to quality first-contact interventions, including but not limited to mental health advocacy, helping skills, and monitoring and referral, all of which respect human dignity and rights, and meet local population needs.

Individuals receiving MHF training represent a broad cross section of the community. Diverse trainee backgrounds increase the possibility of addressing the various gaps in local mental health care, which helps local policy makers, service providers, NGOs and communities meet mental health needs without costly infrastructural investments. Moreover, contextualized MHF training facilitates further development and delivery of community-based care consistent with WHO recommendations for addressing the gap in global mental health services.

Bottom-Up vs. Top-Down Community Strategies

It is commonly known that top-down approaches across public services generally have limited success. Conversely, long-term strategies that enhance the successful implementation of public mental health services are best when they are centrally facilitated from a locally directed, bottom-up approach (Rock, Combrinck, & Groves, 2001). From both a service delivery and administrative perspective, a bottom-up strategy has its advantages. One obvious benefit is that it requires local stakeholders to articulate objective and verifiable goals that use a “common currency” (p. 44) or terminology (Rock et al., 2001).

Similarly, MHFs have the advantage of serving as community leaders developing “upstream” versus “downstream” care, as well as providing important links to professional mental health care (Hinkle, Kutcher, & Chehil, 2006; Hoff et al., 2009; McKinlay, 1990). MHFs working in communities apply primary prevention principles by anticipating mental health services for people who may be vulnerable. For instance, MHFs in Bhutan provide drop-in peer assistance for young people challenged by rapid changes in their society. When MHF services are available at the secondary prevention level, people with mental health issues can often avoid disruptive and costly hospitalization. MHFs can assist with reducing long-term disabling effects among people recovering from a mental disorder by applying tertiary prevention measures from the bottom up (Hinkle & Saxena, 2006; Hoff et al., 2009). Furthermore, governmental direction from the top needs to intersect with community efforts from the bottom (Isaac, 2013; see Figure 1); and once programs are vetted from the top, they need to be diverted to bottom-up management (Eaton, 2013).

Although community mental health programs may achieve local success, few have been systematically scaled up to serve the needs of national populations. Despite the array of treatments for mental health, little evidence exists regarding their feasibility and effectiveness when integrated into routine care settings among low- and middle-income countries. Even though bottom-up approaches offer advantages, they also require outcome measurements, something that mental health workers have found traditionally burdensome (Rock et al., 2001). For example, evidence-based mental health interventions for people exposed to conflict and other disasters are weak, especially for strategies implemented in the midst of emergencies (Patel, Araya, et al., 2007). Only a small fraction of the clinical research trials regarding mental health treatment have been administered in low-income countries, resulting in a dearth of knowledge about treatment effectiveness in poor, culturally diverse settings (Becker & Kleinmen, 2013). Consequently, the MHF process is currently undergoing an evaluation in two diverse countries on two separate continents to seek evidence for the effectiveness of this training program. This is a critical step in the program’s continued development, because empirical evaluation of lay health workers’ implementation of community mental health services in low- and middle-income countries has been historically insufficient (Lewin et al., 2005). However, if the global strategy is only to collect more information and add to data resources, there will continue to be a gap in human resources.

As planned, individuals seeking MHF training have represented a broad cross section of local society, ranging from school teachers and principals to business owners, clergy and neighborhood workers. MHF volunteers are also police officers, neighborhood workers, community leaders, NGO employees, elders and indigenous healers. In fact, such healers in Malawi, Africa have learned to apply their first-contact mental health skills to identify, assess, support and refer people in need of acute mental health care through the MHF program. This diversity of trainee backgrounds at the grassroots level increases possibilities for addressing as many gaps as possible in community mental health care. Indeed, grassroots efforts emanate from the ground level (Eaton, 2013; Hinkle, 2010b, 2012a; Hinkle & Schweiger, 2012; Schweiger & Hinkle, 2013).

The Global MHF Partnership

Partnerships among NGOs, governments, agencies and academia can make a difference in the mental health workforce capacity by integrating global expertise with local knowledge (Fricchione, Borba, Alem, Shibre, Carney, & Henderson, 2012; WHO, 2009). As countries recognize the dearth of community health services and attempt to develop fundamental services with a mental health focus, the MHF training program is appealing because of its emphasis at the “street” or “trenches” level (Hinkle, 2012a). This is a critical component of the MHF training program since local stakeholders always have more at stake in risk reduction and capacity building than agencies outside the local neighborhood, village or barrio (Abarquez & Murshed, 2004). For example, MHF training has benefited the people of Mexico City, who have had historically limited access to mental health services (Suck, Kleinberg, & Hinkle, 2013a).

The initial stage of the MHF training process identifies local partners who have the willingness and ability to increase local mental health care capacity. NBCC-I negotiates MHF training with partners such as educational institutions, government agencies, NGOs, private companies or other entities capable of managing a training. An ideal global partner has the capacity and ability to maintain the MHF program and promote continuing mental health education. NBCC-I and respective training partners identify master trainers who can train more trainers, ensuring a multiplier effect (NBCC-I, 2013). In countries where English is not a primary or spoken language, it is necessary to translate and adapt the MHF curriculum and materials. Thus far, MHF partnerships have resulted in the curriculum being translated into 10 languages:Arabic, Bahasa Malaysian, Bhutanese [Dzongka], Chinese, German, Greek, Japanese, Portuguese, Spanish and Swahili.

The MHF Curriculum: General Features

NBCC-I has responded to the care-need gap challenge, and developed and standardized the MHF curriculum drawing on a variety of competencies derived from related mental health disciplines within a cultural context. General, nonclinical, first-responder forms of community mental health care such as basic assessment, social support and referral are included in the MHF curriculum. Similar models that include assessment, advising, agreement on goals, interventions, support and follow-up have been used successfully in mental health care (Fiore et al., 2000; Hinkle, 2012b, 2012c; Whitlock, Orleans, Pender, & Allan, 2002). Currently there are MHFs on five continents, with new trainings being coordinated almost weekly. In developing the curriculum, an eclectic group of professional contributors allowed for a flexible training model with expertise drawn from various international practices. The training consists of 30 hours that can be taught on consecutive days, or divided into its 20 modules and taught over several weeks, depending on the needs of the local community (Hinkle & Henderson, 2007). As local stakeholders are identified and trained using the MHF curriculum, they become the foundation on which to build community mental health care.

The MHF training includes a certificate of completion for anyone successfully completing the program, and additional certificates of completion for trainers and master trainers. Trainers are required to hold a bachelor’s degree or its equivalent, and master trainers must have a master’s degree or its equivalent in a mental health–related discipline. One affirming by-product of the training is the identification of individuals who desire more training and education in mental health services. For example, the MHF program in Bhutan has led to specified substance abuse training in several communities, as well as two students seeking graduate studies in counseling in the United States.

Specific Features of the MHF Curriculum

The MHF curriculum is based on the universality of mental stress, distress and disorders (Desjarlais, Eisenberg, Good, & Kleinman, 1995; Hinkle & Henderson, 2007). MHF training includes numerous topics such as basic helping skills, coping with stress, and community mental health services. The program consists of fundamental, integrated mental health knowledge and skills ranging from community advocacy and commitment, to specified interventions such as suicide mitigation. Also included in the curriculum are segments on working with integrity and not providing services outside the limits of training and experience (Hinkle, 2010a; Reyes & Elhai, 2004). In general, MHFs are taught that negative and unhealthy assumptions about life and living contribute to additional mental and emotional stress (Browne & Winkelman, 2007; Feiring, Taska, & Chen, 2002; Sonne, 2012).

More specifically, the curriculum begins with a section on the benefits of investing in mental health, cost-effective interventions, impacts of mental disorders on families, barriers to mental health care, confidentiality and privacy, and the goals of the MHF program. Understanding perspectives regarding human feelings, effective nonverbal and verbal communication, and using questions effectively in the helping process also are covered in the curriculum, as well as how to assess problems, identify mental health issues, and provide support (Hinkle & Henderson, 2007). Making effective referrals is a crucial segment of the curriculum because this skill also serves the purpose of steering people to physicians for co-occurring physical disorders such as diabetes, heart disease and chronic pain (Gureje, 2013).

MHF trainees also learn how to effectively end a helping relationship—an essential skill taught to mental health workers for the past 40 years (Hines, 1970; Hinkle & Henderson, 2007). MHFs learn that the helping process involves joining with the person seeking assistance, identifying specific concerns, assessing the level of difficulty, surveying the possibilities, solving problems and making choices, and referring to more formal care where appropriate. This is accomplished within a simple framework emphasizing personal strengths and mitigation of significant stress.

Following the basic helping skills section of the curriculum, which emphasizes the age-old but important phenomena of human development and diversity, trainees concentrate on the abilities, needs and preferences that all people possess and how these are integrated in various cultures (Elder & Shanahan, 2007; Huston & Bentley, 2010; Lerner, 2007). A section on understanding various types of encountered problems introduces trainees to the concept of a balanced, less balanced, little balanced, or off balance mental health continuum, alongside how to solve problems and set goals with people experiencing difficulty coping with life (Hinkle & Henderson, 2007). Similarly, trainees learn about stress, distress and basic mental disorders including anxiety and post-traumatic stress disorder (PTSD), depression and mania, psychosis and schizophrenia, substance abuse and dependence, delirium and dementia, mental retardation (intellectual disability), chronic pain, and epilepsy. Child reactions to trauma (van Wesel, Boeije, Alisic, & Drost, 2012) and child maltreatment (Wekerle, 2011) also are covered in the MHF curriculum, which emphasizes helping children and adolescents in the least restrictive environment and as close to their communities as possible (Hinkle & Henderson, 2007).

Preventing suicide and effectively dealing with an actual suicide are two topics of relevance covered in MHF training. Suicide is a leading cause of death in low- and middle-income countries, especially among young people (WHO, 2006a). Self-poisoning using pesticides is common, with estimates of 300,000 of these deaths a year in the Asia-Pacific region alone (Patel, Araya, et al., 2007), validating the need for suicide’s inclusion in the curriculum.

In the 1990s, humanitarian organizations began to recognize the increased need for psychosocial support after various types of disasters (Barron, 2004; Wells, 2006). Disasters result in tremendous loss of property, resources and life. In addition, political, economic and social disruptions are common consequences that have mental health–related implications. Therefore, information about assisting individuals and families in the aftermath of disasters is included in the MHF curriculum (Hinkle & Henderson, 2007; Wells, 2006). The MHF training also emphasizes ways to assist with situations involving domestic violence, refugees, migrants and victims of human trafficking and war, as well as other unfortunate forms of crisis.

Stress-related disorders, as depicted in the MHF curriculum, go largely untreated in many areas of the world, especially when crises and disasters strike. It is all too often the scenario that an earthquake, typhoon, hurricane or human-made crisis has occurred, and limited or no mental health care services are available following the event. Attempts to provide assistance in the aftermath of these disasters have come from governmental responses, NGOs, and community and religious organizations, but it is important to note that even professional mental health workers receive cursory instruction in disaster interventions (Hinkle, 2010a). The need for greater mental health response services is apparent; MHFs from Lebanon to Liberia have assisted communities following civil war and refugee crises, and MHFs in China have assisted in the aftermath of a major earthquake using the basic mental health training they received from the MHF curriculum.

Regardless of their genesis, many mental health–related concerns are largely dependent on problem-solving abilities, a focus on cultural values regarding mental health functioning, and social and economic support (Hinkle et al., 2006; Hoff et al., 2009), all of which are addressed in the MHF curriculum. Studies from stress-related literature suggest that a fundamental problem-solving coping approach is generally associated with positive outcomes (Benight, 2012; Taylor & Stanton, 2007), whereas avoidant-related coping is associated with negative outcomes (Littleton, Horsley, John, & Nelson, 2007); thus the emphasis on problem-solving skills in the MHF curriculum.

Lastly, consulting with helping professionals during mental health emergencies and recognizing the importance of self-care when working in crisis situations also are part of the MHF curriculum. The curriculum culminates with the all-important local contextualizing of what trainees have learned during their MHF training (Hinkle & Henderson, 2007; Sonne, 2012).

Potential Limitations

Unfortunately, organizational, cultural, and professional concerns coinciding with the often ambiguous role and purpose of mental health care can beset the expanding use of community helpers and may have an unintended impact on role identities among the general health workforce (see Warne & McAndrew, 2004). Possibly complicating matters further, the MHF program is a set of concepts and skills, not a professional designation. One concern associated with the MHF program is therefore its potential for propagating invisibly and resulting in new worker roles that cause confusion within standardized health care. Although “the potential of the fully visible and verbal paraprofessional to effect changes in the delivery of psychiatric care is vast” (Lynch & Gardner, 1970, p. 1478), it could become problematic in some locations if MHFs are not strategically blended into community health services. It has long been known that without a viable, transparent strategy, the utilization of MHFs could make for strained relationships in places where the program is not fully vetted. Furthermore, organizational structures that are not flexible or willing to pursue institutional change and innovation may have more difficulty accepting the MHF program (Hinkle, 2012b). Therefore, local and global political and networking skills are critical to the MHF program’s sustainability.

