Psychology Personal Strategies for Multicultural Humility and Orientation Assignment

Cultural Humility

Joshua N Hook; Don Davis; Jesse Owen; and Cirleen Deblaere

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

Chapter 4 Cultural Humility and the Process of Psychotherapy

The unlike is joined together, and from differences results the most beautiful harmony.

—Heraclitus, The Fragments of the Work of Heraclitus of Ephesus on Nature (Ingram Bywater, Trans.)

Jesse: I have always wondered how therapy works. There are so many complexities to the therapeutic process it can be daunting to consider them all. As psychotherapy researchers, we commonly try to isolate specific techniques or therapeutic processes to gauge whether they are associated with better client outcomes. This approach is common to the scientific process, in which we try to “control” certain variables so we can isolate the effect of one particular variable of interest.

Although we have learned a lot about what works in therapy over the years, I have frequently been dismayed by the field’s lack of attention to the role of culture. Even when culture has been included as a topic of interest, the results often have not been satisfying. For example, at times I have found that the scientific method, when erroneously applied to culture, can promote generalizations and stereotyping (e.g., the best treatment for X race is Y treatment). This prescriptive approach to the study and practice of culture and psychotherapy just never made sense to me.

In my practice and work with clients, I recognized that my therapeutic style is a natural expression of how I am on a daily basis. The language I use, how I sit, the metaphors and examples are all parts of me. When I train future therapists, I try to encourage them to find their voice. Theory, the use of techniques, and empirical support are important to a certain extent. However, the expression of theory, techniques, and research in the therapy room has to be real and true to the therapist. With this mind-set, I think it is important to be genuine and flexible about how we discuss and conceptualize the role of culture in therapy.

This chapter marks the beginning of the second section of this book. The remainder of the book is focused on the practice of therapy and how to engage clients with cultural humility in the therapy room. This chapter can be conceptualized as a bridge between the theory and self-awareness work presented in the first three chapters of the book and the practical application focus of the chapters to come. The purpose of this chapter is to integrate the theoretical pillars of the multicultural orientation model with several of the main tasks of therapy.

Cultural Humility, Multicultural Orientation, and Psychotherapy

In Chapter 1, we described the origins, the broad assumptions, and the three pillars of the multicultural orientation model (i.e., cultural humility, cultural opportunities, and cultural comfort). In this chapter, we build on that foundation and discuss the therapeutic mechanisms of cultural humility in psychotherapy. In other words, how does cultural humility appear in some of the main tasks of therapy? What differentiates more culturally humble therapeutic processes from less culturally humble therapeutic processes? It is these questions we hope to address in this chapter. First, we discuss how cultural humility can inform intake procedures, including intake forms, the initial interview, and creating clarity about the therapy process. Next, we discuss how cultural humility relates to case conceptualization of clients’ distress, the process of diagnosis, the development of a treatment plan, and the techniques used in therapy.

Before we begin our discussion of cultural humility in the context of psychotherapy, we want to be transparent about some of our broad theoretical assumptions about how therapy works. Of course, you can agree or disagree with these tenets as you see fit, but we want to make them explicit, so you know our position. First, it is helpful for therapists to use a theoretical model or an integration of multiple theoretical models to guide their work with clients. These models can inform how you approach a client’s course of treatment from start to finish (e.g., intake processes, termination). Second, the therapeutic relationship is an important mechanism of change (Horvath, Del Re, Flückiger, & Symonds, 2011), and the therapeutic relationship works in tandem with therapeutic techniques to maximize the effectiveness of therapy (e.g., Barber et al., 2006; Owen & Hilsenroth, 2011). Third, therapy is a cultural process, so there may be a wide variety of therapies and therapeutic interventions that could be helpful to clients (Wampold, 2007). For example, possible helpful interventions could include seeking healing from a religious leader or taking medication. It can be helpful to discuss the range of possible therapies with clients. Finally, therapy is a coconstructed process (by the therapist and client) that unfolds over time. That is, therapists’ expression of cultural humility should invite dialogue and joining with clients. Like most relationships, there will be mutual learning about one’s experiences, values, and beliefs as topics evolve over time if there is space for those conversations. However, being culturally humble does not mean that the client moves into a “teacher” role, providing lessons on their cultural identity. Rather, the client and therapist work to understand the cultural experiences in the context of clients’ lives. To further explore these points, we start with the intersection of cultural humility and intake procedures.

CULTURAL HUMILITY AND INTAKE SESSION PROCEDURES

Intake procedures take place in the beginning session (or perhaps the first few sessions) with clients. There are many ways to conduct an intake session. Depending on the type of treatment facility (e.g., community mental health center, university counseling center, private practice, hospital), there may be a particular protocol requiring the therapist to obtain specific information during the intake. It is beyond the scope of this chapter to describe all the various approaches to conducting an intake session. However, we encourage readers to explore different intake approaches, such as the therapeutic model of assessment (e.g., Finn & Tonsager, 1997; Hilsenroth & Cromer, 2007).

Typical goals of the intake are to (a) develop an initial relational bond between client and therapist, (b) assess the client’s presenting concerns (e.g., symptoms, characterological patterns), (c) understand background information (e.g., family history, psychiatric history, education), (d) gather information about current contexts (e.g., family, friends, social network, work or school, legal concerns), and (e) develop an initial sense of the agreed-on goals for treatment. We believe that an important additional goal of a culturally humble intake should be to obtain information about the client’s salient cultural identities, how these identities intersect with the client’s presenting problem, and how the client might want their cultural identities to be incorporated into the therapy process.

Although the first session sets the tone for the therapeutic relationship between therapist and client, this relationship may have started to form even earlier. Therapists can influence clients’ initial impressions through factors such as (a) how they present themselves on their website or advertisements, (b) how they set up their office and waiting room, and (c) whether they use intake forms that the client views as culturally appropriate. Clients commonly complete intake forms describing their demographic information, reasons for seeking help, screening tools (e.g., depressive screening instrument), and insurance information. For instance, consider the following example, which focuses on messages that a client might receive from a therapist when completing the intake form.

Intake Form: Cultural Considerations

In Exhibit 4.1 we have copied an example of part of an initial intake form that a client might fill out before seeing a therapist for the first time. As you read the intake form, see whether you can think of how it might cause some clients to feel as if the therapist might not be culturally safe. As you read the intake form, what aspects did you think were culturally appropriate? Alternatively, were there any aspects you thought might alienate clients from certain cultural backgrounds? For example, did you notice that the gender categories assumed that individuals identify as either male or female rather than the various other types of gender identities (e.g., genderqueer, transgender)? Furthermore, the labels male and female refer to biological sex rather than gender (e.g., man, woman, transgender, genderqueer). How would you feel if you identified as transgender and were asked to fill out a form such as this? You might worry that the therapist does not know much about counseling transgender individuals or, worse, that the therapist might think something negative about you because of your transgender identity. The open response field for race and ethnicity, in contrast, allows clients to define their racial or ethnic identity without imposing a priori restrictions.

EXHIBIT 4.1

Intake Form Example

Name: _______________________________

Please indicate your age: ______________

Please indicate your gender: Male Female

Please indicate your sexual orientation: ________________________

Please indicate your race or ethnicity: __________________________

Please indicate your religious affiliation: Christian  Muslim  Buddhist  Hindu  Jewish  Atheist  Agnostic  Other: _____________

Please indicate your ability or disability status: _____________

Please describe your primary reason for seeking treatment:

_________________________________

_________________________________

A second issue with the intake form is that none of the questions provide the therapist with any sense of which of these cultural demographics are more or less salient for the client. For instance, it could be that the client’s race or ethnicity is not a salient cultural identity, even if the client identifies as a racial or ethnic minority person. In contrast, it could be that their religious identity is more central to their identity and to why they are seeking help. In Chapter 2, you completed the Multigroup Ethnic Identity Measure (Phinney & Ong, 2007), which is an example of a measure that could assess the salience of a client’s ethnic identity. A more thorough intake form that asks not only about various cultural identities but also about (a) the degree of salience of one’s cultural identities and (b) how one’s cultural identities are related to the reason for seeking help can communicate to the client that the therapist is interested in the client’s cultural background and experiences (beyond a superficial level) and also values those aspects of the client’s life.

Initial Contact With the Client

The therapeutic process can also be influenced by the initial greeting and therapeutic approach used during the intake session. How therapists and clients relate to one another during the intake session sets the tone for the foundation of connectedness and trust (cf. Bordin, 1979). In addition, these first impressions can help clients understand whether the therapist and therapeutic setting form a culturally safe place (Frank & Frank, 1991; Wampold & Imel, 2015). In other words, do clients feel as though their cultural identities, perspectives, background, and experiences will be respected and honored by the therapist?

If you are currently involved in clinical work, take some time and think about how the initial environment clients experience might feel more or less culturally safe to them. To do this, think about all the steps a client would take to arrive at the initial intake session. For example, if your clinical site uses advertising or has a website, do you notice anything about these forms of communication that might make a client feel culturally safe or unsafe? What about the intake forms? Also, consider factors such as the therapy office and waiting room. Is your office accessible to people who have physical disabilities? What reading materials do you have in your waiting room? Do they represent a range of cultural identities, or do they mainly reflect your cultural identities? If you have office staff, have they been trained to engage with clients in a culturally humble manner? What other things do you notice about your therapeutic environment that might contribute to cultural safety (or lack thereof)? If you notice something you think could be improved, are you willing to bring this up and advocate for the change? Why or why not? In addition to reflecting on the degree of cultural safety yourself, it can be helpful to consult with cultural experts and have them assess the degree of cultural safety of your clinical environment. This type of consultation can assist you to identify barriers to safety of which you may not be aware.

During the intake process, clients are also evaluating the overall expertise of the therapist, as well as the degree to which they find the therapist capable of relating to their cultural story about the nature of their problem and what might be helpful in therapy. As mentioned in Chapter 1, we contend that the therapeutic relationship is coconstructed by the client and therapist. That is, we do not think it is possible for therapists to present as value neutral or as blank slates. Instead, we believe that both clients and therapists bring their cultural values and experiences to the process of therapy, and these cultural values and experiences affect the initiation and maintenance of the therapeutic relationship.

Case Example: Fredrick and Ronny

Fredrick, a 46-year-old, biracial (Mexican American and Irish American), heterosexual, cisgender man, is a therapist at a local community mental health center in New York City. Many of his clients have lower incomes and struggle with previous trauma experiences. Several of his clients also present with experiences of economic and racial oppression, resulting in complex presentations. His new client, Ronny, is a 31-year-old, biracial (African American and Italian American), heterosexual, cisgender man. Ronny is presenting for treatment after losing his job as a computer analyst. He is currently facing eviction from his house, his girlfriend of 4 years left him shortly after he lost his job, and he describes many depressive symptoms mixed with underlying symptoms of anxiety. The following is part of the dialogue from the initial intake session after Ronny described the combination of factors that are contributing to his depressive and anxious feelings:

Fredrick:  I see that you are really facing a lot of stressors all at once. I can understand how you are feeling down and overwhelmed.

