Connecting Issues to Cultural Identities With Empathy

Joshua N Hook; Don Davis; Jesse Owen; Cirleen DeBlaere

Hook, J. N., Davis, D., Owen, J., & DeBlaere, C. (2017). Cultural Humility. American Psychological Association. https://mbsdirect.vitalsource.com/books/9781433827792

Chapter 8 Working with your limits.

It is unwise to be too sure of one’s own wisdom. It is healthy to be reminded that the strongest might weaken and the wisest might err.

—Mahatma Gandhi

Donnie: We each are likely to run into clinical situations or have certain clients that bring us face to face with our limits. I remember seeing a 29-year-old White cisgender male veteran named Tom in therapy, who used to be part of an elite Special Forces group until an injury abruptly ended this career track. By the time Tom made it to my office, he had been struggling for several years with severe posttraumatic stress disorder symptoms, and he also had developed alcohol dependence. Tom had returned to college to try to put his life back together, but he was having trouble just making it through the day. He saw some terrible things during combat, including some brutal scenes of how his comrades treated enemy combatants and their remains. At first, I focused on building a strong working alliance, and I thought that process was going well. We had a good relationship. I think Tom trusted me, and he was relying heavily on my support. But at the same time, I felt like I was in way over my head. I certainly talked about my experiences in supervision, and I got some helpful resources, but it did not feel like it was anywhere near enough. I was definitely running up against a limit.

There were some cultural factors that were at play in the therapy room. Gender, specifically the idea of masculinity and what it meant to be a strong man, seemed to be pretty important. Tom wanted to be a good man. Before the injury, a lot of Tom’s identity was connected to being in the military, including his physical and mental prowess. Experiencing his injury made Tom weaker, and he was struggling to figure out how to deal with that. There was the physical component (e.g., pain, not being able to engage in the same activities as before), which was difficult for Tom to deal with, but there was also the emotional component. Tom’s experiences at war broke something inside him. He had no idea what to do with his feelings. Tom sometimes felt intense rage that seemed to come out of nowhere, and he had trouble regulating those feelings. I had not served in the military, so I felt limitations in my abilities to understand where Tom was coming from. I was able to ask questions about his experience, and I had an outsider’s understanding of military culture, but I could tell there was a divide between us. I could not fully know what it was like for him to experience war at such a young age.

Age had an interesting impact on our work together as well. We were about the same age, which under some circumstances might have helped connect us. In my work with Tom, however, I felt like our similarity in age accentuated the sense of a divide between us. Here we were, two men of similar age. Someone seeing us in the hallway might view us similarly. However, I was about to finish my doctorate in psychology. I felt positive and optimistic about the future. Tom, however, was struggling. He was a man with a head full of painful memories, broken dreams, and a sense of inner chaos that made it hard for him to make it through a single day without major doses of alcohol to numb the pain. In my work with Tom, I had come face to face with a limit, and I was struggling to figure out how to navigate that.

Cultural Humility and Working Within Your Limits

As you can see from this clinical example, sometimes during therapy we come face to face with our limits. One problem with effective therapy regarding cultural identities is that we sometimes have little awareness about our limits. Sometimes the more limited we are, the less likely we are even to recognize our limits. This problem is called the Dunning-Kruger effect (e.g., Kruger & Dunning, 1999), and it has been documented across a variety of areas of knowledge. For example, the less intelligent a person is, the more prone they are to inaccurately estimate their intelligence. Likewise, the less expertise one has, the more likely one is to misunderstand one’s degree of expertise.

Applied to work with culturally diverse clients, the less experience you have working with a particular cultural issue, the more likely you may be to inaccurately perceive the level of help you need. Consequently, we have to think about systematic ways to help avoid making this mistake because overestimating your ability to work with cultural issues can quickly cause problems in your work with clients. This is not just something that “other people do”; we are all prone to minimize and deny our limitations. This tendency is precisely why our profession relies so heavily on supervision within our training model (Tracey, Wampold, Lichtenberg, & Goodyear, 2014).

Sometimes therapists can become so removed from seeing their limitations that they become almost entirely insulated from client feedback. Our tendency to overlook our limitations raises another issue—we often want other people to see us as more competent than we are. This goal to be viewed well often takes precedence over the more aspirational goal of developing expertise. In fact, for this and other reasons, psychotherapy is, unfortunately, a field in which experience does not necessarily contribute to greater expertise (Tracey et al., 2014). Furthermore, a robust literature has explored why trainees conceal their limitations in supervision (e.g., Mehr, Ladany, & Caskie, 2010).

