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International Journal of Culture and Mental Health

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An analysis of the Multicultural Assessment Intervention Process model

Glenn Gamsta; Richard H. Danab; Lawrence S. Meyersc; Aghop Der-Karabetiana; A. J. Guarinod a Department of Psychology, University of La Verne, La Verne, CA, USA b Regional Research Institute, Portland State University, Portland, OR, USA c California State University, Sacramento, CA, USA d Auburn University, Auburn, AL, USA

To cite this Article Gamst, Glenn , Dana, Richard H. , Meyers, Lawrence S. , Der-Karabetian, Aghop and Guarino, A.

J.(2009) 'An analysis of the Multicultural Assessment Intervention Process model', International Journal of Culture and Mental Health, 2: 1, 51 64 To link to this Article: DOI: 10.1080/17542860802659579 URL: http://dx.doi.org/10.1080/17542860802659579

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International Journal of Culture and Mental Health Vol. 2, No. 1, 2009, 5164

An analysis of the Multicultural Assessment Intervention Process model

Glenn Gamsta+, Richard H. Danab, Lawrence S. Meyersc, Aghop Der-Karabetiana and A.J. Guarinod
Department of Psychology, University of La Verne, La Verne, La Verne, CA, USA; bRegional Research Institute, Portland State University, Portland, OR, USA; cCalifornia State University, Sacramento, CA, USA; dAuburn University, Auburn, AL, USA (Received 2 December 2008; nal version received 10 March 2009) Multiple regression models linking client counselor preferences, client-provider ethnic/ racial match and provider self-perceived cultural competence to clinical outcome was developed with samples of African American, Latino American and White American adult outpatient community mental health clients (n 01153). The models tested hypothesized relationships of cultural factors predicted by the Multicultural Assessment Intervention Process model. Measured variables included clients preferences for the language in which mental health services were to be provided and the culture (race/ ethnicity) of the provider, client-provider ethnic/racial match, self-perceived provider cultural competence and clinical outcome as measured by Global Assessment of Functioning scores at Time 2 statistically controlling for client scores at Time 1. Results indicated that lack of a client-provider ethnic/racial match and higher levels of provider self-perceived sensitivity predicted African American clinical outcome. These same results plus higher levels of provider self-perceived awareness of cultural barriers predicted Latino American clinical outcome. None of the cultural variables were found to predict White American clinical outcome. Multicultural Assessment Intervention Process model implications are discussed. Keywords: mental health; acculturation; ethnic/racial identity; ethnic/racial match; California Brief Multicultural Competence Scale; Multicultural Assessment Intervention Process model
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Introduction Culturally competent mental healthcare in community systems has been advocated for at least 25 years. Reports by the Surgeon General, the New Freedom Commission and by psychologists (Huang et al., 2005; Tolan & Dodge, 2005) legitimize the need to embed cultural issues in mental health services. Nonetheless, access disparities and biased services adversely affect utilization and quality of mental health care and rehabilitation services (Barrio et al., 2003; Dana, 2007a, 2007b; Melfi, Croghan, Hanna, & Robinson, 2000; Snowden & Yamada, 2005) and some experienced professional psychologists are unwilling to employ recognized multicultural competencies in their psychotherapeutic practices (Hansen et al., 2006). The Multicultural Assessment Intervention Process (MAIP) model was designed to systematically embed cultural issues in mental health service delivery (for overviews see, Constantino, Dana, & Malgady, 2007; Dana, Aragon, & Kramer, 2002; Dana, 1993, 1997,
*Corresponding author. Email: gamstg@ulv.edu
ISSN 1754-2863 print/ISSN 1754-2871 online # 2009 Taylor & Francis DOI: 10.1080/17542860802659579 http://www.informaworld.com

