concept of culture is sometimes misleadingly used interchangeably with race. However, the consensus among scientists, including social scientists, is that both concepts are distinct, albeit closely related (see Alvarez et al., 2016; Chavez-Dueñas et al., 2019; Helms & Cook, 1999). Specifically, race describes how individuals are grouped according to their shared phenotype (e.g., skin-color, eye-color, hair texture) and the social, educational, health, and political implications of this method of grouping (e.g., choosing to divide people up according to the color of their skin; see Bonilla-Silva, 2014; Carter & Pieterse, 2005; Chavez-Dueñas et al., 2014; Gannon, 2016; Helms & Cook, 1999; Ifekwunigwe et al., 2017; Jones, 1997). Said differently, race is a social construct and not a biological one. However, this social construct has real life and social consequences such as its impact on health and access to opportunities. The role of race, racism, colorism, and other forms of oppression (e.g., anti-Semitism, sexism, heterosexism) in ethics will be discussed in Chapter 23. In this chapter we focus on culture and its implications for our work as therapists—we provide some steps to recognize and overcome barriers to ethical practice in the context of different cultures.
CULTURE HAS ALWAYS BEEN A PART OF HEALING
Psychotherapy as a healing practice has existed for centuries in different cultures. However, the current practice of psychotherapy is often rooted in a Western philosophy with origins in Europe and the United States. Wampold (2001) explains that
The idea of sitting in a room with the healer, confiding in the healer, responding to questions, and following the implicit or explicit ritualistic expectations of the psychotherapeutic protocol, whether it is expressing one’s feelings, monitoring one’s thoughts, forming a contingency contract, or looking at the rapidly moving hands of the therapist, would be an absurdity in 99% of the societies past or present. On the other hand, participating in some healing practice is universal. As a healing practice, psychotherapy shares commonalities with medicine, but also with laying-on-of-hands, theriac, and shaman rituals. Psychotherapy is not universal; it has existed, in widely different forms, in some (but not all) Western cultures for about 100 years (p. 79).
There is also evidence that the Indigenous people of the Americas were using talk as a form of treatment for mental illness centuries before colonization. Padilla (1984) describes how the Aztecs had a well-developed system of public health that included healing services for mental health-related concerns where conversation was used to heal and care for others. He also wrote that
In essence it was believed that the tonalpouhqui [healer] had the knowledge and more authority to assist the patient by means of lengthy conversations designed to liberate them [from their ailments]. The personal characteristics and language of the tonalpouhqui were the major determinants for a successful outcome…The tonalpouhqui possessed concepts of ego formation and catharsis, as well as techniques of dream interpretation and psychotherapy similar to those developed later by Freud and Jung (p. 7).
These two passages exemplify the ways in which distinct cultural groups around the world used dialogue and other methods to connect and build relationship to address the problems of living. However, the common ways in which psychotherapy is currently practiced are not culturally universal. Consider current counseling practices prevalent in the US, Canada, and many other Western countries: 45 to 55-minute sessions, once a week, often taking place in an office setting or using a Zoom connection, typically between two people. Few would argue that these practices are universal or free of cultural influence. To a great extent, they reflect Western standards and values. If so, how do we form healing relationships with clients of other cultures for whom such practices are a barrier? What do we need to learn about ourselves, the groups we belong to, and other cultures in order to communicate and work more effectively with those from other cultures? The following sections provide some ways to address these complex, arduous, but crucial questions.
CULTURAL COMPETENCE
Psychotherapists are like all people. We too are shaped and influenced by many factors including our cultural heritage and our multiple social group memberships (e.g., race, ethnicity, gender, sexual orientation, religion, ability status). Subsequently, we navigate the world with a set of attitudes and ideologies that shape how we see ourselves and others. Indeed, you and I are “cultural beings,” all of our interactions are cross-cultural, and all of our life experiences are perceived and shaped from within our own cultural stance—the mantra and bedrock of cross-cultural and multicultural practice. As psychotherapists, our culture provides a rich context for becoming more aware of how our mores, values, customs, and traditions influence our own professional practice, ethical views, and reasoning. Ronald Francis (2009) wrote:
One of the singular merits of ethical considerations in a cross-cultural context is the way in which it forces us to confront our own values, to develop them, and to defend them. Cross-cultural comparisons afford a marvelous opportunity to examine the bases of our ethical codes in a manner which does not invite the heat more commonly attending intercultural value debates. Ethics is essentially about human values. Since not all values are shared, we are compelled to consider the issues we have in common; and those on which we divide. For instance, what may seem self-evident in one culture may be ethically repugnant to another. Ethics affords an opportunity to discuss and resolve these human values in a non-threatening frame of reference (pp. 182–193).
Ethical assessment and intervention also depend on our ability to understand culture beyond the surface level and popular culture (see Chapter 20). When considering the role of culture in psychotherapy, scholars have discussed and illustrated ways to examine and understand culture at the deep structural level, address how it impacts the psychotherapeutic process, and plan how to best integrate it into our practice (see Adames & Chavez-Dueñas, 2017; Gallardo et al., 2012; Parham et al., 1999; Vasquez, 2007). Five domains of culture at the deep structural level introduced and described by Ani (1994) include: ontology (nature of reality); axiology (value system); cosmology (relationship to the divine); epistemology (system of knowing and believing what is the truth); and praxis (systems of human interaction). Conversely, examples of surface level culture include food, holidays, celebrations, clothing, visual and performing arts, sports, dancing, language, and the like. The model in Figure 7.1 illustrates culture at both the deep and surface levels, with questions to guide us to explore, unpack, and understand culture in nuanced ways.
Figure 7.1. The Deep and Surface Levels of Culture Model.
Note: The model aims to assist you in thinking about you own assumptions of how you conceptualize culture in your life and in your practice. The model includes two layers: (a) outer layer depicting culture at the surface; and (b) inner layer illustrating the five domains of deep culture. The domains of deep culture influence each other in non-linear but dynamic ways. Each domain includes question(s) for individuals and groups to consider when exploring their culture, which is continuously shaped by context and history. The model can also be used with clients to explicitly introduce and explore culture in therapy—therapists can compare their responses to that of their clients and assess areas where their deep cultures overlap and diverge, which can help inform the therapeutic process.
Source: Pope, Vasquez, Chavez-Dueñas, & Adames (2021).
Our professional responsibility to consider and integrate our clients’ culture in therapy begins with a realistic appraisal of our own multicultural training and competence. When we hear of the word “competence” we often envision an individual who is a content expert, or perhaps someone who has reached the pinnacle in their career—we may also think of a group of people who know what to do in