When therapists fail to recognize the limitations in their clinical work, it may be difficult for them to respond effectively to their clients’ needs. These issues, which pertain directly to cultural humility, have led some psychologists to explore ways to systematically embed client feedback into the formal structure of therapy (Lambert & Shimokawa, 2011). For example, in some clinical settings, clients automatically fill out a short questionnaire after each session rating their assessment of the working alliance. Therapists can review these ratings and can proactively bring up and address issues with clients if they observe possible issues or problems reflected in the client feedback ratings. Thus, one of the pragmatic issues we try to address in this chapter is how to recognize when you have to actively seek assistance to address limitations in your ability to work with a client.

In your work with clients, you may not feel you have the sufficient time and stamina to expand your skills unless the limitation is affecting your competence or expertise in an obvious or blatant way. Because of this, it is important to have a plan for what to do when you are faced with your limits and determine you need additional help or resources. Regardless of your career stage or level of experience, you likely have professional structures in place that are designed to provide support and additional training as you encounter new and challenging cultural situations or issues. However, it is important to identify how you will know when you need more than these typical support structures and what resources are at your disposal when this need arises.

In this chapter, we aim to help you anticipate and put together a plan for what you will do when you inevitably encounter your limitations as a therapist. This awareness of your limits might come up when you are working with a client who presents with a cultural identity (or intersection of identities) with which you have little or no experience. Or an awareness of your limits might occur when you are forced to address a particularly salient value conflict. When you are first learning how to do therapy, there are specific methods of obtaining new knowledge and skills, such as reading books and journal articles, watching therapy skills videos, or visiting online discussion boards. Although these methods may provide a starting point for building knowledge and addressing limitations for working with cultural diversity, there is a different set of skills that are needed to put yourself in a good position to notice and respond effectively to your limitations in working with clients’ cultural identities. In helping you to respond effectively to your limitations, we focus on two primary areas: (a) learning to recognize limits in your clinical work and (b) developing a strategy to address limits when they occur.

LEARNING TO RECOGNIZE LIMITS IN YOUR CLINICAL WORK

A core aspect of cultural humility is being able to acknowledge and own your limitations (Hook, Davis, Owen, Worthington, & Utsey, 2013). In Chapter 3, we discussed how to identify your cultural biases, so you have already done some work on identifying some of the limits you might expect to face in therapy according to your personal cultural identities, background, and experiences. In this chapter, we shift the focus to the therapy room. How can you recognize when you are running into a limit during a therapy session? When you do come face to face with a limit, what steps can you take to get the help and support you need? We first address the issue of learning to identify your limits.

Limits and the Johari Window

Before you get started addressing and working on your limits, the first step is to become more aware of your professional limits and take the time to consider the boundaries of your competence. Again, we all have limits—areas we either do not know much about or with which we struggle to engage. Others may not necessarily see them. We may not necessarily see them. The Johari window (Luft, 1969), presented in Table 8.1, is a model that was created to categorize the kinds of information that are known (or unknown) to the self, as well as the kinds of information that are known (or unknown) to others. It can be a helpful heuristic as you begin to think about your personal and professional limits.

TABLE 8.1

Personal Limits and the Johari Window

Quadrant 1 involves limitations that are clear and open. You are aware of these limits, and other people (e.g., client, supervisor, colleague) know about them also. This could be because you have already addressed a similar issue with another client or, in the course of your training, you recognized this limit as an area for growth and took action to address the concern.

Quadrant 2 involves observable limitations. You don’t know about these limits yet, but other people (e.g., client, supervisor, colleague) can observe them in your behavior. If another person gives you feedback about this limit, it can move from Quadrant 2 to Quadrant 1.

Quadrant 3 involves limitations that are hidden. You may know about this limit, or perhaps you suspect you may have this limit, but others (e.g., client, supervisor, colleague) may not be aware of it. This quadrant could represent cultural identities or issues you recognize you may struggle with (e.g., ability status concerns, sexual orientation), but you have not yet addressed or shared this struggle with others for one reason or another. Also, if these issues got triggered in your work, you have not let others in on your process, and they have gone unnoticed by your clients, supervisor, and colleagues.

Quadrant 4 involves limitations that are unknown. These limits are completely out of your awareness as a therapist, and they have not yet been noticed by others (e.g., client, supervisor, colleague). These limits may be related to lack of contact, knowledge, or experience with various types of individuals or presenting concerns.

Take some time and think, reflect, and journal about the limitations in your work with clients of which you are aware. These limits may be related to the cultural biases you identified in Chapter 3, or they may be other issues that have come up in your work with clients. In what areas are you aware that you have limitations in your ability to work with particular types of clients or cultural identities? What thoughts, feelings, or reactions come up for you when you think about your limits?

