The Need for a Culturally-Aware Approach

Cultural experiences, positive and negative, are fundamental dimensions of every human being’s life. Well-being is intertwined with social relationships and the well-being of one’s cultural groups. For many people, cultural values and affiliations are powerful and sustaining components of their lives. As EMDR therapists, these are resources we can help our clients develop. At the same time, as trauma therapists, we must be aware that many of our clients have grown up under oppressive conditions and have experienced significant social stigmatization and discrimination. Hostile social forces of disregard, intolerance, exclusion, and worse have been directed at many clients simply because of the way they look and talk, their social position, and the families they come from, or who they love.

To maximize our effectiveness as clinicians, we need to embrace our clients’ full experiences including the role of cultural issues. While this seems like common sense, as psychotherapists we must understand that we operate in a broader “psychotherapist” culture that has been criticized for operating with a culture-blind approach that too often tries to separate “cultural” issues from “personal” issues.

Despite the fact that most psychotherapists have egalitarian values and are aware of the importance of cultural forces on a societal level, psychotherapy practice, including trauma-informed psychotherapy, has historically ignored or minimized the cultural context. Critics have described the Western psychotherapy model as being heavily influenced by a medical model that includes the preeminence of the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013) for diagnosis (which locates the problem within the individual and largely ignores etiology), the use of the DSM to determine “medical necessity” for insurance coverage, a focus on pharmacological interventions, the coopting of social workers toward an individual psychotherapy model rewarded with higher pay and higher status, and the established dominance of individually oriented treatment paradigms.

In a sobering caution about the risks of a “culture-blind” approach, Ridley (2005) cites over 80 studies showing that psychotherapists engage in discrimination during their clinical practice. In his review of research on this topic, he discovered that the following clinical decision points were influenced by prejudicial stereotypes: diagnoses, prognoses, referrals, treatment planning, selection of interventions, frequency of treatment, termination, medical therapy, reporting abuse or neglect, duty to warn, involuntary commitment, deciding the importance of case history data, and interpreting test data. Ridley suggested other clinical behaviors might also be impacted, such as seeking consultation, developing empathy, expressing support, advocating for the client, and identifying with a client’s issues.

This culture-blind tendency to sidestep explicit attention to cultural issues may exist, in part, because therapists don’t know how to productively integrate culture within the psychotherapy model. Overcoming this obstacle will be explored throughout this book. Despite the potential for inherent bias within clinical mental health practice, a more culturally competent one-on-one psychotherapy model can create conditions for recovery and growth for individual clients.

Defining Cultural Competence

One of the most fundamental challenges to advancing the discussion about cultural competence in the field is simply defining the concept. The term cultural competence was established in the 1980s as part of a broad examination of the field of health and human services and their systems of care (Cross, Bazron, Dennis, & Isaacs, 1989). Since then, it has gained broader acceptance among individuals and organizations who seek to provide services that are culturally sensitive to a wide range of people.

In the original definition, culture is referred to as an “integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group” (Cross et al., 1989). This broader meaning of culture, which includes a range of socially salient groups in a person’s life, is an important dimension. In fact, within the literature, the terms cultural identity and social identity are often used interchangeably to connote a person’s identification with a larger group.

Competence is defined as “the capacity to function effectively” (Cross et al., 1989). A continuum of competence is depicted from one extreme to the other, which includes cultural destructiveness, cultural incapacity, cultural blindness, cultural precompetence, cultural competence, and cultural proficiency. Although others have added to the growing body of knowledge, definitions, and practice suggestions, the core definition has remained stable and will provide the foundation for the concepts covered in this book.

Since the concept was established, many organizations have aspired toward cultural competence (Denboba, MCHB, 1993; Lavizzo-Mourey & Mackenzie, 1996; National Alliance for Hispanic Health, 2001; U.S. Department of Health and Human Services, & Administration on Developmental Disabilities, 2000; U.S. Department of Health and Human Services, & Substance Abuse and Mental Health Services Administration, 2004). From an organizational perspective, Betancourt, Green, and Carrillo (2002) proposed that cultural competence within broader systems of care should have the capacity to (a) value diversity, (b) conduct self-assessment, (c) manage the dynamics of difference, (d) acquire and institutionalize cultural knowledge, and (e) adapt to diversity and the cultural contexts of communities they serve.

Pedersen (2002) identified three components of clinical competence: (a) awareness/attitude, (b) knowledge, and (c) skills. Awareness was characterized as both an awareness of other cultures and an active effort by practitioners to assess their own beliefs and values toward culture in general and different cultures in particular. This combination of external awareness and internal reflection has been echoed consistently by others as a core component of competence. Kaslow et al. (2004), for example, states that competence should include the capacity to evaluate and adjust one’s decisions through reflective practice.

