Culturally Competent Practice: A Mixed Methods Study Among Students, Academics and Alumni of Clinical Psychology Master’s Programs in the Netherlands

This is the first research into preparation for multicultural clinical psychology practice in Europe. It applies the theory of multicultural counselling competency (MCC) to a case study in the Netherlands. It was hypothesized that cross-cultural practice experience, identification as a cultural minority, and satisfaction with cultural training was associated with MCC. The Multicultural Awareness Knowledge and Skills Survey was completed by 106 participants (22 students, 10 academics, 74 alumni) from clinical psychology masters’ programs. MANOVA detected a main effect of cross-cultural experience on MCC for all groups and universities. The data were enriched with exploratory qualitative data from 14 interviews (5 students, 5 academics, 4 alumni). Interpretative Phenomenological Analysis revealed three themes: limitations of clinical psychology, strategies for culturally competent practice, and strategies for cultural competency development. These outcomes suggest that cultural competency continues to require attention in master’s programs. The paper makes recommendations for further research enquiry related to training clinical psychologists to practice in Europe’s multicultural societies.

experienced colleagues (Allison, Crawford, Echemendia, LaVome, & Knepp, 1994;Hansen et al., 2006;Sehgal et al., 2011). In addition, students who identified as belonging to a cultural minority reported higher levels of MCC compared to their peers (Pope-Davis, Reynolds, Dings, & Nielson, 1995). It needs to be assessed whether the possible pathways to cultural competency, including multicultural training, cross-cultural experience and belonging to a cultural minority, are applicable in a Dutch context. Therefore, research explores two questions. Firstly: Are multicultural training, cross-cultural experience and belonging to a cultural minority associated with culturally competency of students, academics and alumni of clinical psychology master's programs? This will be examined through a standardised self-assessment of MCC, the Multicultural Awareness, Knowledge and Skills Survey (MAKSS;D'Andrea et al., 1991). Research indicates social desirability as a possible covariate of self-reported MCC (Constantine & Ladany, 2000). Therefore, it was hypothesized that, after controlling for the effects of social desirability, satisfaction with cultural training crosscultural practice experience, and personal identification as a cultural minority would be associated with students', academics' and alumni's multicultural counselling competency (Study 1). As this is the first research using a standardised measure of MCC in Dutch universities, this study also seeks to supplement the quantitative MCC data with more exploratory interview data. The second research question is: How do students, academics, and alumni of clinical psychology experience preparation for culturally competent clinical psychology practice? This qualitative question is explored using interview data (Study 2).

Study 1: Survey on Multicultural Counselling Competency
It was hypothesized that after controlling for the effects of social desirability: H1: Satisfaction with cultural training was associated with students', academics' and alumni's multicultural counselling competency.
H2: Cross-cultural practice experience was associated with students', academics' and alumni's multicultural counselling competency.
H3: Personal identification as a cultural minority was associated with students', academics' and alumni's multicultural counselling competency.

Method Participants
In total 132 participants responded to an online survey, however 26 participants responded to less than half of the questions and were excluded from the analysis, bringing the sample size to 106. The final sample consisted multicultural region, the other bordered Germany. Both universities attracted a relatively large number of international students; one university had a separate international master's program taught in English.

Instruments
The online questionnaire included a demographic section, and assessments of satisfaction with cultural training, MCC, and social desirability. The survey was conducted in English, so no translation of the assessments was required, and international students, academics and alumni could participate. To assess readability and clarity, the questionnaire was piloted among one student and two alumni of a clinical psychology program at a university not otherwise involved in the study, and minor revisions took place based on the received feedback.  et al., 1991), low inter-correlations between the subscales (D' Andrea et al., 1991), and factor analysis confirming the three-scale structure (Guy-Walls, 2007). Finally, a Wilcoxon matched pairs test for comparison of pre-and post-test results has confirmed internal consistency and construct validity (Ponterotto, Rieger, Barrett, & Sparks, 1994).
Minor adaptations were made to the MAKSS for cross-cultural application. Explicit reference to the United States in Items 35, 37 and 38 were replaced with references to the Netherlands, and reference to "Europe and Canada" were replaced by two countries which were part of the broader research: Australia and Singapore (Geerlings, Thompson, & Tan, 2017;Geerlings, Thompson, Bouma, & Hawkins, in press). The term "white" removed from the phrase "white mainstream clients" and the terms "gay men" and "gay women" were replaced with the phrases "men who are sexually attracted to men" and "women who are sexually attracted to women" respectively.