Gain Insight Into Limits That Are Observable

As we saw from the Johari window exercise, sometimes we have limits that are observable to others but not to ourselves. We may not know about them, but others may be able to get a sense of our limits from our behaviors or interactions. In this next exercise, you will do some work to get feedback about some of your observable limits from others who are familiar with your professional work. Set up a meeting with two or three people who are familiar with your clinical work. A supervisor would be a great choice, as would be a colleague who is in your group supervision class or someone with whom you consult and discuss your cases. Tell them you are doing an exercise in which you are trying to get a sense of some of your professional and personal limits, even those about which you might not be aware. Ask whether they would be willing to share with you two to three strengths that they see in you as a clinician and two to three weaknesses or limits. As they share the limits observed in you, try to listen non-defensively and see what you can learn from the observation. Remember that it is normal to have limits—even experienced therapists struggle with certain types of clients and issues.

After your meeting, take some time to think, reflect, and journal about your experiences. What came up for you during the discussion? What thoughts, feelings, or reactions were present? What did you think about the feedback you received? Did any part of the feedback ring true for you? Was any part surprising? Did you disagree with any part of the feedback? Revisit your journal a couple of weeks later. Did any other thoughts, feelings, or reactions come up for you as you have sat with the feedback for a while?

Sharing Limits That Are Hidden

Other times we have limits that are hidden. We know about them, but our clients, supervisors, and colleagues are not aware of the limit. There are several reasons we might keep a limit hidden. Maybe we are embarrassed, or we feel a great deal of shame about the limit. Perhaps we are worried there might be negative consequences if we were open about our limit. Whatever the reason, we might keep the limit to ourselves, not letting other people in on our process.

There are a few difficult things about keeping limits hidden. One problem is that it does not always work. We can try our best to keep a limit hidden, but often the things we try to hide, repress, and deny come out sideways (Johnson, 1991). It is stressful to keep something hidden. Sometimes the very act of trying to hide a limit might negatively affect our work with clients because we are less likely to be able to connect in a genuine, real way. Sometimes we might think we are hiding a limitation, but the people around us can get a sense that something is up.

A second problem about hiding limits is that it takes a lot of energy. When we try to hide something, there is a part of us that is always monitoring ourselves, the situation, and the reactions of others: How am I doing at hiding this limit? What will happen if I am found out? I hope they do not know that I am struggling with this issue. To the extent that you are hiding and monitoring your limits, you may find it difficult to be present and engage with your clients.

A final problem is that hiding our limits makes it less likely that we will make progress on addressing and working on them. It’s tough to figure out and work through an issue all by ourselves. Usually, we need the help and support of others in our lives to work through and make progress on our limitations. If we are not open about our limitations, we do not give ourselves the opportunity to get the help and support we need. The next exercise involves sharing one of your hidden limits with someone you trust.

Pick a supervisor or colleague whom you trust and with whom you feel safe. Ask whether you could process something with them. Then take a risk and be open with them about the limit you are experiencing. It may be something that you have not shared with anyone before. We recognize that this is scary, but try to remember that we ask our clients to be similarly vulnerable every session.

After the discussion, take some time to think, reflect, and journal about your experiences. What was it like to be open and share one of your hidden limits? What thoughts or feelings came up for you before, during, and after the interaction? How did the person you shared with respond to your disclosure? Has anything changed about how you approach or engage with the limit in your life or work with clients? Was the person you shared with helpful in any way?

ADDRESSING LIMITS IN THERAPY

In this section, we suggest a practical strategy that can help you address the limits you may face in the therapy room. The model involves (a) an underlying attitude of cultural humility, (b) an attunement to feedback (both from yourself and the client), (c) obtaining feedback about limits from clients, and (d) a step-by-step process to address limits when they occur.

Underlying Attitude of Cultural Humility

First, it is important to have an underlying attitude of cultural humility when thinking about limits (Hook et al., 2013). What this means is that limitations, as a normal part of the therapy process, are to be leaned into rather than avoided. Check professional arrogance at the door. No one needs a therapist who is overly confident and hides insecurity through thinking they can competently treat all clients of various cultural backgrounds. An attitude of cultural humility acknowledges that running into your limitations is part of what it means to learn and grow as a therapist. It is something that is to be expected, rather than something to be anxious about or avoid.

Case Example: Richard and Margaret

Consider the following supervision example between Margaret, a 50-year-old, White, heterosexual, cisgender female supervisor and Richard, a 32-year-old, White, heterosexual, cisgender male therapist. They discuss Richard’s clinical work with Nora, a 30-year-old biracial (Latino and White), heterosexual, cisgender female client. Nora is attending therapy to lose weight. The current dialogue occurred after her second session. As you read, pay attention to how Margaret and Richard discuss Richard’s possible limits. Think about whether he has an underlying attitude of cultural humility.

