Evaluating a Programme for Intercultural Competence in Psychotherapist Training: A Pilot Study Research Article Evaluating a Programme for Intercultural Competence in Psychotherapist Training: A Pilot Study Ulrike von Lersner a, Kirsten Baschin a, Nora Hauptmann a [a] Department of Psychology, Humboldt University of Berlin, Berlin, Germany. Clinical Psychology in Europe, 2019, Vol. 1(3), Article e29159, https://doi.org/10.32872/cpe.v1i3.29159 Received: 2018-08-21 • Accepted: 2019-06-07 • Published (VoR): 2019-09-20 Handling Editor: Cornelia Weise, Philipps-University of Marburg, Marburg, Germany Corresponding Author: Ulrike von Lersner, Department of Psychology, Humboldt-Universität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany. E-mail: ulrike.von.lersner@hu-berlin.de Abstract Background: Great cultural diversity among clients poses considerable challenges to mental health service providers. Therefore, staff in the mental health sector needs to be adequately trained. To date, however, there is little empirical evidence regarding such training. The present pilot study evaluates the effect of a standardised training programme to improve the intercultural competence of therapists. Method: Intercultural competence and therapeutic relationship were measured three times (pre, post and follow-up) in N = 29 psychotherapists. A control group of N = 48 therapists was included at pre-test to control for covariables. Results: The data show a significant increase in intercultural competence as well as an improvement in the therapeutic relationship. Interestingly, this positive outcome extends to non- immigrant clients. Conclusion: The results confirm the assumption that culture is not limited to ethnic or national background but includes other dimensions such as age, gender and socioeconomic status which shape illness beliefs and expectations in the psychotherapeutic context. Therefore, intercultural competence can be considered a general therapeutic skill that can be taught in short interventions like the one developed in this study. Keywords evaluation, intercultural competence, diversity, psychotherapy, migration, awareness This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, CC BY 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.v1i3.29159&domain=pdf&date_stamp=2019-09-20 https://cpe.psychopen.eu/ https://www.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ Highlights • Mental health services and practitioners need to be able to respond appropriately to increasing cultural diversity. • Intercultural competence in psychotherapy can be enhanced by special training programmes. • These training programmes should focus on three components: intercultural knowledge, cultural awareness and culture-specific therapeutic skills. As a consequence of continuously increasing global mobility, as well as war and environ‐ mental migration, cultural diversity in Western societies is growing rapidly. These pro‐ cesses are generating a degree of cultural diversity that requires mental health service administrators and practitioners to be able to respond appropriately. Yet, in mental health services a considerably smaller percentage of immigrants is be‐ ing treated now than would be expected considering their overall population share. This has been explained by some as a product of lower service use by clients with a migration background (Chen & Rizzo, 2010; Claassen, Ascoli, Berhe, & Priebe, 2005; Koch, Hartkamp, Siefen, & Schouler-Ocak, 2008; Lindert et al., 2008; Machleidt, Behrens, Ziegenbein, & Calliess, 2007; Ta et al., 2015). Previous studies have also shown that insti‐ tutional barriers can hamper service uptake, including problems of language and other means of communication (Claassen et al., 2005; Kirmayer et al., 2011; Yeo, 2004), per‐ ceived or expected discrimination, and structural and financial barriers (Chen & Rizzo, 2010; Kirmayer et al., 2011). Moreover, surveys of psychotherapists have shown a high degree of insecurity and helplessness in intercultural contexts, which can lead to a great‐ er likelihood of rejecting them as patients or to higher dropout rates (de Haan, Boon, de Jong, & Vermeiren, 2018; von Lersner, 2015; Wohlfart, Hodzic, & Özbek, 2006). The status quo, outlined above, suggests that an intercultural opening up of the men‐ tal health sector is urgently needed (Kirmayer et al., 2011; Machleidt et al., 2007), imply‐ ing an adaptation of institutional and organisational structures to the needs of immigrant clients. Meanwhile, Benish, Quintana, and Wampold (2011) in their meta-analysis have suggested that intercultural therapies have better outcomes when therapists include pa‐ tients’ culturally shaped explanatory models in treatment. Furthermore, therapists should be better prepared for this group of clients through their professional training, in order to reduce insecurities and improve treatment outcomes in the long run (Aggarwal, Cedeño, Guarnaccia, Kleinman, & Lewis-Fernández, 2016; Kirmayer, 2012; von Lersner, Baschin, Wormeck, & Mösko, 2016). Evaluation of a Program for Intercultural Competence 2 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ Intercultural Competence Training Even though intercultural competence appears to be of high relevance in clinical settings, evaluations of intercultural training in the psychotherapeutic context are unfortunately still very rare (Kulik & Roberson, 2008; Mösko, Baschin, Längst, & von Lersner, 2012). To our knowledge, there has been no such training evaluation in German-speaking areas. In the present study, we evaluated an intercultural training programme for therapists aimed at improving intercultural competence and therapeutic relationship. Thus, we evaluated cognitive, skill-based and affective learning, as well as possible improvements in the therapeutic relationship, as components of behavioural change that should emerge after training. Since the training programme was being conducted for the first time, our evaluation has the character of a pilot study. Before discussing the intercultural training, the concept of culture as it is used in the present study needs to be defined. According to Geertz (1973, p. 83), culture describes ‘a system of inherited conceptions expressed in symbolic forms by means of which men communicate, perpetuate, and develop their knowledge about, and attitudes toward, life’. Thus, it can be said to refer to a set of values and norms shared by a group of people independently of their national or ethnic backgrounds. Meanwhile, in its current usage, the term intercultural competence stands for a wide range of definitions associated with numerous practical implications (Steinhäuser, Martin, von Lersner, & Auckenthaler, 2014). However, a widely used concept in clinical settings is the one formulated by Sue and Sue (1990), which includes the following three dimensions: • Awareness: Exploration of and reflection on one’s own cultural embeddedness as well as its influence on perceptions of clients and the formation of the therapeutic relationship. • Knowledge: Knowledge of the cultural background of the client and possible implications for his or her worldview. • Skills: The development of culturally sensitive intervention strategies and techniques. These three components, which can be said to constitute the basis of effective treatment in intercultural settings, represent a goal that is unlikely to be achieved in a one-off train‐ ing session; rather, it requires an active, ongoing process that practitioners have to go through over a longer period of time (Guzder & Rousseau, 2013). The model developed by Sue and Sue (1990) has also become the basis of national guidelines on intercultural competence in various countries and organisations, such as the Multicultural Guidelines of the American Psychological Association (2003, 2008) and the Guidelines for Training in Cultural Psychiatry (Kirmayer et al., 2012). They have also been applied in a European strategy paper on intercultural competence in the mental health sector (Bennegadi, 2009) and in the German Guidelines for the Training of Intercul‐ tural Competence of Psychotherapists (von Lersner et al., 2016). von Lersner, Baschin, & Hauptmann 3 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ Intercultural competence training can be carried out in multiple ways and can be quite heterogeneous with regard to target groups, duration, methods used and content, to name only a few dimensions. The majority of intercultural training evaluation studies in the health sector have been conducted with nursing staff and doctors as well as universi‐ ty students as subjects (Delgado et al., 2013; Khanna, Cheyney, & Engle, 2009). Four systematic reviews, covering 69 studies from 1980 through to 2010, have ana‐ lysed the effectiveness of intercultural training for nursing staff and medical doctors mainly in the US (Beach et al., 2005; Chipps, Simpson, & Brysiewicz, 2008; Lie, Lee-Rey, Gomez, Bereknyei, & Braddock, 2011; Price et al., 2005). Beach et al. (2005) reported very good evidence of increased cultural knowledge among doctors and nursing staff as a re‐ sult of such training, a result that was replicated by Chipps et al.’s (2008) study focusing on staff in rehabilitation centres. There is also good evidence from these studies that awareness and skills (see Sue & Sue, 1990) can change and improve through such train‐ ing. An evaluation of training programmes by Kulik and Roberson (2008) also reported large benefits in intercultural awareness and knowledge across target groups and train‐ ing settings, but little improvements on the skills dimension. Regarding the quality of training schemes, both Lie et al. (2011) and Price and colleagues (2005) suggest that the quality of the evaluation studies examined was only low to moderate: most of them failed to control for confounding variables and effect sizes varied between zero and moderate. Thus, in contrast to the large number of training schemes available, there is a conspicu‐ ous lack of transparently documented and published studies on their effectiveness. One concept that is widely used in intercultural competence training—and in the training programme evaluated in our study too—is the diversity approach. According to this perspective, there are six diversity dimensions that can influence perceptions of commonality and difference and are likely to lead to forms of discrimination: age; gender; sociocultural background, including migration history and skin colour; handicaps and skills; sexual orientation; and religion (van Keuk, Ghaderi, Joksimovic, & David, 2011). Diversity training can focus on one or more of these dimensions, implying that cultural background is only one possible dimension. Participants should learn to be aware of the different types of diversity among their clients and how to deal with them in a positive way. A meta-analysis of the effectiveness of diversity training by Kalinoski et al. (2013) found significant effects on knowledge and skills but none on attitudes and awareness. Their analysis of training methods and structural factors suggested that training sessions lasting 12−16 hours and applying active training methods such as role play, discussion or critical incident technique had the greatest effectiveness, with training spread over multi‐ ple sessions being more effective than one-session programmes. Effective training should have a positive impact on the cultural competence of the therapist as well as improving the therapeutic process, wherein the therapeutic relation‐ ship is of special interest. Norcross (2010, p. 113) defines the client–therapist relationship as ‘the feelings and attitudes that therapist and client have toward one another and how Evaluation of a Program for Intercultural Competence 4 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ these are expressed’. Meanwhile, Khanna and colleagues (2009) describe the therapeutic relationship within the intercultural therapeutic process as an important predictor of compliance and outcomes. Therefore, the present pilot study focuses on this aspect as well. With regard to efficiency, it is also relevant to evaluate whether rather short inter‐ ventions, such as the one developed for the present study, can initiate such positive change. From the start, we assumed that our programme would have a positive impact on the intercultural competence of participants, and that these effects would be quantifiable across our three points of measurement—before, immediately after and three months af‐ ter participation—of the programme. We further hypothesised that having to consider in‐ tercultural issues during the programme would affect the therapeutic relationship in a beneficial way. As such an impact would probably only unfold with time (Guzder & Rousseau, 2013; Kulik & Roberson, 2008), we assumed that the effects would be most ob‐ servable during the follow-up analysis. Further, as another goal of the pilot study was to assess whether the training programme could serve groups of therapists with different levels of experience, we included therapists in training as well as experienced therapists and analysed the effects of the training on them separately. We assumed that participants would benefit from the training regardless of their level of therapeutic experience; that is, that therapists in training would benefit from the programme in a comparable manner to that of experienced therapists. M e t h o d Study Design Data were collected in Berlin as part of a project conducted in the Department of Psycho‐ therapy and Somatopsychology at Humboldt University of Berlin, in collaboration with the Department of Medical Psychology of University Medical Centre Hamburg-Eppen‐ dorf, from October 2013 until March 2014. The project was funded by the European Inte‐ gration Fund (EIF) and ethical approval for the study was given by the Ethical Review Board of the Department of Psychology at Humboldt. The conceptual underpinnings of the training programme evaluated in this study were based on the Guidelines for Inter-/transcultural Competence