Marlow Crowne Social Desirability Scale Short Form (MCSDS-SF) -
The short form of the MCSDS (Reynolds, 1982) contains 13 short statements (e.g., "I'm always willing to admit it when I make a mistake") with a true or false forced-choice response format. A Kuder-Richardson-20 reliability of .76 and a correlation of .93 with the full MCSDS has been reported for the MCSDS-SF. It is recommended as a viable short form for measuring social desirability in response tendencies (Reynolds, 1982).

Procedure
After institutional ethics clearance, students, academic staff teaching into clinical psychology master's programs, and alumni of these programs were sent an email invitation by the program director, or senior staff members. i Emails were standardised and included a link to the online questionnaire hosted on Qualtrics survey software. As the recruitment emails were sent to program directors and senior staff members who forwarded the invitation to students, academic staff members and alumni, the response rate cannot be estimated. Data were exported into IBM SPSS for analysis.

Statistical Analysis
After data screening and assumptions testing, correlational analysis was conducted to identify collinearity between the MAKSS scales. Additional correlational analysis and MANOVA were used identify covariates for hypothesis testing, such as social desirability. Likewise, MCC differences between groups (students, academics, alumni) and universities were analysed to assess covariates. Two MANOVAs were conducted with the MAKSS subscales as DVs and group and university respectively as IVs.
A correlational analysis tested the first hypothesis that satisfaction with cultural training (a continuous variable) was associated with MCC. To test the second and third hypotheses that multicultural experience and minority identification were associated with MCC, a one-way between-subjects MANOVAs was conducted with Cultural Competency in the Netherlands 92 multicultural experience and minority identification as IVs and the MAKSS scales as DVs, with social desirability and age as covariates.

Data Screening and Assumptions
Maximum likelihood estimation was used to manage occasional missing values in the MAKSS and MCSDS-SF of 27 participants. This method uses all available data to identify the parameter values that have the highest probability of producing the sample data. It is preferred over single imputation methods because it requires less stringent assumptions and provides a relatively unbiased solution to missing data (Baraldi & Enders, 2010).
Missing demographic data were deleted list-wise. Correlations between the variables were calculated to assess collinearity and are listed in Table 2. The MAKSS subscales were significantly inter-correlated, suggesting the MAKSS subscales each measured a related but distinct aspect of the MCC model. The correlation between Skills and Knowledge was quite high at r = .87, however, as highly inter-correlated DVs do not necessarily cause a loss of power in MANOVA (Cole, Maxwell, Arvey, & Salas, 1994), all three MAKSS scales were analysed.

Covariates and Group Differences
Social desirability and age were correlated with MCC to identify covariates. Social desirability significantly correlated with Skills, r = .38, p < .001, and was thus identified as a covariate for further analysis of the MAKSS.
Age also significantly correlated with Awareness, r = .20, p = .035, but not with Knowledge or Skills (see Table   2). A one-way ANOVA with group (students, academics, alumni) as between-subjects IV and age as DV indicated significant differences between groups, Tamhane's T2 F(2, 104) = 9.989, p < .001. Tamhane's T2 was used to adjust for unequal variances (indicated by a significant Levene's Test, p < .001). Post-hoc tests suggested significant differences between all three groups: academics were significantly older (M = 43.00, SD = 10.708) than students (M = 25.09, SD = 3.766, p < .001) and alumni (M = 33.49, SD = 12.230, p = .030), and alumni were significantly older than students (p = .006). Therefore, both age and social desirability were covariates for subsequent analysis of the MAKSS.
A one-way MANOVA with respondents' university as between-groups IV of and the MAKSS scales (Awareness, Knowledge, Skills) as DVs was conducted. Using Pillai's trace, no significant differences between universities in MAKSS subscales were detected, F(3, 103) = 2.20, p = .092, so the two universities were combined in further analyses.