Ronny:  Yah [appears stoic and looks at the floor, with an occasional glance at Fredrick].

Fredrick:  I see that this is difficult for you to talk about. I am wondering why that might be.

Ronny:  I don’t know—just a lot, you know.

Fredrick:  I can understand that, and part of therapy is for you to be open about your thoughts and feelings with me. I am wondering if you can tell me more about how this is affecting you on a daily basis.

Ronny:  I guess so [long pause].

In this example, Fredrick attempted to empathize with Ronny and the challenges he was having in expressing his thoughts and feelings in therapy. After empathizing, Fredrick opted to provide some psychoeducation about how therapy “works” (i.e., “part of therapy is for you to be open about your thoughts and feelings with me”). When he took the conversation in this direction, Fredrick may have missed an opportunity to truly connect with Ronny. It could be that some of Ronny’s reluctance to share and be open with Fredrick is due to not feeling culturally safe in this initial exchange. Imagine you were the therapist in this situation, and consider the following questions:

What cultural beliefs and values could be contributing to Ronny’s reluctance to share?

What could the therapist have done to be more open and curious about Ronny’s process?

Consider the following alternate example for the exchange between Fredrick and Ronny:

Fredrick:  I see that you are really facing a lot of stressors all at once. I can understand how you are feeling down and overwhelmed.

Ronny:  Yeah [appears stoic and looks at the floor, with an occasional glance at Fredrick].

Fredrick:  I see that this is difficult for you to talk about. I can relate to how hard it can be to share these vulnerable aspects about your life.

Ronny:  Yeah.

Fredrick:  I really want this to be a safe place for you to share whatever you feel comfortable.

Ronny:  Thanks, it’s just . . . it’s not typical for me to share these things—just feels weird.

Fredrick:  I can totally get that. We can go at whatever pace you want. No pressure here. Is there anything we can do to help now?

Ronny:  Not sure, but I appreciate it. I know I need to push myself, and it is all very real right now saying it out loud, you know.

The dialogue between Fredrick and Ronny changed quite a bit from the first to the second example. Even though the client did not have a clear sense of what he needed to feel safe, the conversation provided space for Ronny to more fully recognize and explore his feelings. The second conversation also gave Fredrick an opportunity to explore cultural messages about sharing feelings, what it means for Ronny to be in therapy, and to obtain other information about Ronny’s current situation. The process in the second example was much more collaborative.

In addition, from a conceptual perspective, there are several possible explanations for the client’s reluctance to share openly with the therapist. For example, Ronny may be hesitant to disclose because of cultural messages he has received, for example, that men do not show weakness (Mahalik, Good, & Englar-Carlson, 2003), therapy is not a culturally sanctioned place for healing (Wampold, 2001), or therapists should not be trusted (Whaley, 2001). Alternatively, Ronny’s reluctance to share could have little to do with his cultural heritage and more to do with his depressive symptoms. Or the reluctance could indicate some combination of cultural messages and his depressive symptoms. Nonetheless, we contend that by not considering the potential cultural variants to how clients present, the therapist could erroneously “blame the client” for not fully contributing in session. Indeed, Ronny’s reluctance to engage in therapy could be interpreted as “resistance” or “not being ready to change.”

As seen in the previous examples, the initial connection between the client and therapist can be complex and, at times, subtle. We hope as you seek to express greater cultural humility, this will lead you to reexamine the structures (e.g., intake forms) and processes that guide the intake process. More specifically, a culturally humble stance includes, in part, approaching the initial therapeutic encounters with the following questions in mind. First, are my intake structures and practices (e.g., website, forms) inclusive of my clients’ cultural identities? If not, what could I do to change these structures and practices to present a more inclusive and welcoming environment? Second, how are my cultural background, beliefs, and values, as well as my clients’ cultural background, beliefs, and values influencing how we are connecting in this intake session? Finally, am I providing a culturally safe environment for my clients? What specifically am I doing to provide this environment? How would I know whether my environment was not safe for clients?

Intake Process and Assumptions

Take a moment and think about the processes involved in an intake. What are the assumptions underlying these intake processes? Typically, the therapist acquires a lot of information from the client through a series of open-ended questions, semistructured questions, and clinical diagnostic instruments. For some therapists, the intention of such information gathering is to ascertain a mental health diagnosis, develop a conceptualization of clients and their presenting concerns, and create a treatment plan. In many ways, this process is therapist-centric. That is, the therapist determines the diagnosis and generates the conceptualization and treatment plan. However, how would a more collaborative and culturally humble approach to this process look?

To begin, it can be helpful to consider how clients view their presenting concerns. Frank and Frank (1991) discussed the idea of the illness myth, which is the set of assumptions and beliefs about the etiology of illness (broadly speaking). We all have these assumptions and beliefs about all sorts of illnesses and conditions. For example, when Jesse was growing up, his mother would tell him he should not go out in the cold with wet hair, or he would catch a cold. Jesse still believes that to this day. He is not sure whether this is supported by science, but he (and his mother) believes that one way to get a cold is to go outside in the cold with wet hair. Although this is a simple example, the point is that clients will likely have their own illness myth regarding their struggles.

Understanding the illness myths of clients is an important part of the intake process. Think for a moment about the explanations you have for why individuals struggle with depression. Is it due to environmental factors, such as the loss of a job or a car accident? How about psychological reasons, such as how individuals think about themselves or discrepancies between their actual and ideal self? Or what about medical explanations, such as changes in levels of certain neurotransmitters in the brain? Although psychologists may prefer or tend to use one type of explanation for a client’s presenting concerns, many are comfortable with a biopsychosocial model of conceptualization. This model recognizes that there are multiple sources of explanation for mental and behavioral problems. However, in addition to these justifications, there may be cultural explanations for a client’s presenting concern. For instance, in the earlier example, could a client’s presenting concern be linked to struggles with acculturation, racial or ethnic identity development, or experiences of discrimination? Or what if a client attributed their depression to religious or spiritual factors (e.g., God is punishing me)? Counseling and psychotherapy scholars have historically given more attention to psychological, medical, and environmental rationales (e.g., biopsychosocial) than cultural rationales for clients’ distress.

If you are currently seeing clients, pick one of them. If you are not currently seeing clients, pick a friend or family member who is currently experiencing a mental health problem. Respond to the following questions, and practice thinking about possible illness myths that could explain the client’s problem.

Presenting problem:

Biological explanation:

Psychological explanation:

Social explanation:

Cultural explanation:

Which explanation is most consistent with your personal illness myth for this client? Which explanation is most consistent with the client’s illness myth? What aspects of the illness myth are similar between you and the client? What aspects of the illness myth are different? If the client’s illness myth is different from your illness myth for the client, how could you work to resolve this difference in a way that is honoring and culturally humble toward the client’s illness myth?

How therapists assess and conceptualize the distress of clients guides the treatment process (Frank & Frank, 1991; Wampold, 2007; Wampold & Imel, 2015). There are multiple ways to conceptualize clients’ distress; what is key is being open to how clients understand distress and healing. Just because clients are coming to therapy does not necessarily mean they view therapy as the ideal way to solve their concerns. Moreover, for some clients, the very act of going to therapy is stigmatizing, and those stigmatizing beliefs can influence the course of therapy (see Owen, Thomas, & Rodolfa, 2013). Considering clients’ views in the development of the conceptualization of their concerns and then modifying therapy accordingly may enhance the effectiveness of treatment (Benish, Quintana, & Wampold, 2011).

Case Example: Ned

The differences between clients’ and therapists’ beliefs about illness and healing can be important to the therapy process. Consider the following example. Ned, a 38-year-old, White, heterosexual, cisgender man, attended five sessions of individual therapy. He wanted to discuss whether he should stay at his current job, as well as explore his relationship patterns because he was having difficulty staying in a long-term dating relationship. Both of these issues were causing some mild depressive symptoms. The first two sessions focused on Ned telling his story and history. By the third session, Ned was eager to get into these topics in a deeper way. However, the session stayed mostly on the surface with a discussion of his depressive symptoms, which he did not want to focus on because they were not interfering with his day-to-day life. During that session, the therapist suggested Ned try eating one pound of raw cashews. She stated that they have similar antidepressive qualities as some medications. Ned did not want medication and was puzzled by the comment.

Nonetheless, Ned returned for the fourth session. During this session, he stated that he would like to discuss his relationship concerns. The therapist stated they could not do any meaningful work on this topic until he was in a relationship. The session refocused on his work issues. After one more session, Ned felt that the therapist did not fully understand him and was unable to develop deeper insights about his situation. Rather, she focused more on his thoughts about his depressive symptoms and how he could address those, even when Ned said he did not want to do that.

Given this description, how was Ned’s therapist viewing the presenting concerns? How was Ned thinking of his presenting concerns? What was similar in their illness myths? What was different? What cultural factors could have been useful to explore? How could you have addressed Ned’s concerns in a culturally humble way?

An important expression of cultural humility involves providing clients with the chance to understand and influence how their problem is understood and the approach adopted to work toward treatment goals (see Wampold, 2007). Clients’ sense of clarity about their presenting problem can change over time, and some clients are more invested in understanding the therapist’s perspective and buying into the treatment approach.

In this example, if Ned believed his current distress was due to religious or spiritual factors, medication might not have been a viable or effective treatment option. Other instances are more subtle. For example, a cisgender male client who views expression of vulnerable emotions as a sign of weakness might find it counterintuitive to do things that seek to increase emotional expression. We are not saying that the client’s illness myth should be the ultimate guide to structuring therapy. In some cases, changing how clients understand and attempt to address their problems may be a key intervention. That said, disagreement about the goals and tasks of therapy can undermine its potential success. Thus, therapists should be open, curious, and inclusive of clients’ cultural beliefs about their distress and healing process and use all their innate creativities to draw their own and the client’s perspective about the goals and approach to therapy into greater alignment.

In Ned’s case, it would probably have been more helpful for the therapist to engage him in a more culturally humble discussion about his beliefs about his illness myth. This would likely have involved the therapist being open and asking questions about Ned’s perspective, rather than rigidly sticking to her opinion about the cause of Ned’s problems. In this example, the therapist appeared to prioritize a biological explanation for Ned’s problems. If the therapist had been open to Ned’s thoughts and beliefs about the underlying causes of his problems, she would have discovered that Ned believed the cause of his depressive symptoms was his struggles in dating relationships, as well as his struggles in his relationship with God. Again, we are not saying that the client’s illness myth should be the ultimate guide to structuring therapy, but it is important to respect and value the client’s illness myth. If the therapist had respected and valued Ned’s illness myth, they may have been able to work together to collaboratively develop a plan for therapy that would have prioritized more of Ned’s cultural perspective about his problem.