Training of Psychothera‐ pists, which were developed during a previous project by our workgroup (von Lersner et al., 2016). Data were acquired before (pre-), immediately after (post-) and three months after (follow-up) the training programme. Participants were recruited through mailing lists of educational institutions for clini‐ cal psychologists and psychological associations in Berlin. We included five institutes for cognitive behavioural therapy as well as five for psychoanalysis and depth psychology. von Lersner, Baschin, & Hauptmann 5 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ The main inclusion criterion for participation in the training programme was having had professional training in psychotherapy for adult clients. Therapists who were still in training had to have passed on to the practical stage and be treating clients under super‐ vision. A control group that did not participate in the programme was polled online dur‐ ing the pre-measurement phase. Participation in both groups was voluntary, based on in‐ formed consent and without any incentives or remuneration. Unfortunately, as we re‐ cruited participants through mailing lists, we were not able to track a reliable response rate. Figure 1 illustrates the flow of participants in the course of the study. Figure 1. Flow of participants. Evaluation of a Program for Intercultural Competence 6 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ Implementation of the Training Programme Before implementation of the training programme, a pilot training session was carried out with psychology students. Subsequent adjustments were made for the final training manual which would guide the training programme analysed here. The intervention took place in Berlin and consisted of two consecutive days of train‐ ing—16.5 hours in total. Three weeks later, an additional, one-day refresher session was carried out consisting of six units of 45 minutes each (4.5 hours total). Experienced thera‐ pists and therapists in training received separate training circuits, which were run by ex‐ perienced intercultural trainers from the project team. Programme Content The learning objectives defined in the aforementioned Guidelines for Intercultural Compe‐ tence (von Lersner et al., 2016) formed the basis of the content of the training programme. As recommended by Hager, Patry, and Brezing (2000), an outline of the training pro‐ gramme was discussed by an expert panel (consisting of the project team and four expe‐ rienced intercultural trainers from the University Medical Centre Hamburg-Eppendorf and the Transcultural Centre in Stockholm), and subsequent adaptations incorporated in‐ to the final version by the project team. Table 1 provides a brief overview of the different aspects of intercultural competence covered by individual modules of the programme. In terms of the didactic methods employed, input lectures, self-reflective exercises, critical incident technique, plenary discussions and role play were included. Table 1 Overview of the Training Modules Module Content Culture e.g. definition of culture in the personal and therapeutic context, transcultural competence, ethnocentrism, diversity Migration e.g. information on facts and figures on migration pathways, stressors & resources, political framework Experiencing cultural foreignness in everyday life e.g. personal experiences of cultural foreignness, stereotypes & prejudices, individual norms and values, discrimination Working with cultural brokers and interpreters e.g. the meaning of language in the therapeutic process, language barriers, rules for the inclusion of interpreters in the therapeutic setting von Lersner, Baschin, & Hauptmann 7 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ Module Content Psychometric testing & classification of mental disorders e.g. opportunities and limitations of culture-sensitive testing, epidemiology of mental disorders in different cultural settings, culture-specific symptom presentation, cultural concepts of distress in DSM-5 Exploration and anamnesis e.g. Cultural Formulation Interview, culture-specific explanatory models of mental illness Experiencing cultural foreignness in the clinical setting e.g. critical incidents Booster Session (three weeks later) e.g. supervision, clarification of outstanding questions, identification of ‘cultural pitfalls’ (Auernheimer, 2002) on the basis of own examples Measures Sociodemographic Data Basic variables regarding the sociodemographic background of participants—gender, age, migration background, therapeutic approach and first language—were recorded. Further, information regarding prior experience of intercultural competence training as well as level of personal interest in the topic was collected. Personality Traits In order to assess the influence of the personality trait of openness, the survey also inclu‐ ded the short version of the Big Five Inventory (BFI-10; Rammstedt & John, 2005), which measures the Big Five Personality dimensions using just two items for each of them. Rammstedt (2007) reports satisfactory values for the test’s quality criteria, and the items on openness exhibit moderate values for retest reliability (rtt = .62). Intercultural Competence The intercultural competence of participants was measured via the widely used four-di‐ mension Multicultural Counseling Inventory (MCI; Sodowsky, Taffe, Gutkin, & Wise, 1994). The MCI is based on the three dimensions of intercultural competence formulated by Sue and Sue (2012)—knowledge, awareness and skills—but also seeks to capture an ad‐ ditional, fourth dimension: the multicultural therapeutic relationship. This four-factor structure allows single scores to be calculated for each of the dimensions as well as an overall sum score for intercultural competence. The 40 items of the MCI comprise state‐ ments about counselling and therapy in intercultural settings. Participants are asked to respond on a five-point Likert scale, ranging from 1 = ‘very inaccurate’ to 5 = ‘very accu‐ rate’. For the present study, the MCI was translated into German via the back-translation Evaluation of a Program for Intercultural Competence 8 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ method (Brislin, 1970) and adapted linguistically from counselling to therapeutic settings. The MCI meets the requirements for questionnaires in terms of reliability (.71 ≤ α ≤ .90) as well as validity. In our sample, it had a Cronbach’s alpha α = .88 at T1, α = .88 at T3 and α = .89 at T4, which represent good values. Cronbach’s alphas for the subscales were as follows: αrelationship = .68, αawareness = .78, αknowledge = .85 and αskills = .79 at T1; αrelationship = .63, αawareness = .80, αknowledge = .80 and αskills = .76 at T3; and, αrelationship = .67, αawareness = .82, αknowledge = .79 and αskills = .84 at T4. Therapeutic Relationship In addition to the multicultural therapeutic relationship dimension of the MCI, a closer examination of the therapeutic relationship was achieved using the German version of the Scale to Assess the