Continuing the Journey of Cultural Humility

Continuing the journey of Cultural Humility

Chapter 9

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

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Cultural Humility

Joshua N Hook; Don Davis; Jesse Owen;

All endings are also beginnings. We just don’t know it at the time.

—Mitch Albom, The Five People You Meet in Heaven

We have reached the end of this book, but our hope is that this is only the beginning of your development and growth in cultural humility, learning about yourself, and effectively working with cultural identities in therapy. We view the development of cultural humility as a lifelong process, and our desire is that you would continue to invest in this area of your life and work.

Still, for this book, it is time to bring things together and commit to lasting changes that will make us more culturally humble people. What would it take for this book to make a difference in the kind of therapist you are, not just for a few days or weeks but for 5 or 10 years and beyond? One possibility is that you can take the things you have learned in this pages and use them to make commitments that change your sense of identity, including the kind of therapist you aspire to be.

Donnie: I am a father of two children. The moment I became a father for the first time, my life changed forever because the father role came with clear cultural expectations regarding what it would mean for me to be a good father. In a similar way, we imagine that who you are as a therapist is an important part of your identity, and we hope that the themes we discussed in this book provide you with the chance to revisit, in a variety of ways, the kind of therapist you aspire to become, especially in terms of seeing clients from a variety of cultural identities and backgrounds and working with cultural identities in the therapy room.

The psychological literature on cultural humility and developing a multicultural orientation is relatively new (Mosher, Hook, Farrell, Watkins, & Davis, 2016), and we are aware that this book is a beginning. We hope that new theory will build on our initial ideas. Our knowledge of what kind of self-awareness is most important for strengthening relationships and promoting positive outcomes for clients will sharpen. Likewise, our knowledge of how to form, maintain, and repair relationships with clients when cultural ruptures occur will also deepen over time. However, as many others have noted (e.g., Fowers & Davidov, 2006), expertise in working with cultural identities in therapy is more than developing a set of skills, it is an identity and way of life. So to end this book, we as a team wanted to remind you of the key themes herein and provide you with a set of personal challenges that involve putting these themes into practice.

A New Way of Thinking About Working With Diversity

First, let’s take stock of what we have learned so far. Chapter 1 focused on a new theoretical framework regarding what is needed for doing therapy with clients from a variety of cultural identities. This framework assumes clients and therapists create the process and narratives of therapy together, and having a strong multicultural orientation that values diversity can provide a way of engaging with clients that facilitates a vibrant, emotionally responsive relationship that allows clients to feel safe and grow. The three pillars of a multicultural orientation involve (a) cultivating a stance of cultural humility in which one remains open to the client’s experience and adopts a receptive stance that allows for positive and responsive emotional engagement; (b) pursuing cultural opportunities through leaning into cultural interactions or conversations even when this feels vulnerable, difficult, or scary; and (c) developing a way of life that increases one’s cultural comfort for working with a range of culturally diverse clients.

Challenge 1: Find a multicultural orientation buddy. Our first challenge to you is to find at least one other person invested in developing their multicultural orientation and commit to working on this process together. Working on one’s multicultural orientation can be a difficult process, and at times it can be a struggle to stick with it. Having support will help to ensure that you can persist and even grow through the tough times.

Cirleen: I am the practicum supervisor for first-year doctoral students. One thing I recommend and then remind my students often is that it is a good idea to take the time to develop strong relationships with the other students in their cohort and program during their first year. This is important for several reasons. First, no one in your life is going to understand what your graduate program is like better than those who are in the program with you. These people are the ones who can empathize with your stress and triumphs. Let one of those sources of stress and triumph be the development of your multicultural orientation. Also, once you graduate, you will take positions in different types of settings that may or may not support your efforts at promoting cultural understanding and humility. You will need your buddy. Trust me. You will need to have at least one person you trust who you can call to discuss a challenging situation or process an interaction.