Hypothesis Testing
H1: A correlational analysis tested the hypothesis that satisfaction with cultural training (a continuous variable) was associated with MCC. Associations between satisfaction with cultural training and the MAKSS scales (Awareness, Knowledge, Skills) were not significant (all ps > .05; see Table 2).
H2 and H3: A one-way MANOVA with multicultural experience and minority identification as between-subjects IVs and the MAKSS scales (Awareness, Knowledge, Skills) as DVs, and with social desirability and age as covariates, tested the two hypotheses that multicultural experience and minority identification were associated with MCC. The variable for minority identification was constructed based on the self-reported cultural backgrounds; participants who identified as autochtoon were categorised as a cultural majority. The MANOVA

Discussion
It was hypothesized that satisfaction with cultural training, cross-cultural experience, and being a cultural minority would be associated with MCC. However, only cross-cultural experience had a significant effect on multicultural Knowledge and Skills, which is consistent with previous findings by Sehgal et al. (2011). In addition, in the exploratory studies from Hansen et al. (2006) and Allison et al. (1994), psychologists reported that cross-cultural experiences were most valuable in their cultural competency development. Study 1 confirms these findings using a standardised measure of cultural competency.
The results highlight the importance of personal experiences with diversity for cultural competency. The present findings are consistent with Allport's (1954) influential Contact Hypothesis as well as more recent literature (e.g., Binder et al., 2009;Hewstone & Swart, 2011;Lemmer & Wagner, 2015;Pettigrew & Tropp, 2008), which affirms that inter-group contact reduces prejudice between majority and minority group members. A recently conducted meta-analysis of 515 studies demonstrated that inter-group cultural contact decreases prejudice through enhanced knowledge, reduced anxiety about inter-group contact, and increased empathy (Pettigrew & Tropp, 2008). These reported pathways from inter-group contact to reduced prejudice are at close parity with Sue et al.'s (1982) concepts of multicultural knowledge and skills. MCC research reported enhanced cultural knowledge (Sammons & Speight, 2008), increased cultural empathy (Burkard & Knox, 2004;Chao et al., 2011), and decreased racial prejudice (Castillo et al., 2007;Chao et al., 2011)  reported in order to maintain confidentiality.

Procedure
After institutional ethics clearing, students and academics of clinical psychology in two universities were invited to participate via the online survey of Study 1 (n = 13), and through snowball sampling (n = 1). All semistructured interviews were conducted face-to-face at the participants' universities or workplaces, or in public places nominated by the participant. All interviews were conducted in English by the same experienced interviewer for an average duration of 30 minutes (range: 20 -45 min). Interviews were audio-taped and were transcribed verbatim with NVivo software. Participants were invited to check the transcripts for accuracy and sufficient de-identification; five participants provided feedback, including correction of minor grammatical errors and additional information related to the interview.
An interview outline of open-ended questions was designed to invite participants to describe and reflect upon their experiences of studying (e.g. "How much consideration for cultural competency is included in the program?"), teaching (e.g. "How do you prepare students for culturally competent practice?"), or practicing clinical psychology (e.g. "Can you tell me about a multicultural clinical practice situation you encountered?").
The outline was piloted with one clinical psychologist not otherwise involved in the study, and minor modifications were made. The outline was used in a flexible manner and interviewees were explicitly invited to introduce topics or ideas related to the research topic.

Data Analysis
Qualitative analysis used an Interpretative Phenomenological Analysis framework to gain insights into the lived experiences of events from the perspective of the participant (Larkin, Watts, & Clifton, 2006;Smith, Flowers, & Larkin, 2009). This approach allowed for discovery of new themes and constructs based on actual experiences, as opposed to the confirmatory approach used in Study 1. To ensure validity and transparency of the analysis, one analysis was audited by a participant and a second by another researcher. While a lack of clear criteria for Cultural Competency in the Netherlands 96 IPA should be acknowledged, both auditors considered the researcher's analysis highly plausible and sufficiently similar to their own interpretations of the transcripts, so it was decided that no further auditing was required.
After data familiarization, descriptive, linguistic and conceptual comments on the transcripts were noted. Based on these comments, themes were constructed that focused on the participant's experiences. For each of the 14 transcripts, these themes were clustered based on similarity in meaning, with each group representing a superordinate theme. To form homogenous samples for IPA, student, academic and alumni interviews were then analysed in three separate groups. Group analyses focused on identifying patterns and constructing master themes that summarised the experiences of each group (students, academics, alumni). However, as demonstrated in Table 4, the themes showed considerable overlap between the groups. Therefore, superordinate themes were renamed for consistency between the groups and collated into shared master themes. Superordinate themes were included in master themes if they were present in at least half of the interviews in student, academic, or alumni interviews (Smith et al., 2009). Western bias -Students and alumni experienced clinical psychology as culturally biased: "The main root of psychology is western-orientated." In their view, some of the western 'roots' of psychology were American behaviourism, Cartesian mind-body dualism, and psychoanalysis, provocatively summarized as the knowledge of "old white men with beards." These western origins have resulted in models and practices that are tailored toward working with clients who are highly educated, and who value individualism, atheism, and "rationalism".
Frequently stated examples of experiences of these values are the aim of self-actualisation and the practice of discussing and analysing emotions in therapy. According to participants, culturally competent practitioners are aware of these biases. Academics acknowledged the need to pay more attention to cultural competency in master's programs but felt that their hands were tied: "I think there isn't really room for much anymore additions in the master because it's only one year." Consequently, cultural training was not a structural part of the curriculum, and some academics expressed concern about their ability to meet the needs of the culturally diverse client and student populations:

Rigidness of science -
"I hope that there is intermingling between the international students and the Dutch students. And I hope that that way students can [at least] learn something about cultural differences." The structure of clinical psychology training thus limits cultural competency development.

Strategies for Culturally Competent Practice
Participants identified three strategies for culturally competent practice: cross-cultural communication, building a good professional relationship, and person-centred practice. All three competencies are generally applicable.

Cultural Competency in the Netherlands 98
Cross-cultural communication -The ability to effectively communicate cross-culturally was identified by students, academics and alumni as an important cultural competency for practice and training. Communication strategies were generally among the first cultural competencies participants introduced into the interviews, for example:  Professional relationship -In addition to cross-cultural communication, alumni identified the ability to establish a professional cross-cultural relationship as an important cultural competency. In cross-cultural practice, alumni reported to "take things more slowly and take more time to establish a personal relationship and building trust." In order to build trust and set up the professional relationship carefully, alumni reported to openly display empathy and care for their clients, and to take more time to get to know one another. The professional relationship was a key strategy in cross-cultural practice: "I have to make sure that my client is really motivated and really wants and believes in me. I adapt a bit to their culture and so they'll think: oh yes, this one will support me." Person-centred practice -A third and final cultural competency, identified by academics and alumni, was person-centred practice. A generic therapeutic skill, person-centred practice involves trying to understand each client's cultural and social circumstances as well as expressions of individuality and adjust the therapeutic approach to each unique individual. The identification of person-centred practice as a competency for multicultural practice de-emphasises culture and values the individual client: There is always this thing: do you really need to have cultural information or do you always need to adapt to your patients? And that is very fundamental question.
[…] I think the most important thing is to be able to sit next to your patient. To understand how they see things, how they experience it.

Strategies for cultural competency development
All participants identified the need for cultural competency. Three important experiences for developing cultural competency were revealed: cross-cultural social relations, clinical psychology curricula, and generic life experiences.
Social relations -Students, academics and alumni considered their cross-cultural social relations as essential in their cultural competency development. Every participant recalled experiences of cross-cultural intimate relationships or friendships, or cross-cultural interactions with colleagues, clients, or neighbours, or strangers, or a combination of these experiences. These have been key in participants' cultural self-reflection, insights into other cultures, and generic feeling of cross-cultural competency. Relatedly, some cultural minority participants felt that they had an advantage over cultural majority psychologists through increased understanding of cultural differences. This highlights the value of cross-cultural experiential activities for cultural Geerlings,Thompson,Kraaij,& Keijsers 99 competency: "If you experience for yourself that your basic assumptions are not the assumptions, then that experience may be worth it." Clinical psychology curricula -Participants expressed the need for more cultural training opportunities.
Students and alumni opined that cultural training should be part of standardised clinical psychology curricula, to create a baseline exposure to cultural issues. Establishing a baseline is especially pertinent as, despite diversification, most clinical psychology students, academics, and practitioners are still "white" and belong to the cultural majority group in the Netherlands. They may be rarely exposed to cultural issues and unaware of

