Psychotherapy with Alien Beings: Cultural Competence (and Incompetence) in Psychotherapy Practice

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• A Klingon, a Cardassian and a Betazoid walk into Coffee Bar…
• What is Cultural Competence?
• Intersectionality and Integration
• ADDRESSING Multiple Identities
• Working from the Inside Out
• The Ubiquity of Trauma
• Evidenced-Based Failures and Common Factors Successes
• We Are All Other

A Klingon, a Cardassian and a Betazoid walk into Coffee Bar…

A Klingon, a Cardassian and a Betazoid walk into a coffee house in Fremont, Washington, otherwise known as the neighborhood in Seattle where I live and work. If you know something about Star Trek, you will know that in its universe, ethnic differences are represented by differences between the natives of various planets, rather than by within-planet variation. Their phenotypic differences are denoted by ear shape and the size and depth of forehead wrinkles, or the presence or absence of stippling on the skin. Skin tone, the terrestrial marker of phenotypic difference, is meaningless in the Trek world. There are light and dark-skinned Vulcans and Romulans and Bajorans, but what’s important about them phenotypically isn’t how much melanin is there. That’s an Earth-bound preoccupation, a way in which humans socially construct difference.

However, as on Earth, ethnicity in the Trek world comes with assumptions about behavior—stereotypes, as it were. Our Klingon will be aggressive both verbally and physically, possessed of less than perfect impulse control, yet fiercely loyal and courageous. The Cardassians are a tad pompous, overweening, with a tendency to believe themselves correct in all things, which is perhaps why they were so effective as colonizers for so long. And the Betazoid is empathic, in fact way beyond empathic, because Betazoids can read minds and feelings. The first psychotherapist character in the Trek universe was a half-Betazoid/half-human.

So the Trek-savvy among us think that we know what to expect and how to respond to our trio as they order their double tall split shot one pump mocha light foam extra hot lattes from the barista at Fremont Coffee. Their coffee order, by the way, gives you the clue that they all live in Seattle, as locals are famous for complicated coffee ordering. We psychotherapists with our degrees from the Star Fleet Academy have taken a class in diversity. Some of us have even read the Handbook of Psychotherapy with Klingons, given that working with Klingons has become a very popular specialty in the aftermath of recent wars and the uptick in PTSD in the Klingon community.

However, our expectations are entirely unmet with these three. The Klingon turns out to be quiet, polite, and shy, joking a little with the barista about the new purple streaks in her hair. The Cardassian goofs around with the other two, and is wearing jeans with holes in the knees and has a pierced eyebrow. The Betazoid seems utterly insensitive to everything going on around the coffee-drinking threesome, and seems quite self-focused when we listen in on the conversation. We sit, confused, wondering if we missed a chapter in the handbook about special concerns of species living in Seattle. Maybe the communities here are different? (All that coffee and rain). We think that perhaps we should take a continuing education class to update ourselves about the latest findings on these ethnic groups.

You may at this point be wondering why I’m telling you this tale of the extraterrestrials in my local coffee house and the confused psychotherapists who are observing them. The answer is that it illustrates something about what psychotherapists have generally believed cultural competence to consist of, and lays a foundation for my discussion of what I believe cultural competence to truly be—as well as how and why culturally competent practice epitomizes an integrative stance on psychotherapy practice.

What is Cultural Competence?

I define cultural competence as a set of therapist variables that include the capacity for the therapist to be self-aware in regards to her or his own identities and cultural norms, sensitive to the realities of human difference, and possessed of an epistemology of difference that allows for creative responses to the ways in which the strengths and resiliencies inherent in identities inform, transform, and are also distorted by distress and dysfunction. This is a tall order. It is a standard rarely met, even by the most well-intended professional. Why might that be?

The problem lies most fundamentally in the paradigms for culturally competent practice in which most psychotherapists are trained. These paradigms at best generate a false sense of capacity and at worst, and frequently, engender feelings of guilt, shame, and incompetence, none of which are salubrious affects to bring to the practice of psychotherapy.