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1998, 2000, 2001a; Gamst, Rogers, Der-Karabetian, & Dana, 2006). The model was designed to predict clinical outcome and was tested on a culturally diverse sample of consumers of mental health services. Clinical outcome was based on the Global Assessment of Functioning (GAF: American Psychiatric Association, 2000). This outcome variable was hypothesized to be a function of the clients cultural and language preferences, whether the client and mental health professional were of the same or different ethnicity/ race, and the self-reported level of cultural competence of the mental health provider. Over time and through clinical and empirical practice the MAIP model has been delineated, refined and explicated (e.g. Gamst, Dana, Der-Karabetian, & Kramer, 2000, 2001, 2004; Gamst et al., 2003, 2004; Gamst, Dana, Der-Karabetian, & Dana, 2006). This effort has informed the community mental health process in a variety of ways. For example, intake procedures include a Consumer Outcome Profile, a prototype weekly tracking form to systematically mobilize, allocate and channel resources, including appropriate mental health service providers and culturally generic or specific programs. Client-provider ethnic/ racial match occurs by organizational necessity or client request. Client cultural and language preferences provide a convenient way of gaining some understanding of client acculturation and racial identity status. Provider self-perceived cultural competence is routinely assessed using the California Brief Multicultural Competence Scale (CBMCS: Gamst et al., 2004) with available mandatory provider training (Dana, Gamst, & DerKarabetian, 2008). A variety of outcome measures for adults and children have been employed in MAIP studies. Additionally, MAIP applications designed to increase clinical diagnostic reliability for ethnic minority populations (Dana, 2007a) and augment rehabilitation counseling objectives (Dana, 2001b, 2007b) have been described and population-specific MAIP reviews are available for African American and Asian Americans (Dana, 2002a,b). The Multicultural Assessment Intervention Process is amenable to evaluation at individual, agency and community levels consistent with performance measurement (California Department of Mental Health, 2005). At the individual level, clients are tracked by computerized intake and outcome profiles across system components. A weekly team meeting mobilizes and allocates agency resources to meet client needs and gender, language and ethnic match preferences at the individual client level. At the agency level, accountability for quality assurance and multi-stakeholder coordination is available from client service satisfaction measures and provider cultural competence effects upon clinical outcomes. Community level aegis is fulfilled by appropriate outreach and public education. The MAIP model is employed in the present study as a framework for examining predicted relationships between client cultural and language preferences, client-provider ethnic/racial match and perceived provider cultural competence with clinical outcome. Client provider preferences Client provider preferences were a function of two measured variables: language preference and mental health service provider cultural preference. Providers generally lack specialist training with bilingual clients (Ochoa, Rivera, & Ford, 1997) or evaluations of their fluencies in both languages (Altarriba & Santiago-Rivera, 1994). When bilingual language skills are present their interventions are twice as effective as those conducted in English (Griner & Smith, 2006). Clients who prefer an African American racial match with their provider(s) have a better working alliance, positive effects on the therapy process and greater likelihood of a successful therapeutic outcome in a number of studies (Knox, Burkhard, Johnson, Suzuki, & Ponterotto, 2003). The salient reason for this finding is

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International Journal of Culture and Mental Health