CULTURAL HUMILITY AND DIAGNOSIS

In many settings, part of the goal of the intake process is to provide the client with a diagnostic impression. The use of diagnoses is commonplace in many treatment settings and is part of most insurance reimbursement systems. A good deal of controversy exists about diagnostic systems, such as the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM–5; American Psychiatric Association, 2013). For instance, the National Institutes of Mental Health director stated, “The strength of each of the editions of DSM has been ‘reliability’—each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity” (Insel, 2013). In other words, the DSM and other classification systems can help provide a common language for professionals to communicate about clusters of symptoms. However, simply knowing a client’s diagnosis or diagnoses is not a robust predictor of treatment success. This latter point is not surprising given that most diagnostic systems, including the DSM–5, focus on symptom profiles and do not fully account for clients’ cultural experiences.

There are also concerns about how diagnoses have been applied to clients from marginalized groups. For instance, data support that therapists are more likely to diagnosis women as being depressed and as exhibiting dependent, histrionic, and borderline personality disorder traits compared with men with the same symptoms (e.g., Becker & Lamb, 1994; Caplan & Cosgrove, 2004). Therapists’ biases have also resulted in less favorable views of racial and ethnic minority clients, sexual minority clients, and clients from lower socioeconomic backgrounds compared with clients with more privileged identities (Caplan & Cosgrove, 2004).

These concerns about the validity of diagnostic systems and their use (or misuse) should serve as an important reminder to therapists to consider the strengths and weaknesses of the common tools we implement (e.g., intake forms, DSM). At the same time, it is important to not “toss the baby out with the bathwater.” The diagnostic systems are not likely to fade away from the professional landscape in the foreseeable future. Accordingly, it is important to explore how therapists can approach the diagnostic process in a culturally humble manner. Consider the following example.

Case Example: Chris and Carl

Chris, who identifies as a 64-year-old, White, heterosexual, cisgender, male therapist, finished his first session with Carl. Carl, a 34-year-old, White, gay, cisgender man, is a local politician who is a rising star in the Republican Party. Carl came to treatment to have a place for personal growth and to vent his frustrations from the day-to-day inner workings of his campaign. Carl also mentioned that some individuals (both within the gay community and the Republican Party) have a difficult time accepting the various aspects of his identity. Despite these concerns, Carl is functioning well, as noted by his success at work and his loving marriage of 6 years to Frank. Also, he is not exhibiting any significant mental health symptoms that meet criteria for a DSM–5 diagnosis. Chris and Carl seemed to have a good first session, standard in many respects, with Chris gathering a lot of information about Carl’s history and current life situation, as well as setting the foundation for a good working alliance.

The intake session ended with a brief goal-setting discussion, and Chris and Carl scheduled a follow-up appointment for the following week. During the week, Carl received notification from his insurance company that his treatment for anxiety disorder not otherwise specified was approved. Carl was shocked because this diagnosis was not discussed with him, and he felt that Chris must not have understood anything he was saying in their initial session. He was also worried what this diagnosis could mean for his political future. At the next session, Carl confronted Chris about this diagnosis. The following is a part of the dialogue:

Carl:  I received this in the mail [pointing to the insurance letter].

Chris:  Yes, on the intake forms you signed, it informs you that I will provide a diagnosis in order for us to do work together.

Carl:  I don’t think I remember seeing that, but if you say so.

Chris:  Sorry, I thought you did, and it didn’t seem like you had questions. What questions do you have now? I would like to clarify anything that is confusing to you.

Carl:  Sure, but I don’t really feel that anxious. I don’t think this fits for why I am here. I wanted to look at personal growth and vent a bit to someone outside of work/personal life circles—you know?

Chris:  Well, diagnosis is a complicated process. It is done by mental health professionals who have a unique perspective, training, and knowledge base. For instance, I heard you saying that you have internal conflict and questioning of your gay and Republican identities that you are ruminating about.

Carl:  I don’t think I said that. I do want to explore those identities, but I am not sure about the anxiety.

What do you think about the exchange between Chris and Carl? Reflect on any reactions you had as you read this dialogue. What do you think Chris could have done to approach diagnosis in a more culturally humble manner? Do you believe that Chris acted in an ethical manner? What do you think Chris should do now?

As you can see in this example, the therapist did not fully explore or understand the client’s cultural identities and how they intersected before providing a diagnosis. He also applied a label that did not seem to fit for the client without exploring and clarifying that label with the client. There are many ways in which the therapist could have approached this process differently, starting with a stance of curiosity, nonsuperiority, and openness about the client’s cultural identities. The therapist must also believe in and justify the diagnosis he is using. The balancing act for the therapist is to respect the client’s perspective and also be clear and cogent regarding one’s diagnostic impressions. Being sure that the client and therapist are on the same page regarding diagnosis will increase the likelihood that there is greater goal alignment to begin the work of therapy.

In many work settings, the reality is that managed care requires a clinical diagnosis for therapists to be reimbursed by insurance companies for their work. How can therapists navigate the realities of managed care yet still provide culturally humble diagnostic impressions? We have three suggestions. First, be honest and forthright with your clients about your diagnostic impressions, as well as the realities of the managed care setting in which you work. These kinds of honest discussions can go a long way in reducing the likelihood of cultural misunderstandings and offenses around the diagnostic process. Second, be cognizant of including information about cultural considerations in your assessment and therapy reports and notes. There are resources available for how to incorporate cultural considerations into one’s diagnostic impressions of clients (e.g., Dana, 2005). Third, be active in encouraging the profession of psychology to carefully consider issues related to cultural considerations and diagnoses, including the benefits and drawbacks of the current diagnostic system, as well as alternate ways of organizing and categorizing clients and mental health issues.

CULTURAL HUMILITY AND CASE CONCEPTUALIZATION

One of the most difficult tasks to learn as a therapist is how to use theory to conceptualize a client’s presenting problem and then translate that conceptualization into a meaningful treatment plan and interventions in session. In this process, it is first important to clarify what exactly you are conceptualizing: the client’s personality, the client’s diagnosis and presenting concerns, and/or the therapy process? Here, we focus on general principles that can help inform your theory-driven process related to understanding the client’s personality and presenting concerns. Later in this chapter, as well as in subsequent chapters, we discuss the therapy process. To be clear, we are not proposing a framework that takes the place of your theoretical orientation (e.g., cognitive behavioral, interpersonal, psychodynamic). Thus, you will have to refer to other texts to develop a theoretically based case conceptualization (see Eells, 2007). However, it is important to understand that all psychotherapy theoretical orientations have cultural assumptions. For instance, some theories, such as cognitive behavioral and psychodynamic, assume that psychological change originates from the individual (vs. others). The roles of independence and responsibility for change are paramount. Accordingly, we encourage you to consider the cultural values and assumptions inherent in various theoretical orientations. We want to demonstrate how the multicultural orientation framework in general, and cultural humility in particular, can be informative to your conceptualization process.

Connecting Culture to Conceptualization

As we mentioned in Chapter 1, the multicultural orientation framework carries an assumption that those who are more oriented toward cultural dynamics will work harder to learn about their cultural background and the cultural background of their clients. Accordingly, our first assumption is that a deep and thorough understanding of the client’s salient cultural identities can contribute to a more complete conceptualization of the client’s presenting concerns. It is important to assess what cultural identities are most salient to the client. Consider the demographic information presented in Table 4.1 that is commonly provided in client descriptions and reflects a deeper psychological structure. These are examples of commonly reported demographic information, along with examples of psychological processes that can aid in the conceptualization process.

For each of the concepts on the right side of the table, there are associated theories and empirical literature to explore further. Thus, in a description of a client, it might be useful to explore these keywords and integrate them into your conceptualization of the client. For instance, consider an African American, cisgender, female client who shares that she feels angry when she gets into discussions with her African American friends about racism in the United States because she does not believe they take it as seriously as she does. This could reflect a difference in racial and ethnic identity developmental stages between her and her friends. Understanding Nigrescence theory (Cross, 1995), a theory of African American racial and ethnic identity development, could be informative for the therapist (and potentially the client) to help normalize the client’s experience and increase insight into the friendship dynamics (e.g., different stages of racial identity development). Accordingly, the interventions that could be implemented might shift according to the specific theoretical orientation of the therapist.

Connecting Cultural Identities to Beliefs and Values

The second assumption in the conceptualization process is that understanding clients’ cultural identities provides a window into their beliefs and values. When clients are raised within a cultural tradition, they likely have learned a particular set of beliefs, values, behaviors, and customs and not learned others. In turn, these beliefs and values and their relative presence and absence should be integrated into the therapist’s theoretical framework for conceptualization.

Case Example: Ben

Consider the following example of Ben, a 35-year-old, White, heterosexual, cisgender, male client. Due to a diving accident when he was in his mid-20s, Ben is paralyzed from the waist down. Ben describes that he was raised to value working hard and that personal happiness is secondary to the value of providing for others. However, in his current romantic relationship, his partner feels he does not care about her, and they fight frequently. He is currently experiencing some depressive symptoms because he feels he cannot connect with his partner, and his work performance is also suffering. Ben has also been struggling to accept his physical limitations, and sometimes he feels angry and sad about his physical disability.

Using a cognitive behavioral approach combined with a gender role conflict approach (see O’Neil, 2008, for a review), the client’s core schemas can be seen as reflecting masculine norms such as the importance of work, independence, and strength. These core schemas then filter down to intermediate beliefs, such as “I should work hard,” “My partner should value my work ethic,” and “A man should be physically and emotionally strong.” These intermediate beliefs then trickle down into the client’s actions and viewpoints in daily interactions, which may not be consistent with these core schemas and intermediate beliefs. A therapist could try to find the balance between respecting the client’s core schemas that are part of a core cultural identity on the one hand and working with the client to determine what beliefs are flexible (vs. rigid) on the other. The therapist could also attempt to identify the interpersonal skills necessary for the client to navigate his relationships with his partner and at work. The therapist could also work with the client to integrate his physical disability into his identity as a man. Without a clear recognition that part of his struggle is directly related to his gender role identity, the therapeutic process could conceptualize his way of being as pathological and dysfunctional.

Conceptualization Should Be Coconstructed

The last assumption in the conceptualization process is that the conceptualization should include the person of the therapist in the understanding of the client. As we mentioned in Chapter 1, we consider therapy to be a two-person process, coconstructed between the therapist and client. As it relates to conceptualization, this implies that the therapist’s cultural values and beliefs play a role in how the client is understood. For instance, if a therapist highly values self-care, they might see a client who works 60 hours per week to be lacking in self-compassion or balance. A culturally humble approach to case conceptualization acknowledges that the therapist has a particular set of cultural values that affect the manner in which he or she views and conceptualizes the client’s presenting problem. Throughout this volume, we continue to encourage you to explore and understand your cultural beliefs and values. In doing so, consider how those values are influencing your perceptions of your clients, your conceptualization of their presenting concerns, and treatment planning.

CULTURAL HUMILITY AND TREATMENT PLANNING

Like diagnoses, a variety of approaches exist related to developing treatment plans (if you develop one at all). Some treatment settings require behaviorally anchored treatment plans, such as “the client will say three nice things this week” or “the client will exercise for 30 minutes three times this week.” Other treatment plans are less defined, such as “we will meet once per week to explore the links between the client’s past experiences with their family and his or her current struggles with romantic partnerships.” Some of the decisions regarding treatment planning will relate to the conceptualization and theoretical orientation of the therapist. For instance, a psychodynamic therapist could generate a treatment plan that is focused on identifying primary defense mechanisms and relinquishing their maladaptive use. A cognitive therapist, however, could develop a treatment plan that is focused on understanding the cognitive model, identifying automatic thoughts and core beliefs, and challenging cognitive distortions. For our purposes, we have no judgments about the specific type of treatment plan you use (if any).