In the majority of psychotherapy training programs in the U.S. of which I am aware, the development of cultural competence has, until quite recently, been framed as the acquisition of data and algorithms about various groups of people. I call this the "Handbook of Psychotherapy with Alien Beings" strategy. Psychotherapists taking coursework on this topic memorize the “fact” that Asian Americans tend not to be psychologically minded, and will do better with advice and CBT, or that respect is centrally important to Latino men. We learn that in many instances our best course of action is to refer out to the colleague who specializes in Asians, or Latinas, or Cardassians, particularly one who is her or himself a member of one of these groups.

Sometimes in this graduate school class, frequently called “multicultural awareness” or “diverse populations,” there’s a week on lesbian, gay, bisexual and transgendered (LGBT) people, another on aging. If the class is taught on the East Coast of the United States, the instructor may have spent some time on Jews and Italians, the not-quite-as-white Euro-American ethnic groups, while in California there might have been a lecture about Latinos, who occupy a similar niche in the social ecology of that state. A family therapy program may have assigned Monica McGoldrick and her colleagues’ work on the different kinds of ethnic families.

No matter who’s included, the message of such training is that cultural competence is about them—it’s about the Other, the client who is “diverse,” and about how to address the problem of dealing with that other in psychotherapy. These courses also commonly induce feelings of incompetence by conveying the message that psychotherapists probably don’t know how to work with the Other until they have acquired a set of rules about them. A strong subtext of this training is that the psychotherapist is not Other. Even when a psychotherapist is member of one of the groups being studied, such training communicates an interesting meta-message about the default assumption that, similar to police who define themselves as all blue, the therapist in training from the alien culture has now joined the new ethnic group of psychotherapists, who are de facto members of a dominant culture. As they say on Star Trek, “resistance is futile, you will be assimilated.”

This set of instructions is often intriguing to psychotherapists interested in psychotherapy integration. The “use this approach with this group” method encourages therapists to call on paradigms and interventions from several different approaches to psychotherapy, which they may or may not have in their toolbox. Thus when the integrative psychoanalyst meets the Asian client, she or he should have some CBT expertise to bring to bear.

This approach to teaching cultural competence conveys that clients who are Other don’t feel safe with or understood by most psychotherapists, and tends to induce feelings of guilt, shame, and incompetence in students. Psychotherapists will often develop anxiety about working with the Others, fearing that they will unwittingly be insensitive and hurt them, which in turn makes it that much harder for them to settle down and relate empathically with such clients. None of this is to say that having coursework on psychotherapy with the Other is inherently a bad idea; in fact, it has been a very good and necessary first step. The inclusion of any material on human diversity in psychotherapists’ training is a major advance from the state of affairs as late as the 1980s, when, as Robert Guthrie poignantly noted, “even the rat was white.”

My own training in clinical psychology in the early 1970s included absolutely no formal or informal instruction in human diversity. When I had my first African American client while in graduate school, my supervisor was as ignorant as I was about how to best make sense of him. Together we replicated the statistic about the Other dropping quickly out of therapy. We did that via a deadly combination of both therapist and supervisor feeling anxious and guilty, and my supervisor trying to school me, based only on his stereotypes and biases, in what to expect when working with one of “them.”

So the fact that by the 1990s it was becoming more commonplace for psychotherapists in the U.S. to encounter some formal coursework on human diversity in their training seemed wonderful to those of us who, like myself, had become passionate about making psychotherapy a more socially just enterprise. Even with the rules and the guilt and the shame, it was something. Attention to diversity had become a principle in the ethics code of American psychology, and a criterion by which training programs were accredited, and that was an important advance.

There were problems inherent in the first emergent model, however. A therapist could read the Handbook of Psychotherapy with Klingons, and become known among the local psychotherapy community as the person who got the referral when a Klingon client showed up in their practice. This did nothing for one’s competence with Vulcans, though. The norms for behavior in the two cultures are deeply opposite, the themes and metaphors distinct, and the approach to be used by a psychotherapist entirely different. The official Klingon expert might also not have learned much about gender roles in Klingon culture, and accidentally extrapolate earth-bound norms about gender to working with Klingon women, which would be deeply erroneous. Not many Klingons of earlier generations survived into later life, given their tendencies toward violence, so there was no chapter on aging in the Handbook. A 70-year-old Klingon shows up in your office—what do you do with him? The “learn a set of rules for the space aliens” that promoted doing cultural competence by rote gave you no instructions for this particular anomaly.