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therapist willingness to openly discuss racial differences with clients without anxiety (Maxie, Arnold, & Stephenson, 2006). Such discussions avoid stereotypy by recognizing within-group differences, avoid misunderstandings due to communication styles or conceptualizations of mental health/mental illness and minimize effects of power, privilege and racism (Cardemil & Battle, 2003). Ethnic/racial match In previous decades, ethnic-specific agencies paired clients with counselors for race, ethnicity, gender and language in response to client preferences and agency resources. Matching clients and counselors increased utilization but did not demonstrate improved service outcomes (e.g. Kouyoudjian, Zamboanga, & Hansen, 2003; Lau & Zane, 2000; Leong & Lau, 2001). Meta-analyses question the efficacy of match as a significant clinical predictor (Maramba & Hall, 2002; Shin et al., 2005). Moreover, inadequate definition, measurement and evaluation of acculturation, socioeconomic status and within-group client and therapist variables, as well as imprecise conceptualizations of race, ethnicity and culture, have been noted (Karlsson, 2005).
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Perceived provider cultural competence During the last 25 years advocacy for cultural competency resulted in a general tripartite approach (D.W. Sue et al., 1982) using a variety of self-report measuring instruments (Ponterotto, Fuertes, & Chen, 2000) and other assessment methods including observer ratings and portfolio approaches (Constantine & Ladany, 2001). These self-report instruments were augmented by the CBMCS, a composite of earlier instruments, with factors identified as multicultural knowledge, awareness of cultural barriers, sensitivity and responsiveness to consumers and sociocultural diversities. The CBMCS is supported by a structured, organized, open-ended training curriculum, the CBMCS Multicultural Training Program (Dana et al., 2008). This program was pilot tested by experienced, ethnically diverse practitioners from 15 California counties during six days of training, revised and further tested with over 200 mental health practitioners in four California counties (Gamst & Der-Karabetian, 2004, 2007). Cultural competency in assessment (Allen, 2007; Dana, 2005) and therapy (Hansen, Pepitone-Arreola-Rockwell, & Greene, 2000; Hays, 2001) with multicultural populations is considered essential for quality care in a multicultural society (Abe-Kim & Takeuchi, 1996; Sue, 1998; Sue & Sue, 2003; Weaver, 2005). In the present study, ethnic/racial match was a measured variable coded for the correspondence of self-reported client and provider ethnicity/race. Based in part on previous empirical research (Gamst et al., 2000, 2001, 2002, 2003, 2004) and recent literature reviews (Karlsson, 2005; Maramba & Hall, 2002; Shin et al., 2005), it was hypothesized that client and mental health provider ethnic/racial matches for African and Latino American clients would be associated with more positive clinical outcomes. Client preference for a cultural match with their provider was hypothesized to be strongest for African American and Latino American clients. Bilingual Spanish preferences were hypothesized to be associated with Latino American clients. Self-perceived providers cultural competence was indicated by the four factors measured by providers responses to the self-report items on the CBMCS (Gamst et al., 2004). Higher levels of self-perceived cultural competence on the part of the providers was expected to be associated with greater levels of success of clinical outcome (Pope-Davis, Coleman, Liu, & Toporek, 2003).

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Methods Participants Participants were adult clients (18 years or older) who utilized Tri-City Mental Health Center (TCMHC) outpatient services between July 2002 and June 2003. The TCMHC provides mental health services for residents of the cities of Pomona, La Verne and Claremont within the eastern portion of Los Angeles County, CA. The data reflect a complete census during this one-year period for all clients in which a complete set of clinical outcome variables existed. The 1153 clients included 465 (40.3%) Latino American, 415 (36.0%) White American, 212 (18.4%) African American, 36 (3.1%) Asian American and 25 (2.2%) other ethnicities. Client ethnicity was determined by self-report and the other category contained individuals who identified as bicultural. The sample was composed of 856 (74.2%) females and 297 (25.8%) males. Ages of the participants ranged from 1890 years (M 042.29, SD 010.02). Most clients (76.0%) achieved a 12th grade education or less; 16.2% had some college education. At intake all clients in the present study met the criteria for the mood disorder diagnosis. A total of 304 additional clients were eliminated from the present study due to small subsample size within the following diagnostic classifications: schizophrenic disorders (n 0213), other severe or moderate disorders (n 057), substance abuse (n 026) and other (n 08). Clients reporting trauma at intake accounted for 89.4% of the total sample and 10.6% reported no trauma. For those clients reporting trauma, the types of trauma reported were as follows: rape/sexual abuse (20.2%), physical abuse (15.7%), violent death (6.9%), accident/illness (7.5%), serious injury (5.5%), witness traumatic event (4.2%), threats of death (1.9%), loss of personal property (1.0%) and other (37.1%). Clients were either living with immediate family (32.9%), living alone in a house or apartment (21.4%), living with extended family (18.2%), living in group quarters (1.6%), living with non-related person (10.3%) or were unknown/homeless (15.6%). The primary language of the clients was English (86.6%), Spanish (11.7%) and other (1.7%). Bilingual providers were made available for clients needing translation during any of their mental health services. Clients were referred to TCMHC through a variety of referral sources including: self, family and friends (30.2%), mental health program (27.0%), private or public psychiatric facility (39.6%), police or courts (2.4%) and other referrals (0.8%). Clients were provided a variety of individual, group, case management, psychoeducational and psychiatric services through the following programs: Adult outpatient (48.0%), Calworks (California Work Opportunity and Responsibility to Kids, 21.9%), adult drug and alcohol (14.7%), day treatment and psychosocial rehabilitation (6.2%), emergency services (0.8%), homeless outreach (1.3%) and other programs (7.1%).