In regard to how cultural humility can be integrated with the process of treatment planning, our main suggestion is that the treatment plan should be a collaborative process between the therapist and client. One difficulty we have with treatment plans as they are generally used is that designing a treatment plan may place the therapist in an overly powerful position in relation to the client. In developing the treatment plan, the therapist decides the direction and course of the therapeutic process. On the basis of our assumption that the therapy process should be coconstructed by the therapist and client, we believe that decisions about treatment plans and the direction of therapy should also be coconstructed by the therapist and client.

Case Example: Julie and Janet

Collaboratively designing the treatment plan and direction for therapy can be difficult, especially if the therapist and client have important cultural differences that influence what they believe is psychologically healthy or indicative of the “good life.” Consider the following example. Julie, who identifies as a 28-year-old, single, White, heterosexual, cisgender female, nonreligious therapist is working with Janet, who identifies as a 26-year-old married, African American, heterosexual, Christian, cisgender woman in therapy. Janet presents for therapy with symptoms of depression and anxiety related to her marriage. She wants to accept a promotion at her job that would involve more money and responsibility, but her husband does not want her to do that and instead wants to start a family and begin having children. Julie, who identifies strongly as a feminist, believes that treatment should focus on helping Janet become more independent and assertive in her relationship with her husband, which Julie believes will alleviate her depressive and anxious symptoms. Janet, however, appears to be committed to her marriage and would like to focus on how to improve her relationship with her husband.

What would you do if you were the therapist in this case? What would a culturally humble treatment plan look like? Would you be able to acknowledge your cultural background, beliefs, and attitudes and perhaps let your desires for Janet take a back seat to develop a collaborative treatment plan?

CULTURAL HUMILITY AND TECHNIQUES

The role of cultural humility in the delivery of therapeutic interventions is of utmost importance. Depending on the client’s cultural background and perspective, certain techniques may be more or less helpful, and some techniques may be viewed as unacceptable. Clearly, there are many ways to negotiate the tasks of therapy, and there are hundreds of interventions, and we cannot cover them all in the scope of this chapter. Rather, we intend to describe the theoretical and practical overlap of cultural humility and the implementation of techniques. Consider the following example.

Case Example: Frank and Edna

Frank, the therapist, is a 48-year-old, African American, heterosexual, cisgender man. Edna, the client, is a 24-year-old, Asian American, lesbian, cisgender woman. Edna came to therapy for difficulties in her romantic relationship with her partner, Liza, and as a result, Edna is feeling anxious most days. She has also not come out to her parents, which is a major source of conflict in her relationship with Liza. The following excerpt is from the second session.

Edna:  I am worried about Liza leaving me. She has not said that she is going to leave, but I am really worried about it.

Frank:  I can see that she means a lot to you.

Edna:  Yes [tearfully].

Frank:  So, there is the struggle between being out to your parents and not wanting to lose Liza, right?

Edna:  I guess so. I am just not ready to tell my parents; they would never understand.

Frank:  Well, I wonder what your long-term plan is for telling your parents.

Edna:  I’m not sure. I don’t know what to do. I am just so anxious.

Frank:  I can understand how you would feel so anxious. I wonder if we should work on skills to help tell your parents, so you won’t feel so anxious?

In this dialogue, Edna and Frank are trying to negotiate the tasks of therapy. Frank’s conceptualization is that Edna’s anxiety stems from the potential rejection and lack of love from her parents if she were to disclose her sexual orientation. In Frank’s last question, he seems to suggest that disclosing this information is an important next step for Edna.

Think about what you would do in this situation if you were Frank. What information would you want to know about Edna’s cultural heritage when making a decision about whether to suggest she might work on planning to disclose her sexual orientation to her parents? What other information would you want to know about Edna’s relationship with Liza to help inform this negotiation? What other information about Edna’s coming out process would be important to understand? What cultural opportunities did Frank miss in this dialogue?

In this example, there were many options available to the therapist to engage the multicultural orientation framework and be more culturally humble. The therapist could have taken more steps to understand Edna’s goals and how her cultural background, experiences, beliefs, and values fit with them. The therapist also could have used fewer leading questions and comments. A more open stance could have been a more effective way of honoring the client’s autonomy in the process.

The keys to working in a culturally humble manner in the negotiation of tasks for treatment include (a) being aware of your cultural values and how they intersect with the client’s values and presenting problem, (b) taking care not to impose your cultural values onto the client during session, (c) exploring the client’s cultural worldviews and beliefs about the process of psychotherapy, and (d) remaining curious and open throughout the process. We now look at a second example of the delivery of techniques, this time with a high degree of cultural humility.

Case Example: Jannie and Selma

Jannie is a 59-year-old, Irish American, upper class, heterosexual, cisgender, female therapist. She has a strong theoretical orientation toward cognitive behavior therapy. Selma is a 31-year-old, African American, middle class, heterosexual, cisgender, female client. She works as a community organizer for a local nonprofit organization that works to end violence, poverty, and discrimination in the south side of Chicago. Selma is struggling with some interpersonal difficulties at work, which have spiraled into symptoms of self-loathing, alienation from others, and anger (mainly directed at herself). The following is a segment from their fifth session:

Jannie:  You mentioned that you would like to discuss your week at work?

Selma:  Yes, it was the same thing. My coworker clearly doesn’t like me, and I don’t know how to connect. She makes all these plans with other folks and just does not invite me, you know, on purpose.

Jannie:  How does that make you feel in those situations?

Selma:  I get mad, and I just start thinking of all the reasons for why she hates me.

Jannie:  What are the first thoughts that run through your head when you get mad?

Selma:  That I am worthless and stuff.

Jannie:  Do you think you are worthless?

Selma:  Well, yeah, right now, I guess. I don’t know.

Jannie:  What evidence do you have that you are worthless right now?

Selma:  I don’t know. I just don’t fit in, you know? I try, but I feel like I have a sense of anger that’s driving my life right now, and I don’t want to be angry.

Jannie:  So, I hear you saying that you might not be worthless, but you are more angry in general. How do you think those are related?

At this point, the therapist is engaging in Socratic questioning according to cognitive therapy models (e.g., Beck, 1995). The therapist is also linking feelings of worthlessness to anger. However, there are also cultural opportunities within this process. Consider the following alternate dialogue between Jannie and Selma.

Jannie:  You mentioned that you would like to discuss your week at work?

Selma:  Yes, it was the same thing. My coworker clearly doesn’t like me, and I don’t know how to connect. She makes all these plans with other folks and just does not invite me, you know, on purpose.

Jannie:  How does that make you feel in those situations, especially as the only African American in your office?

Selma:  I get mad, and I just start thinking of all the reasons for why she hates me.

Jannie:  How do those thoughts of being mad fit with how you see yourself?

Selma:  I don’t want to be the angry black woman! So, that’s why I feel like I am not living up to what I am supposed to be.

Jannie:  What do you think you are supposed to be?

Selma:  I don’t know, but I just feel crazed that I don’t know how to be and how to be with other folks.

Jannie:  So, there is a sense that this persona “the angry black woman” is not what you want folks to see you as, and at the same time, you are angry. How do you deal with that conflict?

Selma:  I don’t know. I just don’t know.

What reactions do you have to the two dialogues between Jannie and Selma? What differences did you notice between the first and second dialogue? How did cultural humility influence Jannie’s use of techniques in the first and second dialogue? What would you do if you were the therapist in this situation? How would you respond to Selma’s last statement?

In both examples, the therapist is engaging in Socratic questioning, which is a common intervention in cognitive therapy (Beck, 1995). However, in the second example, the use of cultural humility changed the nature of the Socratic questioning to focus on Selma’s cultural identity. The subsequent conversation could have led to a deepening of the therapeutic relationship.

Conclusion

Cultural humility is closely linked to many important processes in psychotherapy. This chapter gave an overview of how to infuse cultural humility into various aspects of the therapy process, including intake, diagnosis, case conceptualization, treatment planning, and the use of interventions and techniques. The key principle is that therapists may come across as culturally arrogant to the extent that they are not willing to integrate the client’s cultural perspective and accept influence from the client as they set the course for therapy. Imposing our assumptions about these factors can undermine effective therapy by eroding trust. Cultural humility calls therapists to authentically value their clients’ perspectives and rights to influence their experience in therapy. Now that we have set the stage, in the subsequent chapters we continue to explore how therapists can express cultural humility in their work with clients.

Chapter 5 Strengthening the Working Alliance

We are like islands in the sea, separate on the surface but connected in the deep.

—William James

Cirleen: My father passed away during the fall semester of my predoctoral internship. Although he died of cancer, his illness progressed rapidly, and he transitioned from surgery, to hospice care, to dying very quickly. I was shocked by his loss and knew I needed support if I was going to thrive in my internship and transition to the next phase of my professional life as something other than an emotional zombie. So I decided it was time to go to counseling—my first experience as a client.

My supervisor recommended his good friend, Dr. W, a well-respected local psychologist. When I first met Dr. W, I observed that he looked like the prototypical therapist—he was a man, he was White, and after briefly discussing his family, I learned he was married to a woman. I was aware of the differences between Dr. W and myself regarding gender and race and ethnicity, and I wasn’t certain whether he was a lesbian-gay-bisexual-transgender ally. Although these identity differences were not explicitly named, you can be certain I noticed.

Despite my supervisor’s trusting this man and recommending him to me, I was immediately wary. There were some pretty big differences between Dr. W and myself, and I wasn’t confident that he would be able to understand me, my background, or where I was coming from. Therapy involves being completely open and honest with another person, and there was something inside me that just couldn’t do that with Dr. W. I knew I was holding back.

Something shifted around the eighth session. I don’t recall the exact topic we were discussing, but I do remember feeling disconnected from Dr. W. Again, at the time I could not put my finger on why—he was insightful, intelligent, and his psychodynamic leanings were an excellent match for my own, but still I was guarded. I think he must have felt something similar, because he said, “You don’t really trust me, do you?” and I blurted out, “No, not really.” That exchange was the start of a deeper and more honest connection between Dr. W and myself. I shared my doubts about his being able to understand me fully or truly empathize with me. I told him that a lot of the time I was guarded because I wanted to protect myself from the next offense. I protected myself outside the therapy room, and I felt the need to do the same inside the therapy room.