Working conditions and available remuneration for community programs and workers raises several questions that will need to be addressed at some point (Hongoro & McPake, 2004). For instance, could municipalities and governments make MHF a job classification with an upwardly mobile career ladder within existing mental health services? Where financial incentives are not possible, could ad hoc benefits such as access to more training be feasible? How will MHF trainings be sustained in communities over time? Will volunteers be able to conduct the MHF program with limited resources? Additionally, for the program to be sustainable, trainers must have incentives to train more MHFs as community service providers. Without trainers teaching more programs, it is likely that a multiplier strategy will have limited success.

Another potential criticism of the MHF program is that the quality and safety of care could be compromised using community workers. However, the more critical point remains that providing basic assistance is much safer and salubrious than providing no care at all (see Hongoro & McPake, 2004). As in mental health nursing, supervision and mentoring of MHFs will at some point become an issue (Eaton, 2013; Warne & McAndrew, 2004). Furthermore, supportive supervisory relationships are important because supervisors are perceived as role models (Thigpen, 1979) in addition to providing needed guidance for informal community mental health workers.

Future MHF training strategies will need to incorporate continuing community educational development in mental health. Twinning or pairing universities in developing countries with those in less-developed countries is one method for increasing continuing education efforts. Distance learning can be an effective delivery method as well. However, twinning and distance education are all too often not core interests in developing nations, which tend to lack expertise in managing such partnerships (see Fricchione et al., 2012; Hongoro & McPake, 2004).


For the MHF program to proliferate, it will take not only training, education and implementation in often less than optimal working conditions, but also savvy negotiation of often poorly managed political systems that experience some level of corruption and inability to impact the universal stigma that plagues mental illness. To manage the program effectively, the global MHF strategy will need to continue to be accessible from the bottom up and maintain an uncomplicated implementation process. Patel (2013) has advocated that community mental health must be simplified, available where people live, locally contextualized, affordable and sustainable. The MHF program has met all of these criteria with the exception of sustainability, and only more time will tell the level of program longevity.

Advances in alleviating the costs of mental disorders have been limited and slow in coming (Becker & Kleinman, 2013). It is abundantly obvious that the challenges of unmet mental health needs negatively impact societies and economies around the globe. Becker and Kleinman (2013) have recently reported that “according to virtually any metric, grave concern is warranted with regard to the high global burden of mental disorders, the associated intransigent, unmet needs, and the unacceptable toll of human suffering” (p. 71). The burden of mental disorders at the social and individual level is comparable to that of physical disorders and substantially impacts the capital of all countries. Social factors are critical to the promotion and prevention of mental health (GGMHP, 2013b). Furthermore, children exposed to adult mental health disorders among their caregivers, as well as emotional psychological trauma, are predicted to have higher risks of mental disorders in adulthood, further compounding the problem (Chatterji, He, & Alonso, 2013; Patel, Araya, et al., 2007; Patel, Flisher, Hetrick, & McGorry, 2007). WHO (2010a, 2010b) has recommended bridging the care-need gap; however, this will not occur while services are embedded in professional silos rather than being population-centered (Chatterji & Alonso, 2013; Hinkle, 2012c).

The need to address workforce issues affects the quality and quantity of international mental health services (Warne & McAndrew, 2004); there is a clear link between human resources and population health. Community and family caregiving for mental disorders, often uncompensated, has a “tremendous value from a public health perspective by way of offsetting the costs and services of expensive and critically shorthanded healthcare professionals” (Viana et al., 2013, p. 134). At the American Psychiatric Association’s annual convention in 2013, Galea reported that the social aspects of mental health are not a sideshow, but at the very core and not being paid attention to. Unfortunately, not even the laudable efforts of the WHO or United Nations have been able to bring countries that are in desperate need of basic mental health care together effectively. Sadly, psychiatry alone cannot do enough in the global context; world mental health is a social issue (Galea, 2013) and much larger than any one profession (Furtos, 2013). This reality underscores the need for urgent development of grassroots community mental health programs.

For over 40 years, community mental health workers have known that a key component of any program’s design is its ability to be flexible (see Lynch & Gardner, 1970). Flexibility allows for the modification and contextualization of programs by local leaders to reflect realities of current social contexts and circumstances (Furtos, 2013; Rock et al., 2001). As aforementioned, this approach grounds the MHF program on the principle that mental health care is a combination of basic, universally applicable and context-specific knowledge and skills. Supportive social networks in the community result in less need for expensive professional treatments and hospitalizations (Forchuk et al., 2005). Moreover, grassroots approaches will aid global attempts at deinstitutionalization.

Governments of low-income countries are constrained by a lack of resources. In fact, in 85% of low-income countries, essential psychotropic medications are not available (Becker & Kleinman, 2013); monies for mental health care are disproportionately lacking even though their associated burden is tremendous (WHO, 2004a). Wider horizontal approaches to global community health care have been successful in the management of childhood illness (Gwatkin, 2004) and can likewise be successful in general mental health care. Furthermore, the benefits of essential psychotropic medications can be greatly enhanced by adjunctive psychosocial treatments including population-based models of mental health care (Patel, Araya, et al., 2007; Patel, Flisher, et al., 2007).

In summary, the MHF program is making an impact from Bhutan to Berlin and from Botswana to Bulgaria. Its training process provides equitable access to first-responder interventions including mental health promotion, advocacy, monitoring and referral, and the implementation of community MHF training furthers the development and delivery of community-based care consistent with WHO’s recommendations for addressing global mental health needs. The population-based, transdisciplinary MHF training model provides countries with a workable human resource development strategy to effectively and equitably bridge the mental health need-care service gap, one country at a time.


Conflict of Interest and Funding Disclosure

The author reported no conflict of interest or funding contributions for the development of this manuscript.




Abarquez, I., & Murshed, Z. (2004). Field practitioner’s handbook. Bangkok, Thailand: Asian Disaster Preparedness Center.

Albee, G. W. (1967). The relationship of conceptual models to manpower needs. In E. L. Cowen, E. Gardner, & M. Zax (Eds.), Emergent approaches to mental health problems (pp. 63–73). New York, NY: Appleton-Century-Crofts.

Alonso, J., Chatterji, S., He, Y., & Kessler, R. C. (2013). Burdens of mental disorders: The approach of the World Mental Health (WMH) surveys. In J. Alonso, S. Chatterji, & Y. He (Eds.), The burdens of mental disorders: Global perspectives from the WHO World Mental Health surveys (pp. 1–6). Cambridge, United Kingdom: Cambridge University Press.

Alonso, J., Petukhova, M. V., Vilagut, G., Bromet, E. J., Hinkov, H., Karam, E. G.,…Stein, D. J. (2013). Days totally out of role associated with common mental and physical disorders. In J. Alonso, S. Chatterji, & Y. He (Eds.), The burdens of mental disorders: Global perspectives from the WHO World Mental Health surveys (pp. 137–148). Cambridge, United Kingdom: Cambridge University Press.

Anand, S., & Bärnighausen, T. (2004). Human resources and health outcomes: Cross-country econometric study. The Lancet, 364, 1603–1609.

Bach, S. (2004). Migration patterns of physicians and nurses: Still the same story? Bulletin of the World Health Organization, 82, 624–625.

Barron, R. A. (2004). International disaster mental health. Psychiatric Clinics of North America, 27, 505–519.

Becker, A. E., & Kleinman, A. (2013). Mental health and the global agenda. New England Journal of Medicine, 369, 66–73.

Benight, C. C. (2012). Understanding human adaptation to traumatic stress exposure: Beyond the medical model. Psychological Trauma: Theory, Research, Practice, and Policy, 4, 1–8.

Bloom, D. E., Cafiero, E. T., Jané-Llopis, E., Abrahams-Gesse, S., Bloom, L. R., Fathima, S., … Weiss, A. (2011). The Global Economic Burden of Non-communicable Diseases. Geneva, Switzerland: World Economic Forum.

Breslau, J., Lee, S., Tsang, A., Lane, M. C., Aguilar-Gaxiola, S., Alonso., J.,…Williams, D. R. (2013). Associations between mental disorders and early termination of education. In J. Alonso, S. Chatterji, & Y. He (Eds.), The burdens of mental disorders: Global perspectives from the WHO World Mental Health surveys (pp. 56–65). Cambridge, United Kingdom: Cambridge University Press.

Browne, C., & Winkleman, C. (2007). The effect of childhood trauma on later psychological adjustment. Journal of Interpersonal Violence, 22, 684–697.

Chan, M. (2010). Foreword. In mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings (p. iii). Geneva, Switzerland: World Health Organization.

Chatterji, S., He, Y., & Alonso, J. (2013). Conclusions and future directions. In J. Alonso, S. Chatterji, & Y. He (Eds.), The burdens of mental disorders: Global perspectives from the WHO World Mental Health surveys (pp. 244–247). Cambridge, United Kingdom: Cambridge University Press.

Chen, L., Evans, T., Anand, S., Boufford, J. I., Brown, H., Chowdhury, M.,…Wibulpolprasert, S. (2004). Human resources for health: Overcoming the crisis. The Lancet, 364, 1984–1990.

Chisholm, D., James, S., Sekar, K., Kumar, K. K., Murthy, S., Saeed, K., & Mubbashar, M. (2000). Integration of mental health care into primary care. The British Journal of Psychiatry, 176, 581–588.

Coups, E. J., Gaba, A., & Orleans, T. (2004). Physician screening for multiple behavioral health risk factors. American Journal of Preventive Medicine, 27, 34–41.

Craft, A. (2005). What are the priorities for child health in 2004? Child: Care, Health and Development, 31, 1–2.

Demyttenaere, K., Brufferts, R., Posada-Villa, J., Gasquet, I., Kovess, V., Lepine, J. P.,… Chatterji, S. (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization Mental Health Surveys. Journal of the American Medical Association, 291, 2581–2590.

Desjarlais, R., Eisenberg, L., Good, B., & Kleinman, A. (1995). World mental health. Oxford, United Kingdom: Oxford University Press.

Eaton, J. (2013, October). Document two. In J. de Almeida (Chair), Innovation in deinstitutionalization: A WHO expert survey. Symposium conducted at the International Forum on Innovation in Mental Health, Gulbenkian Global Mental Health Platform, Lisbon, Portugal.

Eaton, J., McCay, L., Semrau, M., Chatterjee, S., Baingana, F., Araya, R.,… & Saxena, S. (2011). Scale up of services for mental health in low-income and middle-income countries, The Lancet, 378, 1592–1603.

Elder, G. H., & Shanahan, M. J. (2007). The life course and human development. In R. M. Lerner & W. Damon (Eds.), Handbook of child psychology. (Vol. 1, pp. 665–715). Hoboken, NJ: John Wiley & Sons.

Feiring, C., Taska, L., & Chen, K. (2002). Trying to understand why horrible things happen: Attribution, shame, and symptom development following sexual abuse. Child Maltreatment, 7, 25–39.

Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Goldstein, M. G., Gritz, E. R., …Wewers, M. E. (2000). Treating tobacco dependence and use: Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

Forchuk, C., Martin, M. L., Chan, Y. L., & Jensen, E. (2005). Therapeutic relationships: From psychiatric hospital to community. Journal of Psychiatric and Mental Health Nursing, 12, 556–564.

Fricchione, G. L., Borba, C. P. C., Alem, A., Shibre, T., Carney, J. R., & Henderson, D. C. (2012). Capacity building in global mental health: Professional training. Harvard Review of Psychiatry, 20, 47–57.

Furtos, J. (2013, May). Globalization and mental health: The weight of the world, the size of the sky. Presidential symposium conducted at the American Psychiatric Association Annual Meeting, San Francisco, CA.

Galea, S. (2013, May). Re-emerging research around the social and economic production of mental health: Toward a comprehensive model of mental health. Presidential symposium conducted at the American Psychiatric Association Annual Meeting, San Francisco, CA.

Goldberg, D., & Huxley, P. (1992). Common mental disorders: A bio-social model. London, England: Routledge.

Gulbenkian Global Mental Health Platform. (2013a). Integrating mental and physical health, promoting social inclusion, humanizing mental health care. Retrieved from http://www.gulbenkianmhplatform.com/

Gulbenkian Global Mental Health Platform. (2013b). International forum on innovation in mental health. Lisbon, Portugal: Author.

Gureje, O. (2013, October). Document one. In B. Saraceno (Chair), Integrating the response to mental disorders and other chronic diseases in health care systems. Symposium conducted at the International Forum on Innovation in Mental Health, Gulbenkian Global Mental Health Platform, Lisbon, Portugal.

Gwatkin, D. R. (2004). Integrating the management of childhood illness. The Lancet, 364, 1557–1558.

Hines, L. (1970). A nonprofessional discusses her role in mental health. American Journal of Psychiatry, 126, 1467–1472.