The reality that knowing a great deal of specific knowledge about a given group was a problematic paradigm for developing cultural competence as a psychotherapist became increasingly apparent toward the end of the '90s. Like the visitors to my neighborhood coffee house, many of our clients were refusing to follow the rules about their groups that psychotherapists had carefully learned and memorized in the diverse populations classes. Those of us who, like myself, had spent the '70s and '80s most preoccupied with gender and sexuality were impertinently commenting that these factors influenced expressions of ethnicity. The folks interested in social class and disability had similar notions about the possibility that those kinds of experiences might make for a different creature than the generic humanoid that we’d studied in our diverse populations class. Our coffee-drinking Klingon is a woman; the Cardassian is a trans man, and the Betazoid is a hip young cis-gender guy. The chapter on Cardassians never even mentioned gender expression. Eek. What’s the well-meaning psychotherapist to do?

Intersectionality and Integration

In response to these increasingly sophisticated questions and observations about diversity and complexity of diversity, what we began to see emerging among theorists of culturally-aware practice were paradigms of intersectionality that allowed psychotherapists to have a more sophisticated meta-theory of human difference to inform our work. We also began to see epistemologies of differences that allowed us to generate responses to our clients here and now, in the psychotherapy moment, rather than operating from the rote manualized versions of diversity. This has led us to new, and, I would argue, more psychotherapeutically effective models of cultural competence; it is within these models that I have seen culturally competent practice as the fulfillment of the vision of integration in psychotherapy.

To understand these models, it helps to comprehend what we mean by the construct of intersectionality. Put simply, it is that each of us is more than the most obvious component of our identity, and that these mixtures of aspects of self occur in a myriad of ways. This also means that we have aspects of self, referred to as social locations, which inform identity even, or particularly, when they are invisible to others, and that relate one to another in a range of ways. As the protean actress Sarah Jones, who performs one-woman shows in which she becomes many characters, noted in a speech at the 2009 TED conference, “We are all born into certain circumstances with particular physical traits, unique developmental experiences, geographical and historical contexts, but then to what extent do we self-construct, do we self-invent? How do we self-identify? And how mutable is that self-identity?”

Psychotherapy is all about changing identities, from spoiled to whole—but perhaps we might find that we are more effective at making those changes when we are attuned to the component parts of the person’s tapestry of self. Appreciating intersectionality, which is core to culturally competent practice, to some degree requires openness and flexibility on the part of a psychotherapist; conducting psychotherapy from the starting point of grasping an individual’s intersecting identities is by and of itself an intentionally integrative strategy for conducting the business of psychotherapy.

Intersectionalities provide both psychotherapist and client with information about those processes of self-invention to which Sarah Jones refers. Attending to intersectionalities allows for interrogating the process of self-invention via the disentanglement of the strands of self, including those that have generated psychological distress and problematic behaviors. This disentanglement is to my way of thinking, central to the enterprise of psychotherapy. For many of the people who come to us with their misery, the process of self-construction has been one of problematic conflation—a tangling of negative characteristics and experiences of powerlessness and hopelessness with important aspects of self. All the while, other components of self, which might lead to a different and more functional and peaceful construction, remain in the background, ignored or unexplored.

ADDRESSING Multiple Identities

Various acronyms have been developed by 21st century cultural competence theorists that function to remind psychotherapists that humans fit poorly, if at all, into the single check boxes of life. My favorite one of these is Pamela Hays’ ADDRESSING model, which I’ll describe to you in depth in a moment. What it shares with other similar constructs is the explicit focus on two phenomena.

The first is a broadening of the dimensions on which human diversity might be considered. Rather than privileging ethnicity/phenotype as the sole or primary marker of human difference, these 21st Century models describe a multiplicity of the variables that I refer to as social locations—aspects of the social and interpersonal domain in which a person is located, some or all of which contribute to the development of identity.