Margaret:  Let’s stop the tape for a minute. Any thoughts or reactions to how Nora is presenting this week?

Richard:  Well, I thought it was a pretty good session. I felt like she really opened up, especially about some of her past struggles and emotional issues that seem related to her difficulties with losing weight. I also think we have a pretty good plan in place for moving forward with the diet and weight loss goals.

Margaret:  Yes, it does seem like you and Nora started to get to a deeper place this session, which was neat to see. I guess I was having a bit of a reaction to how quickly you were moving toward implementing a plan of action. I’m not sure we have a clear understanding yet about all the factors that are contributing to her struggles with her weight.

Richard:  OK, so maybe I could have slowed it down a bit. But she was pretty clear that she wanted to lose weight. I thought it might help to get her started on some things.

Margaret:  I get that, but it just seems like there’s a lot going on. She seems to feel a lot of shame about her weight, and we do live in a society that gives women very clear messages that they need to look a certain way. I guess I wonder how much you are considering those factors in your treatment.

Richard:  I understand that society gives all of us messages about weight and appearance, but for her, it seems to be more of a health issue.

What reactions do you have to the supervision dialogue between Margaret and Richard? Did it seem as though Richard was culturally humble and open to considering a limitation? What cultural identities were relevant in this discussion? What cultural identities did Margaret and Richard discuss during the dialogue? What cultural identities might they have missed?

In this example, Richard did not seem open to discussing the importance of gender and the sociocultural context that is likely connected with Nora’s goal of losing weight. He also did not respond in a culturally humble manner when his supervisor attempted to point out some of his limits. Also, there were other cultural identities that were not discussed during the dialogue that may be important to consider to effectively treat this client (e.g., race or ethnicity). Finally, it is worth considering whether losing weight is an appropriate goal for Nora. A discussion about size as a cultural identity, as well as considering alternate perspectives on dieting and weight loss (e.g., Health at Every Size; Bacon, 2010), may also be helpful for this client. Consider the following alternate dialogue between Margaret (the supervisor) and Richard (the therapist):

Margaret:  Let’s stop the tape for a minute. Any thoughts or reactions to how Nora is presenting this week?

Richard:  Well, I thought it was a pretty good session. I felt like she really opened up, especially about some of her past struggles and emotional issues that seem related to her difficulties with losing weight. I also think we have a pretty good plan in place for moving forward with the diet and weight loss goals.

Margaret:  Yes, it does seem like you and Nora started to get to a deeper place this session, which was neat to see. I guess I was having a bit of a reaction to how quickly you were moving toward implementing a plan of action. I’m not sure we have a clear understanding yet about all the factors that are contributing to her struggles with her weight.

Richard:  OK, so maybe I could have slowed it down a bit. But she was pretty clear that she wanted to lose weight. I thought it might help to get her started on some things.

Margaret:  I get that, but it just seems like there’s a lot going on. She seems to feel a lot of shame about her weight, and we do live in a society that gives women very clear messages that they need to look a certain way. I guess I wonder how much you are considering those factors in your treatment.

Richard:  Hmm, yeah, you know, I think you make a really good point. I think I was being action oriented and just trying to solve the problem. But you’re right; there are things about our society that probably make this issue really tough for Nora. And I’m not sure I always understand that as a man. I probably need to look into this a bit more.

Margaret:  I appreciate you acknowledging what you don’t know in this situation—that’s really important to be aware of. What do you think are some ways you could get more information?

What did you think about this second dialogue between Margaret and Richard? What was different about Richard’s attitude and reactions in the two dialogues? In which dialogue was Richard more culturally humble? What behaviors did you notice that were markers of cultural humility?

Attunement to Feedback

In addition to engaging with an attitude of cultural humility, it is essential to be attuned to feedback about limits, both from yourself and from the client (Hook, Watkins, Davis, & Owen, 2015). Feedback from yourself involves being curious about situations in therapy in which you experience discomfort, anxiety, or distress, especially when these feelings accompany discussion that involves a client’s cultural identities. The discomfort could be a signal that you may be in a situation in which you are confronting one of your limits.

Case Example: Karla, Julia, and Jeff

Consider the following therapy example of Julia, a 58-year-old, Latina, heterosexual, cisgender woman, and her husband, Jeff, a 62-year-old, White, heterosexual, cisgender man who presented for couples therapy. The impetus for seeking therapy was that after 30 years of marriage, Julia wanted a divorce. The couple has one child, a son, currently in graduate school. Karla, a 24-year-old, Asian American, heterosexual, cisgender woman is their therapist. She is in the second month of her first practicum at a community mental health center. The following excerpt is from the couple’s first session.