Hinkle, J. S. (2006, October). MHF town meeting: Ideas/questions. Presentation at the NBCC Global Mental Health Conference: Focus on the Never Served, New Delhi, India.

Hinkle, J. S. (2007, June). The mental health facilitator training: Ongoing developments. Presentation at the 12th International Counseling Conference, Shanghai, China.

Hinkle, J. S. (2009, July). Mental health facilitation: The challenge and a strategy. Keynote address at the Association for Multicultural Counseling and Development/Association for Counselor Education and Supervision 2nd Annual Conference on Culturally Competent Disaster Response, Gabarone, Botswana.

Hinkle, J. S. (2010a). International disaster counseling: Today’s reflections, tomorrow’s needs. In J. Webber & J. B. Mascari (Eds.), Terrorism, trauma, and tragedies: A counselor’s guide to preparing and responding (3rd ed., pp. 179–184). Alexandria, VA: American Counseling Association.

Hinkle, J. S. (2010b, August). Mental health facilitation: A global challenge and workable strategy. Manuscript presented at the 18th Asian Pacific Education Counseling Association Biennial Conference-Workshop, Penang, Malaysia.

Hinkle, J. S. (2012a, September). The Mental Health Facilitator program: Optimizing global emotional health one country at a time. Retrieved from http://www.revistaenfoquehumanistico.com/#!Scott Hinkle/c1lbz

Hinkle, J. S. (2012b, May). Mental health facilitation: A global strategy. Manuscript presented at the Asian Pacific Educational Counseling Association Conference, Tokyo, Japan.

Hinkle, J. S. (2012c, October). Population-based mental health facilitation (MHF): A strategy that works. Manuscript presented at the Seventh World Conference on the Promotion of Mental Health and the Prevention of Mental and Behavioural Disorders, Perth, Australia.

Hinkle, J. S. (2013a, February). Population-based mental health facilitation (MHF): Community empowerment and a vision that works. Manuscript presented at the North Carolina Counseling Association 2013 Conference, Greensboro, NC.

Hinkle, J. S. (2013b, November). La salud mental en e mundo. Presentation at the Old Dominion University Counseling Institute, Buenos Aires, Argentina.

Hinkle, J. S., & Henderson, D. (2007). Mental health facilitation. Greensboro, NC: NBCC-I.

Hinkle, J. S., Kutcher, S. P., & Chehil, S. (2006, October). Mental health facilitator: Curriculum development. Presentation at the NBCC International Global Mental Health Congress, New Delhi, India.

Hinkle, J. S., & Saxena, S. (2006, October). ATLAS: Mapping international mental health care. Presentation at the NBCC International Global Mental Health Congress, New Delhi, India.

Hinkle, J. S., & Schweiger, W. (2012, September). Mental health facilitation around the world. Manuscript presented at HOLAS Second Counseling Conference of the Americas, Buenos Aires, Argentina.

Hoff, L. A. (1993). Review essay: Health policy and the plight of the mentally ill. Psychiatry, 56, 400–419.

Hoff, L. A., Hallisey B. J., & Hoff, M. (2009). People in crisis: Clinical and diversity perspectives (6th ed.). New York, NY: Routledge.

Hongoro, C., & McPake, B. (2004). How to bridge the gap in human resources for health. The Lancet, 364, 1451–1456.

Huston, A. C., & Bentley, A. C. (2010). Human development in societal context. Annual Review of Psychology, 61, 411–437.

Isaac, M. (2013, October). Document two. In J. de Almeida (Chair), Innovation in deinstitutionalization: A WHO expert survey. Symposium conducted at the International Forum on Innovation in Mental Health, Gulbenkian Global Mental Health Platform, Lisbon, Portugal.

Jorm, A. F. (2012). Mental health literacy: Empowering the community to take action for better mental health. American Psychologist, 67, 231–243.

Kabir, B. (2011, January–May). Compassionate and dignified emergency health service delivery in Bangladesh. Asian Disaster Management News, 17(1), 4–6.

Lerner, R. M. (2007). Developmental science, developmental systems, and contemporary theories of human development. In R. M. Lerner & W. Damon (Eds.), Handbook of child psychology (Vol. 1, pp. 1–17). Hoboken, NJ: John Wiley & Sons.

Lewin, S. A., Dick, J., Pond, P., Zwarenstein, M., Aja, G., Van Wyk, B.,…Patrick, M. (2005). Lay health workers in primary and community health care. The Cochrane Database of Systematic Reviews, 2005(1), CD004015.

Littleton, H. L., Horsley, S., John, S., & Nelson, D. V. (2007). Trauma coping strategies and psychological distress: A meta-analysis. Journal of Traumatic Stress, 20, 977–988.

Lynch, M., & Gardner, E. A. (1970). Some issues raised in the training of paraprofessional personnel as clinic therapists. American Journal of Psychiatry, 126, 1473–1479.

Marks, I., & Scott, R. (Eds.). (1990). Mental health care delivery, impediments and implementation. Cambridge, United Kingdom: Cambridge University Press.

McKee, L., Ferlie, E., & Hyde, P. (2008). Organizing and reorganizing: Power and change in health care organizations. Houndmills, Bastingstoke, Hampshire, United Kingdom: Palgrave MacMillan.

McKinlay, J. B. (1990). A case for refocusing upstream: The political economy of illness. In P. Conrad & R. Kern (Eds.), The sociology of health and illness: Critical perspectives (3rd ed., pp. 502–516). New York, NY: St. Martin’s Press.

Mosher, L. R., & Burti, L. (1994). Community mental health: A practical guide. New York, NY: W. W. Norton.

Murray, C. J. L., & López, A. D. (1996a). Evidence-based health policy: Lessons from the Global Burden of Disease study, Science, 274, 740–743.

Murray, C. J. L., & López, A. D. (1996b). The global burden of diseases: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Boston, MA: Harvard School of Public Health, WHO and World Bank.

Murray, C. J. L., Vos, T., Lozano, R., Naghavi, M., Flaxman, A. D., Michaud, M.,…Andrews, K. G. (2012). Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 380, 2197–2223.

Murthy, R. S. (Ed.). (2006). Mental health by the “people.” Peoples Action for Mental Health, Bangalore, India.

National Board for Certified Counselors-International. (2013). Mental health facilitator (MHF). Retrieved from http://www.nbccinternational.org/What_we_do/MHF

Nolan, K. J., & Cooke, E. T. (1970). The training and utilization of the mental health paraprofessional within the military: The social work/psychology specialist. American Journal of Psychiatry, 127, 74–79.

Paredes, D., Schweiger, W., Hinkle, S., Kutcher, S., & Chehil, S. (2008). The mental health facilitator program: An approach to meet global mental health care needs, Orientacion Psychologica, 3, 73–80.

Patel, V. (2013, October). Integrating mental health care in priority health programs: Addressing a grand challenge in global mental health. Manuscript presented at the International Forum on Innovation in Mental Health, Gulbenkian Global Mental Health Platform, Lisbon, Portugal.

Patel, V., Araya, R., Chatterjee, S., Chisholom, D., Cohen, A., DeSilva, M.,…Van Ommeren, M. (2007). Treatment and prevention of mental disorders in low-income and middle-income countries. The Lancet, 370, 991–1005.

Patel, V., Flisher, A. J., Hetrick, S., & McGorry, P. (2007). Mental health of young people: A global public-health challenge. The Lancet, 369, 1302–1313.

Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M. R., & Rahman, A. (2007). No health without mental health. The Lancet, 370, 859–877.

Rachlis, M., & Kushner, C. (1994). Strong medicine: How to save Canada’s health care system. New York, NY: HarperCollins.

Reyes, G., & Elhai, J. D. (2004). Psychosocial interventions in the early phases of disasters. Psychotherapy: Theory, Research, Practice, Training, 41, 399–411.

Rioch, M. J., Elkes, C., Flint, A. A., Usdansky, B. S., Newman, R. G., & Silber, E. (1963). National institute of mental health pilot study in training mental health counselors. American Journal of Orthopsychiatry, 33, 678–689.

Rock, D., Combrinck, J., & Groves, A. (2001). Issues associated with the implementation of routine outcome measures in public mental health services. Australasian Psychiatry, 9, 43–46.

Saraceno, B., van Ommeren, M., Batniji, R., Cohen, A., Gureje, O., Mahoney, J.,…Underhill, C. (2007). Barriers to improvement of mental health services in low-income and middle-income countries. The Lancet, 370, 1164–1174.

Schweiger, W. K., & Hinkle, J. S. (2013, October). The Mental Health Facilitator (MHF): A program to meet diverse international and domestic needs. Presentation at the 2013 Association for Counselor Educators and Supervisors Conference, Denver, CO.

Scott, K. M., Wu, B., Saunders, K., Benjet, C., He, Y., Lépine, J.-P.,…Von Korff, M. (2013). Early-onset mental disorders and their links to chronic physical conditions in adulthood. In J. Alonso, S. Chatterji, & Y. He (Eds.), The burdens of mental disorders: Global perspectives from the WHO World Mental Health surveys (pp. 87–96). Cambridge, United Kingdom: Cambridge University Press.

Sonne, J. L. (2012). PsychEssentials: A pocket resource for mental health practitioners. Washington, DC: American Psychological Association.

Suck, A. T., Kleinberg, E., & Hinkle, J. S. (2013). Counseling in Mexico. In T. H. Hohenshil, N. E. Amundson, & S. G. Niles (Eds.), Counseling around the world: An international handbook (pp. 315–322). Alexandria, VA: American Counseling Association.

Taylor, S., & Stanton, A. L. (2007). Coping resource, coping processes, and mental health. Annual Review of Clinical Psychology, 3, 377–401. doi:10.1146/annurev.clinpsy.3.022806.091.520

Thigpen, J. D. (1979). Perceptional differences in the supervision of paraprofessional mental health workers. Community Mental Health Journal, 15, 139–148.

Unützer, J. (2013, October). Document one. In B. Saraceno (Chair), Integrating the response to mental disorders and other chronic diseases in health care systems. Symposium conducted at the International Forum on Innovation in Mental Health, Gulbenkian Global Mental Health Platform, Lisbon, Portugal.

Ustün, T. B., & Sartorius, N. (Eds.). (1995). Mental illness in general health care: An international study. Chichester, England: John Wiley and Sons.

van Wesel, F., Boeije, H., Alisic, E., & Drost, S. (2012). I’ll be working my way back: A qualitative synthesis on the trauma experience of children. Psychological Trauma: Theory, Research, Practice, and Policy, 4, 516–526.

Viana, M. C., Gruber, M. J., Shahly, V., de Jonge, P., He, Y., Hinkov, H., & Kessler, R. C. (2013). Family burden associated with mental and physical disorders. In J. Alonso, S. Chatterji, & Y. He (Eds.), The burdens of mental disorders: Global perspectives from the WHO World Mental Health surveys (pp. 122–135). Cambridge, United Kingdom: Cambridge University Press.

Vidaver, R. M. (1969). The mental health technician: Maryland’s design for a new health career. American Journal of Psychiatry, 125, 1013–1023.

Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M.,…Murray, C. J. L. (2012). Years lied with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: A systemic analysis for the Global Burden of Disease Study 2010. The Lancet, 380, 2163–2196.

Walt, G. (1988). Community health workers: Policy and practice in national programmes. London, England: London School of Hygiene and Tropical Medicine, EPC publication number 16.

Warne, T., & McAndrew, S. (2004). The mental health assistant practitioner: An oxymoron. Journal of Psychiatric and Mental Health Nursing, 11, 179–184.

Warner, L., & Ford, R. (1998, October). Mental health facilitators in primary care. Nursing Standard, 13, 36–40.

Weissman, M. M., Bland, R. C., Canino, G. J., Faravelli, C., Greenwald, S., Hwu, H. G.,…Yeh, E. K. (1994). The cross national epidemiology of obsessive compulsive disorder. Journal of Clinical Psychiatry, 55, 5–10.

Weissman, M. M., Bland, R. C., Canino, G. J., Faravelli, C., Greenwald, S., Hwu, H. G.,…Yeh, E. K. (1997). The cross-national epidemiology of panic disorder. Archives of General Psychiatry, 54, 305.

Weissman, M. M., Bland, R., Canino, G., Greenwald, S., Lee, C., Newman, S.,…Wickramaratne, P. J. (1996). The cross-national epidemiology of social phobia: A preliminary report. International Clinical Psychopharmacology, 11, Suppl: 3, 9–14.

Wekerle, C. (2011). Emotionally maltreated: The under-current of impairment? Child Abuse & Neglect, 35, 899–903. doi:10.1016/j.chiabu.2011.09.002

Wells, M. E. (2006). Psychotherapy for families in the aftermath of a disaster. Journal of Clinical Psychology: In Session, 62, 1017–1027.

Whitlock, E. P., Orleans, C. T., Pender, N., & Allan, J. (2002). Evaluating primary care behavioral counseling interventions: An evidenced-based approach. American Journal of Preventive Medicine, 22, 267–284.