ADDRESSING, for instance, stands for Age, Disability, Religion, Ethnicity, Social Class, Sexual orientation, Indigenous Origins, National Origin, and Gender. This is clearly not an exhaustive list—in my own recent work on cultural competence in trauma practice, for instance, I have expanded Hays’ list to include such factors as histories of colonization—both as colonizer and colonized—relationship and parenting statuses, size, attractiveness, combat experience, and interpersonal violence. Hays explicitly states, and I concur, that all humans have a stake in almost every one of these dimensions.

The second aspect that these emerging models of human difference offer is the vision of these factors intersecting in a multiplicity of ways. As I mentioned a moment ago, these intersections are not simply additive, or even multiplicative, nor necessarily layered. They are sometimes the sum of their parts; they are, on occasion, more than, or different from, that sum. Maria Root, who has been at the forefront of proposing new paradigms for theorizing the experience of people of mixed phenotype and heritage (aka “racially mixed”) has found, in her research on sibling pairs from such families, that there are as many as five different and equally likely trajectories of intersectional identity development. These include everything from going along with what the culture thinks you are, to “add and stir,” to the Tiger Woods “I’m a Casablanasian” strategy, to what Root calls “symbolic” identity in which the phenomenology of self is in no way visibly linked to biological characteristics such as phenotype or sex.

Understanding intersectionalities is a first step towards cultural competence. The parameters of cultural competence are no longer met by reading and memorizing the rules from the handbook of psychotherapy with the Other. While some specific cultural knowledge can be helpful, we are beginning to see it as being as potentially misleading as it is informative. It is useful to know that Klingon culture is war-oriented largely so that we can consider what it means that our coffee-drinking Klingon is, herself, not.

Instead, what the 21st century paradigms for cultural competence have generated is a new way of understanding how we, as psychotherapists, can understand the facets of people’s identities that are important to them, both those that transcend the distress for which they seek treatment, as well as those that inform that distress in terms of its etiology, its expression, and its treatment. From this standpoint of cultural competence, all symptoms are what the DSM calls “culture-bound.” A culturally competent lens lets us know that the thing we call Major Depressive Disorder is the Euro-American/European culture-bound version of expressing this particular subjective experience, for instance.

The next important component of these emerging paradigms is that they also require the psychotherapist to understand her or his own biases, and to engage with them mindfully rather than operate from the fantasy that they can be put aside in the name of that great illusion, objectivity. Culturally competent practice informs us that objectivity is what those in positions of power call their own subjectivities. Thus, the culturally competent psychotherapist has discarded the notion of neutrality in favor of that of compassion: observation without judgment, including judgment of oneself for being human and biased. She or he learns to notice bias, and to bring its realities into the foreground of consciousness, to say to the client, “Perhaps we can talk for a bit about the fact that I’m from Earth and you’re Klingon—what might that mean for you.” The old model of cultural competence that would be blind to difference is washing away; after all, how can one not notice the many deep furrows in a Klingon’s brow? Or the melanin tint in the skin of someone whose ancestors did not mostly come from Europe?

Working from the Inside Out

Many psychotherapists operate with clients in a top-down fashion. That is, we have a model of psychotherapy practice, usually linked in some fashion to a theory of personality, and when we encounter a client, we do some kind of assessment of their psychopathology, and then develop a treatment plan, which may or may not, depending on our dominant theoretical model, be done in a collaborative fashion with the client. We proceed from there and try to be skillful and responsive to our clients, doing our best to avoid operating in a cookie-cutter manner. But a good percentage of what informs our behavior over the course of treatment emerges from our particular models. We may or may not utilize formal diagnosis, but our model guides us. And those of us who train the next generation value a psychotherapist’s development of her or his theoretical orientation in part because we know that this orientation functions as such a guide.

What if, instead of working in this top-down manner we switched polarities and, using our shared commitments to integrative work, began to tailor the therapy to the specific needs of our clients, and to work with them from the inside out? This is not a new idea; Prochaska and his colleagues’ “stages of change” model offers a meta-theory of psychotherapy which invites us to do just that, noticing that at each point in the process clients are more likely to respond to certain types of therapeutic interventions than to others. John Norcross has been suggesting using assessment of client stage of change as a strategy for customizing psychotherapy for most of this century. I’m suggesting we this a step further, and see cultural competence in psychotherapy as an ultimate outcome of integration, particularly of a common-factors model.