Jeff:  We want to work on our marriage.

Julia:  “We” do not want to work on our marriage. I have not been happy with Jeff for a long time but stayed because of his diagnosis.

Karla:  What diagnosis is that? I didn’t see anything about a medical or mental health condition on the intake form.

Julia:  Yeah, Jeff doesn’t like to list it, but he was diagnosed with early onset Alzheimer’s disease 5 years ago. He’s getting worse all the time.

Karla:  I am so sorry to hear that.

Jeff:  I don’t like it any more than Julia does, but I need Julia to take care of me. Can you believe she would want to leave me knowing that I am getting worse? She should stay and take care of me. I mean, we said the vows. For better or worse. In sickness and in health.

Julia:  Honestly, the guilt of leaving is what has kept me in the marriage for the last few years. I just don’t think I can do it anymore.

Toward the end of the first session, Karla asked how the couple felt about the session.

Karla:  Well, I really appreciated getting to know you both a bit better today. I think I have an initial sense of the issues you two are facing. It seems like the first issue may be to agree on a goal for therapy. Does that sound right to you two?

Jeff:  I guess so.

Julia:  I suppose.

Karla:  How did you feel about today? Do you have any questions for me?

Jeff:  Yeah, how old are you?

Karla:  I’m 24.

Julia:  You have got to be kidding. My son is about your age. What can you possibly know about working on a 30-year marriage?

Do you have any reactions to the dialogue between Karla, Julia, and Jeff? How would you feel if you were the therapist in this situation? How would you respond to the question about your age and the client’s comments about your lack of experience? What might this exchange say to you about some of your possible limits in seeing these clients?

After the session, Karla felt overwhelmed for a number of reasons. First, she had never conducted therapy with a couple before now. Second, she had not previously had a client with a disability. Finally, the couple had hit on one of Karla’s main insecurities as a therapist—her young age and feelings of inexperience.

Obtaining Feedback About Limits From Clients

In addition to being attuned to your own feedback, it is important to obtain regular feedback from your clients about how they are feeling about therapy. Sometimes asking for feedback from clients about how therapy is going can be scary, because it can be difficult to hear that there may be some negative aspects of your work or how you are engaging with clients. This can be particularly true considering topics related to culture and diversity because therapists tend to like to view themselves as culturally competent and can be defensive about the idea that they are not respecting cultural differences in therapy. If therapists can sit with the anxiety that comes with obtaining feedback from clients, however, this can be a good source of information about situations in which you may have come into contact with a limit. Earlier in the book, we discussed one idea for obtaining structured feedback from clients: Have clients fill out consistent ratings of their perceptions of the working alliance. Spend some time thinking about your current clinical work and setting. Do you have any structures in place for receiving consistent feedback from clients about your limits? If so, how are you using this feedback? If not, how would you feel if this kind of structure were implemented? What do you see as the positives or negatives that could come from this kind of system?

It is also possible to obtain unstructured feedback about limits from your clients. Do you ever check in with clients about how they feel the therapy process is going? What about checking in about how clients feel about how their cultural identities are addressed in therapy? Sometimes we accidentally send messages that we are not that interested in or open to feedback. It is possible clients may not share negative feedback with you because of the power differential between therapist and client, but by asking for feedback, you give them the opportunity. If you have done a good job building trust in the relationship, clients may be more willing to be open and honest about how they are feeling about the therapy process, as well as their relationship with you. If difficulties or problems are present, it may give you an opportunity to address these issues.

If you are currently seeing clients, pick a client from whom you will obtain some unstructured feedback about how the therapy process is going. If you are not currently seeing clients, pick a friend or colleague to check in about your relationship with them. The next time you see the client, ask if you could check in with them about how therapy is going. How are they feeling like you are connecting during the therapy hour? How do they feel like they are doing in progressing toward their therapy goals? How do they feel like their cultural identities are being addressed in therapy? Is there anything about therapy or how you are connecting that they would like to shift or change?

After you have a discussion with a client to obtain feedback, check in with yourself about how the experience went. What thoughts or feelings came up for you before, during, and after the interaction? Did anything about your relationship with the client shift or change as a result of asking for feedback? Are there any changes you would like to make regarding asking clients for feedback?