That conversation shifted the dynamic between Dr. W and me and began the process of forming a deeper, more intimate connection and working alliance. I remember that my time with Dr. W was helpful. There were a few really important insights I developed during my work with him, not the least of which was recognizing how vigilant I was for potential experiences of discrimination and bias. But when I look back, I remember that he asked; he did not make me have to be the one to bring up our struggle to connect. Also, when I shared my difficulties in trusting him or my doubts that he could understand my cultural background and experience, he didn’t get defensive. He didn’t discount my fears or try to reassure me in a superficial way. Instead, he created a cultural opportunity for us to connect. We didn’t act like our therapy occurred in a vacuum unencumbered by social, cultural, and political influences—influences that have shaped my experience as a woman of color in the United States. That is what I remember the most. As a person who now trains other psychologists, I tell this story. I tell students not to let their fear of being vulnerable stop them from asking important questions. It is critical to developing a strong working alliance. In truth, the session when Dr. W and I had that conversation about trust was the beginning of our best work because my trust in him truly began to develop on that day.

Cultural Humility and the Working Alliance

In this chapter, we begin to consider how cultural humility can help therapists honor, respect, and fully integrate clients’ cultural identities in the therapy process. The focus of the next four chapters is on developing skills that will help in different phases of psychotherapy, including (a) establishing a strong working alliance, (b) repairing the alliance after cultural ruptures or microaggressions, (c) navigating values conflicts in therapy, and (d) working within your limits. This chapter, in particular, focuses on how therapists’ cultural humility can aid in the formation and maintenance of a strong working alliance.

As illustrated in Cirleen’s personal story, there are many ways culture can influence the early phases of a therapy relationship and the building of a strong working alliance. A strong working alliance is marked by a sense of trust between the therapist and client, a collaborative and open relationship, and the purposeful joining to meet the needs of the client. The working alliance is made up of three parts: bond, goals, and tasks (Bordin, 1979).

The bond aspect involves the development of trust and attachment between the therapist and client.

The goals aspect involves an alignment between the therapist and client for what the primary aims of therapy should be.

The tasks aspect involves a collaborative agreement on the therapeutic methods that are used to reach the client’s goals.

Cultural humility can positively affect each aspect of the working alliance.

Close relationships require sacrifice, investment, and support to flourish (see Rusbult, 1983, for a description of the relational investment model), and our relationships with our clients grow and develop in a similar way. We develop these relationships through being unselfish, other oriented, and responsive to our clients in positive ways. Thus, cultural humility plays an integral role in helping build a strong working alliance with our clients, especially when cultural identities are salient to therapy. The importance of cultural humility in building and maintaining a strong emotional bond with your clients aligns squarely with theory and research on the benefits of humility for the development, maintenance, and repair of relationships (Davis et al., 2013; Farrell et al., 2015). The social bonds hypothesis states that perceptions of humility regulate the strength of a social bond (Davis et al., 2013). A social bond is an affinity for a person or group that causes one to act in a relationship-oriented way—that is, to prioritize the needs of the relationship (S. L. Brown & Brown, 2006). Clients who view their therapist as culturally humble (i.e., culturally safe, other oriented, emotionally engaged, and responsive to their needs) will be more able and willing to deepen the therapeutic bond and working alliance. Indeed, cultural humility was positively correlated with working alliance for Black individuals currently in therapy (Hook, Davis, Owen, Worthington, & Utsey, 2013).

Accordingly, the purpose of this chapter is to provide therapists with practical ways of implementing positive behaviors that will strengthen the bond, goals, and tasks of the working alliance. We focus on three main areas. First, we explore how engaging clients with an interpersonal stance of cultural humility can help therapists deepen the emotional bond and connection in therapy. Second, we discuss how therapists can strengthen the therapeutic bond by identifying and prioritizing discussion of cultural opportunities in therapy. Finally, we discuss how therapists can check in with clients and get feedback regarding how clients feel about the ongoing goals and tasks of therapy.

CULTURAL HUMILITY AND DEEPENING THE EMOTIONAL BOND

Engaging clients with cultural humility can deepen the emotional bond in therapy. In this section, we look at cultural humility from two different perspectives. First, we explore how cultural humility can counteract the natural tendency to be self-focused when working with clients who have different cultural identities. Second, we talk about how the other-oriented nature of cultural humility can help therapists to be better attuned to the emotional needs of clients.

It can be challenging to have conversations with clients about their cultural identities in therapy. Therapists might feel afraid they could make a mistake or say something that might offend a client. When we feel afraid, the natural tendency is to avoid the thing we fear. This is a common practice. In many communities, there are strong norms against discussing potentially divisive topics, such as racism, religion, politics, or other emotionally charged issues. It would be natural to extend these norms to the therapy context by avoiding topics related to cultural identity and potential cultural differences.

In this book, we are asking you to do the opposite: to move toward the difficult dialogues and engage with your client in discussions about the cultural identities that are most important to them. If you want to develop a strong bond with clients and have them trust you with all parts of themselves and their experience, we believe this is necessary. Avoidance is not an effective option.

If you do engage with clients in deep discussions about their cultural identities and worldviews, it is likely you will experience some anxiety. This is normal. In therapy, as in any relationship, taking risks to deepen intimacy can be scary. When you do experience anxiety, the natural tendency is to focus on yourself, closely monitoring your reactions and interventions. When you become self-focused, it is difficult to be your real, authentic self and engage with the client in a natural, comfortable way. Cultural humility counteracts this natural tendency to focus on yourself and instead maintains an other-oriented focus. But how do we deal with the inevitable anxiety that comes up during session? The first step is to be self-aware of your internal states when this occurs.

Cultural Security and Anxiety

In this exercise, we would like you first to think of a time when you felt a strong sense of fear and anxiety about making a cultural mistake in your work with clients. If you have not begun to see clients, think about a time when you felt a strong sense of fear and anxiety about making a cultural mistake in a friendship. Take some time to journal about your experience. What was it about the situation, the client, or your perspective that contributed to the anxious feelings? What thoughts, feelings, or physiological reactions came up for you during this experience? Were you more focused on your client or more focused on yourself?

After you have completed this first part, think of a time when you recognized an important limitation in your cultural work with a client, but you felt grounded, secure, and courageous. Again, if you have not begun to see clients, think about a time when you felt grounded, secure, and courageous about a cultural issue in a friendship. Take some time to journal about your experience. What was it about the situation, the client, or your perspective that contributed to the feelings of security? What thoughts, feelings, or physiological reactions came up for you during this experience? Were you more focused on your client or more focused on yourself?

Finally, take a few minutes to contrast these two experiences. What differences did you notice in your thoughts? What differences did you notice in your feelings or emotions? What differences did you notice in your body or physical sensations? What was different about your interactions with your clients? What are the primary markers that you are aware of when you feel a high degree of cultural anxiety?

Mindfulness

Once you become aware that you are experiencing cultural anxiety or insecurity and are beginning to become self-focused, the next step is to learn to cope effectively with these feelings so that they do not undermine your ability to attend to the client’s needs and affective experience. One potentially promising strategy involves drawing on mindfulness practices to attend to and accept your experience but maintain an other-oriented stance of cultural humility. Mindfulness involves cultivating a nonjudgmental awareness of your mental states and has been linked to a variety of positive effects associated with self-regulation and well-being (K. W. Brown & Ryan, 2003; Carmody & Baer, 2008; Galla, 2016). When you notice cultural anxiety or insecurity in therapy, one option is to practice a nonjudgmental awareness of these states, which may help relieve self-focused defensive processes and help you to maintain an other-oriented stance with your clients.

The following activity is designed to help you practice a mental habit of mindfulness regarding cultural anxiety or insecurity in your work with clients. Find a place where you are comfortable. Feel free to sit in a comfortable chair, or sit cross-legged on the floor with your hands resting in your lap. Soften your gaze or close your eyes. Take four deep breaths, spending about 4 seconds on the inhalation and 8 seconds on the exhalation. Notice the different physical sensations in your body, such as what it feels like in your chest or your nose as you are breathing. Now take about 10 minutes to reflect on your work as a therapist, particularly as it relates to engaging with culturally diverse clients. Relax your mind and see what comes up for you. Often our minds tend to gravitate toward the things we feel anxious or insecure about, such as not knowing enough or making a cultural mistake or misstep. If this happens, just observe these thoughts with curiosity. Notice the kinds of situations or experiences that seem to draw your attention.

After you have spent some time reflecting and noticing what comes up for you, repeat the same activity, but this time see whether you can cultivate a sense of compassion toward yourself for these painful experiences of anxiety and insecurity. Imagine yourself tensing and then relaxing any anxious strivings like a muscle. Notice your thoughts closely, but then release them, let them go, and return to a compassionate stance toward yourself.

After you have completed the mindfulness activity, write down any insights you had. If you spend time practicing being in a mindful state, you might find it easier to return to that state in the future, especially when you are feeling anxious or stressed. If you were able to gain a sense of greater peace and security during this exercise, see whether you can link this experience with an emotional image or a phrase. The next time you are feeling culturally anxious or insecure in therapy, try to bring this image or phrase to mind to relax, accept your feelings of anxiety, and maintain a connection with your client.

Offering Care and Support

When you can regulate your anxiety and maintain an other-oriented stance through cultural humility during cultural discussions, the emotional bond between therapist and client is likely to deepen because you are better able to tune into the client and respond to their needs for care and support. Importantly, clients’ needs for care and support may look different according to their cultural background, worldview, and preferences.

For example, Donnie’s dad is from rural South Georgia. To connect with others in this area of the country, people have relaxed conversations on their front porch and tell lots of stories. There is an art to it. Donnie forgot how important this was to Southern, rural culture until he moved back to Clemson, South Carolina, for his predoctoral internship. Everywhere, from the post office to the dry cleaner, people engaged with each other like they had all the time in the world, just like those relaxed front-porch conversations Donnie recalled from his childhood. People from this community connected and provided care and support for one another in a specific way, and it was important to be in tune with what was needed if you wanted to develop a strong bond. In the same way, cultural humility and empathy are necessary to explore how you can best provide care and support for your client.

In this next exercise, we ask you to explore how you tend to offer care and support to those in need. First, think about what you learned growing up in your culture and family about deeply connecting with other people. How did people offer care and support to each other? Take out a sheet of paper and write down whatever thoughts come to mind. Growing up, what things did you learn are crucial when making deep connections with others? What is the pace and nature of the conversation? What kinds of behaviors indicate interest, patience, and curiosity? What kinds of behaviors indicate love, caring, and support?

Next, spend some time thinking and journaling about your natural way of expressing care and support to others. Consider a few key times you had loved ones in pain and tried to offer care and support. What behaviors did you try? What words did you say? What questions did you ask? How did you listen? What strategies seemed to work well, and what strategies did not seem to work as well? Now think about some of your clients who have been in the most pain. What did you try to do to offer relief? What did you say and do? How did you listen? What seemed to work well, and what did not seem to work as well? Do you notice any themes or commonalities across these interactions? How do these themes relate to your cultural or family upbringing? Consider and reflect on these primary strategies you use to provide care and support to others.

If you are reading through this book in a class or practicum team, pair up with another individual in your group, share the main ways you offer care and support, and have the other person do the same. Were there any categories of care and support the other person used but you did not use? If so, this could represent an unexplored or underdeveloped way of offering care and support that you could think about developing in your life and work with clients. Finally, contact (e.g., e-mail, call) several people who know you well and ask them what they see as your strengths in terms of offering support and caring to people in pain. Also, ask whether they have noticed any ways you might improve in offering care and support to others who are struggling.