Therapeutic Relationship in Community Mental Health Care, Clinician Version (STAR-C; McGuire-Snieckus, McCabe, Catty, Hansson, & Priebe, 2007). The self-report STAR-C questionnaire consists of 12 items that seek to evaluate the quali‐ ty of the therapeutic relationship from the perspective of the therapist. It consists of three factors: 1) positive collaboration, 2) positive clinician input and 3) emotional diffi‐ culties. Participants rated the therapeutic relationship separately for their clients with and without a migration background. Retest reliability of the German version is r = .54, which is satisfactory (Gairing, Jäger, Ketteler, Rössler, & Theodoridou, 2011). In our sam‐ ple, Cronbach´s alphas were as follows: αSTAR_German clients = .67 and αSTAR_Immigrant clients = .42 at T1; αSTAR_German clients = .64 and αSTAR_Immigrant clients = .45 at T3; and, αSTAR_German clients = .64 and αSTAR_Immigrant clients = .62 at T4 which reflect moderate to poor values. Figure 2 gives an overview of the research design and the measures used at different sections of the study. Evaluation at T1 and T4 was carried out online, whereas at T2 and T3 data was collected in a paper and pencil format. Figure 2. Overview of the research design. Note. IG = Intervention group. CG = Control group. von Lersner, Baschin, & Hauptmann 9 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ Statistical Analysis Data analysis was carried out using SPSS (Version 22.0). In order to compare characteris‐ tics of the intervention and the control group, between-subject descriptive variables were compared using independent-sample t-tests or Wilcoxon rank-sum tests for continuous data and chi-square analysis for categorical data. Within-subject descriptive variables were compared using either paired-sample t-tests or Wilcoxon signed-rank tests, depend‐ ing on data level. Internal consistency of the STAR-C, BFI and MCI variables and therefore the reliabili‐ ty of the measures used in this study was examined by calculating Cronbach’s alpha for the pre-, post- and follow-up total scores. In order to control for possible selection bias for the variables of prior intercultural competence (MCI pre) and prior knowledge, as well as proportion of immigrant clients, personal interest and openness, univariate ANOVAs were carried out. Post-hoc tests us‐ ing Bonferroni correction allowed us to localise the effects. Further, to calculate the influence of the training programme on intercultural compe‐ tence the Friedman test was used. For localisation of the effects over time, Wilcoxon signed-rank tests were applied to non-parametric data and t-tests to parametric data. Meanwhile, interaction between time and status of participants (trainee vs. experienced therapist) was examined in a MANOVA with repeated measures. Throughout the whole study, effect size is reported as Cohen’s d, r and ω. An alpha of .05 was used to define statistical significance in all analyses, and power analysis was carried out using G*Power (Faul, Erdfelder, Lang, & Buchner, 2007). R e s u l t s Sample Characteristics At T1 the intervention group consisted of 35 participants. Table 2 shows demographic characteristics of this group in comparison to the control group. Statistical analysis showed significant differences between the groups in terms of age and therapy method with the control group being younger and containing a larger percentage of CBT thera‐ pists. Evaluation of a Program for Intercultural Competence 10 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ Table 2 Demographic Variables of Training Group and Control Group at T1 Intervention group (N = 35) Control group (N = 48) Demographic variables n % n % p Gender .55 Female 31 88.6 42 88.0 Male 4 11.4 6 12.0 Age .01 21 – 30 years 8 22.9 18 37.5 31 – 40 years 10 28.6 23 47.9 41 – 50 years 9 25.7 5 10.4 51 – 60 years 5 14.3 2 4.2 > 61 years 3 8.6 0 0.0 Therapy method < .001 CBT 18 51.4 45 93.8 Psychoanalysis 14 40.0 3 6.3 No information 3 8.6 Previous intercultural training .34 Yes 3 8.6 8 16.7 No 32 91.4 40 83.3 Proportion of immigrant clients in daily practice .70 < 10% 14 40.0 19 39.6 10 – 30% 13 37.1 19 39.6 30 – 60% 4 11.4 7 14.6 60 – 90% 2 5.7 2 4.2 > 90% 2 5.7 1 2.1 Immigrant background .35 Yes 14 40.0 14 29.2 No 21 60.0 34 70.8 Note. CBT = Cognitive Behavioural Therapy. *p ≤ .05. **p ≤ .01. The whole training programme and evaluation was completed by N = 24 participants, 33% of whom were between 31 and 40 years old and 82% female; 58% were trained (or still in training) in CBT; and 13% had previously participated in intercultural training programmes lasting on average six hours. Regarding prior experience of immigrant cli‐ ents, a quarter of participants reported that immigrants made up about 30% of their clien‐ tele, whereas the remaining participants treated significantly fewer. Furthermore, 38% of von Lersner, Baschin, & Hauptmann 11 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ participants had a migration background themselves, meaning that either they them‐ selves or one of their parents had immigrated to Germany (Federal Statistics Office, 2016). Prerequisites and Verification of Selection Bias The verification of differences between the intervention and control groups before train‐ ing revealed no significant differences in terms of intercultural competence before train‐ ing (MCI-Pre), t(68.53) = -1.35, p = .183, proportion of immigrant clients, H = 2.739, p = .434, χ2(4) =3.01, p = .556, or openness (W = 726.5, p = .361). However, there were significant differences between the intervention group and control group regarding inter‐ est (W = 1509.5, p < .001) and prior intercultural knowledge (W = 261, p < .001). Within groups, i.e. between trainees and therapists, no significant differences in mean values were detected. Intercultural Competence Table 3 shows the development of intercultural competence over time by presenting the results of the four subscales as well as the total score for the MCI. Table 3 Intercultural Competence on the MCI Over the Course of the Training Sub-scale of the MCI Pre Post Follow-up Pre- Post Pre- Post- T1 T3 T4 Follow-up Follow-up M SD M SD M SD d d d Skills 3.80 0.51 3.75 0.51 3.93 0.40 -.10 .28** .39* Awareness 3.09 0.86 3.32 0.67 3.33 0.74 .35* .30* .01 Therapeutic Relationship 3.39 0.46 3.38 0.47 3.54 0.31 -.02 .38 .40** Knowledge 3.22 0.58 3.51 0.50 3.64 0.48 .54* .79** .27 Total Score 3.41 0.46 3.52 0.30 3.62 0.33 .28* .53** .32* *p ≤ .05. **p ≤ .01. The data indicate a significant effect of time as a variable across both groups (experi‐ enced therapists and therapists in training, χ2(2, N = 24) = 17.70, p < .01, ω = .86). The Wilcoxon signed-rank test revealed significant changes between all three measurement times (Pre to Post: z = -3.29, p < .01, φ =.67, 1 - β = .43; Post- to Follow-up: z = -2.29, p < .001, φ =.47, 1 - β =.44; Pre to Follow-up: z = -4.00, p < .01, φ =.82, 1 - β =.79). Significant changes on the dimensions of awareness and knowledge occurred immediately after training, whereas values for