Plan for Addressing Limits

What do you do when you become aware that you have reached one of your limits? In what follows, we describe a structured process that can be helpful for addressing the limits you might face with a potential client. The process involves five possible steps: (a) identify limitations; (b) acknowledge existing strengths, skills, and resources; (c) access education and professional resources; (d) identify sources of support; and (e) have a dialogue with the client about your limit. In the next activity, you will walk through these steps with a hypothetical case. Once you get familiar with the process, the following exercises involve applying the steps with one of your current clients.

Read the following case example and imagine that you have been assigned the following client. Marena is a 30-year-old, heterosexual, transgender Latina woman who moved to the United States from Ecuador. Though she possesses male external genitalia, Marena’s voice never deepened at puberty, she does not have facial hair, and her physical frame is petite. Marena has felt she was female since she was a young child. Marena was bullied throughout school by her peers, and she describes her childhood as socially isolating and full of shame. Marena’s parents would not allow her to identify openly as female, so she attended college far away from home so she could pursue hormone therapy and live freely as a woman. She presents for therapy because she is pursuing gender-affirming surgery, and therapy is required before having the surgical intervention.

Step 1: Identify Your Limitations

Take some time and consider what some of your limits might be for working with Marena. What limitations are you aware of currently? Using the Johari window, in what quadrant would you place your limits? Do you think you might have any limits of which you are not aware? If you are struggling to identify your limitations, the following are some questions to ask yourself.

Have you worked with a transgender client before? If so, how many? What is your level of familiarity with gender-affirming surgery and what it entails? What documents will you be required to provide, if any? How much do you know about transgender identity? What is your gender identity, and how might your identity be related to gender and sex privilege? What is transphobia and internalized transphobia? How might these concepts affect your therapy relationship and your conceptualization of Marena? How might the intersection of Marena’s identities (e.g., race, ethnicity, gender) affect your therapy relationship and your conceptualization of her presenting concerns? Are you aware of local transgender-affirming organizations and resources? How do you feel about working with Marena? What thoughts, feelings, and expectations come up for you as you think about beginning therapy? How might those feelings inform your understanding of your limitations?

These questions represent only the beginning of the introspective process necessary to better identify your potential limitations for working with Marena. You might also consider completing an inventory on transgender issues to more specifically identify gaps in your knowledge or particular biases you may possess. As you think about beginning therapy with this client, generate at least three additional questions you feel are important to consider as you work with Marena.

Step 2: Acknowledge Existing Strengths, Skills, and Resources

In addition to thinking about your limitations, it is also important to acknowledge the strengths and skills you already possess that would be applicable to your client. Not only will your existing strengths and skills be helpful as you begin therapy, but they may also help you to work on addressing your limits with this client. For instance, the ability to provide unconditional positive regard and basic counseling skills remain functional skills that can be applied to different types of clients. As you work to develop the awareness and knowledge necessary to conduct therapy most effectively with Marena, these skills will allow you to be of service to her. Take some time to think about your existing strengths, skills, and resources for working with Marena. If you are struggling to identify your current strengths, skills, and resources, the following are some examples of questions to ask yourself.

What specific strengths and skills do you think you could bring to bear with this client? These could include basic counseling skills such as effective use of open-ended questions, rapport building, or affirming Marena’s strengths. Or you might have had some specific training for working with transgender clients. Maybe you have struggled with your gender identity in the past, and you have a high level of empathy for clients who present with a similar struggle. What resources are already at your disposal? For example, perhaps there is a local lesbian–gay–bisexual–transgender–queer community center you could connect with.

Step 3: Access Opportunities for Education and Professional Resources

If you know you are in a situation in which you are faced with a limit, an important next step is to identify and access opportunities for education, training, and other professional resources. For example, you could attend training sessions for continuing education or conference presentations. You could access books or articles on the cultural identity you know little about. The American Psychological Association (http://www.apa.org/practice/guidelines/) and American Counseling Association (https://www.counseling.org/knowledge-center/competencies) have published a number of guidelines for ethical practice with various populations. These guidelines integrate evidence-based practices into their recommendations and can be a particularly effective place to begin your search.

Take some time and think about beginning therapy with Marena. What opportunities for education or professional resources might be available in your area? Try to find at least one training course and one reading that would be a helpful first step. If you are struggling to think about what opportunities for education or resources might be available, the following are some examples of things to think about.

Depending on your limitations (e.g., use of appropriate terminology, gender-affirming surgery procedures), you might seek out books, journal articles, documentaries, and websites related to transgender concerns. You might also review psychological research on the experiences of transgender people. Importantly, in this search for resources, Marena’s multiple marginalized identities would have to be considered. Issues of culture and Marena’s unique location at the nexus of her gender and ethnic identities, as well as other identities you would assess (e.g., sexual orientation, social class), will directly affect her experience.