Empathy is closely linked with cultural humility and involves putting ourselves in our clients’ shoes and trying to understand their perspective. Empathy communicates an intention to understand and extend caring, and it is a critical step. After empathy, the next step is to try to learn how a specific client gives and receives care and support. Clients may give and receive care and support in different ways. For example, Chapman (1992) proposed that individuals have different love languages, or various ways people naturally give and receive love. Some people tend to give and receive love through quality time, whereas others tend to give and receive love through other “languages,” such as encouraging words, physical touch, gifts, or acts of service. Similarly, we each give and receive support in a variety of ways. As we saw in the previous exercise, your ways of giving and receiving support are likely connected to your cultural identities and family upbringing. To develop a strong bond with your client, it is important to tune in and be flexible to how your client experiences care and support. As we discussed in Chapter 1, developing knowledge about various cultural groups is helpful as a starting place for developing our empathy and ability to offer care and support for our clients. However, generalized information about various cultural groups is only a starting place and requires adaptation and contextualization to the needs of the specific client sitting in front of you.

Case Example: Dell and Courtney

Consider the following therapy example between Dell, a 25-year-old, biracial (African American and White), heterosexual, cisgender, male therapist and Courtney, an 18-year-old, White, heterosexual, cisgender, female client. Courtney presented for counseling to work on struggles adjusting to college. She had been feeling sad and homesick and had difficulty making friends and finding a place for herself at her new school. The following is an excerpt from their third therapy session. As you read, think about how Dell offers care and support to Courtney, and consider whether he does so in a culturally humble way.

Dell:  It’s good to see you, Courtney. How have things been going this week?

Courtney:  Not too good [shaking her head].

Dell:  Can you tell me a bit more about how you have been feeling? What hasn’t been good?

Courtney:  I just hate it here. I thought I was ready to move away for school, but I don’t think I am. I feel sad all the time, like I’m always about to cry. All the other people in my classes and dorm seem so confident. They’re always going out, making friends. I just can’t do it [starting to cry].

Dell:  It definitely sounds like the transition to college has been a tough adjustment for you. I wonder if it might be important to clarify your goals, so we have a better sense of what it would look like if things were better.

Courtney:  [Beginning to cry harder] I don’t know. I just want to be happier, more confident in what I’m doing, you know? But I don’t think I can do it.

Dell:  I can see that this is really tough for you. And I think those are good goals—being happy and more confident in tackling this new transition of yours. I wonder if you could imagine being in that place of happiness and confidence—what does that look like for you? What kinds of things would you be thinking about or doing?

Courtney:  [Still crying] I don’t know, I just don’t know.

What reactions do you have to the dialogue between Dell and Courtney? In what ways did Dell try to provide care and support to Courtney? Do you think he missed anything in his interaction with Courtney? What cultural identities of Dell and/or Courtney could have been relevant in this exchange? Do you think Dell engaged Courtney with cultural humility? If not, what could he have done differently?

One thing to consider about this dialogue is the degree to which Dell responded to Courtney’s emotions when they came up. Instead of attending to Courtney’s emotions, he preferred to focus on clarifying Courtney’s goals and helping her to outline what life would look like if those goals were met. Although this may have been consistent with Dell’s solution-focused approach (de Shazer, 1988), it may not have been what Courtney most needed. It may also be helpful for Dell to consider his comfort level with emotions such as sadness and how he could work to support clients in their sadness, even if that is not his natural manner of providing care and support. The following is an alternative way Dell could have responded.

Dell:  It’s good to see you, Courtney. How have things been going this week?

Courtney:  Not too good [shaking her head].

Dell:  Can you tell me a bit more about how you have been feeling? What hasn’t been good?

Courtney:  I just hate it here. I thought I was ready to move away for school, but I don’t think I am. I feel sad all the time, like I’m always about to cry. All the other people in my classes and dorm seem so confident. They’re always going out, making friends. I just can’t do it [starting to cry].

Dell:  I’m sorry to hear that, Courtney. It sounds like things have been pretty tough lately, and you’re feeling really sad and down [offering her the box of tissues].

Courtney:  [Beginning to cry harder] Thanks. Yeah, I don’t know. I was so excited to come to school, but since coming here, I just haven’t been myself. I miss my mom and my family, and I don’t think I really fit in.

Dell:  Yeah, so it sounds like there are two things going on. You miss your mom and family back home, and then it’s been a challenge to feel like you fit in here. It makes sense that you would be sad. I want to be here for you—whatever you need.

Courtney:  [Still crying] Thanks. It helps to get it out, you know? I don’t really have anyone I can talk to about this.

What reactions do you have to this second dialogue between Dell and Courtney? What was the main difference between the two dialogues? In which dialogue do you think Dell was more in tune with Courtney’s needs for care and support? In which dialogue do you think Dell responded to Courtney in a more culturally humble manner? Think about how can you tune into your client’s needs for care and support, even if providing for those needs does not necessarily come naturally to you.

EXPLORING CULTURAL OPPORTUNITIES TO DEEPEN THE BOND

To this point, we have focused on how engaging clients with cultural humility can deepen the emotional bond in therapy. Now, we focus on when and how to explore cultural opportunities that arise in therapy. Exploring cultural opportunities is essential to the process of deepening the bond between therapist and client, especially when the client has particular cultural identities that are salient to the client’s sense of self. Developing a strong bond with a client is usually a process that involves a progression of deepening intimacy over time. Intimacy often grows and develops through self-disclosure (Finkenauer & Buyukcan-Tetik, 2015)—over time, clients share deeper and deeper parts of themselves. Through this process of progressive sharing, a greater trust in and attachment toward the therapist develops. This deeper sense of trust often results in even more self-disclosure and increased vulnerability, and the bond between therapist and client is further enhanced. For many clients, their cultural identities are important and salient aspects of who they are as people. If culture is not an integral part of the therapeutic discussion or if the therapist does not seem open or interested in learning about and understanding the client’s cultural identities, a critical opportunity to deepen the bond between therapist and client may be missed.

Practice Cultural Disclosure

In this next exercise, we ask you to practice having a discussion with a friend or colleague about an important aspect of your cultural identity and see what effect this has on your relationship with that person. The next time you are having a conversation with a friend or colleague, spend some time discussing one of your cultural identities that is important to you. Take a risk and be a bit more vulnerable about your cultural identity than you usually would. Notice any thoughts, feelings, and physiological reactions that come up for you during the conversation.

After the dialogue, spend some thinking, reflecting, and journaling about what happened. How did your friend or colleague respond to your sharing? Was their response culturally humble? Was there anything about the person’s response that was not culturally humble? How did your disclosure about your cultural identity affect the conversation or your relationship with that person? After sharing, do you feel more close to this person, less close, or about the same? What lessons about cultural humility or the importance of exploring the cultural identities of your clients can you take with you as a result of this exercise?

As therapy progresses, there may be times when therapists can get caught up in a focus on symptom reduction or adherence to a particular treatment plan and forget that discussions about cultural identities may be helpful or important in developing a strong bond with the client and, ultimately, in the success of therapy. To maintain a strong bond, therapists have to identify and strategically evaluate opportunities to explore a client’s cultural identity with other aspects of therapy.

This theme dovetails with questions about whether explicitly discussing identity issues in therapy leads to better outcomes. For example, one possible intervention might involve directly noting racial differences in the first session. Currently, research on these questions lacks theoretical and practical nuance (e.g., Hayes, McAleavey, Castonguay, & Locke, 2016). There are many reasons therapists might decide to focus on cultural identities in session, and some strategies are more likely to help contribute positively to the therapeutic bond than others. On one end of the spectrum, it is probably not helpful for therapists to engage in a discussion about race or culture if the impetus for doing so is their own insecurity. On the other end of the spectrum, it can be helpful (or at least it usually does not hurt) to ask clients about how their family or culture views a particular presenting problem or focus of therapy (e.g., grief) and how their personal view is similar to or different from the view of their family or culture. The context is important when deciding whether to explore cultural dynamics within the therapy relationship.

Case Example: Jane and Mateo

Consider the following therapy example between Jane, a 25-year-old, White, heterosexual, cisgender, female therapist, and Mateo, a 65-year-old, Mexican American, heterosexual, cisgender, male client. Mateo sought help to work through issues related to grief and depression following the death of his wife. The following is an excerpt from Jane and Mateo’s eighth session.

Jane:  So how have you been feeling this week?

Mateo:  OK, I guess.

Jane:  Can you tell me a bit more about how you are feeling?

Mateo:  I’m not feeling quite as down as before, but still not great, you know?

Jane:  Yes, I understand—it can be a slow process. How would you rate your depression this week on a 1-to-10 scale?

Mateo:  I’d say about a 6. It’s just tough, you know? Lisa was my life. Everything revolved around our family and community. And now it’s just gone. I mean, people still invite me to things, and my kids still call me, but it’s not the same. I feel like they’re reaching out because they pity me, not because they really want to see me. Family was everything to me, and now I’ve lost it.

Jane:  Yeah, that does sound really tough. I’m wondering if we could talk a bit more about what you think about how people around you are acting. It sounds like some of your friends and family are reaching out to you, but you’re thinking of those actions as reflecting pity, that they don’t really want to see you. It sounds like there’s an automatic thought coming up for you when that happens that might be important for us to explore.

What is your reaction to the dialogue between Jane and Mateo? Did you notice any cultural opportunities in what Mateo shared? How did Jane respond to those cultural opportunities? If you were Mateo’s therapist, how might you have responded in a way that could have communicated to Mateo that his cultural identities were important to explore in therapy?

One thing Jane could have done was explore Mateo’s feelings about his family in greater depth and how his experience of family, as well as his wife’s death, related to his cultural background as a Mexican American. Instead of taking advantage of this cultural opportunity, Jane decided to focus on Mateo’s automatic thoughts about the motivations of his friends and family members who were reaching out to him. This may have been an important aspect of Mateo’s therapy, but Jane may have missed a cultural opportunity as well as an opportunity to deepen their bond by not asking about Mateo’s cultural experiences related to the loss of his wife. Consider the following alternate dialogue between Jane and Mateo.

Jane:  So how have you been feeling this week?

Mateo:  OK, I guess.

Jane:  Can you tell me a bit more about how you are feeling?

Mateo:  I’m not feeling quite as down as before, but still not great, you know?

Jane:  Yes, I understand, it can be a slow process. How would you rate your depression this week on a 1-to-10 scale?

Mateo:  I’d say about a 6. It’s just tough, you know? Lisa was my life. Everything revolved around our family and community. And now it’s just gone. I mean, people still invite me to things, and my kids still call me, but it’s not the same. I feel like they’re reaching out because they pity me, not because they really want to see me. Family was everything to me, and now I’ve lost it.