As an early career psychologist, my community of buddies has been critical to my growth as a therapist and person. Once I was out of graduate school, I lacked some of the inherent structures that can promote cultural growth. For instance, our research team in my doctoral program was composed of passionate social justice advocates. I was bombarded with ideas and new ways of thinking almost daily. Relatively early on in my first faculty position, I realized I was missing this community of people. I had maintained a connection with several of my colleagues from graduate school but felt the need to add to this group. Through participation in professional psychological organizations, I was able to connect with other individuals who had a deep commitment to diversity and social justice, and they helped me to develop my multicultural orientation in this phase of my professional development.

Self-Awareness: Examining the Log in Your Own Eye

We often judge others who are culturally different. Cultural humility is antithetical to judgment because it involves an open and curious stance toward cultural differences. Like the parable in which we are encouraged to examine the log in our own eye instead of pointing out the speck in another person’s eye, the self-awareness component of cultural humility invites us to examine our own cultural limitations. Thus, in Chapters 2 and 3, we focused inward because self-awareness often precedes shifts in one’s expression of cultural humility in therapy. In Chapter 2, we focused on what it looks like to gain greater self-awareness in a holistic way, including with regard to your knowledge, motivations, relational experiences, and meta- or epistemic cognitions. We invited you to consider your most important cultural identities and cultural beliefs and values, as well as the relationship or intersection between your cultural identities and experiences of power, privilege, and oppression.

In Chapter 3, we refined our discussion to focus on becoming more comfortable with exploring cultural differences, as well as identifying and reducing your cultural biases and exploring what to do with your power and privilege. In this way, self-awareness provides the starting place for working on reducing your biases and being more comfortable engaging with clients who are different from you. We invited you to engage in learning activities about cultural groups that you do not know much about, actively work on reducing your cultural biases, and develop a plan for how to use your experiences of power and privilege to fight for justice.

Challenge 2: Find places where your cultural worldview and perspective is challenged and stay there. When it comes to cultural beliefs and values, people often gravitate toward communities in which people share the same values and perspectives. This occurs even in professional organizations (e.g., the American Psychological Association) that appear to be culturally heterogeneous. Our worlds can quickly become smaller and smaller unless we make an explicit commitment to put ourselves in situations in which our cultural worldview and perspective are challenged.

Donnie: Sometimes being challenged means finding new communities and forming new relationships that are outside your comfort zone. Other times, being challenged means staying in communities, even though you may have personally changed. In my first few years in the profession, I was part of several professional psychological communities interested in the integration of spirituality and counseling (e.g., Christian Association of Psychological Studies). These groups were important to my development as a psychologist and helped me explore and develop my perspective of what it meant to be a Christian and a psychologist. It was helpful to hear other people talk about issues involved with integrating these identities in their lives.

These groups helped me gain a sense that part of my role is to take a seat at the table and become a good citizen within the broader profession. For me, this stands in contrast to a tendency within some of my communities to pull away, wanting “Christian music,” “Christian schools,” or “Christian psychology.” As I started to feel more comfortable in my professional psychological groups, however, I noticed feeling less connected to conversations happening in other Christian communities. Sometimes I felt a tension in my Christian community and felt like people did not understand some of the ways I was growing and changing. An easy way to resolve these tensions might have been to leave, but I was committed to sitting with the discomfort and working to seek greater integration.

What I realized looking back is that “sitting at the table” is key to having one’s worldview challenged. Real change and growth occur within the context of community and having relationships with real people. Each of us has had to strategically work to expand our relationships according to our areas of developing expertise. It is easy to join communities that resonate strongly with our values, but it is also important to seek relationships that will expand our ability to form strong relationships with people with different values and perspectives.

Challenge 3: Develop a plan to grow in cultural humility in areas of limitations. A key aspect of cultural humility involves having an accurate sense of one’s strengths and limitations. Instead of looking for ego-boosting evidence and attempting to justify ourselves and our position, cultural humility involves sincerely wanting to see and understand ways we can do a better job meeting the needs of our clients. More than anything, cultural humility involves a willingness to continue to seek feedback. We never fully “make it” or “arrive” at a place where we do not need feedback from other people to help us see our potential limitations. Believing one has made it or arrived might work in a variety of other professional areas, but it simply does not work when the intention is to cultivate one’s cultural humility. We must adopt a stance that is responsive to continual change and growth.