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Data set A data base management system minimizing potential data entry errors the Human Service Information System was used at TCMHC. This software is frequently employed by mental health and medical facilities to collect information and track clients for purposes of accounting, billing, case management, internal proprietary research and outcome research. This software captured client information by mental health providers using standardized forms and input into the computer system by clerical workers who, in turn, use fix-formatted computer screens to guide data entry.

International Journal of Culture and Mental Health Variables Ethnic/racial match

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Previous investigations (e.g. Gamst et al., 2000, 2001; Gamst, Dana, Der-Karabetian, & Kramer, 2004; Russell, Fujino, Sue, Cheung, & Snowden, 1996) operationalized an ethnic or racial match on the intake providers race/ethnicity during the admission evaluation of client functioning. The present study utilized a different conceptualization, developed by Gamst et al. (2002, 2003), positing that an ethnic/racial match existed when the modal provider (i.e. the mental health provider who had the most sessions with the client as indicated by computer activity logs) had the same ethnicity/race as the client. The rationale for this new operationalization was that a match based on a modal provider sidestepped the sometimes awkward situation of focusing on the typically non-representative staff member who happened to handle the admission evaluation but may not have been involved in the clients treatment regimen. In large urban community mental health facilities, clients are often offered mental health services from a variety of providers (e.g. psychologists, social workers, marriage and family therapists, psychiatrists and case managers) any of whom can be the most frequent service provider. Clients received services from 159 modal providers; 62.9% were female. Providers saw an average 6.8 clients during the study period with a minimum value of 1 and maximum value of 82. Provider ethnic breakdown was as follows: Latino American (45.9%), White American (24.8%), Asian American (21.5%) and African American (7.7%). Provider degree status included masters degree (40.9%), doctorate (24.1%), bachelors degree (20.2%), medical degree (1.1%) and less than bachelors degree (13.7%). About 50% of the 159 providers had a second language capability that included Spanish (88.4%), Chinese (4.6%), Arabic (4.4%), Tagalog (2.2%) and Korean (0.4%). Client preferred culture At intake, clients were asked if they had a particular cultural preference regarding the staff member(s) who would provide them with mental health services. The majority of clients (94.5%) indicated it does not matter and the remainder (5.5%) indicated a preference for a provider of the same culture or ethnicity, a finding corresponding with to previous findings by Gamst et al. (2002, 2003). Client preferred language Clients were also queried (at intake) as to their preferred language for mental health services. The majority of clients (93.0%) preferred English only while (7%) indicated a preference for bilingual Spanish. Provider self-perceived cultural competence The self-reported cultural competence of the TCMHC staff was assessed with the CBMCS. The CBMCS is a 21-item self-report measure of a mental health providers self-perceived cultural competence. The CBMCS is a multidimensional measure of self-reported cultural competence consisting of the following subscales: Multicultural Knowledge (5 items), Awareness of Cultural Barriers (6 items), Sensitivity and Responsiveness to Consumers (3 items) and Sociocultural Diversities (7 items) (formerly called Non-ethnic Ability). The CBMCS requires respondents to indicate to what degree they agree or disagree with a