Jane:  Yeah, that does sound really tough. It seems like one of the things that is especially tough about losing Lisa is that your marriage was something that was so very important to you and felt like a link to your family and community, and now it’s hard to figure out where to go next. I’m curious about how those values of marriage, family, and community might be related to your cultural background. Would you like to talk a bit more about that?

What do you think about Jane’s response to what Mateo shared? Notice how she asked a question about Mateo’s cultural background and invited him to explore that if he wanted to. We want to stress that as a therapist, you will have several decisions about which direction to take in the therapy process. In both examples, Jane chose a certain direction, and the chosen direction could have led to great work by the client. However, we believe that the second example exhibited higher levels of cultural humility and may be more likely to lead to a deeper bond between therapist and client, especially if the cultural identity is particularly important or salient to the client.

Bringing up Cultural Opportunities

It can help to use smooth transitions when we act on cultural opportunities. Sometimes clients might explicitly mention an aspect of their cultural identity during a therapy session. For example, a client may disclose having a sexual experience with someone of the same gender. Or a client who usually does not discuss their religious identity might disclose feeling abandoned by and distant from God. When clients make disclosures about an aspect of their cultural identity, expressing curiosity and interest reinforces the disclosure and likely strengthens the bond. Alternatively, not expressing interest may punish the disclosure and send an implicit message that the topic is off-limits. Thus, our clients may engage in cultural “tests” in which they gauge trust and get a sense of what topics are more or less welcome within the therapeutic relationship.

Other times, we may want to initiate conversations by capitalizing on cultural opportunities related to our client’s salient cultural identities or experiences. These interventions have the potential to backfire when they involve abrupt transitions that come across as unnatural and/or forced. A general principle of therapy, which applies here, is that smooth transitions provide clients with a sense of security and trust (Sullivan, 1954). Especially for clients in acute distress, shifting directions quickly can feel unsettling or even stressful. When we do plan to shift directions, we can acknowledge the shift and perhaps provide a rationale (e.g., “This seems important—your disappointment this week with your brother. It reminds me of something you said earlier that seemed really important.”). We can use similar techniques to explore cultural opportunities. There are often opportunities to link the current topic of conversation to what you know about the client’s salient cultural identities. Even if the client does not have much energy in response to these interventions, their strategic use does signal to the client your general willingness to incorporate cultural themes into therapy and, as trust develops, clients may initiate links between the current themes of therapy and their salient cultural identities at a later time.

Before you see each of your clients this week, spend 5 minutes and think about the various cultural identities of your clients. List the cultural identities that you know about for each client. Then, make a commitment to take advantage of at least one cultural opportunity that arises during the session. Keep it simple. If the client mentions something during session about one of their cultural identities, keep track of it, and when there is a break in the conversation, ask whether the client might want to explore that aspect of their cultural identity in more depth. In particular, see whether you can link the discussion of the client’s cultural identity to what is happening in therapy—either the client’s presenting problem, their values, or how the client is working toward their goals. Do not force the conversation, just mention it and see whether the client wants to discuss it in further depth.

After each session, spend some time thinking and reflecting on what happened. Did you notice any cultural opportunities that arose? Did it help to “prime yourself” by thinking about the client’s cultural identities before the session? How was it to ask an intentional question about the client’s cultural identity? Did it feel comfortable? Did it feel like a normal part of the conversation? Do you think you asked the question in a culturally humble manner? How did the client respond? Did the client want to talk about their cultural identities in more depth? If so, do you feel as if the cultural conversation deepened your bond? How could you work on recognizing cultural opportunities more in your work with clients?

Given the centrality of cultural identities, every session likely has some opportunities to explore connections between a client’s cultural identity and what is happening in therapy. These interventions do not have to be clunky or awkward. For example, a therapist might simply ask, “What did your family think when you did that?” In other cases, you may have reason to risk bringing up more explicit cultural themes, such as naming a cultural difference between you and your client. The bottom line is that regularly taking such risks to explore cultural opportunities sends the message that you care about the client’s salient cultural identities, which strengthens the quality of the bond.

Connecting Issues to Cultural Identities

In this exercise, we list several topics that might be a focus in therapy. For each one, think about the various cultural identities you have learned about, either in your life, your classes, or your work with clients. Consider cultural identities that might be relevant for each topic. Also, think about how you might ask a question about culture if one of your clients brought up the topic.

MONITORING ALIGNMENT OF THE GOALS AND TASKS OF THERAPY

Now that we have discussed engaging with cultural humility and bringing up cultural opportunities to strengthen the relationship bond, the final portion of this chapter focuses on ways of monitoring the goals and tasks of therapy (the other two aspects of the working alliance). This section builds on what you learned in Chapter 4 about negotiating the tasks and goals of therapy in intake, diagnosis, conceptualization, and treatment planning. We recognize that such negotiation is an ongoing process that evolves throughout the course of therapy. Consequently, it is likely helpful to routinely check with clients about how they perceive therapy to be progressing and to confirm that they continue to agree with the therapy goals and approach.

Case Example: Peter and Georgia

Consider the following therapy example between Peter, a 30-year-old White, gay, cisgender male therapist, and Georgia, a 19-year-old South Korean, heterosexual, cisgender female client. Georgia attended counseling to help her to navigate the transition to college. The following excerpt is from Peter and Georgia’s fifth session.

Peter:  Before we get started today, I’d like to check in with you about how you feel counseling has been going. When we started, we identified our main goal as working on your transition to college, specifically navigating your classes and making friends. I like to check in periodically just to see if those are still the main goals, or if we want to have a different focus. What do you think?

Georgia:  Thanks for asking. I would say that some of my goals are the same as before and that some are different now. I think at first I was just really overwhelmed with my schoolwork, and counseling has been really helpful in helping me to get organized and having a plan for myself. So maybe we don’t need to talk about that as much anymore. But the friends thing has still been kind of tough. I still feel really lonely here, like I don’t fit in.

Peter:  OK, yeah, so it sounds like we have seen some good progress on the transition to school and the academic stuff, but we still want to work on getting connected socially.

Georgia:  Yeah, that’s right.

Peter:  Any new goals or things you want to add that we haven’t talked about?

Georgia:  Well, one thing that has been a little tough is my family. I really miss them, and they miss me too, so we talk a lot, and I have gone home to see them quite a bit this semester, but sometimes I feel like maybe I should be pushing myself to stay on campus and make friends where I’m at—you know? But when I don’t have anything to do on the weekend, it’s hard to stay.

Peter:  OK, so it sounds like one of the things you’d like to talk about is your relationship with your family. It sounds like you value those relationships quite a bit, but you wonder if spending a lot of time with your family might be working against your goals of connecting here. Is that right?

Georgia:  Yeah, that’s right! And it’s tough because my family is really close, so I don’t want to lose that or disappoint my parents. But I need to be here too. It’s just tough.

Peter:  Yeah, it sounds like, on the one hand, you have a strong value related to wanting to stay connected with your family, and then, on the other hand, you are wanting to make friends here at school. Would it be helpful to talk about how to navigate that?

Georgia:  Yes, definitely!

What is your reaction to the dialogue between Peter and Georgia? How do you feel about the way in which Peter checked in with Georgia about her goals for therapy? Do you think you could do something similar with your clients? Think about how you might phrase a check-in about the goals for therapy with your clients. Also, what is your reaction to the way in which Peter addressed Georgia’s cultural identities during this discussion? If you were Georgia’s therapist, would you have done anything differently?

Checking in About Tasks

Related to the importance of checking in regularly with clients about the goals for therapy is that cultural humility is integral to maintaining agreement on the tasks of therapy. The tasks involve the specific interventions that the therapist and client engage in that hopefully move the client toward the therapeutic goal. Several factors influence the tasks that are implemented in therapy, including the theoretical orientation of the therapist. However, it is important to check in periodically assess how the client is feeling about the primary tasks of therapy, as well as the extent to which the tasks of therapy are consistent with their cultural worldview.

Before you see each of your clients this week, spend 5 minutes and think about the primary tasks you have used in therapy with each client. The tasks might be related to your theoretical orientation. For example, if you are a cognitive behavioral therapist, your primary tasks may have been reviewing homework, Socratic questioning, and working through the cognitive model with your client, emphasizing the connection between thoughts, emotions, and behaviors. If you are an interpersonal therapist, your primary tasks may have been discussing the client’s relational patterns and perhaps connecting these relational patterns with the client’s family of origin and the client’s therapeutic relationship with you.

Brainstorm how you might check in with your client about how she or he is feeling about the tasks of therapy. For example, you might start by conducting a general check-in and asking about how your client feels therapy is progressing. You might review some of the main tasks of therapy and ask which tasks the client has found more or less helpful. You might ask the client how the tasks of therapy are congruent with (or not) with the client’s cultural values.

Once you have brainstormed some ideas for how to check in with your client, do the check-in. Pay attention to any thoughts or feelings that come up for you as you do this. Do not force a long conversation if the client does not seem interested in talking about it, but ask the question and see where it goes. After you have finished your session, take some time and think, reflect, and journal about how the check-in went. Did you learn anything new about the client? Did the client view any of the tasks you were doing in therapy to be unhelpful? If so, are you willing to adjust your approach to be more in line with the client’s wants? How can you work with your client in a culturally humble manner to collaborate on the most helpful tasks for therapy?

It is reassuring when we ask our clients how things are going and they confirm the direction of therapy, but sometimes they may provide feedback that requires us to change course. Even if not explicitly mentioned, these course changes can often involve aspects of the client’s cultural identity. As therapists, we are highly trained (or are becoming so) in various theoretical languages, which give us the tools to dismiss or explain away any feedback we might receive from clients. Sometimes viewing their feedback through a theoretical lens (e.g., viewing feedback as resistance) is precisely what is needed. At the same time, we encourage you to carefully weigh the possibility that our clients are “right” because they are experts on their needs and inner experience. The American Psychological Association (APA) Guidelines for Multicultural Education and Training, Research, and Practice in Psychology specifically note the unique capacity of therapists to explore and understand their impact on their clients in therapy as a tool of promoting “racial equity and social justice” (APA, 2003, p. 382). We always observe indirectly what they observe through more direct experience. Thus, it can be culturally arrogant to minimize or dismiss client feedback.

Case Example: Dave and Jeff

Consider the following example of Jeff (the client) and Dave (the therapist). Jeff, a 41-year-old, White, heterosexual, married, cisgender man, presented for therapy to discuss struggles in his relationship with his wife of 12 years. In the first session, Dave, a 55-year-old, White, heterosexual, cisgender male marriage and family therapist, listened to Jeff’s story and noticed he appeared to have difficulty expressing his emotions. Dave thinks that emotional expression and connection could be a useful thing to work on during therapy. However, Jeff shared that he would like to spend his time in therapy learning specific skills, such as problem-solving and communication skills, so he can better navigate arguments with his partner, Judy. The following is an excerpt from the dialogue between Dave and Jeff.

Jeff:  Yeah, so Judy and I just fight all the time. I think the main thing that I am hoping to do in therapy is to learn how to talk things through better when she and I disagree.

Dave:  That makes really good sense, and it seems like you’re hoping to improve your connection with Judy—is that right?