WHO World Mental Health Survey Consortium. (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization world mental health surveys. Journal of the American Medical Association, 291, 2581–2590.

World Health Organization (2004a). Atlas: Country resources for neurological disorders. Geneva, Switzerland: Author.

World Health Organization. (2005). Mental health atlas. Geneva, Switzerland: Author.

World Health Organization. (2006a). Integrating mental health into primary care: A global perspective. Geneva, Switzerland: Author.

World Health Organization. (2006b). Preventing suicide: A resource for counsellors. Geneva, Switzerland: Author.

World Health Organization. (2009). Scaling up nursing & medical education: Report on the WHO/PEPFAR planning meeting on scaling up nursing and medical education. Geneva, Switzerland: Author.

World Health Organization. (2010a). Mental health and development: Targeting people with mental health conditions as a vulnerable group. Geneva, Switzerland: Author.

World Health Organization. (2010b). mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva, Switzerland: Author.


Dr. J. Scott Hinkle is the Director of Professional Development at NBCC-I. For further information on the MHF program, please contact Adriana Petrini at petrini@nbcc.org. The author appreciates editorial contributions from Laura Jones, Katherine Clark, Ryan Vale, Traci Collins, Allison Jones, and Keith Jones. A version of this article was originally presented at the World Mental Health Congress, August 28, 2013, Buenos Aires, Argentina (Spanish: “Facilitación de Salud Mental (MHF): Una Estrategia Comunal”). Correspondence can be addressed to J. Scott Hinkle, NBCC, 3 Terrace Way, Greensboro, NC 27403, hinkle@nbcc.org.

Counselors Abroad: Outcomes of an International Counseling Institute in Ireland

Lorraine J. Guth, Garrett McAuliffe, Megan Michalak

As the counseling profession continues to build an international community, the need to examine cultural competence training also increases. This quantitative study examined the impact of the Diversity and Counseling Institute in Ireland (DCII) on participants’ multicultural counseling competencies. Two instruments were utilized to examine participants’ cross-cultural competence before and after the study abroad institute. Results indicated that after the institute experience, participants perceived themselves to be more culturally competent, knowledgeable about the Irish culture, skilled in working with clients from Ireland, and aware of cultural similarities and differences. Implications for counselor education and supervision, and future research also are outlined.

Keywords: study abroad, multicultural competencies, cross-cultural competence, international, counselor education  and supervision, Ireland

The standards set by the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2009) require programs to provide curricular and experiential opportunities in social and cultural diversity. Specifically, CACREP requires counseling curricula to incorporate diversity training that includes “multicultural and pluralistic trends, including characteristics and concerns within and among diverse groups nationally and internationally” (CACREP, 2009, Section II, Code G2a; p. 10). Endorsement of diversity training by the counselor education accrediting body underscores its importance in counselor training; therefore, counselors-in-training must be provided opportunities to be culturally responsive in their work with clients (McAuliffe & Associates, 2013; Sue & Sue, 2012).

This cultural responsiveness is particularly important given the globalization of the counseling movement and the need for counselors to become globally literate (Hohenshil, Amundson, & Niles, 2013; Lee, 2012). However, counselor education training programs have fostered this multicultural competence with students in myriad ways (Lee, Blando, Mizelle, & Orozco, 2007). For example, multicultural courses have often focused on developing trainees’ cross-cultural competencies in the three broad areas of awareness of their own cultural values and biases; knowledge of others’ customs, expectations, and worldviews; and culturally appropriate intervention skills and strategies (Sue, Arredondo, & McDavis, 1992).

A body of literature has examined the progress of educational programs in incorporating these aspects of diversity into the curricula. For example, Díaz-Lázaro and Cohen (2001) conducted a study that explored the impact of one specific course in multicultural counseling. They found that cross-cultural contact, such as with guest speakers, helped students develop multicultural knowledge and skills; however, they found no indication that the course impacted students’ self-awareness. Guth and McDonnell (2006) examined counseling students’ perceptions of multicultural and diversity training. Courses were found to contribute somewhat to students’ knowledge, but the study found that students gained greater knowledge from personal interactions among peers, interactions with faculty, and other experiential activities outside of coursework. Additional research has shown that multicultural training is significantly related to multicultural competence (Castillo, Brossart, Reyes, Conoley, & Phoummarath, 2007; D’Andrea, Daniels, & Heck, 1991; Dickson, Argus-Calvo, & Tafoya, 2010). A clear message from the literature highlights the importance of personal cross-cultural contact in culturally responsive counseling.

This previous research was limited in that the authors examined only the impact of training offered in the United States, leaving out the potential added value of personal cross-cultural experiences in an international context. Given the impact of direct cross-cultural experiences, a study abroad experience for counselor trainees might be a powerful way to deepen cultural understanding and responsiveness. This quantitative study was designed to examine the outcomes of this counselor trainee study abroad institute on participants’ perceptions of their multicultural competence.


Research on Study Abroad Experiences


Study abroad programs are not commonly rigorously researched because “program evaluation is an afterthought to an ongoing program undertaken by extremely busy program administrators” (Hadis, 2005, p. 5). Although data regarding study abroad experiences are primarily anecdotal, the literature does suggest several positive outcomes of a study abroad institute including personal development, intellectual growth and increased global-mindedness (Carlson, Burn, Useem, & Yachimowicz, 1991). Short-term study abroad experiences also were found to produce positive changes in cultural adaptability in students (Mapp, 2012). However, most of the study abroad research has been conducted in disciplines other than counseling, such as business (Black & Duhon, 2006), nursing (Inglis, Rolls, & Kristy, 1998), and language acquisition (Davidson, 2007). Furthermore, the research has mainly focused on the experiences of undergraduate university students and has not examined the experiences of graduate trainees (Drews & Meyer, 1996).

Several studies have been conducted that are relevant to the counseling profession. Kim (2012) surveyed undergraduate and graduate social work students and found that study abroad experiences are a significant predictor of multicultural counseling competency. Jurgens and McAuliffe (2004) also conducted a study that explored the impact of a short-term study abroad experience in Ireland on graduate counseling student participants. The results indicated that this program was helpful in increasing students’ knowledge of Ireland’s culture, largely due to experiential learning and personal interactions. The current study expands on Jurgens and McAuliffe’s research (2004) by further examining the impact of a counseling and diversity institute that was offered in Ireland. The primary research questions for this quantitative study were as follows: (1) Did the study institute have an impact on participants’ multicultural counseling competencies? (2) Did this study institute have an impact on participants’ multicultural counseling competencies in working with individuals who are Irish?





Twenty (87%) graduate counseling students and three (13%) professional counselors voluntarily participated in this research study while attending the DCII in Ireland. The sample consisted of 83% women and 17% men; 82% identified themselves as Caucasian/European American, 9% as African American, and 9% did not identify their race. The mean age for the sample was 32 (range: 22–60 years). Regarding sexual orientation, 91% of the participants indicated they were heterosexual; 4% indicated they were gay; and 4% indicated they were bisexual. Regarding disability status, 87% of the participants reported not having a disability, 9% indicated they had a disability, and 4% did not answer the question.



The study assessed participants’ cross-cultural counseling competence with the Cross-Cultural Counseling Inventory-Revised (CCCI-R, LaFromboise, Coleman, & Hernandez, 1991). The CCCI-R is a 20-item instrument initially created so that supervisors could evaluate their supervisees’ cross-cultural counseling competence. Questions on this instrument are rated on a 6-point Likert-type scale (1 = strongly disagree; 6 = strongly agree). The scale has been found to have high internal consistency and reliability, and high content validity (LaFromboise et al., 1991). Another “recommended use of the CCCI-R is as a tool for self-evaluation” (LaFromboise et al., 1991, p. 387). Therefore, the CCCI-R was slightly modified so that participants could rate themselves to understand perceptions of their own cultural competence, rather than rate other counselors on their cultural competence. Higher scores on this instrument indicate an individual’s belief that he or she has greater cultural competence. Sample prompts include the following: “I am aware of my own cultural heritage,” “I demonstrate knowledge about clients’ cultures,” and “I send messages that are appropriate to the communication of clients.” In the present study, Cronbach’s alpha was used to assess the internal consistency of the CCCI-R and it was reliable at both times of measurement (pretest = .91; posttest = .93).

Four additional Likert-type items were added to the pretest and posttest questionnaires, which asked participants to rate their multicultural awareness, knowledge, and skills related to the Irish culture. The items included were as follows: (1) I am knowledgeable of the culture of Ireland; (2) I possess the skills in working with a client from Ireland; (3) I am aware of the differences between the Irish culture and my own culture; and (4) I am aware of the similarities within the Irish culture and my own culture. Participants rated the extent to which they agreed with each item from 1 (strongly disagree) to 6 (strongly agree). Because of the significant (p < .01) correlation among these four items, a single variable was established called Ireland Multicultural Counseling Competencies Scale (IMCCS). In the present study, Cronbach’s alpha was used to assess the internal consistency of the IMCCS, which was reliable at both times of measurement (pretest = .88; posttest = .90).



At the beginning of the study abroad institute, participants completed a pretest questionnaire that contained a demographic information form, the CCCI-R, and the IMCCS. Participants then participated in the two-week study abroad institute. At the conclusion of the institute, participants completed a posttest questionnaire that contained the CCCI-R and the IMCCS.


Diversity and Counseling Institute in Ireland. Study abroad institutes offered in the counseling profession can further counselors’ multicultural competence by immersing trainees in a non-American culture for a period of time. With that intent, the two-week DCII was created to increase participants’ cultural awareness, knowledge and responsiveness. The goals of the DCII were to increase participants’ (1) awareness of their own cultural background and values; (2) knowledge of the American, Irish, and British cultural perspectives; and (3) knowledge of culturally appropriate counseling strategies. Participants learned about the counseling profession in Ireland from leaders in the Irish mental health field; studied core multicultural issues with nationally known U.S. counseling faculty; were immersed in the Irish culture through tours, lectures, and informal experiences; and visited Irish counseling agencies and social programs.




A t-test was performed to examine differences between participants’ CCCI-R mean score across time from pretest to posttest (see Table 1 for mean differences and standard deviations). There were significant differences (p < .0001) in participants’ overall scores on the CCCI-R after they attended the DCII in Ireland, indicating that participants perceived themselves to be more culturally competent by the end of the study abroad experience.

A t-test also was utilized to examine differences between participants’ IMCCS mean score across time (see Table 1 for the mean difference and standard deviations). There were significant differences (p < .0001) in participants’ overall scores on the IMCCS after attending the DCII in Ireland. Thus, participants thought they were more knowledgeable about the culture of Ireland, possessed more skills in working with clients from Ireland, had an increased awareness of differences between the Irish culture and their own, and had an increased awareness of similarities between the Irish culture and their own.


Table 1

Mean Difference between Participants’ Pre- and Post-Institute Multicultural Competence Scores





Regarding the under-researched topic of intentional study abroad counselor education experiences, this study indicated that such an experience can have a positive impact on counselors’ multicultural competency. Previous research on non-counseling study abroad opportunities found that participants experienced personal development, intellectual growth and increased global-mindedness (Carlson et al., 1991). This study begins to address whether a counseling international experience has an effect on counselor multicultural competency.

International study abroad experiences can affect individuals’ perspectives on other cultures, as well as on their own. In the case of this research, participants reported an increase in their cultural competence after the intentional study abroad counselor education experience. These results confirm previous social work research that found a positive relationship between studying abroad and multicultural competencies (Kim, 2012). Further research should explore what components of this institute in particular influenced participants’ multicultural awareness, knowledge and skills.

The overall multicultural counseling competency improvement demonstrated in this study is encouraging. It is important to note that the institute included both experiences and conceptual material. The learning was perhaps enhanced by the experiential learning theory model used to design the institute (Kolb & Kolb, 2009). In this study abroad institute, experiences included visits to specific counseling and educational programs. Participants then reflected on those experiences through journaling and large group processing. Counselor educators might pursue such international initiatives to trigger counselor cultural self-awareness, increase knowledge of other cultures, and build culturally responsive counseling skills.

Study abroad for counselors might be seen as a “value-added” learning opportunity. While at-home multicultural counselor education has been studied (Cates, Schaefle, Smaby, Maddux, & LeBeauf, 2007; Zalaquett, Foley, Tillotson, Dinsmore, & Hof, 2008), such learning may be enhanced by the experience of being immersed in a foreign culture (Kim, 2012). Prolonged immersion in another culture allows counselors-in-training to gain a more nuanced understanding of the differences and similarities among cultures. Participants reported being more aware than before of differences and similarities between the Irish culture and their own culture. Although not all immersion opportunities happen internationally, the degree to which these participants were immersed was novel and led to a significant increase in culturally relevant knowledge, skills and awareness. The degree to which immersion experiences are effective should continue to be explored within the counseling profession.