Josh: It has been important to me to continue to seek out feedback for how I engage with cultural humility in my personal and professional relationships, as well as in the context of teaching the graduate multicultural counseling course. This process isn’t always easy. Even though I am committed to the process, I still struggle sometimes to maintain an open and nondefensive stance when receiving feedback about my struggles or limitations. For example, I was part of a discussion in which students expressed frustration about a lack of engagement and support about social justice issues. At first, I felt the pull to argue and defend myself. Don’t they notice how I’m trying to implement issues related to social justice in my coursework? Don’t they see me trying to integrate social justice issues in my research and writing?

When I felt these reactions coming on, I tried to press the pause button on my response and see whether there was anything I could learn from this feedback. Once I took a breath and thought about it, I realized my reactions were defensive, and I had to ask myself some tough questions. How much did I value social justice and advocacy, even when it was inconvenient or difficult for me? How involved had I been in supporting the students in their work on advocacy and social justice? How much was I infusing my coursework with activities and discussion related to advocacy and social justice? These were tough questions, and they didn’t have easy answers. But if I want to continue to grow and develop in my cultural humility, I have to be open to this type of feedback. I have to sit with the feedback, even if it is uncomfortable and see what it might have to teach me. I have to view feedback as a gift and not back away from it or avoid it.

Self-awareness is only the first step. For self-awareness to lead to growth, it is crucial to engage in the process of responding to what you have learned. In this book, we suggested some general strategies, but you will need to take these strategies and contextualize them to your professional goals, cultural identities, and developmental needs. As you do this, our main encouragement is to stay realistic and to focus on follow-through. It’s easy to overpromise. Develop professional rhythms in which you assess, set new goals, monitor progress, and assess again. Make strategic investments that will build on your strengths and help soften some of your limitations.

Donnie: For example, as I was starting my doctoral program, I realized I had considerable experience with spiritual clients. I completed a master’s program specifically focused on the integration of spirituality into counseling and completed nearly 500 hours within a religiously affiliated counseling center that was different from my personal faith. I was also working with a doctoral mentor who focused on similar issues. So, in my clinical work, I explicitly decided to focus on other aspects of diversity. For example, I realized I needed and wanted a better understanding of gender in my clinical work. So, in my second year, I co-led a group on men’s issues with a staff member with that expertise. This put me in a position to grow quickly. I had a strong supervisor who was aware of my goals. He gave me lots of readings. He got to know me personally and as a clinician and could contextualize what I was reading within our supervision. The next year, I reassessed and set new training goals. The key is strategically turning awareness into action. Awareness alone does little good. Neither does making a bunch of unrealistic plans. Learn to regularly assess areas for potential growth and put yourself in places where growth can occur.

Infusing Cultural Humility Throughout the Entire Process of Therapy

In Chapter 4, we started to focus on the implications cultural humility has for the various aspects of the psychotherapy process, including intake, diagnosis, case conceptualization, treatment planning, and use of interventions and techniques. Given that the multicultural orientation framework is intended to be pantheoretical—not loyal to or derived from any particular theory of psychotherapy—this chapter was necessarily a conversation starter and will require elaboration within various theoretical communities.

We do acknowledge that some theoretical traditions may have elements that are in greater alignment or misalignment with some of the core themes of the multicultural orientation model, especially as practiced within certain settings or professional communities. For example, if you primarily conduct therapy using a structured manualized therapy approach, this may not line up neatly with our suggestion to cocreate a treatment plan with clients, infusing cultural considerations along the way. Our main suggestion is to take what you can from what we have presented and think about ways in which you might creatively integrate aspects from the multicultural orientation model into your chosen theoretical approach. Also, some communities may not view issues related to culture and diversity to be of high importance. If you are brave, you might consider how you could use some of the key ideas in our framework to challenge the assumptions within the community of people who share your theoretical orientation.

Challenge 4: Seek explicit ways to integrate cultural humility into each part of your process of therapy. The psychology profession creates opportunities to think about how culture might affect business as usual. For example, a common question on internship interviews involves giving someone a case to conceptualize. After the interviewee discusses their conceptualization of the client for a while, the follow-up question might ask how knowing that the client is from another racial or ethnic background might affect one’s conceptualization and treatment plan. This sort of perspective taking is important and can generate ideas worth exploring, but in Chapter 4, we explored more specific ways to incorporate culture into several aspects of the psychotherapy process. We discussed some specific ideas and activities, but actualizing this professional commitment will require ongoing creativity based on your current setting and developmental needs.

