go in the field of mental health to move beyond just highly encouraging people to consider the role of culture in assessment and interventions to requiring the integration of culture as a standard in practice.
BUILDING CULTURAL COMPETENCE
Building cultural competence in clinical practice often begins with effective training. Many programs in psychology and related fields historically have not provided adequate training on how to effectively integrate cultural knowledge into assessment and therapy. Adames et al. (2013) posit that
While psychology as a discipline maintains that diversity and multiculturalism training is important, some departments do not adequately address it as a central topic, emphasize its importance by making it a requisite, or provide a sound framework for effectively addressing diversity and multiculturalism (p. 3).
To what degree is culture and diversity respected, valued, welcomed, and its potential, approached in positive and creative ways? To what extent is it approached in ways that divide, isolate, set people against each other? For instance, several studies support how conversations about culture, ethnicity, and race provoke and exacerbate uncomfortable feelings including defensiveness, anxiety, anger, helplessness, blame, and invalidation (Bell, 2003; Helms & Cook, 1999; Sue et al., 2011; Utsey et al., 2005). Other scholars posit that when culture is addressed it is at the cost of Students of Color. Franklin (2009), for example, wrote:
Ethnic minority students often felt trapped between, if not victimized by, the roles of cultural educator and student. However, students as cultural brokers in class are often educators without a portfolio in the eyes of professors and fellow classmates. Challenging psychological information being presented that did not accurately represent our experiences could bring … a label as an impudent student. Parenthetically, it was not uncommon to have our personal insights as members of the community also challenged or dismissed by professors or researchers who had no experience with our communities other than their readings in psychology. This was infuriating to many colleagues and students, given their lived experiences … These in class and work experiences were frustrating, intimidating, humiliating, and discouraging to students and subsequently early career professionals in particular. This circumstance continues to contribute to the attrition of Students of Color in training programs and later becomes a deterrent to participation in organized psychology (p. 419; see also Kaduvettoor et al., 2009).
When we neglect how our own worldviews and cultural values influence the ways in which we navigate the world and interact with others—or when we fail to understand and appreciate the role of culture in our clients’ lives and in the work that we do as therapists—we end up straying from the appropriate and helpful to the useless or even oppressive. We cannot operate from a one-size-fits-all approach to training and psychotherapy by applying frameworks and interventions grounded solely in the experiences of the dominant group (Burkard & Knox, 2004; Gómez, 2015; Sue, 2015). The road toward cultural competence, or the ability to develop interventions that are culturally responsive begins by looking inward toward the self and outward toward others.
Looking Inward
We encounter people who practice different cultures and who differ from us in many ways as we go about our lives. We learn about cultural diversity in our studies, we work on developing ethical awareness in approaching it in our clinical work, but often we forget that we also carry our own private—and sometimes not so private—views and feelings about specific cultures, races, religions, and so on. Most readers would have no trouble naming areas in the world in which people are fighting each other in part because of religion, culture, ethnicity, and similar factors. Most could name groups in their own countries that view members of another group with suspicion, unease, resentment, disdain, or hate.
It is impossible for us as therapists to be completely free of the prejudices that afflict the rest of humanity; after all, we are socialized in societies that have long histories of racism, colorism, nativism, ethnocentrism, and many other forms of othering (Chavez-Dueñas et al., 2019). Life is remarkable in so many ways, but not that one. For any of us, various cultural, racial, ethnic, political, religious, and other groups—or topics related to these groups—may evoke an intense emotional response. The response may be subtle or powerful. We may be ashamed of it or embrace it as important. We may be reluctant to mention it to certain people. We may view it as not politically correct or—a more forbidding barrier for many of us—as not emotionally correct (Pope, Sonne et al., 2006).
These psychological reactions may block or diminish our cultural competence to work with specific groups or certain topics. Thus, it is vital to assess not only our intellectual competence but also what Pope and Brown (1996) termed emotional competence for therapy. We invite each of us to take a moment now to ask ourselves the following set of questions:
Do you have positive or negative feelings toward most or virtually all members of any particular social groups based on their cultural traditions, values, and practices? Does a person’s skin color ever affect the way you view them or interact with them? How about a person’s religion (e.g., Muslim, Southern Baptist, Catholic, Mexicayotl, Hasidic Judaism)? Social class (e.g., those people known as the super-rich; those people who are poor and homeless)?
If so, how if at all do you think it affects your clinical work?
Would you feel comfortable hiring, supervising, or accepting as a client, or working with a member of that group?
Would you feel comfortable sharing these feelings with your graduate school faculty, internship supervisors, employer, or colleagues?
Have you shared these feelings with your graduate school faculty, internship supervisors, employer, or colleagues?
Would you be okay sharing your thoughts publicly? Posting them on public social media accounts?
How well do you believe your graduate program, internship, and continuing education courses have dealt with these issues? What improvements could you suggest?
How well do you believe the profession has dealt with these issues? What improvements could you suggest?
Do you believe the profession is paying too much, too little, or just about the right amount of attention to these topics?
How do your own cultural values inform and shape the way you interact with clients?
How do they impact your assessment and diagnosis of clients of cultures different from your own?
How do your cultural values impact or inform your interventions?
Do you ever consider how the client’s understanding, description, and expression of symptoms may impact treatment? If so, how do you integrate this information into your work?
Becoming aware of the ways we may fail to recognize and respect a group that is different from our own challenges all of us. It is easy to recognize in theory, the influence of our own culture and context, but it often escapes our notice in practice. A remarkable book, The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures (Fadiman, 1997), illustrates the potential costs of overlooking the influence of culture and context on everyone involved. The book describes the efforts of a California hospital staff and a Laotian refugee family to help a Hmong child whose American doctors had diagnosed with epilepsy. Everyone involved had the best of intentions and worked hard to help the girl, but a lack of awareness of cultural differences had tragic effects. The book quotes medical anthropologist Arthur Kleinman:
As powerful an influence