Working from the inside out with a model of intersectionality allows a psychotherapist to drill down deeply into the core of two things. The first are the sources of distress, of pain, of woundedness, of overload and disconnection—for it is at the emotional locations of our identities that many of our wounds lie. Sometimes the very fact of being wounded is one of the powerful threads running through the weave of our intersectional fabric; often, the wounds attach to other powerful threads. Conceptualizing people’s psychological problems not only as symptoms to be eradicated, but also as evidence of aspects of identity, generates some very novel ways of approaching the problem of alleviating distress.

The Ubiquity of Trauma

Along with sex, gender, various ethnic, sexual orientation, cultural, and social class identities, there is also the question of how trauma is a part of identity. Research by Shirley Feldman-Summers and Kenneth Pope (1992) tells us that approximately thirty percent of practicing psychologists admit to a history of childhood abuse. As a teacher, I urge therapists in training to begin to speak of trauma survivors as “we” rather than “they,” given the ubiquity of this experience in psychotherapists’ lives. Add in other common experiences of trauma, such as combat, natural disaster, assault and sexual assault in adulthood, and traumatic loss, and the numbers of trauma survivors here grow.

Many of us are children of trauma survivors, living with legacies of intergenerational transmission of trauma experiences. Indigenous peoples of this continent, African-Americans, Jews, Khmer, Native Hawaiians and Armenians are but a few of the groups that have been on the receiving end of genocidal violence.There is a plethora of additional examples, since trauma has been pervasive in human experience.

We are also perpetrators. Some of us are the descendants of slave-holders, of soldiers who shot women and children in this country’s genocidal wars against its indigenous people, of those who imprisoned or tortured others in the countries from which they came. Our ancestors suffered what Shays calls the “moral injury” of being trauma perpetrators, and in many cases that was traumatic to them, and to the family cultures that they created and of which we are the inheritors. Some of our families served in the governments of Batista’s Cuba, Stalin’s USSR, Hitler’s Germany, South Africa under apartheid. Some of our ancestors have been beaten; some of our ancestors administered those beatings. For some of us, our ancestors include both; many African Americans carry the genes of a slaveholder great-great-grandfather who raped their enslaved great-great-grandmother. Perpetrator and victim consciousness live within our cultures, our families, our psychological realities. They are a component of our constructions of identity.

The phenomenon of trauma attaches itself to the threads of intersectionality. Conceptualizing an individual’s distress from the standpoint of cultural competence leads us to query not only whether she or he is sleeping or eating or having terrible images of past or future come into her or his mind, but to consider the various facets of identity and how they interact one with another and create an individual’s suffering. We can then tailor our therapy relationship and the interventions that emerge from it to the identities and realities that are salient to this individual.

The second, equally important thing revealed by the adoption of an epistemology of intersectionality are the sources of strength, resilience, joy, and creativity that reside in the social locations which comprise the warp and woof of each individual’s identity. Just as these variables of identity inform distress, so they also generate narratives of survival, thriving, and active responses to the vicissitudes of the world.

Culturally competent psychotherapy practice thus begins with the client at the center of conceptualization, not with the diagnosis, not with a treatment manual, not with the therapist’s idea of what to do next. Rather than conceptualizing the problem, culturally competent practice “diagnoses” the person via a sensitive understanding of her or his identity, allowing that to generate a narrative which reveals distress and strengths alike. Questions of how to heal, and how to evoke strengths in the service of, and in collaboration with, the specific modalities of psychotherapy being offered, emerge from an understanding of those various strands of identity, rather than from the imposition of a particular psychotherapeutic model.

Evidenced-Based Failures and Common Factors Successes

In a discussion of the effectiveness of evidence-based practices in psychotherapy with people who are members of target groups, a number of authors, myself included, have been in remarkable convergence around the theme that almost all of therapy as usual, and almost all of the so-called evidence-based treatment models available, do a terrible job of responding to the therapeutic needs of such clients. The problem with almost all extant models of psychotherapy is that they originally developed in relationship to a generic, dominant group ideal of humanity that falls far short of applying to its many-splendored parts. But one place where research has shown that therapy-as-usual has a chance of being culturally sensitive is when therapists turn to, and emphasize the value of common factors and psychotherapy relationship variables in their work.