Jesse: I try to infuse cultural humility throughout the course of my therapy work. For me, this process starts with the acknowledgment that I know I am going to make some mistakes—I am not perfect (or even close) in how I address culture in the therapy room. However, having grown up in a working-class family, I believe that what I lack in natural talent, I can make up in dedication, caring, and loyalty. In my work with clients, I am frequently humbled by what they bring to the therapy room—much of which is outside my personal experience. Cultural humility for me is a way of being with my clients, an attunement to cultural opportunities, and trust in the process of psychotherapy—even the ups and downs. I try to ground myself before every session, through mindfulness, to be better connected with my clients (including their cultural identities) and let go of the other distractions in daily life. Moreover, I attempt to fully put myself in the shoes of my clients—to truly understand how they live, how they think, how they feel, and why they do what they do. This immersion is at the heart of cultural humility.

Challenge 5: See whether you can use cultural humility to initiate change within the community of people who share your theoretical orientation. As noted earlier, after reading through Chapter 4, an important next step will be to contextualize the multicultural orientation framework within your theoretical tradition and community of people who share your theoretical orientation. This process will require ongoing professional dialogue and development and refinement of one’s theory and practice.

Josh: When I began to focus more of my professional and personal work in the area of cultural humility, one of my struggles was figuring out how to integrate this framework within the broader community of psychologists interested in the intersection of psychology and religion. My sense was that cultural humility was a difficult concept for some religious psychologists because it can be challenging to remain humble when a client challenges one of your deeply held religious or moral values. But I believed it was important, so I tried to start the discussion. I wrote an autobiographical paper sharing my experiences developing cultural humility in my work (Hook, 2014). I conducted research about what it looked like to be culturally humble about one’s religious and spiritual perspective (Owen, Jordan, et al., 2014; Woodruff et al., 2014). I gave presentations about cultural humility at conferences in this community. And I used my blog to disseminate some of what I was learning related to the intersection of cultural humility and religion or spirituality.

I have received a variety of reactions to my attempts to integrate cultural humility in this professional community. Some people have thanked me for giving words to things they were struggling with themselves and encouraged me to do even more. Others have not necessarily agreed with me but have been interested in engaging in the discussion and dialogue. Still others have been critical or questioned whether I was moving away from my faith, which was hurtful and difficult to navigate. Although the reactions have been varied, the process has been good for me. It has been challenging to refine my thinking on cultural humility and even see some of the limitations of the model. We imagine you may encounter difficulties or struggles yourself when trying to integrate the multicultural orientation framework within your professional community. Our hope is that you would stick with it, even when it is difficult. Even when tough and challenging, the process of dialogue and engagement is likely to result in movement and advancement for how to positively engage cultural identities in a variety of theoretical approaches.

Cultural Humility During the Formation, Maintenance, and Repair of Therapy Relationships

Chapters 5 through 8 focused on what it looks like to express cultural humility throughout the process of a therapy relationship. We need cultural humility to form a strong working alliance with clients (Chapter 5), repair relationships after cultural offenses (Chapter 6), and navigate value conflicts when they arise (Chapter 7). Moreover, because one of the core components of cultural humility involves an awareness of our limitations, it is inevitable that we will experience situations during our therapy work in which we struggle and run into a limit. A big part of what it means to be a culturally humble therapist is to have the humility to admit limitations and to get help (Chapter 8).

We function best when we are integrated into a community. What should be quite clear by now is that cultural humility is not something you can develop through taking a single course or by reading a book. In fact, it does not make sense to think of cultural humility as something you possess as an individual alone. The world is just too complex. Imagine a person in today’s society who tried to function only on the information they could access by personal experience or memory. This person would fail in almost any industry. Tools such as Google and PsycINFO make large quantities of information highly accessible. Making good decisions requires humility—knowing when you have limits and having a good sense of the tools available to help address those limits. These examples should make us aware of how dependent we are on others to best serve our clients’ needs. We are functioning within a broader system with a charge to help improve the mental health of those who trust us with their psychological welfare. We have limitations, and to grow and become more culturally responsive, we have to invest in our various personal and professional communities.