skills and therapeutic relationship increased significantly at follow-up. The status of trainees had no influence on training outcomes, meaning that Evaluation of a Program for Intercultural Competence 12 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ experienced therapists and therapists in training benefitted from the training programme to the same degree, F(2, 44) = 2.23, p = .12, η2 = .09. The therapeutic relationship, as seen from the perspective of the therapist, was inves‐ tigated in further detail using STAR-C. Thus, participants were asked at T1, T3 and T4 to rate their therapeutic relationships with their non-immigrant and immigrant clients, sep‐ arately. Statistical analysis revealed significant improvement in the therapeutic relationship with non-immigrant clients from T1 to T3, t(28) = -1.73, p = .047, and a clear trend toward significant change from T1 to T4, t(24) = -1.47, p = .076, and T3 to T4, t(22) = -0.43, p = .334. Yet, in contrast, no significant changes were observed with immigrant clients, T1 to T3: t(28) = -0.58, p = .284, T1 to T4: t(24)= -1.40, p = .086, and T3 to T4 t(22) = -0.82, p = .210 (see Table 4). Table 4 Therapeutic Relationship Over the Course of the Training Measured With STAR-C Therapeutic Relationship Pre Post Follow-up Pre- Post Pre- Post- T1 T3 T4 Follow up Follow up M SD M SD M SD d d d Non-immigrant clients 3.40 .39 3.47 .26 3.52 .25 .21 .37 .20 Immigrant clients 3.35 .30 3.37 .25 3.46 .30 .07 .37 .33 D i s c u s s i o n In this pilot study we evaluated an intercultural training programme for psychothera‐ pists, focusing particularly on changes over time in the intercultural competence of par‐ ticipants as well as the therapeutic relationship from the perspective of the therapist. In order to control for a possible selection bias among participants a control group was in‐ cluded at T1 and we measured variables such as interest in intercultural issues prior to training and prior knowledge and experience of immigrant clients, as well as work expe‐ rience. International evaluation studies point to a general effectiveness of intercultural com‐ petency training (Benish et al., 2011; Betancourt & Green, 2010; Kalinoski et al., 2013; Kulik & Roberson, 2008), and our first evaluation of one such training programme in Ger‐ many follows these studies in its overall assessment. Even though intercultural compe‐ tence training programmes for therapists existed prior to our study, no systematic evalu‐ ation had been carried out with this target group. Applying our approach, intercultural competence as measured with the MCI in‐ creased significantly. This was the case for the total score as well as the separate scores for each of the four dimensions of the inventory. von Lersner, Baschin, & Hauptmann 13 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ Our training programme also had an immediate effect on the dimensions of aware‐ ness and knowledge, as described by Beach et al. (2005). In the domain of awareness, this implies, for example, reflecting on one’s own prejudices and examining stereotypes so as to develop better awareness of and openness to cultural diversity, and learning about the interplay between one’s own attitudes towards immigrant clients and the therapeutic process. Meanwhile, increases in the domain of knowledge imply being better informed about the diversity of cultural groups, differences in cultural concepts of distress and styles of communication, and the use of cultural brokers in therapy. It may also include greater understanding of the socio-political contexts in which intercultural therapy takes place. These are areas of improved intercultural competence that can be absorbed rather quickly and immediately. In contrast, effects on the dimensions of skills and the therapeutic relationship, again as measured by the MCI, only became evident at the three-month follow-up. As already presumed by Kulik and Roberson (2008), it seems that such changes only become preva‐ lent with direct interaction with clients; thus, these aspects can only be reliably evaluated after participants have returned to work rather than immediately after participation in the programme. Campinha-Bacote (2002) and Guzder and Rousseau (2013) describe the development of intercultural competence as an ongoing process in which trainees are constantly chal‐ lenged to be aware of and question their own cultural imprints, thereby becoming able to take their clients’ different cultural backgrounds into account in therapy. But critical analysis of one’s own values and norms, and the acquiring of new skills, are comprehen‐ sive and long-term developmental processes that do not happen overnight. Interestingly, though, the results of the present study indicate that this process can be successfully ini‐ tiated through training programmes like the one presented here. Our comparison of the study group and the control group revealed that groups did not differ in terms of intercultural competence before training, proportion of immigrant clients or openness but did differ in terms of interest and prior intercultural knowledge. We cautiously take this to assume that selection bias can thus be excluded, and that by and large training outcomes can be attributed solely to the training programme. At the same time, we have to consider that the sample of this pilot study was too small to carry out reliable regression analyses and to safely rule out a selection bias. This shortcoming could be addressed in future research by larger samples and the inclusion of a control group across all times of measurement. One reason for the positive outcome of the programme could be the teaching meth‐ ods used. According to Kalinoski et al. (2013), emotion-focused techniques such as critical incident technique, self-reflective units or active sessions can be more effective in inter‐ cultural training than simply imparting theoretical knowledge. The training programme that we developed, implemented and evaluated here includes a high proportion of emo‐ tion-activating methods throughout. In each module, a brief introduction is followed by Evaluation of a Program for Intercultural Competence 14 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ exercises in which participants can try out a new approach, discuss case vignettes or re‐ flect upon their own perspective. Kalinoski et al. (2013) also demonstrated that training sessions distributed over two or more points in time tend to be more effective compared with longer, one-off interventions. As our training programme consisted of core or pri‐ mary training sessions spread over two days and an additional refresher session three weeks later, this could also account for the positive outcomes observed. Besides effective training methods and structure, an additional success factor could be the greater specific‐ ity of the target group we selected compared with those participating in previous train‐ ing programmes, given that the programme was specifically both developed for and eval‐ uated by psychotherapists. As