Step 4: Identify People Who Can Support You

In addition to obtaining opportunities for education and resources, seeking supervision and consultation is likely warranted in this case. It is important to obtain support and guidance when you are operating in a situation in which you have reached a limit in your knowledge and skills. Also, trainees often experience anxiety and threats to their sense of self-efficacy when presented with a client or client issue that represents a limit. Supervision and support from colleagues can normalize this process and reinforce existing strengths, skills, and resources. If your limits involve negative biases or countertransference issues, it might also be worth considering discussing your issues in personal therapy. Take some time and think about your work with Marena. Who could support you in this process? If you are having difficulty identifying people, here are some examples to think about.

As an initial contact, it is probably a good idea to connect with your supervisor about your work with Marena. Or, if you are not a trainee, you might think about setting up a time to consult with a colleague. Before working with this client, it would be helpful to identify any biases you might have about Marena and explore potential value conflicts you may have in working with her. If you experience a strong amount of countertransference in your work with Marena, it might be useful to process these reactions in your own therapy work.

Step 5: Consider Having a Dialogue With the Client About Your Limits

This next step may not be appropriate for all clients, but one option when you experience a limit in your work with clients is to explore the issue with the client. Your willingness to do so demonstrates vulnerability, openness, and a willingness to learn. This kind of dialogue could also lead to deeper discussions about cultural issues because the client may feel that the therapist is interested and wants to know more about the client’s cultural identities. Whether you actually implement this intervention requires careful consideration of a variety of factors. Talking with your clients about your limits may feel unsettling for some clients. This kind of intervention works best when it openly names an area in which the client clearly possesses greater cultural knowledge and expertise, and you communicate a desire to learn. Engaging in this process with a supervisor will likely help you make a good decision about how to strike the right balance of remaining professional while also sending a clear message that you are interested and open to learning more about your client’s cultural identities.

Take some time to think and reflect on your work with Marena. Do you think it would be appropriate to engage in a dialogue with her about some of your limits? Why or why not? If you engaged in this type of dialogue, what would you share with Marena? What would be the purpose of your dialogue?

If you do decide to have a dialogue with Marena about your limits, it can be helpful to practice this type of dialogue with a supervisor or colleague. Take some time to think and reflect on the limitations you experience with Marena. Next, recruit a supervisor or colleague to help you practice. Give them a bit of background about Marena and this exercise. Then practice having a conversation about the limits you experience in your work as a therapist. Be honest—acknowledge when you feel as though you are struggling to understand your client. Be positive—share your heart and desire to understand and connect with your client in a deeper way. Be curious and seek to understand—ask how you could better support the client and the cultural identities that are important to your client.

Once you have completed the practice dialogue, ask your supervisor or colleague for feedback. Did the supervisor or colleague feel respected and supported? Did they feel you were being genuine? Did the conversation feel more connecting or more distancing? See whether you can incorporate the feedback as you think about having these kinds of dialogues with your clients.

Practice may not make us perfect—but it does help us grow. In fact, one of the key behaviors associated with cultural humility involves consistently being willing to acknowledge, own, and take appropriate steps to address one’s limitations (Hook et al., 2013). This can become part of the rhythm of one’s development and growth as a therapist.

Case Examples

The key to learning a new skill is consistent practice, so in this next exercise we would like you to use the following four case examples, which involve complex cultural issues, to work through the five steps to addressing your limits. Choose the case example you find most challenging and that most clearly pushes your limits as a therapist. In other words, try to select the one that would require the most explicit plan for you to address your limits to effectively meet the client’s needs. Once you have done so, work through the five steps we described earlier.

Case 1

Tammi is 35 years old and identifies as an African American queer, cisgender woman. She is currently involved in a polyamorous relationship with an interracial (African American cisgender woman and Asian American cisgender man) married couple, Kim and Jacob Chiu. Kim identifies as queer as well, and Jacob identifies as heterosexual. Kim and Jacob are both 28 years old. Tammi recently moved in with the couple, and although the relationship was progressing well when Tammi had her own place, the three have been fighting a lot since Tammi moved into the Chiu’s residence. In particular, Jacob is feeling less and less a part of the relationship. The three would like to work on their issues and present to you for relationship counseling.

Case 2

Bill is 58 years old and identifies as a White, heterosexual, cisgender man. He is single, with no children. He was recently diagnosed with Stage 4 lung cancer and has only 3 to 6 months to live. Bill shares that he never smoked and has tried to live a healthy lifestyle. He is seeking therapy at the recommendation of his physician, who noticed Bill has been showing symptoms of depression, as well as angry outbursts. During his intake session, Bill shares that he sees no point in engaging in therapy because he is just waiting to die.