Transferability of the learning from study abroad is of course crucial, as it would be insufficient to merely learn the particulars of another counseling culture. In that sense, the overall dislocation of being in a foreign culture may transfer to an increase in trainees’ empathy for members of non-dominant cultures in their homelands. It would be difficult to simulate such experiences in the domestic environment. Thus, when designing training experiences, educators could consider the impact of experiential training experiences outside of the home country. While planning these experiences are logistically challenging, the payoff can be impactful (Shupe, 2013).

International study abroad institutes have implications for the counseling community at large. As the profession continues to construct a professional identity and establish its role in the mental health community, counselors must consider the counseling profession as a whole, not solely the parts of the profession within the cultural worldview. Incorporating international experiences into the training practice allows more counselors to communicate and connect as a whole, in order to best develop and advocate for the counseling profession. Furthermore, collaborating with counselors internationally provides counselors-in-training the opportunity to increase their cultural self-awareness, as well as allows counselor educators to examine current training practices and their effectiveness. This assessment may take place through direct observation of international training practices, or more covertly in reflecting on the components of the institute that appeared to impact students.

The results of this study need to be examined in light of several limitations. First, this pre-post design only examined the impact of this study abroad institute. Future research could compare study abroad experiences to other training methods. Future research also could disaggregate the factors that actually contributed to positive outcomes, by investigating the relative contribution of informal encounters, lectures on Irish counseling and social issues, general seminars on culturally alert counseling, and other experiences in the study abroad program. Second, participants volunteered to be part of this study and were predominantly Caucasian/European American and heterosexual women. Future research could seek to replicate these results, using a control group and a more diverse, randomly selected group of participants. Finally, the focus of this research was the impact of a DCII in Ireland. Future research could explore the impact of counseling study abroad programs in other countries. Long term follow-up measures also could be utilized to see if the positive changes in multicultural counseling competencies remain stable over time.




This study was designed to examine the impact of the diversity and counseling study abroad program in Ireland on participants’ multicultural competencies. The results indicate that the study abroad experience in Ireland enhanced participants’ multicultural counseling competencies. These results provide beginning data regarding the benefits of this type of study abroad diversity training and encourage counselor educators to pursue and evaluate such experiences.



Black, H. T. & Duhon, D. L. (2006). Assessing the impact of business study abroad programs on cultural awareness and personal development. Journal of Education for Business, 81, 140144. doi:10.3200/JOEB.81.3.140-144

Carlson, J. S., Burn, B. B., Useem, J., & Yachimowicz, D. (1991). Study abroad: The experience of American undergraduates in Western Europe and the United States. New York, NY: Center for International Education Exchange. (ERIC Document Reproduction Service No. ED 340 322)

Castillo, L. G., Brossart, D. F., Reyes, C. J., Conoley, C. W., & Phoummarath, M. J. (2007). The influence of multicultural training on perceived multicultural counseling competencies and implicit racial prejudice. Journal of Multicultural Counseling and Development, 35, 243254. doi:10.1002/j.2161-1912.2007.tb00064.x

Cates, J. T., Schaefle, S. E., Smaby, M. H., Maddux, C. D., & LeBeauf, I. (2007). Comparing multicultural with general counseling knowledge and skill competency for students who completed counselor training. Journal of Multicultural Counseling and Development, 35, 2639. doi:10.1002/j.2161-1912.2007.tb00047.x

Council for Accreditation of Counseling and Related Educational Programs. (2009). 2009 CACREP Standards. Retrieved from http://www.cacrep.org

D’Andrea, M., Daniels, J., & Heck, R. (1991). Evaluating the impact of multicultural counseling training. Journal of Counseling & Development, 70, 143150. doi:10.1002/j.1556-6676.1991.tb01576.x

Davidson, D. E. (2007). Study abroad and outcomes measurements: The case of Russian. The Modern Language Journal, 91, 276280.

Díaz-Lázaro, C. M., & Cohen, B. B. (2001). Cross-cultural contact in counseling training. Journal of Multicultural Counseling and Development, 29, 4156. doi:10.1002/j.2161-1912.2001.tb00502.x

Dickson, G. L., Argus-Calvo, B., & Tafoya, N. G. (2010). Multicultural counselor training experiences: Training effects and perceptions of training among a sample of predominately Hispanic students. Counselor Education and Supervision, 49, 247265. doi:10.1002/j.1556-6978.2010.tb00101.x

Drews, D. R., & Meyer, L. L. (1996). Effects of study abroad on conceptualizations of national groups. College Student Journal, 30, 452461.

Guth, L. J., & McDonnell, K.A. (2006, April). Counselor education students’ perspectives on multicultural and diversity training. Poster session presented at the American Counseling Association Convention, Montréal, Quebec, Canada.

Hadis, B. F. (2005). Gauging the impact of study abroad: How to overcome the limitations of a single-cell design. Assessment & Evaluation in Higher Education, 30, 319. doi:10.1080/0260293042003243869

Hohenshil, T. H., Amundson, N. E., & Niles, S. G. (2013). Introduction to global counseling. In T. H. Hohenshil, N. E. Amundson, & S. G. Niles (Eds.), Counseling around the world: An international handbook (pp. 38). Alexandria, VA: American Counseling Association.

Inglis, A., Rolls, C., & Kristy, S. (1998). The impact of participation in a study abroad programme on students’ conceptual understanding of community healthy nursing in a developing country. Journal of Advanced Nursing, 28, 911917. doi:10.1046/j.1365-2648.1998.00732.x

Jurgens, J. C., & McAuliffe, G. (2004). Short-term study-abroad experience in Ireland: An exercise in cross-cultural counseling. International Journal for the Advancement of Counselling, 26, 147161.

Kim, W.-J. (2012). Enhancing social work students’ multicultural counseling competency: Can travel abroad substitute for study abroad? International Social Work, Advance online publication. doi:10.1177/0020872812454313

Kolb, A. Y. & Kolb, D. A. (2009). Experiential learning theory: A dynamic, holistic approach to management learning, education, and development. In S. J. Armstrong and C. V. Fukami (Eds.), The SAGE handbook of management learning, education, and development (pp. 42–68). Los Angeles, CA: Sage.

LaFromboise, T. D., Coleman, H. L. K., & Hernandez, A. (1991). Development and factor structure of the Cross-Cultural Counseling Inventory-Revised. Professional Psychology: Research and Practice, 22(5), 380388. doi:10.1037/0735-7028.22.5.380

Lee, C. C. (2012, September). The promise of counsel(l)ing’s globalization. Counseling Today, 1415.

Lee, W. M. L., Blando, J. A., Mizelle, N. D., & Orozco, G. L. (2007). Introduction to multicultural counseling for helping professionals (2nd ed.). New York, NY: Routledge.

Mapp, S. C. (2012). Effect of short-term study abroad programs on students’ cultural adaptability. Journal of Social Work Education, 48, 727737. doi:10.5175/JSWE.2012.201100103

McAuliffe, G. J., & Associates (2013). Culturally alert counseling: A comprehensive introduction (2nd ed.). Thousand Oaks, CA: Sage.

Shupe, E. I. (2013). The development of an undergraduate study abroad program: Nicaragua and the psychology of social inequality. Teaching of Psychology, 40, 124129. doi:10.1177/0098628312475032

Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20, 6488. doi:10.1002/j.2161-1912.1992.tb00563.x

Sue, D. W., & Sue, D. (2012). Counseling the culturally diverse: Theory and practice (6th ed.). Hoboken, NJ: John Wiley & Sons.

Zalaquett, C. P., Foley, P. F., Tillotson, K., Dinsmore, J. A., & Hof, D. (2008). Multicultural and social justice training for counselor education programs and colleges of education: Rewards and challenges. Journal of Counseling & Development, 86, 323329.

Lorraine J. Guth, NCC, is a Professor and Clinical Coordinator at Indiana University of Pennsylvania. Garrett McAuliffe is a Professor at Old Dominion University. Megan Michalak, NCC, is an Assistant Professor at Antioch University New England. Correspondence can be addressed to Lorraine J. Guth, IUP Department of Counseling, 206 Stouffer Hall, Indiana, PA 15705, lguth@iup.edu.

A Relational-Cultural Framework: Emphasizing Relational Dynamics and Multicultural Skill Development

Kristopher G. Hall, Sejal Barden, Abigail Conley

Increases in diverse clientele have caused counselor education to enhance its focus on multicultural pedagogy, using the Tripartite Model (TM) to impart multicultural learning. While knowledge and awareness are important, it also is important to enhance skill development in counselors-in-training. Counselor educators have a unique opportunity to blend knowledge and awareness with skills learned in counseling techniques courses by incorporating microskills training in the multicultural classroom. Additionally, other theories, such as Relational-Cultural Theory (RCT), can be used as a framework to merge the TM and microskills. This article includes an overview of RCT, a brief history on microskills training and a case study to integrate the two concepts for use in counselor training. The reader should begin to see how microskills, RCT and the TM can serve to enhance skill development in the multicultural classroom.

Keywords: microskills, multicultural, Relational-Cultural Theory, counselor education, pedagogy

Counseling as a profession espouses the need for counselors to be culturally competent, as evidenced by the inclusion of diversity training in preparation standards (Council for Accreditation of Counseling and Related Educational Programs [CACREP], 2009) and in ethical standards (American Counseling Association [ACA], 2005). According to the 2009 CACREP standards, an institution must provide instruction that includes “an understanding of the cultural context of relationships, issues, and trends in a multicultural society” (Section II, Code G.2, p. 10). Although the importance of multicultural competence is supported in preparatory and ethical standards, current pedagogical practices may be ineffective as graduates of counseling programs frequently report feeling unprepared to effectively work with culturally diverse clients (Bidell, 2005; Bidell, 2012; Rock, Carlson, & McGeorge, 2010). Therefore, counselor educators need to consider how to more effectively meet the challenge and responsibility of cultivating cultural competence for counselor trainees by focusing on increasing skill development (Cates, Schaefle, Smaby, Maddux, & LeBeauf, 2007; Dickson & Jepsen, 2007; Hays, 2008).

Priester et al. (2008) conducted a content analysis of 64 introductory master’s-level multicultural course syllabi to understand the content of contemporary multicultural courses. The authors collected the syllabi by examining counseling program Web sites and contacting the instructor of record. Results indicated high emphasis in multicultural knowledge across syllabi, with over 84% of the syllabi highly emphasizing knowledge and moderate emphasis on self-awareness, with 41% of syllabi emphasizing self-awareness and a significantly lower emphasis of skill acquisition, and with only 12% of syllabi emphasizing skill development. Findings highlight relatively high emphasis on knowledge when working with culturally diverse groups and markedly lower levels of skill acquisition, potentially perpetuating the issue of counselor graduates not feeling adequately prepared. Although knowledge and self-awareness are critical components in developing cultural sensitivity, it is imperative to teach counselor trainees skills that will aid them in therapeutically connecting with their clients (West, 2005).

Counselor preparation programs are responsible for training students how to work with clients from all backgrounds; however, multicultural pedagogy has been found to be lacking in key areas (Braden & Shah, 2005), including focusing primarily on obtaining multicultural knowledge and awareness related to working with diverse groups, while failing to reinforce training in discrete skills (Priester et al., 2008). Knowledge alone does not lead to behavior or attitude change among counselor trainees and may actually reinforce culturally insensitive practices (Alberta & Wood, 2009; Arredondo & Toporek, 2004), creating a significant gap in education; while counselors-in-training are taught effective practices for personal multicultural development, they may not be given the necessary skills to use their new knowledge with diverse clients. Therefore, it is imperative to introduce new theories and integrate current theories into counselor education curricula to ensure that students are receiving well-rounded instruction in relation to multicultural competence.

To this end, the purpose of this paper is to highlight the use of RCT (Miller, 1986) as a vehicle to develop skills and integrate existing emphasis of knowledge and awareness in multicultural courses. The authors will begin with a brief overview of multicultural pedagogy and current approaches to multicultural instruction, followed by an introduction to microskills and a brief overview of RCT. The manuscript will close with a case study which integrates the concepts of the TM, microskills, RCT, implications for the field of counseling and conclusions.


Multicultural Pedagogy


As counseling professionals have become more aware of the complexity and interactions of culture on counseling relationships (Daniel, Roysircar, Abeles, & Boyd, 2004), several models have been developed that make recommendations for what constitutes a culturally competent counselor (Buckley & Foldy, 2010; Collins & Arthur, 2010; Sue, 2001). Although these models were pioneered by recognized experts in the field of multiculturalism, many authors agree that the central model in the field remains the TM, developed by Sue, Arredondo and McDavis (1992) (Holcomb-McCoy & Myers, 1999; Mollen, Ridley, & Hill, 2003). The TM has influenced major counseling bodies such as ACA and CACREP, standardizing multicultural content in counselor training ethics and accreditation (Holcomb-McCoy, 2000). Additionally, the TM has largely influenced current literature on multicultural pedagogy, placing considerable emphasis on teaching multicultural knowledge, skills and awareness to counselors-in-training (Hipolito-Delgado, Cook, Avrus, & Bonham, 2011). Essentially, the TM asks that counselors (a) have the necessary cultural knowledge of the population they will be assisting; (b) be aware of any cultural biases that the counselor may have regarding the client’s culture and biases their client may have due to the counselor’s perceived culture; and (c) have the necessary skills to assist clients of that particular culture, including understanding when to refer to more knowledgeable colleagues.