we have mentioned, there was no significant difference in programme outcomes between experienced therapists and therapists in training, suggesting that the pro‐ gramme is appropriate for all therapists regardless of level of experience. This is impor‐ tant for the practical applicability of the programme, as one can either use one pro‐ gramme for all therapists or develop separate curricula for participants of different expe‐ rience levels. The data suggest that the level of therapeutic experience is not important and thus that the training programme could be applied in postgraduate training as well as in trainings at a later point in therapists’ careers. This finding is in line with the Guidelines for Intercultural Training (Kirmayer et al., 2012, von Lersner et al., 2016), which are based on the same assumption and define quality criteria for intercultural training across all groups of therapists. Therapeutic Relationship To assess the impact of the programme on the therapeutic process, we examined the per‐ ceived therapeutic relationship from the perspective of the participants over the course of the training. However, our study generated unexpected findings. Overall, from the per‐ spective of the therapist, it seems that the therapeutic relationship benefits significantly from additional training. This was evident from the STAR-C post measurement as well as the relevant sub-domain of the MCI at follow-up. Yet, when participants were asked to rate the therapeutic relationship for non-immigrant and immigrant clients separately, significant improvement was observable for non-immigrant clients only. At first sight this would appear to be an unexpected outcome, given that the training programme fo‐ cused on intercultural issues with the intention that immigrants should particularly ben‐ efit from it. Two possible reasons for this counter-intuitive effect are considered here. First, if we recall the definition of culture on which our training programme is based, this effect should not be so surprising. According to Geertz (1973), culture consists of a set of values and norms shared by a group of people independently of their regional origin, a perspec‐ tive that is also linked to the concept of diversity introduced earlier in this paper. Thus, during the training sessions regional origin and migration status were only two of nu‐ von Lersner, Baschin, & Hauptmann 15 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ merous dimensions associated with culture and diversity. The results found here would seem to confirm this perspective: the quality of the therapeutic relationship improved for the majority of clients irrespective of their immigrant status, suggesting that factors such as openness, greater sensitivity towards clients’ socio-cultural background and better awareness of one’s own cultural norms and expectations can be beneficial to all clients. Secondly, our sample size was rather small at T1 and had decreased further by the time of the follow-up, with the remaining therapists treating a rather small number of immigrants—at or below 30% of their clients—in their daily practice. Thus, it may be due to the small size of this reference group that improvements in the therapeutic relation‐ ship between these immigrant clients and their therapists were simply not readily appa‐ rent. At the same time, our statistical results clearly point to a positive trend regarding the effect of the training on the therapeutic relationship. This appears to have been con‐ firmed when we used the MCI—on which only the therapeutic relationship with immi‐ grant clients was rated—which reported significant improvement. Nonetheless, we feel that, as a consequence of this pilot study, the evaluation should be repeated with a larger sample and more reliable measures in the future. Internal consistencies of STAR-C scales were unsatisfactory and might have had a negative effect on the outcome values. Consid‐ eration should also be given to modifying the training programme’s units on migration- related issues, so as to increase the likelihood that the therapeutic relationship with im‐ migrant clients benefits in the same way as that with non-immigrant clients did. Further‐ more, in order to achieve robust positive training outcomes, Guzder and Rousseau (2013) recommended ongoing supervision following training. This could support participants in terms of strengthening their newly acquired skills and dealing with any uncertainties arising in the process, both of which may have a long-term, positive impact on the thera‐ peutic relationship. Limitations and Implications In addition to its positive outcomes, the study also has a number of limitations. Because of the small sample size, some statistical trends may have been imperceptible that may have been significant with a larger dataset. Also, effect sizes were relatively small. An‐ other result of the small sample size is that our findings cannot be confidently general‐ ised to all therapists. Thus, further studies with larger sample sizes are urgently needed to underpin the effects found in this study. In the meantime, in view of the lack of studies in this field internationally, as well as in Germany, our pilot data provide important infor‐ mation and empirical insights. The statistical values of the STAR-C were also unsatisfactory, potentially reducing the explanatory power of our findings on the therapeutic relationship. This limitation should be addressed in future research. Nevertheless, significant effects of the programme were established in spite of the poor statistical values of the STAR-C and the small sample size. Evaluation of a Program for Intercultural Competence 16 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychopen.eu/ Hence, necessary further studies with larger samples are currently being carried out by our team. In line with Kulik and Roberson (2008), we believe that in future research it would be interesting to evaluate the impact of single training units or specific interventions. In ad‐ dition, shorter versions of the programme could be evaluated to increase the applicability of the approach in time-strapped clinical settings. Turning to methodological issues, we feel that in the intercultural therapy context it is difficult using questionnaires to meas‐ ure awareness or attitudes as they may manifest instead at the behavioural level. Hence, it might be useful to examine video recordings of therapy sessions—with real or simula‐ ted clients, before and after training intervention—to examine the behavioural level more directly. Other indicators of behavioural change resulting from the training might be cli‐ ent satisfaction with treatment, duration of treatment, percentage of immigrant clients and immigrant-client drop-out rates. It would also appear to be necessary to evaluate cli‐ ent perspectives on the therapeutic relationship, especially those of immigrants. C o n c l u s i o n s We conclude from this first evaluation of our intercultural training programme that it of‐ fers an