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series of multicultural statements (1 0strongly disagree, 2 0disagree, 30agree, 4 0strongly agree). The CBMCS yields one total score and four subscale scores. Because we were interested in the various types of competencies and their relationship to clinical outcome, data analysis was conducted with the four subscales of the CBMCS. Provider self-perceived cultural competence was measured during the same data collection time period. Criterion validity of the CBMCS was established by demonstrating low-to-moderate correlations of the scores of the Multicultural Counseling Inventory (MCI: Sodowsky, Taffe, Gutkin, & Wise, 1994) and the scores of the CBMCS subscales. Construct validity was also achieved by means of a confirmatory factor analysis that supported the original four-factor model with an independent sample of mental health practitioners. Indexes of internal consistency (Cronbachs alpha) for the scores of the CBMCS subscales for the present study were as follows: Multicultural Knowledge0.85, Awareness of Cultural Barriers 0.78, Sensitivity and Responsiveness to Consumers (formerly Sensitivity to Consumers) 0.50 and Sociocultural Diversities (formerly Non-ethnic Ability) 0.86. All coefficients were consistent with those reported by Gamst et al. (2004) with the exception of Sensitivity and Responsiveness to Consumers. This relatively low alpha value may be a function of the paucity of items that make up the subscale. Additionally, Gamst et al. (2004) reported that all four subscales did not correlate significantly with the Social Desirability Scale (SDS) (Crowne & Marlowe, 1960), with the average correlation between the SDS and CBMCS subscales hovering around .01. This lack of correlation supports the argument that the CBMCS is probably not contaminated by social desirability effects. Provider self-perceived cultural competence is composed of the three original Sue et al. (1982) factors (i.e. knowledge, skills and abilities) plus a new factor, Sociocultural Diversities, acknowledging other oppressed groups affected by ethical and social justice inequities impacting on cultural/racial identities. Sociocultural Diversities adds a new dimension to the self-report cultural competence and training literature by focusing on other dimensions of otherness categories, noted by Israel (2006), including: . . . race/ ethnicity, gender, religion, sexual orientation, socioeconomic status, age and physical/mental ability, with respective oppression of racism, sexism, religious-oppression/anti-Semitism, heterosexism, classism and abelism (p. 149). Clinical outcome The GAF Axis V rating of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision: American Psychiatric Association, 2000) was used as a measure of clinical outcome success. The GAF was completed at intake (GAF-T-1) and at termination or annual review (GAF-T-2). Global Assessment of Functioning scale values can range from 1 (severe impairment) to 100 (good general functioning). Adequate reliability and validity have been reported (e.g. Jones, Thornicroft, Coffey, & Dunn, 1995; Schorre & Vandvik, 2004; Spitzer, Gibbon, Williams, & Endicott, 1994). All GAF ratings were provided by the modal provider. It is possible that the level of client functioning at the onset of treatment could confound any direct interpretation of post-treatment GAF. To minimize this potential confound, scores on the GAF-T-2 were statistically adjusted to remove the variance attributable to GAF-T-1 by using this latter measure as a covariate; the adjusted GAF-T-2 scores were then taken to represent the clinical outcome measure in the model.

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International Journal of Culture and Mental Health

Table 1. Correlation coefcients among variables used to examine MAIP model. 1 1. 2. 3. 4. 5. 6. 7. 8. Culture Language Match Knowledge Awareness Sensitivity Sociocultural Clinical Outcome 2 .16* 3 .21* .39* 4 .11 .39* .11* 5 .08 (.17* (.03 .05 6 .06 .18* .13* .36* .44* 7 .11* .24* .09 .54* .28* .49* 8

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.01 .05 .01 .04 .09* .16* .13*

Note. *0p B.05; Culture0clients cultural preference (0Doesnt matter, 10same culture); Language0 clients language preference (0English only, 10Bilingual Spanish), Match 0ethnic/racial match (0no match, 10match); Knowledge0multicultural knowledge subscale; Awareness0awareness of cultural barriers; Sensitivity0sensitivity and responsiveness to consumers; Sociocultural0sociocultural diversities, GAF-T-10 GAF at Time 1; and Clinical Outcome0GAF at Time 2 after using GAF-T-1 as a covariate.