Discussion
Study 2 was designed to explore how students, academics, and alumni of clinical psychology experience preparation for culturally competent clinical psychology practice. The results show that despite the efforts to increase diversity in the sector, clinical psychology training and practice still does not cater for cultural diversity in the Netherlands. Study 2 indicates the 'western' cultural bias and ethnocentrism of the models and practices as one reason. In addition, as reported previously (e.g., Henrich, Heine, & Norenzayan, 2010), psychological science continues to neglect diversity, leaving scientist-practitioners empty-handed with no information to guide their cultural training and practice. Meanwhile, training and practice has become more regulated and structured.
Due to interplay of these factors, clinical psychology curricula do not reflect the increasing cultural diversity of the Dutch society and are delivering practitioners who feel ill-equipped for multicultural practice. The need for cultural inclusiveness in the Dutch mental health care sector has been acknowledged previously (e.g., Bekker & van Mens-Verhulst, 2008;Knipscheer et al., 2011;Van Dijk, 2008), and in Study 2 it was expressed by participants who completed their training two decades ago, as well as by current students, suggesting that updates in curricula are past due.
Cultural Competency in the Netherlands 100 The reported strategies for multicultural practice indicate to possible directions for cultural competency training.
The most pertinent cultural competency identified in Study 2 was the ability to effectively communicate crossculturally. This contributes to the growing recognition of the role of communication in cross-cultural relations in the Netherlands (e.g., Schinkel, Schouten, & van Weert, 2010;Shadid, 2007;Shadid & Van Koningsveld, 1999;Universiteit Utrecht, 2016). Research has demonstrated that communication patterns differ when Dutch medical doctors interact with cultural minority or majority patients. Communication with cultural minorities was characterised by less empathy and involvement, and more emphasis on the patients' symptoms (Meeuwesen, Harmsen, Bernsen, & Bruijnzeels, 2006). In clinical psychology practice, such patterns may interfere with forming a therapeutic alliance. Thus, intercultural communication training may benefit cross-cultural practice.
Indeed, health care practitioners who were competent cross-cultural communicators expressed more empathy (Gibson & Zhong, 2005), were more culturally sensitive, and felt more culturally competent (Ulrey & Amason, 2001 Study 2 suggests that culturally competent practitioners are generally therapeutically competent, are emotionally mature due to myriad professional and life experiences, and are familiar with diversity. The importance of personal familiarity with diversity for cultural competency development is consistent with Study 1 and existing literature (e.g., Allport, 1954;Binder et al., 2009;Hewstone & Swart, 2011;Lemmer & Wagner, 2015;Pettigrew & Tropp, 2008). Cross-cultural contact may enhance cultural awareness and knowledge, and foster a sense of cultural competency. However, the need to integrate cultural components in master's curricula, pointed out by students and alumni, suggests that commencing clinical psychologists may need more preparation for cultural competency. These practitioners miss the professional experience, and often also the life experience needed to feel culturally competent, as they are generally younger (Study 1). This suggests that, apart from integrating cultural training into clinical psychology curricula, it may be beneficial to encourage crosscultural social encounters between cultural majority and minority students in the classroom, or to facilitate study abroad programs to increase students' experiences with diversity.
All interview participants were familiar with cultural issues in clinical psychology. This suggests the possibility of self-selection bias: those with strongest opinions may be more likely to volunteer to be interviewed. Thus, the findings may not be fully representative of the population of clinical psychology students, academics and alumni Geerlings,Thompson,Kraaij,& Keijsers 101 in the Netherlands. Consequently, the importance of culture in clinical psychology training and practice may be overestimated. More research is needed to assess the validity of the present findings in other universities and regions of the Netherlands.

Conclusion
This is, to our knowledge, the first mixed-methods study of culturally competent clinical psychology practice in the Netherlands using the theory of MCC. Study 1 and 2 demonstrate the importance of experiences with diversity for cultural competency, as well life experience and cultural training. While the standardised model of MCC may be partly applicable, more research is needed to determine which model for cultural competency is best suited to guide cultural competency training in the Netherlands. The present paper has made suggestions for further research that may assist in this enquiry. Such research is timely. The experiences of students, academics and alumni indicate that cultural competency continues to need attention in research and practice, so that psychologists feel confident and well-prepared to cater for the mental health needs in the increasingly diverse society.

Notes
i) As a separate list of clinical psychology alumni was unavailable for one university, so all alumni were emailed an invitation to participate. The email specified that the survey was targeted at clinical psychology alumni only, and a question to check whether the participant was indeed a clinical psychology alumnus was added. The survey automatically ended when participants identified as alumni from other programs.

Funding
This research was financially supported by VSB Fonds, Fundatie van de Vrijvrouwe van Renswoude te 's Gravenhage and Vreedefonds.