Challenge 6: Continuously explore and assess your privileged and marginalized identities, as well as their potential impact on your ability to form a strong working alliance with clients. A critical requirement of this challenge is to recognize first that our identities are not stagnant. They are fluid and can be influenced by life events, context, and contacts with others. We are not suggesting that all your identities will change, but the idea that your constellation of identities today will be identical to your constellation of identities 5 years from now or maybe even 5 months from now is a fallacy. If you accept this point about your identities possibly moving or shifting over time, you will recognize the need to consistently explore your identities for areas of privilege and marginalization and the ways your current constellation of identities could affect your work with clients.

Cirleen: As I shared in the Introduction, I am a first-generation college student. Despite the fact that my parents did not graduate from college, there was never a question that I would obtain a college degree. Eventually, I did obtain a bachelor’s degree, then a master’s, and finally a doctorate. Within my lifetime, the educational attainment within my family shifted greatly. Thus, although being a first-generation college student remains a part of my identity and allows me to relate to others with a similar experience, I now also have to integrate my identity as a highly educated person into my overall constellation of the identities that make up who I am. Interestingly, it took some time for this identity to become salient for me. It didn’t feel easy to integrate “doctor” into my understanding of myself. However, by not doing so, I was creating a point of potential disconnect with my clients—both the highly educated and less educated ones. By not acknowledging this identity, I was not acknowledging my privilege, and I was missing points when this could have been a salient factor for my clients. I was also less integrated myself, which wasn’t great for working with clients (or for life in general).

Now, in addition to having a doctoral degree, I am a professor. I not only obtained a high level of education but I also now do education for a living. Again, because this isn’t exactly something I imagined for myself, I tend to minimize the status that may be associated with my occupation (beyond the fact that I have a so-called occupation or career), and again, I have to process what this identity means to me and how it may affect my interactions with others. So, this is a process. As I develop and my identities shift and change, I will try to recognize those shifts and explore how they affect my relationship to power and privilege and the ways in which I develop my relationships with others, including my clients. It is crucial for us to continually examine our cultural identities, including the intersection between our identities and experiences of power, privilege, and oppression.

Challenge 7: Refuse to dismiss or deny the perspectives of clients. This commitment might appear simple on the surface, but it is difficult to accomplish. Inevitably, our set of identities (i.e., who we are) makes it easier for us to hear certain perspectives and harder for us to hear other perspectives. We each have mental ruts, narratives, and loyalties that can make it hard to fully understand the lives and experiences of our clients. In addition, we want to see ourselves as good and moral people. We want to believe our behavior helps clients and does not harm them. So we are motivated to defend our honor and perspective on life, including our interactions with clients. But sometimes we do hurt or offend clients. A key expression of cultural humility involves owning our tendency to view ourselves well, which can make us susceptible to justification and defensiveness in the context of conflict. To counteract this tendency across all our relationships, we must refuse to dismiss or deny the perspectives of others, even when we strongly disagree with their values or worldview.

Donnie: I once had a client who was very defensive. She had recently gone through a bad breakup. I got the sense that she did not like men, and she expressed as much when we explored this issue. After a session or two, she seemed frustrated. I wasn’t sure why. I remember starting to challenge her on the basis of a few ideas I had discussed in supervision. She stopped coming to therapy after her third session. I don’t know for sure why she didn’t come back to therapy, but if had it to do over again, I would try something different. I remember feeling defensive and ultimately blaming her for being a “resistant client.” The blame may have been masked behind some complex conceptualization, but the conclusion was that the issue was with my client, not me. In hindsight, I needed to listen when I noticed signs of damage to our relationship. I’m not sure what she would have said if I had slowed down and asked.

Make a commitment to soften your defensive reactions and explore signs of cultural rupture with your clients. Let go of your need to be “right” and instead focus on being open and curious toward your client’s experience. Having a therapist who is right does the client little good. What clients need is a therapist who will model effective ways of exploring and working through conflict and hurts.