Results Correlations between the eight measured variables in the study are shown in Table 1. Low to moderate correlations were found among some of the CBMCS subscales. Statistically significant low positive correlations were also observed between the clinical outcome measure and three of the CBMCS subscales.

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Evaluating the hypothesized models Prior to performing the analysis, the data set was examined to assess the fit between the distributions of the variables and the assumptions of the statistical analysis (e.g. normality, homogeneity of variance, linearity and multicollinearity); no assumption violations were found. No missing values on any of the measured variables were discovered in the present data set. Three standard multiple regression analyses were conducted with GAF-T-2 as the dependent variable and client preferred culture, client preferred language (for Latino American clients), client-provider ethnic/racial match and provider self-perceived cultural competence as the independent variables for each of the three ethnic/racial groups in the present study. As can be seen in Table 2, regression results for White American clients yielded a multiple R for regression that was not statistically significant (F [6,362] 01.11, p.05). This result indicates that for White American clients, the two dichotomous variables (client preferred culture and client-provider ethnic/racial match) and the four CBMCS subscales did not predict adjusted GAF. However, regression results for African American clients produced a multiple R for regression that was statistically significant (F [6, 193] 03.86, p B.001, R2 0.08). Two of adj the six independent variables (ethnic/racial match, and sensitivity and responsiveness to consumers) contributed significantly to the prediction of adjusted GAF-T-2 (pB.01). Greater levels of provider self-perceived sensitivity and the lack of a client-provider ethnic/ racial match was associated with higher adjusted GAF scores. Analogously, for the Latino American clients, regression results yielded a multiple R for regression that was also statistically significant (F [7, 417] 06.12, p B.001, R2 0.08). adj Three of the seven independent variables (ethnic/racial match, awareness of cultural barriers, and sensitivity and responsiveness to consumers) contributed significantly to the

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Table 2. Regression analysis summary for consumer multicultural variables predicting adjusted global assessment of functioning by race/ethnicity. Predictors Language preference Cultural preference Ethnic/racial match Knowledge Awareness Sensitivity Sociocultural White American B SEB b NA NA NA (3.28 5.18 .04 (1.18 .98 (.07 (.71 .86 (.06 .01 1.04 .01 (1.93 1.45 (.09 3.36 1.43 .18** African American B SEB b NA NA NA (.12 3.25 (.01 (6.85 2.51 (.19** (1.85 1.31 (.12 (1.42 1.80 (.07 5.85 2.35 .25** 1.95 2.09 .09 Latino American B SEB b (1.97 (2.21 (1.67 (.83 2.25 4.76 (.11 1.08 (.10 1.69 (.07 .87 .11* .75 (.07 1.04 .12* 1.69 .19** 1.32 (.01

Note: *pB.05; **pB.01; White American0Adj.R2 0.01 (n0415, p.05); African American0Adj. R2 0.08 (n0212, pB.001); Latino American0Adj. R2 0.08 (n0465, pB.001); Knowledge0multicultural knowledge; Awareness 0awareness of cultural barriers; Sensitivity0sensitivity and responsiveness to consumers; Sociocultural0sociocultural diversities.

