It seems that workplaces, schools, companies, and organizations are increasingly paying more attention to diversity and culture.

While this growing interest is encouraging, there are times when there is a significant lack of follow-through regarding the attention these issues receive. This is a disservice to everyone involved, but it comes at a special price in the realm of therapy.

I know of several graduate programs that pride themselves on their emphasis on diversity, yet have only a few course offerings specifically related to the topic and do not consistently revisit cultural issues throughout other courses.

With regard to psychology and therapy, the lack of consistent attention to cultural issues has the potential to create and maintain impasses that can affect the client’s progress.

As aspiring mental health professionals, we have the best of intentions in our work with clients. It is very important, however, to assess for cultural importance and issues of diversity in our first meetings with clients and then to be mindful of the ways we communicate with those clients moving forward.

The ADDRESSING Model

I’m assuming many people reading this have heard of Dr. Pamela Hays’s ADDRESSING model, which is a great starting point. Dr. Hays created this model as a framework for assessing clients holistically. It includes aspects of life such as age, disabilities, sexual orientation, socioeconomic status, indigenous heritage, and gender. When it comes to issues of diversity and culture, some of the things not accounted for in this model relate to the effects of systemic and institutional oppressions.

Members of each of the areas of the ADDRESSING model inevitably present with their own unique experiences.

For example, many people of color are frequently subjected to racist interactions by both white people and other people of color. These instances may exacerbate low self-esteem, anxiety, rage, and volatile emotions.

Further, research indicates that racial discrimination is significantly correlated with cardiovascular issues, so it is important to assess for physical health issues as well. Women may encounter sexist situations which are the product of historical “norms,” yet sexism manifests differently for women of color, trans* [1] women, and folks who identify as gender nonconforming.

Practicing Cultural Competence With Your Clients

You may be wondering, “How can I possibly assess for those types of things?” That’s an important question, and one that needs a lot of unpacking – way more than can be included in this article!

While it is necessary to know about these issues and how they affect our clients, asking directly can sometimes feel invasive or insensitive.

So, where to start?

Here are three ways that can aid in the (ever-evolving) practice of cultural competence:

1. Do Your Own Research

I believe that it is important for therapists and clinicians to do their own research.

When we rely solely on the client to explain all of their experiences, we shift the burden of responsibility to them. This is not to say that we know more than the client, by any means. However, with more knowledge about specific cultures, conditions, traditions, and oppressions, it becomes easier to identify certain struggles and how they may be affecting clients.

When working with a client whose culture is different from my own, I acknowledge that there will probably be things I don’t understand about their culture. In session, if it is crucial that I understand some cultural reference that I have never heard before, I will usually admit that I don’t know, and ask if the client feels comfortable explaining it to me (only done when context clues do not suffice).

Later, I will ask a colleague who has experience in that area, or look online for resources to better understand my client’s experience. Granted, I know that time is a luxury, but it is a privilege to be able to help others as a therapist, and I believe that clients deserve competent therapists…which requires us to do some extra work on occasion.

2. Immerse Yourself in Different Cultures

Immerse yourself in cultures that are different from your own, without intruding on their traditions or sacred time. For example, this can be done by attending local festivals that celebrate various cultures, or engaging with your friends of different cultures and listening (rather than prodding) when they speak.

It is definitely possible to learn a lot about a culture without asking pointed questions…we are trained in listening, and this skill comes in handy! If it is not possible to attend events such as festivals or other public cultural celebrations, it may be worthwhile to watch documentaries and “virtually immerse” yourself.

Be sure to keep in mind that someone who is from a different culture than your own may not subscribe to the traditions of that culture. Additionally, some clients who seem to share a cultural identity with us may have vastly different experiences, and making assumptions about shared experiences has the potential to interfere with therapeutic rapport.

It is also important to move beyond movie representations and literature to understand cultural experiences. It is unreasonable to expect that textbooks, articles, or videos will tell us all (or a majority) of what we need to know. It is our responsibility to understand the nuances of cultural diversity, and also the impact of our language.

3. Be Mindful of Your Language

Language is a powerful tool that has the power to heal, hurt, and inadvertently offend or uplift. I have found it useful to steer clear from heteronormative language when asking about my clients’ upbringing, relationships with significant others, preferred gender pronouns, etc.

Here are some example questions that take culture and language into consideration:

• Regarding caretakers, you can ask “Who lived in your home growing up?” instead of asking about the client’s “parents” (who may or may not have been the primary caretakers), or assuming that they were raised by a married heterosexual couple (mom and dad).
• Regarding sexual orientation, ask questions like, “Who are you attracted to when it comes to romantic relationships?” instead of, “Are you primarily attracted to men, women, or both?”
• Regarding race/ethnicity: “How do you racially/ethnically identify?” Also, rather than just asking if your client has experienced racism or prejudice before, you can word it in the following manner:“Have you ever experienced any negative situations that you felt were due to your race? What was that like for you (support systems, coping skills, etc.)?”
• Concerning trauma: “Have you ever experienced anything that was especially upsetting for you, or that you have had a difficult time dealing with?” My phrasing of this question occasionally varies, but most times I try to steer clear of the word “trauma.” I have found that there is stigma associated with that word for some survivors, and they choose not to claim that word as a part of their experiences.

Similarly, some clients do not fully understand the meaning of the word trauma, so it is important to phrase your questions with relatable wording. For example, I once asked a client if he had ever experienced anything traumatic and he said no. Several sessions later, he spent time processing how he had witnessed a violent act against someone very important to him, and has had difficulty adjusting since that time. At that point I realized that “trauma” was a word with which he was not familiar, and it forced me to think about how I posed certain questions to my clients.

The Power of Cultural Competence

The list is endless for how to sensitively and thoroughly address these issues, and these are just a few examples. As I previously mentioned, language is a powerful tool.

Asking someone a pointed question posed in a binary (i.e. mom/dad, men/women, Black/Hispanic, etc.) can possibly be perceived as distancing language, despite our best intentions, because dichotomous language is not always representative of our clients’ lived experiences.

This type of work requires consistent intentionality, which isn’t always easy. It is definitely helpful to have a strong support system of colleagues who are committed to emphasizing cultural diversity, and to engage in these discussions on a regular basis. These discussions can sometimes be uncomfortable as they call for us to actively acknowledge our privilege and the ways we may unintentionally be contributing to systems of oppression.

There is good news, though! Through the difficult conversations and discomfort, there is growth. That growth helps us to create change toward more inclusive and culturally competent therapy with each of our clients, and helps us to stay more aware of what is going on around us in our daily lives.

Footnote

[1] “Trans” is meant to recognize and be inclusive of those who identify as transgender, transsexual, transvestite, and/or other corresponding trans- identities.

This article was originally published on July 11, 2016.

Interested in more work by Dr. Wilson? Check out her article, “Big Boys Don’t Cry: Navigating Masculinity in Therapy.”