Challenge 8: Consistently work to stretch your zone of toleration for connecting with clients who hold different cultural beliefs and values. Some cultural limitations will resolve with intentional effort. However, we all have some cultural issues or biases that are fundamental to who we are, and it may take consistent effort over a long period to experience significant growth and learning in these areas. In his work with couples, John Gottman said that some problems are perpetual—they reflect differences that can be managed respectfully but that will never completely disappear (Gottman & Silver, 1999). One aspect of cultural humility involves acknowledging parts of our identity that may require lifelong processes of growth and refinement.

Donnie: Religion and spirituality is one of those areas for me. I am deeply committed and believe that I will always consider myself a person of faith. At the same time, the communities I am involved with (e.g., religious and professional) are deeply divided on other issues of diversity, including gender roles, sexuality, and race and ethnicity (or other political issues that have racial overtones).

I remember one conversation that stands out in my mind as an example of how a person can work to increase their cultural zone of toleration over time. I attended a conference in which Ralph Hood gave a talk that included a documentary he made on religious traditions that practice snake handling (Hood, 2009). What stood out to me was how respectful he was toward that religious tradition. For example, he systematically debunked some common misperceptions of that group, including information about the likelihood of being bitten (much smaller than one might expect). Deeply curious, after the talk, I asked Ralph whether he had ever tried snake handling himself. He quickly responded, “Oh, no! I do not share that belief, so I would not mock their beliefs in that way.” Ralph’s reaction shifted my perspective. I still had major reservations about that particular faith perspective, but I realized why he is one of the few psychologists who has ever been trusted to study this community. He deeply respected their way of life—not in a manner that was condescending but with genuine, full-bodied respect.

Sometimes our cultural perspectives and biases change more slowly, but we do believe it is possible to put yourself in relationship contexts that will lead to greater cultural humility and an increased zone of tolerance for developing relationships with others who hold cultural beliefs and values that are different from your own. Through these relationships, we can internalize more complex ways of understanding cultural differences.

Challenge 9: Own your cultural limitations when you recognize them. As described in Chapter 8, one expression of cultural humility is remaining committed to owning limitations that arise in clinical work. When we respond to our current level of awareness, we set the stage for growth and increased awareness. In contrast, adopting a defensive stance closes the door to growth. This is the danger of “competence” language. As soon as we think we have made it or arrived, we become less receptive to learning and growing.

Jesse: As a clinical supervisor, I remember recognizing a significant limitation for both the treating therapists (cotherapy model) and myself in the treatment of a couple who was engaging in BDSM (i.e., bondage/discipline, domination/submission, sadism/masochism) behaviors, as well as intimate partner violence. The difficulty I had with this particular case was that the line between consensual sexual expression on the one hand and emotional manipulation and physical abuse on the other hand was quite blurred for this couple. It was difficult to figure out whether their sexual practices were a normal variant of sexual expression that should be respected or whether the behaviors were abusive and dangerous (especially to the female client, who was on the receiving end of the sometimes violent behavior). The treating therapists were still new to couples therapy, and I had never encountered this type of dynamic in a couple in my practice. I quickly sought consultation from a trusted colleague. After discussing the case, we determined that because of the complexity of the case, combined with the cotherapist’s inexperience and my own lack of experience with these issues, it would be best to transfer the case to a more experienced therapist.

Final Thoughts

At the beginning of this book, we suggested a shift in perspective that involves adopting a multicultural orientation that values diversity. We are all deeply affected by identity-related wounds associated with privilege and marginalization. Our privilege can blind us to the pain of others and make us comfortable treating others as less, rather than equally, deserving of dignity and respect. Likewise, we have experiences of marginalization and hurt, but these experiences do not necessarily show us a way forward to work through our pain, help alleviate the pain of others, or effectively engage relationships or systems in advocating for greater levels of justice.

One of the best ways to change who you are as a person is to change your commitments. Commitments have the power to shape our future because they involve clarifying the kind of people we hope to become, making specific plans, and making ourselves accountable to follow through. With this in mind, we presented nine challenges. We have made these challenges to each other, and we invite you to share them with us. We cannot actualize these commitments alone. We need one another to work out these commitments in real life.

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