The TM has been refined on three occasions (1992, 1996, 2001), but past refinements have failed to address some of the major limitations of the model (Arredondo et al., 1996; Sue, 2001; Sue et al. 1992). Criticisms of the model are based on the lack of supporting literature to ground the three-dimensional model, difficulty measuring the factor structure of the model, and lack of relevance for practical application (Constantine, Gloria, & Ladany, 2002). Furthermore, although the TM provides a helpful framework in conceptualizing multiculturalism, it fails to highlight the importance of the therapeutic alliance when working with clients from diverse backgrounds. Extensions and applications of the TM include the development of the multicultural competencies (Sue et al., 1992). While the multicultural competencies highlight the importance of considering culture when developing the relationships, they fail to offer requisite skills that are necessary when developing relationships with culturally diverse clients. For example, the authors espouse using the model to “promote culturally effective relationships, particularly in interpersonal counseling” (Arredondo et al., 1996, p. 55); however, the competencies emphasize only that diverse relationships should be considered, not how they are to be achieved. Given that the TM is the preeminent model in which most multicultural courses are grounded, emphasis on relationships between the client and counselor and relationships between minority clients and majority society is minimal, highlighting the need for alternate conceptualizations and models that emphasize the therapeutic alliance (West, 2005).

Researchers suggest that often counselors teach clients how to best operate within the majority culture, failing to address the significance of contextual factors (e.g., socioeconomic status, education, literacy) that may be related to client distress (e.g., Comstock et al., 2008). When contextual factors are overlooked, the counselor and client are at increased risk for perpetuating cultural misunderstandings and negative attitudes toward counseling (Hartling, Rosen, Walker, & Jordan, 2000). Specifically, failing to attend to contextual factors may lead to disconnection, feelings of being misunderstood, and potential for weakening the therapeutic alliance, which increases the likelihood for treatment withdrawal (Duffey & Somody, 2011). In sum, there is heightened importance for multicultural pedagogy to increase focus on the relational and contextual factors when working with clients from diverse backgrounds. Therefore, it is imperative to teach counselors-in-training specific skills regarding how to be attentive to contextual factors.

Researchers (Roysircar, Gard, Hubell, & Ortega, 2005; Sodowsky, Kuo-Jackson, Richardson, & Corey, 1998) have found that exposure to varied multicultural experiences—both inside and outside of the classroom—increase various aspects of multicultural competence. Sodowsky et al. (1998) assessed multicultural competence while controlling for social desirability, race and attitudes of social inadequacy and locus of control. The authors found that multicultural training variables including minority client load, number of research projects, and multicultural training courses significantly contributed to overall multicultural counseling competency. In another study, Roysircar et al. (2005) used a mentoring program in which counseling students in a multicultural course were exposed to middle school students in an English as a Second Language course to develop trainee multicultural awareness. Counseling students in the study reported increased multicultural awareness as a result of the exposure to different cultures (Roysircar et al., 2005). It can be inferred from these studies that the inclusion of multicultural experiences during counselor training can contribute to student development in regard to the TM.

In sum, counselor educators have adapted to CACREP requirements through the application of several teaching models for multicultural competency including didactic (Abreu, 2001; Kim & Lyons, 2003) and experiential (Platt, 2012; Tomlinson-Clarke & Clarke, 2010) models for teaching multicultural competence. However, the efficacy of many of the existing models is unknown. Therefore, it may be helpful to employ a common standard across counselor education curricula to ensure that counselors-in training are receiving similar emphasis on the development of multicultural knowledge, awareness and skills. This common standard already exists in the microskills training that are used in counseling techniques courses.



Microskills training is the primary pedagogy used in counselor education training. Counselors-in-training are taught the building blocks of counseling through discrete skills used to simplify abstract concepts (Mollen, Ridley, & Hill, 2003). The training model was developed as a result of work began by Truax and Carkuff (1967), who noticed that beginning and highly experienced counselors were equally skilled in facilitating therapeutic change, an anomaly given an experienced counselor’s increased time in the field. The authors concluded that counseling students were being taught the importance of the relationship in counseling, but not how it is achieved; therefore experienced counselors had the knowledge base but lacked the ability to demonstrate respective skills. Ivey (1971) continued the work of Truax and Carkuff and coined the term microskills or “communication skill units of the [counseling] interview that will help [the student] interact more intentionally with a client” (Ivey & Ivey, 2003, p. 22). Microskills has been the preeminent method of counselor training for over 40 years, with over 450 studies completed on microskills training, highlighting the strong empirical base supporting its utility in counselor education (Ridley, Mollen, & Kelly, 2011). Although microskills are well researched and supported, the need to adapt these core counseling skills when working with diverse clients is not clear. Therefore, we, the authors, propose integrating RCT with microskills training to best meet the needs of diverse mental health clients.


Relational-Cultural Theory: A Fresh Perspective


Counselors are faced with an increased challenge to find ways to relate to diverse clients and build strong therapeutic alliances (Constantine, Hage, Kindaichi, & Bryant, 2007; Owen, Tao, Leach, & Rodolfa, 2011). While it is not feasible for counselors to understand the idiosyncrasies of every culture, it is possible to increase attention to cultural and contextual factors when building the therapeutic alliance (Vasquez, 2007). Furthermore, researchers have suggested that successful counseling must include empathic relationships that are culturally sensitive in nature and that employ techniques grounded in mutual empathy, defined as a mutual exchange of empathic experiences during the counseling session (Comstock, 2005; Duffey & Somody, 2011; Fuertes et al., 2006). Therefore, it is imperative for counselor educators to focus on emphasizing culture and empathy, and how to build therapeutic alliances when teaching counselor trainees to be culturally sensitive. An overview of RCT will be explored as a framework for incorporating the strategies of multicultural pedagogy, strong therapeutic alliance and mutual empathy into counseling with diverse clients.


Overview of RCT’s Basic Tenets

Similar to multicultural theories, RCT is grounded in feminist theory. The theory was developed at the Stone Center for Women in 1977 through weekly meetings with Jean Baker Miller, Irene Stiver, Judith Jordan, and Janet Surrey (Jordan, 2008; West, 2005). Miller’s (1986) book, Towards a New Psychology of Women, solidifies the ideas presented at these meetings and establishes a formal introduction of RCT. Theoretical underpinnings of RCT are grounded in the notion that primary counseling theoretical orientations placed unnecessary blame on the clients for their problems and did not account for the importance of relationships and contextual factors (West, 2005). Therefore, RCT was developed as a theory that emphasizes relationships and external factors, as opposed to focusing on internal pathology and mental illness. RCT states that individuals develop through mutually empowering relationships with others, asserting that the relationship, not autonomy, is the key to growth (Duffey & Somody, 2011). Furthermore, RCT highlights the importance of mutuality and authenticity between client and counselor, both gaining from shared experiences and leaving with a deeper understanding of themselves and the other person’s perspective (Duffey & Somody, 2011).This mutual growth experience begins with the formation of relational images (West, 2005).

Relational images, defined as internal relational schemas or beliefs about an individual’s relationships, are formed from experiences throughout the lifespan (Miller & Stiver, 1997). Positive or negative images form related connections or disconnections within the individual, resulting in the formation of relational images (Miller & Stiver, 1997; Napier, 2002). As individuals move throughout the lifespan, relational images are either confirmed or denied by various experiences. When an event is mutually empowering, it is referred to as a connection (Miller & Stiver, 1997). Conversely, when a person’s experiences are in conflict with their relational images or when they are not mutually beneficial and empowering, they experience disconnections (Napier, 2002). Continuous damage to relational images may lead to negative beliefs including self-blame, isolation and immobilization (Jordan, 2001). Counselors may be at risk of weakening the therapeutic alliance by reinforcing disconnections or by neglecting the cultural context of the client’s concerns (Duffey & Somody, 2011).

Disconnections are an expected occurrence and are necessary for growth (Jordan, 2008). However, constant disconnections can damage the client’s relational images, possibly leading to counseling as a result of feelings of shame, confusion and decreased self-worth (Napier, 2002). When clients successfully move through disconnections, they may experience relational growth or relational resilience. Relational resilience refers to the ability to alter relational images and rebound from disconnection. Clients who experience relational resilience are more able to reconnect to others by increasing mutuality in relationships such as mutual support and growth (Duffey & Somody, 2011). In summary, RCT suggests that all persons seek connections, but internalized feelings may cause them to continually disengage as a mode of self-protection, resulting in a relational paradox; therefore, counselors can use the therapeutic alliance to reframe disconnections and reconstruct relational images (Miller & Stiver, 1997).

Counselors are well-positioned to facilitate dialogues with clients regarding relational disconnections, by discussing reasons and causes for disconnections and enabling the client to avoid placing complete responsibility or blame on their internal self. RCT suggests that the best way to realign and strengthen new relational images is through the therapeutic alliance (Jordan, 2008). The therapeutic alliance gives the client the opportunity to establish positive connections and repair relational distortions (West, 2005). By establishing a strong therapeutic alliance, the counselor provides an environment in which the client is able to begin reconnecting with his/her true self and demonstrating this behavior outside of counseling (Banks, 2006). Freedburg (2007) suggested that clients benefit when they can see their counselor as a fully dimensional human being, encouraging the client to carry the skills learned in therapy back into the real world. Therefore, the client must see the counselor as a mutually engaging human being who sees the client in a way that others have not.

In addition to emphasizing the therapeutic alliance, the use of mutual empathy in RCT encourages counselors to allow themselves to be affected by their client and share their experiences with clients when appropriate (Duffey & Somody, 2011). Mutual empathy also can be taught and reinforced during clinical internship/practicum. RCT suggests that counselors express their connections with their clients and invite feedback about how this has impacted the client (Comstock et al., 2008). During training counselor educators can illuminate instances where mutual empathy could be implemented in the counseling session. Additionally, RCT can be taught in conjunction with the ideas regarding authenticity in counseling. One-way empathy is considered a barrier that blocks authenticity due to creating a more contrived relationship, whereas counselors should instead strive for a relationship based on mutual respect, maximizing possibilities for relational equality and desires for emotional connectedness (Freedburg, 2007). Abernethy & Cook (2011) state that authenticity in counseling with RCT opens up both the client and the counselor to connect in a safe environment. This safe environment is important for multicultural understanding, as researchers (e.g., Comstock et al. 2008) have indicated that minority clients tend to feel disconnected in therapy due to feelings of being misunderstood by majority culture.

The goal of RCT in therapy is to first change negative self-images through mutual empowerment and mutual empathy (West, 2005). The counselor seeks to understand the reasons for relational disconnections and assist the client in repairing their distorted views of the relational process (Miller & Stiver, 1997). For example, a client’s thoughts may change from “I could not make connections, so I am wrong” to “I could not make connections, so the connection is wrong.” Change is achieved through genuine and authentic connections between the client and the counselor, grounded in mutual empathy and mutual exchange of ideas on the direction of treatment and goal setting (Duffey & Somody, 2011; West, 2005).


RCT and Counselor Training

RCT is a practical model which counselor educators can use to integrate multicultural knowledge with skill development through the use of mutual empathy to enhance the therapeutic alliance. Given that relationships between the clients and counselors have been found to be one of the most important aspects of the therapeutic alliance and a consistent predictor of client outcomes, it is clear that there is primacy for the therapeutic alliance when teaching multicultural counseling (Baldwin, Wampold, & Imel, 2007; Castonguay, Constantino, & Holtforth, 2006). RCT emphasizes that individuals grow through their relationships with others and that the primary therapeutic goal is for the client to move out of perceived isolation (Duffey & Somody, 2011). By infusing RCT into multicultural courses, trainees may be better suited to form strong therapeutic alliances and demonstrate culturally appropriate forms of empathy when working with clients from diverse backgrounds. By encouraging counselor trainees to pay increased attention to contextual factors and relationships that may be impacting the client, trainees may have more insight and ability to empathize with their clients (Comstock, 2005; West, 2005). West (2005) suggests that by acknowledging external relationships and contextual factors, clients may feel more engaged in the counseling process, helping to reinforce the therapeutic alliance.


Integrating RCT, the TM, and Microskills Training


Microskills exist as the basis of counselor skill training and are widely used throughout the profession. These skills are carried through the counseling curricula into other courses, reinforcing and developing these basic skills to proficiency. Additionally, counselor educators have attempted to integrate the TM into multicultural training, following accreditation (CACREP, 2009) and ethical code (ACA, 2005) revisions. RCT can be used as a vehicle to blend both microskills and the TM to reinforce and simplify multicultural teaching strategies. Below is an overview of the ways that the TM, microskills and RCT can be combined for multicultural training.



