Culturally Competent Psychotherapy: How we can do better

by Amanda Arulpragasam, Emory University

This article was originally published in the PCSAS newsletter on July 21, 2020. Click here to subscribe

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The recent murders of George Floyd, Ahmaud Arbery, Breonna Taylor, and Rayshard Brooks highlight the continued racism and discrimination experienced by Black Americans. Racist events have been linked to increased mental health risks and poor clinical course (Loeb et al., 2018; Sibrava et al., 2019). Incidents of police brutality and race-based killings re-expose this population to racial-traumas and reinforce the fear that they are not safe in their own country. In fact, police killings of unarmed Black Americans have been linked to worse mental health in Black Americans residing in that state (Bor, Venkataramani, Williams, & Tsai, 2018). In light of this, mental health professionals must urgently prepare for and address the increased mental health needs of Black Americans in the aftermath of these events.

Despite increased need, Black Americans have decreased access to mental health services, higher dropout rates, and are more likely to receive poor-quality care when treated compared to White Americans (McGuire & Miranda, 2008). Some potentially relevant mechanisms contributing to racial mental health disparities include provider bias and stereotyping, limited mental health provider diversity (McGuire & Miranda, 2008), and lack of provider cultural competency.

Now, more than ever, providers must practice and prioritize cultural competence in the therapy room. Cultural competence is defined as an individual’s demonstrated ability to interact and communicate effectively, respectfully, and empathetically with people whose cultural identities and backgrounds may differ from their own. Without it, they risk alienating or even harming their clients. But what steps can we take to become culturally competent providers?

1. Conduct Cultural Assessments. Becoming culturally competent means learning about other cultures, but also becoming aware of our own cultural context, and how we, as cultural beings, impact those around us. One way to understand our own cultural context is through the use of a cultural genogram (Kenneth V. Hardy, 1995) or conceptualization. The primary goal of this tool is to promote cultural awareness and sensitivity by helping us understand our own cultural identities and how these unique identities may impact our therapeutic style and effectiveness. For more detailed information on preparing a cultural genogram please click here.
   In addition to understanding our own cultural contexts, we must also understand that of our clients. The Cultural Formulation Interview (CFI) has emerged as one such assessment tool to assist clinicians in making person-centered cultural assessments to inform diagnosis and treatment planning. Despite its development, it has yet to be systematically and consistently integrated into clinical training programs, manualized treatments, or assessments. Moving forward, I believe it will be valuable to incorporate such formulations into our own practice, and continue pushing for their systematic and widespread use.
2. Stop Hesitating. Identity is critical and it may be difficult for Black clients to discuss race-related issues with non-Black clinicians. Luckily, if we incorporate the use of a cultural formulation assessment with all our clients, we will have already spent time understanding the cultural features of our relationship with our clients, and how these features act as barriers or facilitators affecting assessment and treatment. I have found it exceptionally helpful to embrace these differences and discuss them openly; directly address the ways we differ from our clients and understand how these differences impact the therapeutic alliance; and initiate conversations about race and racial experiences in the therapy room. If we are unsure how to discuss these topics, we can be honest. We can share our uncertainty with our clients while emphasizing that it’s important and that we understand anti-Black violence and discrimination is likely impacting them. We can create space for them to talk about race and process their experiences, should they choose to. Importantly, we must remember that it is ultimately up to the client to bring these topics into the room. We cannot, nor is it helpful to, force race-based discussions if the client is uncomfortable. We can, however, work to create an open, validating space for our clients, thereby increasing the probability of difficult, vulnerable conversations.
3. Get Comfortable with Discomfort. While it is imperative that we have open discussions to better understand our clients’ identities and experiences, we do not want to burden our clients with the task of educating us. I’ve found this to sometimes be a tricky balance. On the one hand, we want to practice humility, that is, removing our assumptions and allowing the client to illuminate the individualized way in which their cultural background may or may not impact their personal identity and presenting symptoms. However, this does not give us a free pass to put the whole burden of educating on the patient. We need to read and educate ourselves to learn more about different backgrounds and identities, while being careful to not move away from an individualized approach and fall prey to group stereotyping. Sometimes it may seem these approaches can be at odds with each other. That is okay. No matter our intentions to understand and be supportive, we will undoubtedly make mistakes, and thus learn and grow. Given the inevitability of mistakes, how we respond will be key in developing rapport, repairing relationships, and increasing our therapeutic efficacy. Can we apologize, give ourselves permission to make mistakes, hold ourselves accountable, and commit to learning and improving?

These steps are only a few considerations and suggestions based on my experiences and opinions. Aspiring toward cultural competence is not a one-time effort. Instead, it is a lifelong commitment that creates many opportunities to become more empathetic, effective clinicians able to provide higher quality care to all our clients. Let’s get to work.

References

Bor, J., Venkataramani, A. S., Williams, D. R., & Tsai, A. C. (2018). Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study. Lancet, 392(10144), 302–310. doi:10.1016/S0140–6736(18)31130–9

Kenneth V. Hardy, T. A. L. (1995). The cultural genogram: key to training cultural competent family therapists. Journal of Marital and Family Therapy, 21(3), 227–237.

Loeb, T. B., Joseph, N. T., Wyatt, G. E., Zhang, M., Chin, D., Thames, A., & Aswad, Y. (2018). Predictors of somatic symptom severity: The role of cumulative history of trauma and adversity in a diverse community sample. Psychol Trauma, 10(5), 491–498. doi:10.1037/tra0000334

McGuire, T. G., & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Aff (Millwood), 27(2), 393–403. doi:10.1377/hlthaff.27.2.393

Sibrava, N. J., Bjornsson, A. S., Perez Benitez, A. C. I., Moitra, E., Weisberg, R. B., & Keller, M. B. (2019). Posttraumatic stress disorder in African American and Latinx adults: Clinical course and the role of racial and ethnic discrimination. Am Psychol, 74(1), 101–116. doi:10.1037/amp0000339