As it turns out, an attention to the common factors and to psychotherapy relationship variables is frequently a way to be accidentally laying the foundation for culturally competent practice. What those of us who practice from the starting point of cultural competence have repeatedly found is that the intentional application of common factors, combined with a thoughtful and respectful attention to clients’ identities and intersectionalities, largely described how we operated. This has been true in my own work developing feminist therapy practice.

The more I developed theory in feminist therapy and deepened my own comprehension of what it implied, the more I realized that, not only is feminist practice a technically integrative one, as I had long been saying, but it is also a practice that is founded in the common factors, with strong emphasis on relationship variables. It is also founded most centrally in attention to cultural competence through the lens of gender. When, as feminist therapists do, I pay attention to intersectionalities via the strategy of analyzing gender, power, and social location, I inevitably find that my most effective therapeutic tools include the person-centered facilitative conditions of empathy, genuineness, and positive regard, as well as those variables that contribute to therapeutic alliance.

For instance: the presence of cultural empathy in a therapist—that is, the ability to suspend one’s frames of reference in order to deeply enter that of the client—has been strongly associated with good psychotherapy outcomes for clients who are members of target groups. The therapist’s capacity to own and acknowledge bias, and to apologize for its unintentional infliction (aka relationship repair) is also strongly associated with client reports of satisfaction and good outcome. Many clients who are members of target groups experience dominant group therapists as distant or chilly; these “cold therapist” variables, which are associated with weak therapeutic alliance, are often a by-product of the absence of a culturally-informed and competent stance on the client and the relationship.

Discourse needs to occur, in both and all directions, between those whose central focus on psychotherapy derives from the position of cultural competence and those most centrally interested in understanding the common factors of psychotherapy and integration across paradigms. One thing that I have found interesting, and curious, is that while the research on culturally competent practice comments on therapists’ capacities to engage in the sorts of behaviors that contribute to good outcomes through the lenses of cultural awareness, the common factors literature does not, at least in my reviews of it, pay any attention to issues of culture, identities or intersectionalities. While there is some very beginner work on matching of therapist and client on factors such as sex or ethnicity, there’s not really much in the psychotherapy outcome world that asks about identities, intersectionalities, and therapist awareness of bias and privilege. But how might the power of our work be enhanced if we also assessed such variables as the impact of cultural awareness and cultural empathy on client and therapist alike, and on the outcomes of psychotherapy? How might we be better served in our quest to develop psychotherapies that serve more people, more effectively, if researchers of outcomes routinely attempted to assess the cultural competence of the psychotherapist?

We Are All Other

Even more radical, what if we stopped limiting this inquiry to psychotherapy with members of target groups, e.g., people disadvantaged by virtue of their place in the social hierarchy? What if we took the larger, more genuinely culturally competent stance that each of us, and all of us, are diverse, and that understanding intersectionalities of identity is as important for our work with a Euro-American heterosexual Christian married man as it is with an African-American lesbian pagan who lives in a polyamorous relationship? Or a Klingon, for that matter?

My own bias, and that of the growing band of hardy souls who have been pioneering the broader model of culturally competent psychotherapy practice, is that when we start with the client’s identities and our own, and then work our way backwards into the therapy, we are not only more effective at integration across theories and applications, we are also more likely to meet clients where they are. This, I would argue, creates the interpersonal conditions within which people are more willing to take the risky steps inherent in a change process, because as psychotherapists we have initiated, and modeled, the willingness to change our stance, and modify our ways of seeing, and hearing, and knowing, in order to encounter our clients in their social and phenomenological realities. What I have learned by practicing from a foundation of striving toward cultural competence is that sometimes what looks like being stuck in the pre-contemplation stage can as easily be someone saying, “Why should I admit vulnerability and imperfection to you, oh member of the dominant group that already judges me from the moment you see me?”

I encourage each of us to remember that while we are all human, we are all each, in some important way, Other. If cultural competence infuses our work, then we are more likely to make the connections from which genuine psychotherapy occurs. Cultural competence is not a special topic, nor a political interest; it is, and should be, central to the work of psychotherapists seeking to most effectively empower our clients.


Copyright © 2014 Laura S. Brown