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prediction of adjusted GAF-T-2 (pB.05). Greater levels of provider self-perceived awareness of cultural barriers and sensitivity and responsiveness to consumers and again the lack of a client-provider ethnic/racial match were associated with higher adjusted GAF scores. Discussion Results from the present multiple regression analyses provide some empirical support for the MAIP model. The MAIP is predicated on evaluating the effects of key multicultural factors like client-provider ethnic/racial match and client provider preferences, as well as provider self-reported cultural competence, on subsequent client clinical outcome. Separate regression analyses for each of the three ethnic/racial groups indicated that the various cultural measures did not contribute appreciably to the clinical outcome of White American clients. This may underscore, for White American clients, the lack of saliency of cultural factors in their treatment regimen (see also Maramba & Hall, 2002; Yeh, Eastman, & Cheung, 1994). Conversely, some cultural factors played a statistically significant role in predicting clinical outcome. For African American clients, higher levels of provider self-perceived Sensitivity and Responsiveness to Consumers predicted GAF outcome. For Latino American clients, increases in provider Sensitivity and Responsiveness to Consumers and Awareness of Cultural Barriers also predicted GAF outcome. Interestingly, for both Latino and African American clients, ethnic/racial match was also a statistically significant predictor. However, counter to our hypothesis, a lack of an ethnic/ racial match was associated with higher clinical outcome. These somewhat counterintuitive ethnic/racial match findings have some support in the recent empirical literature. For example, Gamst et al. (2000) found with a large sample (n04554) of adult outpatient clients that adjusted GAF difference scores increased for ethnically/racially matched Latino and Asian American clients, but declined for matched African and White American clients. Gamst et al. (2001, 2004) also failed to find a consistent effect of ethnic/racial match with additional samples of outpatient clients. One commonality between the previous studies cited, which failed to find a consistent pattern of matching effects, and the present study is that client acculturation status and ethnic/racial identity were not captured and possibly covaried with the matching variable. Alternatively, perhaps some client-provider mismatches

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prompted a concern for cultural sensitivity on the clients part and, in this situation, clinical outcome was affected. This somewhat counterintuitive ethnic/racial match finding will need to be further replicated and scrutinized before a more definitive explanation can be offered. Neither of the client preference variables (culture and language) predicted client adjusted GAF scores. The lack of variability on these items, particularly the cultural preference item, may suggest that this intake query needs to be reconstituted. Two of the four CBMCS subscale measured variables (i.e. Awareness of Cultural Barriers and Sensitivity and Responsiveness to Consumers) reliably predicted Latino American clinical outcome, while only one CBMCS subscale (Sensitivity and Responsiveness to Consumers) contributed to the prediction of African American adjusted GAF scores. These two CBMCS subscales measure mental health service provider understanding of the human costs of prejudice, discrimination and white privilege (Awareness) and provider expectations and therapeutic relationships that are central to the healing and recovery process (Sensitivity). In the present study, the Multicultual Knowledge subscale and the Sociocultural Diversities subscale (i.e. issues of gender, sexual orientation, social class, age and disability) did not predict clinical outcome for any of the ethnic/racial groups. Limitations
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There are several limitations to the present study that should be noted. First, the MAIP model specifies routine intake assessment of clients acculturation and/or ethnic/racial identity status. Such an assessment was not accomplished with the present sample. Instead, the clients preferences for treatment language and providers culture were utilized. This substitution of client preferences for established identity and acculturation devices did not capture enough dimensions of cultural identity. Second, clients were sometimes matched to providers on the basis of available resources and internal agency pragmatics and thus, not always as a function of a systematic MAIP assessment. Third, culture-specific and culturegeneral clinical interventions, when they occurred, were again sometimes driven by pragmatic considerations and not necessarily as a by-product of MAIP model assessments. Future research and implications Future research with the MAIP model would benefit from replication with another adult outpatient sample that tests the limits of agency resources. Other behavioral health domains, like childrens systems of care and university counseling centers, could also provide advantageous MAIP target populations. Perhaps the most salient element regarding future research with the model is the MAIPs call for behavioral health researchers to examine simultaneously cultural factors related to client functioning and service satisfaction (Costantino et al., 2007). Structural modeling might be employed in the future to evaluate the interrelationships among the variables when they are working simultaneously and in a specified and sometimes complex structure (Meyers, Gamst, & Guarino, 2006). Future research should also include the agency resources necessary to provide direct measures of key cultural variables hypothesized to affect clinical outcome. Accommodating good ethnic science to practice may be realized by successive approximations during systematic replications of the present research in the interests of cost-effective services. As noted previously, one of the unexpected findings based on our multiple regression results was that clinical outcome for African American and Latino American clients appears to increase in the presence of a non-match between client and provider. This somewhat counterintuitive finding requires further study. Examining client-provider match