The knowledge portion of the TM encourages multiculturally competent practitioners to gather information regarding the cultural and environmental histories of their clients (Arredondo et al., 1996). This information gathering allows practitioners to create a well-informed picture of client issues for accurate assessments and goal setting. RCT also espouses cultural knowledge through its belief in the client worldview. Client worldviews are important as they give detail to how clients interpret life events and how they form the basis of connections and disconnections (Jordan, 2001).

Understanding worldview can be achieved through targeted, open-ended questioning, which was first introduced during counseling skills courses. Rodriguez and Walls (2000) introduced the concept of culturally educated questioning, in which practitioners use knowledge-based questions to gather information relevant to treatment. Information from previous questions is used to build on more focused questions for a deeper understanding of the client. This concept can be tied into RCT by teaching counseling students to ask future clients questions specific to RCT concepts, including significant relationships and power structures.



Multicultural awareness entails understanding how the counselors’ cultural history may impact their clients (Arredondo et al., 1996). It is important for practitioners to understand how their multicultural makeup (e.g., race, gender, age) may have a bearing on the counseling relationship due to the client’s experiences with these factors outside of counseling, as cultural mistrust has been identified as a barrier to treatment in minority clients (Duncan & Johnson, 2007; Whaley, 2001). RCT encourages practitioners to be aware of the power-over structures, which may exist within the relationships presented by the client (Jordan, 2008). Power-over structures include culturally relevant systemic issues that may affect client functioning, creating constant disconnection due to an effort to assimilate into majority culture (Jordan, 2008). It is important for counselors to be aware of how their role as the counselor and the hierarchical nature of the counselor-client relationship may affect the therapeutic alliance. Therefore, counselor educators can remind students of the importance of the relationship development from the onset of the counseling experience.



From a microskills perspective, counselor educators can remind students of the necessity of relationship building with clients as a foundation for therapeutic engagement. Rogers (1951) asserts that the counseling relationship is a key component for client growth and should be attained before interventions are begun. Young (2012) asserts that students should begin by establishing liking, respect and trust, which leads to client communication and openness. As reinforcement, RCT encourages practitioners to engage in authenticity with clients to create deeper engagement and to demonstrate positive connections that can be repeated outside of counseling (Jordan, 2008). Through the development of the relationship, clients and counselors work to decrease the hierarchical nature of the relationship. Counselor educators use microskills training to teach counselors-in-training to use empathy as a method for connecting to clients and to understand issues from the client’s frame of reference (Ivey & Ivey, 2003). RCT goes a step further with its emphasis on mutual empathy, a technique to allow the client to see, hear and feel that their story has affected the counselor (Jordan, 2001).

Mutual empathy has many similarities to the widely accepted definition of empathy; however, a few key differences exist. Mutual empathy requires that the counselor allow themselves to be affected by the client because detachment may interfere with therapeutic healing (Duffey & Somody, 2011). Mutual empathy is demonstrated by continually checking in with the client through empathic exchange, enabling the counselor to better understand the client’s worldviews and inviting the client to react to the mutual exchange. Allowing the client to react to the exchange constitutes the difference between mutual empathy and empathy, with the counselor inviting the client to engage in empathic exchange instead of the counselor simply making empathic statements. Counselor educators can reinforce this behavior in the classroom by teaching students to request client reactions to certain empathic statements. The act of mutual empathy can create a more meaningful relationship by encouraging both client and counselor to fully participate in the exchange and feel the impact that each participant has on the other (Freedburg, 2007). For example, after making an empathic statement, trainees can be requested to respond based on the empathic statement from the client in order to demonstrate mutual empathy.

In conclusion, infusing central tenets of RCT in multicultural pedagogy through the use of microskills may be an effective way to prepare counselor trainees to meet the demands of working with clients from all backgrounds. RCT’s synthesis of multicultural knowledge and focus on obtaining skills provides trainees with universal tools for developing strong multicultural competence at every stage of the counseling process. By focusing on the relational aspects of counseling through the use of microskills, trainees will be able to demonstrate culturally sensitive counseling. We provide a brief case illustration to highlight core tenets of RCT in practice.


Case Illustration


James (pseudonym) is a 22-year-old college student at a large university and has entered counseling with feelings of “constant anger” and “frustration” toward his family, friends and professors. James states that his actions are pushing others away, resulting in feelings of isolation. He describes spending much time in his bedroom in order to avoid conflict and reports feeling increasingly depressed. When he does engage with others, he finds that conflict often arises, causing him to either minimize the importance of the issue or withdraw from the offending individual in an effort to refrain from lashing out. James reports that while there are important things he would like to say during these moments, he relents because he does not want to heighten conflict.

Through the course of counseling, James describes varying degrees of emotional connection to his family and friends. He currently lives with his older sister and another roommate in a home owned by his parents. James is of Colombian descent and moved back and forth between his home country and Miami between the ages of 9 and 16. His parents are married, although his mother lives in Miami while his father lives in Colombia in order to maintain the family business. Both of his siblings are pursuing what he considers “successful” careers; his older brother is in law school and his older sister is in medical school. James has one year left to complete his undergraduate degree and is currently studying accounting. His relationships with his parents and siblings are important to him; however, he admits to hiding information, including his visits to therapy and feelings regarding friends and familial issues, as he fears reprisal or invalidation. He also consistently compares himself to his older siblings and feels that he does not live up to his potential within his family. Lastly, James has a fairly large social network, belonging to a coed fraternity for the past 2 years. Although he interacts with several members of the organization, he consistently feels misunderstood or ignored.


RCT Counselor Response

RCT is a broad and flexible framework, which can be employed in a multitude of ways. For the purposes of this article, the authors take a closer look at using worldview/cultural context, authenticity, disconnections, and mutual empathy in order to understand a different way to relate to James. The authors also demonstrate how each of these facets can be incorporated with microskills training.

Worldview/cultural context. In order to set the stage for client conceptualization, the initial focus of the relationship should be the client’s cultural context. Exploring the client’s worldview will give the practitioner an opportunity to understand the client’s cultural context and allow the client to feel heard, which is essential to RCT and the therapeutic alliance. After a few sessions, the counselor notes that James operates in many different areas, creating a rich worldview for the counselor to explore.

It is important at this stage to employ culturally educated questioning to enhance the counselor’s multicultural knowledge regarding the client. The counselor asks open-ended questions that are tailored to gather specific information about the client’s worldview as more information is shared between the client and counselor. Through exploration of his worldview, James indicates that his primary identification is a student, which colors all of his other worldviews and affects the primacy of other responsibilities contained within his other cultural contexts. James’s secondary identification is being a fraternity member. However, due to his studies, there are times when he is forced to forgo fraternity events so that he can be prepared for classes. The stress caused from his failing grades and inability to meet fraternal obligations adds to his anger issues. James also discusses his Colombian heritage and the importance of family, giving insight to his decision making. Exploring James’s daily activities, cultural groups and relationships helps build initial rapport and creates an early therapeutic alliance, while also giving insight into possible stressors for James. This alliance is carried through to other parts of the session, as the client feels comfortable giving detail, knowing that his particular worldview will be encouraged and respected.

Connections and disconnections. James feels unheard by his fraternity brothers and inferior to his family members. Deeper investigations into these relationships reveal that James’s peers and family members are not able to accept and understand his feelings, creating an empathic disconnect. The results of this disconnect cause James to become aggressive when he cannot get his point across. Using RCT, the counselor and James analyze the disconnection in each of his familial relationships and how they affect his current functioning and relationships with others. For example, James’s relationship with his brother is often very tense, causing him to retreat from conflict or release his anger in a nonproductive fashion. These behaviors are repeated when James comes into conflict with others, such as his fraternity brothers.

Next, the counselor helps James identify positive, mutually beneficial connections with others in his social circle. When asked what is different about these relationships, he shares that he feels open to discussing his emotions with these individuals and that his feelings are valued. To help build the therapeutic alliance, the counselor directly asks James what can be done to build a similar, mutually beneficial connection within their counseling sessions. James responds that he wants to feel safe and respected so that he can share his views without judgment. The counselor then seeks to create this type of environment using the tenets of mutual empathy and authenticity.

Counselors should be aware of power-over structures, which can alter how relationships are perceived. When counselor educators teach students to employ multicultural awareness, it is important to remind students of how existing societal structures may determine how students form relationships with members of society. RCT asks that counselors analyze client relationships and how they contribute to functioning with regard to positive and negative aspects of various relationships. Counselors can inquire about the important relationships in their clients’ lives and whether these relationships are mutually beneficial.

Mutual empathy and authenticity. While less emphasized in multicultural courses, counselor educators who teach counseling technique courses have the opportunity to reinforce multicultural skill development. Empathy development is taught as a foundational skill in counseling techniques courses, which begins during the initial phases of relationship development. Using RCT, counselor educators can teach the advanced skill of mutual empathy to help deepen the relationship between client and counselor.

In order to move from disconnection to connection, the counselor attempts to create a supportive environment using the RCT concepts of mutual empathy and authenticity by reaffirming the client’s story and attempting to accurately reflect the client’s emotion. When the client shares something that was particularly difficult, the counselor reflects feeling and shows appreciation for the client’s strength in addressing a difficult issue. In order to demonstrate mutual empathy, the counselor shares how he has been affected by James’s disclosure and asks how he feels about that action. James affirms being heard and respected, qualities that are necessary for mutually beneficial connection. For example, after James shares a particularly difficult story regarding feeling frustrated by others making decisions for him, the counselor re-affirms his story through empathic response, but then uses mutual empathy to ask how it feels to hear that his frustration is understood. Using RCT allows the client to feel that he is truly understood, and evidence of a more robust therapeutic alliance is seen through James’s increased willingness to share and explore themes.


Implications for Counselor Educators


Counselor educators have done much to incorporate multicultural development into counseling curricula. Through CACREP and ACA standards, counselor educators have received a blueprint for developing multiculturally competent practitioners. Counselor educators also have an established method of training through microskills, which are used to help students learn the building blocks of counseling. However, at this time very few counseling theories have sought to bridge both multicultural development and microskills training.

The purpose of this article is to provide a tool for counselor educators to help integrate the TM, (awareness, knowledge, skills) into classroom instruction using microskills training. The TM and RCT have concepts that mirror each other and that, when combined, can create a practical framework for students in progressing toward multicultural competence. When microskills training is used as a vehicle for instruction, students will have a tangible and discrete set of skills to use with diverse clients which may increase self-efficacy, improve the counseling relationship and improve treatment outcomes. Using RCT in multicultural coursework provides counselor educators with an educational tool to better apply the TM and meet the need to increase the emphasis of skills in multicultural courses.

Counseling using RCT principles includes bringing meaning to the client’s relationships and exploring his or her relational images (Jordan, 2001). Additionally, Jordan (2010) states that clients must be aware that they are having an impact on their counselors. Counselor educators have the ability to combine elements of RCT with microskills to enhance multicultural development in students. By linking knowledge, awareness and skills with the RCT elements of emphasis on worldview, power-over structures, and mutual empathy, counselor educators give students tangible skills that can be employed with multicultural clients. Funneling these two concepts through microskills gives counselor educators an available and proven framework to structure student learning.


Suggestions for Future Research


Like all theories, RCT is not without shortcomings. Because RCT is based on relational focus and views on openness between counselor and client, RCT may not be suitable for all counseling relationships. For example, Jordan (2010) states that RCT may not be effective with clients who have sociopathic personalities, due to such clients’ avoidance of authentic interactions. If a client is not willing to honestly engage the counselor, mutuality is lost. RCT also requires a level of authenticity that some counselors may not be comfortable with, specifically those with boundary issues. Counselors trained in other theories are taught to keep certain levels of relational distance between themselves and the client. However, Walker (2004) makes note that RCT practitioners strive for a level of relational clarity while avoiding language that implies separateness and objectification.

Currently, research is sparse in the area of using RCT as a method of instruction, most likely because RCT has not yet been operationalized, making it difficult to teach. Previously, the theory has been described as a way of being or an understanding, instead of a direct set of techniques that can be imparted to students. Oakley et al. (2013) have suggested using RCT in a brief model of treatment, stating their intention to develop a manual, which may help counselor educators in teaching the elements of RCT. Researchers should continue to focus on finding ways to clarify the process of RCT; its strong focus on relationships, worldviews and advanced techniques such as mutual empathy could create stronger counselors.




In summary, it is essential for counselors-in-training to be aware of how to put the TM into action. Current multicultural pedagogy primarily emphasizes learning in the knowledge and awareness domains, rarely making skill development a focus during counselor training. Given the changing demographics and increased growth of the minority population in the United States, training counselors to be effective with working with all clients is imperative. Counselor educators are in the unique position to prepare students for multicultural engagement before they begin practice. The infusion of RCT into counseling techniques courses gives counselors-in-training exposure to a different perspective, which incorporates the multicultural competencies with relationship building skills. RCT, with its emphasis on mutual empathy, relationships and contextual factors, enables counselors to gain a greater depth and breadth of minority client experiences, potentially strengthening the therapeutic alliance.