Related to this need for internal reflection, Tervalon and Murray-Garcia (1998) introduced the concept of cultural humility as an important mindset or stance from which to approach cultural issues. They proposed that three factors are fundamental for cultural humility: (a) a commitment to self-evaluation that includes qualities of humility, (b) a desire to fix unjust power imbalances, and (c) aspiring to develop partnerships with people and groups who advocate for others. They point out that the commitment to self-reflect should be lifelong and can build the capacity to respond flexibly with newly acquired knowledge. Yet, they warn that any insights are of limited value if not implemented in culturally informed clinical approaches that convey an understanding of a client’s cultural experience, especially those who have endured social injustice. They emphasize that a commitment to diversity and undoing social injustices should be a collaborative effort with like-minded advocates for societal change.

Waters and Asbill (2013) have added that the term cultural humility is an attitude of openness from which one seeks to explore one’s own cultural perspectives and biases. Cultural humility generates a natural curiosity that motivates one to learn and expand understanding. Cultural humility entails suspending one’s own culture-centric views when entering the world of a client. Hook, Davis, Owen, Worthington, and Utsey (2013) describe cultural humility as the “ability to maintain an interpersonal stance that is other-oriented in relation to aspects of cultural identity that are most important to the [person].”

Other recommendations for cultural competence have been proposed. Goodman et al. (2004) suggested that counselors should act as “agents of change” and identified several competencies for a social justice approach to multicultural counseling, including (a) ongoing self-examination and self-awareness, (b) sharing power, (c) giving voice, (d) facilitating consciousness raising, (e) building on strengths, and (f) offering clients tools for creating social change. Gallardo, Yeh, Trimble, and Parham (2011) proposed six concrete stages of multicultural counseling: (a) connecting with clients, (b) conducting a culturally relevant assessment, (c) facilitating awareness, (d) setting goals, (e) taking action and instigating change, and (f) welcoming feedback and maintaining accountability.

Many of the professional organizations that represent the different mental health disciplines have made efforts to define and support cultural competence. Generally, these efforts fall into two categories: supporting diversity of membership and offering culturally attuned and effective services.

The National Association of Social Workers (NASW) highlights two major cultural forces requiring ongoing attention: the civil rights movement launched in the 1950s, including any disadvantaged and oppressed populations; and the increasing number of new immigrants to this country. An NASW statement acknowledges that “both helping professionals and society at large have a long way to go to gain cultural competence” while taking some pride in “social workers . . . longstanding history of understanding both people’s differences and the impact of social injustices on their well-being” (NASW, 2011). NASW Standards for Cultural Competence and Social Diversity emphasize three dimensions for social workers: understanding culture and recognizing cultural strengths; having knowledge of specific clients’ cultures; and obtaining education to better understand social diversity and oppression.

The American Psychological Association Task Force on Inclusion and Diversity is developing a definition and standards for cultural competence and seeking to develop diversity among its membership. Their challenge has been described as “a complicated matter of defining diversity, attracting and engaging diverse members, sharing the power and accepting that the future will hold a very different climate of racial demographics” (American Psychological Association, 2011). The American Psychiatric Association has emphasized the need to assess and correct disparities in the delivery of mental health services related to cultural factors and to reduce stigma for those seeking care (psychiatry.org).

The International Society for Traumatic Stress Studies has established a diversity and cultural competence special interest group (SIG). The SIG has raised awareness of cultural factors and noted that “these factors mediate, moderate and in many cases, even determine traumatic exposure and post-traumatic response, such as through exposures to hate crimes, general community violence, forced internment, enslavement and other trauma or via contributing factors occurring within societies hostile to particular groups, such as social attitudes and actions contributing to a hostile environment” (International Society for Traumatic Stress Studies, 2016). The SIG also notes that “demographic characteristics may also be proxies for or directly countervail the effects of trauma through culturally-specific strengths and resilience factors” (International Society for Traumatic Stress Studies, Diversity and Cultural Competence SIG. Copyright ©2016 ISTSS. All rights reserved).

EMDR as a Culturally Competent Therapy: Embracing the Challenge

Summary

Within the field of mental health, there is a much needed conversation about cultural competence. EMDR clinicians and organizations can actively join this discussion for mutual benefit. EMDR therapy has the potential to be a leader in the field because of the cultural adaptability of our treatment model, and its capacity for alleviating the effects of trauma, including culturally based trauma.

At the same time, cultural competence is an ongoing challenge, and it is important that all clinicians take a clear look at how they can apply the ASK model to enhance a culturally aware attitude, stretch their skills, and deepen their knowledge. Culturally competent EMDR therapy welcomes cultural awareness, embraces social and cultural identity, integrates the EMDR approach within a cultural context, and implements EMDR therapy to dismantle culturally based trauma.

References