effective intervention in terms of enabling psychotherapists to be more culturally sensitive towards clients from migration backgrounds. Such effects were demonstrable to our satisfaction, even with our small sample. We suggest that this training programme— which is actually a rather brief intervention—could lead to significant improvements in therapeutic practice in crucial ways. Funding: The authors received no financial support for the research, authorship, and/or publication of this article. Competing Interests: The authors declare no conflicts of interest. Acknowledgments: The authors have no support to report. R e f e r e n c e s Aggarwal, N. K., Cedeño, K., Guarnaccia, P., Kleinman, A., & Lewis-Fernández, R. (2016). The meanings of cultural competence in mental health: An exploratory focus group study with patients, clinicians, and administrators. SpringerPlus, 5(1), Article 384. https://doi.org/10.1186/s40064-016-2037-4 American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58(5), 377-402. https://doi.org/10.1037/0003-066X.58.5.377 von Lersner, Baschin, & Hauptmann 17 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://doi.org/10.1186/s40064-016-2037-4 https://doi.org/10.1037/0003-066X.58.5.377 https://www.psychopen.eu/ American Psychological Association. (2008). Report of the task force on the implementation of the multicultural guidelines. Washington, DC, USA: Author. Retrieved from http://www.apa.org/pi/ Auernheimer, G. (2002). Interkulturelle Kompetenz und Professionalität (Interkulturelle Studien, 13). Opladen, Germany: Leske und Budrich. Beach, M. C., Price, E. G., Gary, T. L., Robinson, K. A., Gozu, A., Palacio, A., . . . Powe, N. R. (2005). Cultural competency: A systematic review of health care provider educational interventions. Medical Care, 43(4), 356-373. https://doi.org/10.1097/01.mlr.0000156861.58905.96 Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct comparison meta-analysis. Journal of Counselling Psychology, 58(3), 279-289. https://doi.org/10.1037/a0023626 Bennegadi, R. (2009). Cultural competence and training in mental health practice in Europe: Strategies to implement competence and empower practitioners. Paris, France: Minkowska Centre. Betancourt, J. R., & Green, A. R. (2010). Linking cultural competence training to improved health outcomes: Perspectives from the field. Academic Medicine, 85(4), 583-585. https://doi.org/10.1097/ACM.0b013e3181d2b2f3 Brislin, R. W. (1970). Back-translation for cross-cultural research. Journal of Cross-Cultural Psychology, 1(3), 185-216. https://doi.org/10.1177/135910457000100301 Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13, 181-184. https://doi.org/10.1177/10459602013003003 Chen, J., & Rizzo, J. (2010). Racial and ethnic disparities in use of psychotherapy: Evidence from U.S. National Survey data. Psychiatric Services, 61(4), 364-372. https://doi.org/10.1176/ps.2010.61.4.364 Chipps, J. A., Simpson, B., & Brysiewicz, P. (2008). The effectiveness of cultural‐competence training for health professionals in community‐based rehabilitation: A systematic review of literature. Worldviews on Evidence-Based Nursing, 5, 85-94. https://doi.org/10.1111/j.1741-6787.2008.00117.x Claassen, D., Ascoli, M., Berhe, T., & Priebe, S. (2005). Research on mental disorders and their care in immigrant populations: A review of publications from Germany, Italy and the UK. European Psychiatry, 20(8), 540-549. https://doi.org/10.1016/j.eurpsy.2005.02.010 de Haan, A. M., Boon, A. E., de Jong, J. T. V. M., & Vermeiren, R. R. J. M. (2018). A review of mental health treatment dropout by ethnic minority youth. Transcultural Psychiatry, 55(1), 3-30. https://doi.org/10.1177/1363461517731702 Delgado, D. A., Ness, S., Ferguson, K., Engstrom, P. L., Gannon, T. M., & Gillett, C. (2013). Cultural competence training for clinical staff: Measuring the effect of a one-hour class on cultural competence. Journal of Transcultural Nursing, 24, 204-213. https://doi.org/10.1177/1043659612472059 Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G* Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175-191. https://doi.org/10.3758/BF03193146 Evaluation of a Program for Intercultural Competence 18 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 http://www.apa.org/pi/ https://doi.org/10.1097/01.mlr.0000156861.58905.96 https://doi.org/10.1037/a0023626 https://doi.org/10.1097/ACM.0b013e3181d2b2f3 https://doi.org/10.1177/135910457000100301 https://doi.org/10.1177/10459602013003003 https://doi.org/10.1176/ps.2010.61.4.364 https://doi.org/10.1111/j.1741-6787.2008.00117.x https://doi.org/10.1016/j.eurpsy.2005.02.010 https://doi.org/10.1177/1363461517731702 https://doi.org/10.1177/1043659612472059 https://doi.org/10.3758/BF03193146 https://www.psychopen.eu/ Federal Statistics Office. (2016). Zahlen und Fakten: Migration und Integration. Retrieved from https://www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/Bevoelkerung / MigrationIntegration/MigrationIntegration.html Gairing, S. K., Jäger, M., Ketteler, D., Rössler, W., & Theodoridou, A. (2011). “Scale to assess therapeutic relationships, STAR”: Evaluation der deutschen Skalenversion zur Beurteilung der therapeutischen Beziehung. Psychiatrische Praxis, 38(4), 178-184. https://doi.org/10.1055/s-0030-1265979 Geertz, C. (1973). Dichte Beschreibung. Beiträge zum Verstehen kultureller Systeme. Frankfurt am Main, Germany: Suhrkamp. Guzder, J., & Rousseau, C. (2013). A diversity of voices: The McGill ‘Working with Culture’ seminars. Culture, Medicine, and Psychiatry, 37(2), 347-364. https://doi.org/10.1007/s11013-013-9316-0 Hager, W., Patry, J., & Brezing, H. (Eds.). (2000). Evaluation psychologischer Interventionsmassnahmen: Standards und Kriterien: Ein Handbuch. Göttingen, Germany: Hogrefe. Kalinoski, Z. T., Steele‐Johnson, D., Peyton, E. J., Leas, K. A., Steinke, J., & Bowling, N. A. (2013). A meta‐analytic evaluation of diversity training outcomes. Journal of Organizational Behavior, 34(8), 1076-1104. https://doi.org/10.1002/job.1839 Khanna, S. K., Cheyney, M., & Engle, M. (2009). Cultural competency in health care: Evaluating the outcomes of a cultural competency training among health care professionals. Journal of the National Medical Association, 101(9), 886-892. https://doi.org/10.1016/S0027-9684(15)31035-X Kirmayer, L. J. (2012). Rethinking cultural competence. Transcultural Psychiatry, 49(2), 149-164. https://doi.org/10.1177/1363461512444673 Kirmayer, L. J., Fung, K., Rousseau, C., Tat Lo, H., Menzies, P., Guzder, J., ... McKenzie, K. (2012). Guidelines for training in cultural psychiatry. Ottawa, Canada: Canadian Psychiatric Association. Kirmayer, L. J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A. G., Guzder, J., . . . Pottier, K. (2011). Common mental health problems in immigrants and refugees: General approach in primary care. Canadian Medical Association Journal, 183(12), E959-E967. https://doi.org/10.1503/cmaj.090292 Koch, E., Hartkamp, N., Siefen, R. G., & Schouler-Ocak, M. (2008). Patienten mit Migrationshintergrund in stationär-psychiatrischen Einrichtungen. Nervenarzt, 79, 328-339. https://doi.org/10.1007/s00115-007-2393-y Kulik, C. T., & Roberson, L. (2008). Common goals and golden opportunities: Evaluations of diversity education in academic and organizational settings. Academy of Management Learning & Education, 7(3), 309-331. https://doi.org/10.5465/amle.2008.34251670 Lie, D. A., Lee-Rey, E., Gomez, A., Bereknyei, S., & Braddock, C. H. (2011). Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research. Journal of General Internal Medicine, 26(3), 317-325. https://doi.org/10.1007/s11606-010-1529-0 von Lersner, Baschin, & Hauptmann 19 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/Bevoelkerung/MigrationIntegration/MigrationIntegration.html https://www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/Bevoelkerung/MigrationIntegration/MigrationIntegration.html https://doi.org/10.1055/s-0030-1265979 https://doi.org/10.1007/s11013-013-9316-0 https://doi.org/10.1002/job.1839 https://doi.org/10.1016/S0027-9684(15)31035-X https://doi.org/10.1177/1363461512444673 https://doi.org/10.1503/cmaj.090292 https://doi.org/10.1007/s00115-007-2393-y https://doi.org/10.5465/amle.2008.34251670 https://doi.org/10.1007/s11606-010-1529-0 https://www.psychopen.eu/ Lindert, J., Priebe, S., Penka, S., Napo, F., Schouler-Ocak, M., & Heinz, A. (2008). Versorgung psychisch kranker Patienten mit Migrationshintergrund. Psychotherapie Psychosomatik Medizinische Psychologie, 58(03/04), 123-129. https://doi.org/10.1055/s-2008/1067360 Machleidt, W., Behrens, K., Ziegenbein, M., & Calliess, I. T. (2007). Integration von Migranten in die psychiatrisch-psychotherapeutische Versorgung in Deutschland. Psychiatrische Praxis, 34(7), 325-331. https://doi.org/10.1055/s-2007-986192 McGuire-Snieckus, R., McCabe, R., Catty, J., Hansson, L., & Priebe, S. (2007). A new scale to assess the therapeutic relationship in community mental health care: STAR. Psychological Medicine, 37(1), 85-95. https://doi.org/10.1017/S0033291706009299 Mösko, M. O., Baschin, K., Längst, G., & von Lersner, U. (2012). Interkulturelle Trainings für die psychosoziale Versorgung. Psychotherapeut, 57(1), 15-21. https://doi.org/10.1007/s00278-011-0878-4 Norcross, J. C. (2010). The therapeutic relationship. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (pp. 113−141). https://doi.org/10.1037/12075-004 Price, E. G., Beach, M. C., Gary, T. L., Robinson, K. A., Gozu, A., Palacio, A., . . . Cooper, L. A. (2005). A systematic review of the methodological rigor of studies evaluating cultural competence training of health professionals. Academic Medicine, 80, 578-586. https://doi.org/10.1097/00001888-200506000-00013 Rammstedt, B. (2007). The 10-Item Big Five Inventory (BFI-10): Norm values and investigation of sociodemographic effects based on a German population representative sample. European Journal of Psychological Assessment, 23, 193-201. https://doi.org/10.1027/1015-5759.23.3.193 Rammstedt, B., & John, O. P. (2005). Kurzversion des Big Five Inventory (BFI-K). Diagnostica, 51(4), 195-206. https://doi.org/10.1026/0012-1924.51.4.195 Sodowsky, G. R., Taffe, R. C., Gutkin, T. B., & Wise, S. L. (1994). Development of the Multicultural Counseling Inventory: A self-report measure of multicultural competencies. Journal of Counseling Psychology, 41(2), 137-148. https://doi.org/10.1037/0022-0167.41.2.137 Steinhäuser, T., Martin, L., von Lersner, U., & Auckenthaler, A. (2014). Konzeptionen von “transkultureller Kompetenz” und ihre Relevanz für die psychiatrisch-psychotherapeutische Versorgung. Ergebnisse eines disziplinübergreifenden Literaturreviews. Psychotherapie Psychosomatik Medizinische Psychologie, 64(09/10), 345-353. https://doi.org/10.1037/0022-0167.41.2.137 Sue, D. W., & Sue, D. (1990). Counseling the culturally different: Theory & practice (2nd ed.). New York, NY, USA: John Wiley. Sue, D. W., & Sue, D. (2012). Counseling the culturally diverse: Theory and practice (6th ed.). Hoboken, NJ, USA: John Wiley & Sons. Ta, T. M. T., Neuhaus, A. H., Burian, R., Schomerus, G., von Poser, A., Diefenbacher, A., . . . Hahn, E. (2015). Inanspruchnahme ambulanter psychiatrischer Versorgung bei vietnamesischen Migranten der ersten Generation in Deutschland. Psychiatrische Praxis, 42(05), 267-273. https://doi.org/10.1055/s-0034-1370008 Evaluation of a Program for Intercultural Competence 20 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://doi.org/10.1055/s-2008/1067360 https://doi.org/10.1055/s-2007-986192 https://doi.org/10.1017/S0033291706009299 https://doi.org/10.1007/s00278-011-0878-4 https://doi.org/10.1037/12075-004 https://doi.org/10.1097/00001888-200506000-00013 https://doi.org/10.1027/1015-5759.23.3.193 https://doi.org/10.1026/0012-1924.51.4.195 https://doi.org/10.1037/0022-0167.41.2.137 https://doi.org/10.1037/0022-0167.41.2.137 https://doi.org/10.1055/s-0034-1370008 https://www.psychopen.eu/ van Keuk, E., Ghaderi, C., Joksimovic, L., & David, M. (Eds.). (2011). Transkulturelle Kompetenz in klinischen und sozialen Arbeitsfeldern. Stuttgart, Germany: Kohlhammer. von Lersner, U. (2015, January). Kultursensibel aber wie? Leitlinien für Trainings transkultureller Kompetenzen von Psychotherapeuten und Implikationen für die Praxis. Paper presented at the Berliner Psychiatrietage, Berlin, Germany. von Lersner, U., Baschin, K., Wormeck, I., & Mösko, M. (2016). Kultursensibel, aber wie? Leitlinien für Trainings inter-/ transkulturelle Kompetenzen in der Aus-, Fort- und Weiterbildung von Psychotherapeut_innen. Abschlusspublikation des Projektes. Retrieved from https://www.psychologie.hu-berlin.de/prof/the/Leitlinien/view Wohlfart, E., Hodzic, S., & Özbek, T. (2006). Transkulturelles Denken und transkulturelle Praxis in der Psychiatrie und Psychotherapie. In E. Wohlfart & M. Zaumseil (Eds.), Transkulturelle Psychiatrie & Interkulturelle Psychotherapie. Interdisziplinäre Theorie und Praxis (pp. 142−168). Heidelberg, Germany: Springer. Yeo, S. (2004). Language barriers and access to care. Annual Review Nursery Research, 22(1), 59-73. https://doi.org/10.1891/0739-6686.22.1.59 Clinical Psychology in Europe (CPE) is the official journal of the European Association of Clinical Psychology and Psychological Treatment (EACLIPT). PsychOpen GOLD is a publishing service by Leibniz Institute for Psychology Information (ZPID), Germany. von Lersner, Baschin, & Hauptmann 21 Clinical Psychology in Europe 2019, Vol.1(3), Article e29159 https://doi.org/10.32872/cpe.v1i3.29159 https://www.psychologie.hu-berlin.de/prof/the/Leitlinien/view https://doi.org/10.1891/0739-6686.22.1.59 https://www.psychopen.eu/ Evaluation of a Program for Intercultural Competence (Introduction) Intercultural Competence Training Method Study Design Implementation of the Training Programme Programme Content Measures Statistical Analysis Results Sample Characteristics Prerequisites and Verification of Selection Bias Intercultural Competence Discussion Therapeutic Relationship Limitations and Implications Conclusions (Additional Information) Funding Competing Interests Acknowledgments References