Abernethy, C., & Cook, K. (2011). Resistance or disconnection? A relational-cultural approach to supervisee anxiety and nondisclosure. Journal of Creativity in Mental Health6(1), 2–14. doi:10.1080/15401383.2011.560067

Abreu, J. M. (2001). Theory and research on stereotypes and perceptual bias: A didactic resource for multicultural counseling trainers. The Counseling Psychologist29(4), 487–512. doi:0.1177/0011000001294002

Alberta, A. J., & Wood, A. H. (2009). A practical skills model for effectively engaging clients in multicultural settings. The Counseling Psychologist, 37(4), 564–579. doi:10.1177/0011000008326231

American Counseling Association. (2005). ACA code of ethics. American Counseling Association. Alexandria, VA: Author.

Arredondo, P., & Toporek, R. (2004). Multicultural counseling competencies = ethical practice. Journal of Mental Health Counseling26(1), 44–55.

Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C, Sanchez, J., & Stadler, H. (1996). Operationalization of the multicultural counseling competencies. Journal of Multicultural Counseling and Development, 24, 42–78. doi:10.1002/j.2161-1912.1996.tb00288.x

Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75, 842–852. doi:10.1037/0022-006X.75.6.842

Banks, A. L. (2006). Developing student affect in a university self-defense course. Physical Educator, 63, 8–17.

Bidell, M. P. (2005). The Sexual Orientation Counselor Competency Scale: Assessing attitudes, skills, and knowledge of counselors working with lesbian, gay, and bisexual clients. Counselor Education and Supervision44(4), 267–279. doi:10.1002/j.1556-6978.2005.tb01755.x

Bidell, M. P. (2012). Examining school counseling students’ multicultural and sexual orientation competencies through a cross-specialization comparison. Journal of Counseling & Development90(2), 200–207. doi:10.1111/j.1556-6676.2012.00025.x

Braden, J. P., & Shah, K. G. (2005). A critique of multicultural training in school psychology: Rationale, strategies, and tactics. In C. L. Frisby & C. R. Reynolds (Eds.), Comprehensive handbook of multicultural school psychology (pp. 1023–1047). New York, NY: Wiley.

Buckley, T. R., & Foldy, E. G. (2010). A pedagogical model for increasing race-related multicultural counseling competency. The Counseling Psychologist, 38, 691–713. doi:10.1177/0011000009360917

Castonguay, L. G., Constantino, M. J., & Holtforth, M. G. (2006). The working alliance: Where are we and where should we go? Psychotherapy: Theory, Research, Practice, Training, 43, 271–279. doi:10.1037/0033-3204.43.3.271

Cates, J. T., Schaefle, S. E., Smaby, M. H., Maddux, C. D., & LeBeauf, I. (2007). Comparing multicultural with general counseling knowledge and skill competency for students who completed counselor training. Journal of Multicultural Counseling and Development35(1), 26–39. doi:10.1002/j.2161-1912.2007.tb00047.x

Collins, S., & Arthur, N. (2010). Culture-infused counseling: A fresh look at a classic framework of multicultural counselling competencies. Counselling Psychology Quarterly, 23, 203–216. doi:10.1080/09515071003798204

Comstock, D. L. (Ed.). (2005). Diversity and development: Critical contexts that shape our lives and relationships. Belmont, CA: Thomson Brooks/Cole.

Comstock, D. L., Hammer, T. R., Strentzsch, J., Cannon, K., Parsons, J., & Salazar II, G. (2008). Relational-cultural theory: A framework for bridging relational, multicultural, and social justice competencies. Journal of Counseling & Development, 86, 279–287. doi:10.1002/j.1556-6678.2008.tb00510.x

Constantine, M. G., Gloria, A. M., & Ladany, N. (2002). The factor structure underlying three self-report multicultural counseling competence scales. Cultural Diversity & Ethnic Minority Psychology8, 334–345. doi:10.1037/1099-9809.8.4.335

Constantine, M. G., Hage, S. M., Kindaichi, M. M., & Bryant, R. M. (2007). Social justice and multicultural issues: Implications for the practice and training of counselors and counseling psychologists. Journal of Counseling & Development, 85, 24–29. doi:10.1002/j.1556-6678.2007.tb00440.x

Council for Accreditation of Counseling and Related Educational Programs. (2009). 2009 standards for accreditation. Alexandria, VA: Author.

Daniel, J. H., Roysircar, G., Abeles, N., & Boyd, C. (2004). Individual and cultural-diversity competency: Focus on the therapist. Journal of Clinical Psychology, 60, 755–770. doi:10.1002/jclp.20014

Dickson, G. L., & Jepsen, D. A. (2007). Multicultural training experiences as predictors of multicultural competencies: Students’ perspectives. Counselor Education and Supervision47(2), 76–95. doi:10.1002/j.1556-6978.2007.tb00040.x

Duffey, T., & Somody, C. (2011). The role of relational-cultural theory in mental health counseling. Journal of Mental Health Counseling, 33, 223–242.

Duncan, L. E., & Johnson, D. (2007). Black undergraduate students attitude toward counseling and counselor preference. College Student Journal, 41, 696–719.

Freedburg, S. (2007). Re-examining empathy: A relational-feminist point of view. Social Work, 52, 251–259. doi:10.1093/sw/52.3.251

Fuertes, J. N., Stracuzzi, T. I., Bennett, J., Scheinholtz, J., Mislowack, A., Hersh, M., & Cheng, B. (2006). Therapist multicultural competency: A study of therapy dyads. Psychotherapy: Theory, Research, Practice, Training, 43, 480–490. doi:10.1037/0033-3204.44.1.13

Hartling, L. M., Rosen, W. B., Walker, M., & Jordan, J. V. (2004). Shame and humiliation: From isolation to relational transformation. In J. V. Jordan, M. Walker, L. M. Hartling (Eds.), The complexity of connection: Writings from the Stone Center’s Jean Baker Miller Training Institute (pp. 103–128). New York, NY: Guilford.

Hays, P. A. (2008). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy. Washington, DC: American Psychological Association.

Hipolito-Delgado, C. P., Cook, J. M., Avrus, E. M., & Bonham, E. J. (2011). Developing counseling students’ multicultural competence through the multicultural action project. Counselor Education and Supervision50, 402–421. doi:10.1002/j.1556-6978.2011.tb01924.x

Holcomb-McCoy, C. C. (2000). Multicultural counseling competencies: An exploratory factor analysis. Journal of Multicultural Counseling and Development28, 83–97. doi:10.1002/j.2161-1912.2000.tb00609.x

Holcomb-McCoy, C. C., & Myers, J. E. (1999). Multicultural competence and counselor training: A national survey. Journal of Counseling & Development, 77, 294–302. doi:10.1002/j.1556-6676.1999.tb02452.x

Ivey, A. E. (1971). Microcounseling: Innovations in interviewing training. Springfield, IL: Charles C. Thomas.

Ivey, A. E., & Ivey, M. B. (2003). Intentional interviewing and counseling: Facilitating client development in a multicultural society (5th ed.). Pacific Grove, CA: Brooks/Cole.

Jordan, J. V. (2001). A relational-cultural model: Healing through mutual empathy. Bulletin of the Menninger Clinic, 65, 92–103.

Jordan, J. V. (2008). Recent developments in relational-cultural theory. Women & Therapy, 31, 1–4. doi:10.1080/02703140802145540

Jordan, J. V. (2010). Relational-cultural therapy. Washington, DC: American Psychological Association.

Kim, B. S., & Lyons, H. Z. (2003). Experiential activities and multicultural counseling competence training. Journal of Counseling & Development81(4), 400–408. doi:10.1002/j.1556-6678.2003.tb00266.x

Miller, J. B. (1986). Toward a new psychology of women (2nd ed.). Boston, MA: Beacon Press.

Miller, J. B., & Stiver, I. P. (1997). The healing connection: How women form relationships in therapy and in life. Boston, MA: Beacon Press.

Mollen, D., Ridley, C. R., & Hill, C. (2003). Models of multicultural competence: A critical evaluation. In D. B. Pope-Davis, H. L. K. Coleman, W. M. Liu, & R. Toporek (Eds.), Handbook of multicultural competencies in counseling & psychology (pp. 21–36). Thousand Oaks, CA: Sage.

Napier, M. B. (2002). Staying connected: Incorporating a client centered nondirective attitude into the Stone Center’s model of relational-cultural therapy (Doctoral dissertation). Retrieved from PsycINFO database. (Accession No. 2002-95020-134)

Oakley, M. A., Addison, S. C., Piran, N., Johnston, G. J., Damianakis, M., Curry, J.,…Weigeldt, A. (2013). Outcome study of brief relational-cultural therapy in a women’s mental health center. Psychotherapy Research23(2), 137–151. doi:10.1080/10503307.2012.745956

Owen, J. J., Tao, K., Leach, M. M., & Rodolfa, E. (2011). Clients’ perceptions of their psychotherapists’ multicultural orientation. Psychotherapy48(3), 274–282. doi:10.1037/a0022065

Platt, J. J. (2012). A Mexico City-based immersion education program: Training mental health clinicians for practice with Latino communities. Journal of Marital and Family Therapy38(2), 352–364. doi:10.1111/j.1752-0606.2010.00208.x

Priester, P. E., Jones, J. E., Jackson-Bailey, C. M., Jana-Masri, A., Jordan, E. X., & Metz, A. J. (2008). An analysis of content and instructional strategies in multicultural counseling courses. Journal of Multicultural Counseling & Development, 36, 29–39. doi:10.1002/j.2161-1912.2008.tb00067.x

Ridley, C. R., Mollen, D., & Kelly, S. M. (2011). Beyond microskills: Toward a model of counseling competence. The Counseling Psychologist39, 825–864. doi:10.1177/0011000010378440

Rock, M., Carlson, T. S., & McGeorge, C. R. (2010). Does affirmative training matter? Assessing CFT students’ beliefs about sexual orientation and their level of affirmative training. Journal of marital and family therapy36(2), 171–184. doi:10.1111/j.1752-0606.2009.00172.x

Rodriguez, R. R., & Eugene Walls, N. (2000). Culturally educated questioning: Toward a skills-based approach in multicultural counselor training. Applied and Preventive Psychology9(2), 89–99.

Rogers, C. R. (1951). Client-centered therapy. Boston, MA: Houghton Mifflin.

Roysircar, G., Gard, G., Hubbell, R., & Ortega, M. (2005). Development of counseling trainees’ multicultural awareness through mentoring English as a second language students. Journal of Multicultural Counseling and Development33, 17–36. doi:10.1002/j.2161-1912.2005.tb00002.x

Sodowsky, G. R., Kuo-Jackson, P. Y., Richardson, M. F., & Corey, A. T. (1998). Correlates of self-reported multicultural competencies: Counselor multicultural social desirability, race, social inadequacy, locus of control racial ideology, and multicultural training. Journal of Counseling Psychology45, 256–264. doi:10.1037/0022-0167.45.3.256

Sue, D.W. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29, 790–821. doi:10.1177/0011000001296002

Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling & Development, 70, 477–486. doi:10.1002/j.1556-6676.1992.tb01642.x

Tomlinson-Clarke, S. M., & Clarke, D. (2010). Culturally focused community-centered service learning: An international cultural immersion experience. Journal of Multicultural Counseling and Development38(3), 166–175. doi:10.1002/j.2161-1912.2010.tb00124.x

Truax, C. B., & Carkhuff, R. R. (1967). Toward effective counseling and psychotherapy:

Training and practice. Chicago, IL: Aldine.

Vasquez, M. J. T. (2007). Cultural difference and the therapeutic alliance: An evidence-based analysis. American Psychologist, 62, 878–885. doi:10.1037/0003-066X.62.8.878

Walker, M. (2004). How relationships heal. In M. Walker & W. B. Rosen (Eds.), How connections heal: Stories from relational-cultural therapy (pp. 3–21). New York, NY: Guilford.

West, C. K. (2005). The map of relational-cultural theory. Women & Therapy, 28(3–4), 93–110. doi:10.1300/J015v28n03_05

Whaley, A. L. (2001). Cultural mistrust: An important psychological construct for diagnosis and treatment of African Americans. Professional Psychology: Research and Practice, 32, 555–562. doi:10.1037/0735-7028.32.6.555

Young, M. E. (2012). Learning the art of helping: Building blocks and techniques (5th ed.). New York, NY: Pearson.

Kristopher G. Hall is a doctoral student at the University of Central Florida. Sejal Barden is an Assistant Professor at the University of Central Florida. Abigail Conley is an Assistant Professor at Virginia Commonwealth University. Correspondence can be addressed to Kristopher G. Hall, University of Central Florida, College of Education and Human Performance, 12494 University Boulevard, Orlando, FL 32816, kristopher.g.hall@knights.ucf.edu.