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and client cultural preference by client ethnic/racial group may provide an important insight concerning this crucial process. This MAIP study provides several insights that may be relevant in addressing the challenges managed care faces in embracing cultural issues sufficiently to permit access and provide equitable services for ethnic minority populations (Snowden & Yamada, 2005). First, this study contributes to the empirical basis for culturally sensitive mental health care as contained in the definition of evidence-based practice in psychology as the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 73). Second, the adequacy of the cultural responsiveness hypothesis is reaffirmed empirically by employing multiple regression models in this study and covariate analyses elsewhere (Gamst et al., 2006). That this support occurs in a context that recognizes both the limitations and advantages of matching for clients from some ethnic groups while simultaneously elucidating the importance and reaffirming the necessity of cultural competence training for all providers in a variety of locations (Evans, Delphin, Simmons, Omar, & Tebes, 2005; Gamst et al., 2004). These state-sanctioned models represent two versions of cultural competency implementation that can be realized nationwide; a description and comparative details are available elsewhere (Dana, 2007a). Third, provider self-reported cultural competence ultimately affects clinical outcomes measured differentially for racial/ethnic minorities by two CBMCS subscales. Fourth, the MAIP exemplifies a formal structure for continuing to examine these complexities costeffectively within mental health facilities by combining culturally competent practice with ongoing outcome research. Notes on contributors Glenn Gamst is Professor and Chair of the Psychology Department at the University of La Verne, where he teaches the doctoral advanced statistics sequence. He received his doctorate from the University of Arkansas in experimental psychology. His research interests include the effects of multicultural variables, such as client-therapist ethnic match, client acculturation status and ethnic identity, and therapist cultural competence, on clinical outcomes. Additional research interests focus on conversation memory and discourse processing. Richard H. Dana is Research Professor (Honorary) at the Regional Research Institute for Human Services, Portland State University. During his teaching career, 19531988, he served as Professor, Director of Clinical Training, Psychology Department Chair, and Dean. Since retirement from the University of Arkansas as University Professor Emeritus in 1988, he has collaborated in a California research program that has published empirical studies on the Multicultural Assessment-Intervention Process (MAIP) practice model including the California Brief Multicultural Competency Scale Multicultural Training Program, Participant Workbook, and Multicultural Reader (Sage, 2008). Other recent books include Multicultural Assessment Perspectives for Professional Psychology (Allyn & Bacon, 1993), Understanding Cultural Identity in Assessment and Intervention (Sage, 1998), Handbook of Cross-Cultural and Multicultural Personality Assessment (Erlbaum, 2000), Multicultural Assessment Principales, Applications, and Examples (Erlbaum, 2005), TellMe-A-Story Assessment of Multicultural Populations (With G. Costantino and R. Malgady) (Erlbaum, 2007), and Cultural Competency Training in a Global Society (J. Allen) (Springer, 2008).

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Laurence S. Meyers is Professor of Psychology at California State University, Sacramento, where he teaches undergraduate and graduate courses in research design, data analysis, data interpretation, testing and measurement, and the history and systems of psychology. He received his doctorate from Adelphi University and worked on a National Science Foundation Postdoctoral Fellowship at the Univesity of Texas, Austin and Purdue University. A.J. Guarino is on the faculty at Auburn University, teaching the statistics sequence, of ANOVA, multiple regression, MANOVA, and structural equation modeling (SEM) in the College of Education. He received his bachelors degree from the University of California, Berkeley. He earned a doctorate in statistics and research methodologies from the Unversity of Southern California through the Department of Education Psychology. Aghop Der-Karabetian, Ph.D., is a Professor of Psychology and Associate Dean of the College of Arts and Sciences at the University of La Verne where he has taught for the last 27 years. His Ph.D. is in social psychology. He has conducted research on multicultural issues, ethnic and multiethnic identity, seeking psychological help, sex roles, worldmindedness and environmental activism. He has authored or co-authored over fifty refereed publications. He is also a co-author of the CBMCS Multicultural Training program for mental health practitioners published by SAGE in 2008. He is one of the cofounders of the Armenian American Mental Health Association based in southern California. References
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