Case 3

Macy is 17 years old and identifies a White, heterosexual, cisgender woman. She is 8 weeks pregnant and is seeking therapy to decide what to do with the baby. She is leaning toward having an abortion, but she worries she will never forgive herself if she does so because she believes abortion is a sin. She is not sure who the father of the child is. She has also not told her parents or family she is pregnant because she is worried about what they would think of her. She feels pressure to make a decision about the baby immediately because she thinks she will soon get to the point at which her family will realize she is pregnant.

Case 4

Simon is 30 years old and identifies as a biracial (White and Mexican American), heterosexual, cisgender man. He is homeless, and in your initial session you struggle to maintain focus because he has a strong odor. During the session, Simon admits he contracted HIV 6 months ago and that he regularly uses intravenous drugs and has unprotected sexual intercourse. He views his behavior as problematic but does not see himself changing his lifestyle. Instead, he wants to work on obtaining a job and affordable housing.

Addressing Limits With a Current Client

To this point, we have done a lot of practice with hypothetical scenarios, but now we would like you to apply the themes and skills of this chapter to your actual work with clients. We hope the structure we provided—or something like it that fits your personality and context—can help you develop a rhythm of practice that involves making the most of your experience and opportunities for learning, supervision, and collaboration. The major barriers are factors that would keep you from (a) letting people know where you are regarding limitations, and (b) being willing to reach out consistently and accept help and support.

In this final exercise, we would like you to apply the steps for acknowledging and addressing limits with a current client. Take some time and think about a client with whom you are currently working that you feel least confident about being able to achieve a successful outcome. Another idea is to select a client who has a cultural identity you know little or nothing about or a cultural identity you struggle with or toward which you experience negative countertransference. Once you have selected a case, work through the five steps we described earlier. After you have worked through the five steps, take some time and think and journal about what it was like to complete this activity. How did completing this activity influence or change your perspective of your client? Did you learn anything new about the client as a result of this exercise? Did you learn anything new about yourself?

Case Example: Karla, Julia, and Jeff

Let us return to the example of Karla, who was seeing Julia and Jeff in couples therapy. Recall that Jeff and Julia made a critical comment about Karla’s age, which triggered her insecurities about her age and lack of experience, especially seeing couples. Take a minute to consider how Karla might use the steps discussed earlier to address her limitations.

Karla does seem to be aware of her limitations, which is a good place to start. She should also seek supervision to identify any other limitations she may not be aware of and also to help identify the strengths and resources she already possesses (e.g., she completed additional training in couples therapy). Karla may also investigate Jeff’s diagnosis and the typical progression of his disease, as well as consider what role being an interracial couple has played in the couple’s relationship. The following week, the couple returned for their second session, and with the support of her supervisor, Karla directly addressed some of her anxieties about her limits with the couple through dialogue.

Karla:  You know, last week felt a little anxiety provoking for me.

Jeff and Julia:  Us too.

Karla:  I thought that might be true. What might have made you nervous?

Julia:  Well, that you are so young, for one.

Jeff:  Yeah, we weren’t sure how you would be able to help.

Karla:  Well, I want to thank you both for being so honest about that. I think therapy works a lot better when you both feel you can be honest with me, and you can count on the same from me. I hear that you are concerned about my age. What exactly about my age makes you nervous?

Julia:  We really need help. We really need to figure out if our marriage can work at all, and I am just not sure you will be able to do the job.

Karla:  I can’t give you guarantees about whether I will get everything right, but I do think I can help. For example, you both shared that communication and intimacy are areas you have been struggling with. I think I can help with that. Could we try? And, let’s continue to talk about how both of you are feeling. I’ll check in with you pretty regularly to see if it feels like things are moving forward, if that’s OK. If they’re not, we can discuss other options. How does that sound?

Jeff and Julia:  OK.

Do you have any reactions to this follow-up dialogue between Karla, Jeff, and Julia? What do you think of Karla’s strategy to bring up the limitation and discuss it with the couple? Through supervision and consideration of the strengths that Karla did bring to the therapy process, she was able to regulate her anxiety and engage the couple authentically. In addition, by accessing resources about Jeff’s condition, additional information about couples therapy (including research on interracial couples), and seeking support, Karla is creating a strong foundation for moving forward in light of her limits.

Conclusion

Inevitably, we will run into situations or clients that test our limits as therapists. This can be an anxiety-provoking experience, especially when the limits have to do with clients’ cultural identities or the intersection between their cultural identities and our own. Because of this, it is essential to have a plan to not only recognize our limits when they occur but also to address them and move forward in our work.