Jeff:  Yeah, I think that’s right. I didn’t think of it that way. I was thinking I was just tired of fighting, but feeling more connected would be good.

Dave:  I noticed when you were describing your relationship that you tended to talk about the fights and arguments but not much about how you were feeling. How is it for you to discuss feelings?

Jeff:  I don’t really talk about them at all. That’s just not how I was raised. Guys don’t do that. I tend to get quiet when things get overwhelming and go into problem-solving mode.

Dave:  Similar to what is happening now?

Jeff:  Ha, I guess so, yeah.

Dave:  I wonder if discussing both your emotions and ways of communicating more effectively with Judy could be an important use of our time here in therapy. What do you think?

Jeff:  I am not sure I totally see the point just yet, but we can see.

Dave:  Sounds good. Let’s talk about that next time.

What was your reaction to the dialogue between Jeff and Dave? Did you notice any differences or disconnect between how each was approaching therapy? In this example, Dave was beginning to hypothesize that Jeff’s upbringing was rooted in more traditional White, male gender norms (e.g., valuing being strong and independent, controlling emotional expression; see Mahalik, Good, & Englar-Carlson, 2003), which might explain Jeff’s perspective on the problem (i.e., poor communication and desire to decrease arguments) and possible solutions (i.e., learning new communication and problem-solving skills). As a therapist strongly committed to feminist theories, Dave began to hypothesize that Jeff’s lack of emotional expression could be contributing to his marital issues.

This conceptualization may be valid (i.e., working on emotional expression may help Jeff to improve his marriage); however, if Dave fails to recognize that Jeff may have different ideas for how therapy should progress and these ideas may be related to Jeff’s cultural background, the two might struggle to build and maintain a strong working alliance. Jeff might even drop out of therapy and feel like Dave does not understand him (or his cultural background, whether or not this is explicitly stated). Asking the client for feedback may open the door to a collaborative discussion about how therapy is progressing and also provide an opportunity to discuss the cultural identities that are important to Jeff. Consider the revised dialogue between Jeff and Dave.

Jeff:  Yeah, so Judy and I just fight all the time. I think the main thing that I am hoping to do in therapy is to learn how to talk things through better when she and I disagree.

Dave:  That makes really good sense, and it seems like you’re hoping to improve your connection with Judy, is that right?

Jeff:  Yeah, I think that’s right. I didn’t think of it that way. I was thinking I was just tired of fighting, but feeling more connected would be good.

Dave:  I noticed when you were describing your relationship that you tended to talk about the fights and arguments, but not much about how you were feeling. How is it for you to discuss feelings?

Jeff:  I don’t really talk about them at all. That’s just not how I was raised. Guys don’t do that. I tend to get quiet when things get overwhelming and go into problem-solving mode.

Dave:  Similar to what is happening now?

Jeff:  Ha, I guess so, yeah.

Dave:  I wonder if discussing both your emotions and ways of communicating more effectively with Judy could be an important use of our time in therapy. What do you think?

Jeff:  I am not sure I totally see the point just yet, but we can see.

Dave:  Let me pause for a second and check in with you. It seemed like when I suggested delving into your emotions more as part of the work here, it didn’t quite connect with you. I think for me, it has been helpful to work with clients on emotion because I think that’s one of the ways we can connect with others who are close to us. But I don’t want to put that on you if that isn’t what you are wanting right now. Any thoughts about that?

Jeff:  Well, it just seems to me like Judy and I are in crisis right now—like if something doesn’t change, I’m not sure if the marriage is going to last. Trying to work on sharing my emotions seems really different to me, like it might take a long time for me to change that. I’m not sure my relationship with Judy has that kind of time. I understand what you’re saying, and I am willing to talk about that part if you think it’s important, but I want to make sure I’m getting help with the day-to-day stuff too, so I can save my marriage.

Dave:  Got it. So what I’m hearing you say is that you’re feeling like your marriage is in crisis because of all the arguments and fighting. You’re open to exploring the emotional stuff but also want to make sure we spend adequate time on trying to deal with the arguments and fighting. I’m definitely on board with that—I want to spend this time on the things that are most important for saving your marriage.

What did you think of this second exchange between Dave and Jeff? How did Dave obtain feedback from Jeff about the course of therapy? What did you think of how Dave asked for feedback? Did it feel natural or unnatural to you? If you were to ask a client for feedback, would you do so in a similar manner, or would you try something different? If you were Dave, how would you incorporate the feedback from Jeff?

Developing a Plan for Feedback

Some therapists may navigate the task of obtaining client feedback in subtle and nonstructured ways through cultivating the kind of relationship in which clients feel comfortable voicing their concerns about the direction of therapy. However, there are some advantages to providing a more formal structure for feedback. A structured process normalizes feedback and makes it routine. In addition, a structured process communicates a systemic commitment to valuing client perspectives and acknowledging that therapists can (and probably will) make mistakes and not always “get it right.”

In this next exercise, we give you an opportunity to explicitly develop a plan for inviting feedback from clients. Take some time and design a plan for evaluating whether your interventions and approach to therapy are working for your client. Will you directly broach the topic or try to get feedback indirectly? If you do plan to directly introduce the topic, how often do you plan to check in with the client? Do you plan on using a survey, or will you simply ask? If you plan to be less direct in soliciting or encouraging feedback, how do you imagine this process happening? After you have spent some time thinking and brainstorming about how you will ask your client for feedback, role play a discussion with a colleague or classmate in which you ask your discussion partner for feedback about how the treatment process is going. Take notice of any thoughts, feelings, or reactions that come up for you before, during, or after the discussion.

Take some time to reflect and journal about your experience. How was it to engage in a role-play discussion within which you asked for feedback about how the therapy process was going? Was the feedback mostly positive, mostly negative, or a mix? Did it feel comfortable or uncomfortable? Did it feel vulnerable? Did it bring up any fears or insecurities about your abilities as a therapist? Did anything come up during the discussion or feedback that might influence your therapy process in the future? Did you feel more close or less close to your discussion partner following the feedback? Do you think you could have a similar discussion with one of your clients? What barriers do you see to having a discussion such as this?

Conclusion

Building, developing, and strengthening the working alliance is a critical component of effective therapy. As noted in this chapter, it is essential to think about and reflect on how the cultural identities of your client, as well as your cultural identities, intersect to affect the development of the working alliance. In this chapter, we discussed how cultural humility can play an integral role in helping build the working alliance with clients, especially when cultural identities are salient to the therapy work (which we believe is always the case). In the next chapter, we discuss situations in which ruptures occur in the working alliance and how cultural humility can play a role in recovering from cultural ruptures when they occur in therapy.

Chapter 6 Repairing the Relationship After Cultural Ruptures

In this country American means white. Everybody else has to hyphenate.

—Toni Morrison, The Guardian (1992)

Cirleen: Early in my practicum training, I saw Lakshmi, a Muslim, heterosexual woman, at a community mental health center. She was 23 years old and her family had emigrated from India when she was five. Lakshmi came to therapy because she had been feeling depressed for several months and it was impacting her motivation at work and her marriage. On multiple occasions, Lakshmi mentioned that she was just “too different.” We explored this idea. When did she start to feel this way? How did these feelings develop over time? Lakshmi slowly began to recollect a number of pivotal experiences. She recalled being in school, the only student of color in her class, fasting for Ramadan, and being directed by a teacher to sit in a classroom alone during the lunch hour every day of that month so as not to subject the other students to her religious practice. She talked about how she hated that her father was a “walking stereotype” because he owned a Dunkin Donuts. She hated the racist things that people would say to her and her mother when they worked shifts at the store, or just the raised voices of people who assumed that she didn’t speak English. Lakshmi wanted to be “normal.”

At the time, I was a doctoral student learning concepts and language that helped me better understand and express my experiences growing up as a biracial Asian American woman in a predominately White community—concepts such as internalized racism, benevolent sexism, marginalization, and intersectionality. For me, learning about oppression and acquiring the language to talk about it was empowering. Do not get me wrong—it can also be demoralizing at times to sit with the understanding of systemic oppression. However, with the knowledge I was gaining as a graduate student, I was obtaining tools, and I intended to use these tools to combat oppression—both in my life and in the lives of my clients.

Given that background and context, you may not be surprised to hear that I wanted to share this knowledge with Lakshmi. In our fifth session, I decided to include some psychoeducation in our work together. I explained the concept of internalized racism and how it could apply to her experience. I told her there was nothing wrong with her, that it was society that was flawed, not her. Lakshmi nodded, but was quiet in response. As I was writing my case note after the session, I felt good about our interaction and believed that it would really help Lakshmi to understand that experiencing racism and discrimination wasn’t her fault. Looking back, I thought I could rescue Lakshmi from her pain. I wanted to do that. In retrospect, I can identify my own projection and countertransference. After a lot of supervision and introspection, I saw I didn’t meet my client where she was. I thought about what I would need or want in that situation, and assumed that my client needed or wanted the same thing. Unfortunately, Lakshmi never returned to therapy after that session and I never had the opportunity to work through the rupture with her.

Although the outcome of our therapy work was not as positive as I had hoped it would be, I did learn an important lesson. When we are more self-focused than client-focused, we are vulnerable to a variety of cultural ruptures (e.g., microaggressions, countertransference due to overidentification). It is important to note that the message of this story is not to avoid conversations about culture, oppression, and privilege in therapy. It is quite the opposite. In considering my work with Lakshmi, I wish I had asked more questions about her culture, her identity development, and her understanding of her identities. Even if I think I understand a client’s cultural background and experiences, each client is unique. As we discussed in Chapter 5, a better understanding of these aspects of Lakshmi’s experience would have allowed me to intervene in a way that would have fit with where she was. It takes cultural humility to be patient, meet clients where they are, and admit my limitations as a therapist.

Cultural Humility and Identifying and Repairing Cultural Ruptures

The topics we covered in the last chapter set the stage for developing a strong working alliance that can withstand the work of therapy. However, as much as we might try to be as humble and respectful as possible toward our clients’ cultural identities, it is likely that we will sometimes make a mistake or misstep regarding our clients’ cultural identities or how we engage in a discussion about culture in the therapy room. When these cultural strains or ruptures in the therapeutic relationship occur, it is important to repair the break in trust, attachment, and connectedness. In this chapter, we focus on two primary aspects of this process. First, we discuss how to identify when a cultural rupture may have occurred in therapy. Second, we discuss how to repair a cultural rupture after it has occurred.

IDENTIFYING CULTURAL RUPTURES

There has been quite a lot of research on general alliance ruptures, which involve tension or breakdown in the collaborative relationship between the therapist and client (Safran & Muran, 2006). This body of work indicates that the first major challenge is noticing that a rupture has occurred. Unfortunately, many therapists overlook the subtle signs that indicate a rupture has taken place (Binder & Strupp, 1997), and most clients do not directly address a rupture until it may be too late and they are already strongly considering termination. The following activity is intended to help you begin to identify characteristics of ruptures in general to inform your ability to identify ruptures in therapy.

Noticing Offenses in Everyday Life

We would like you to consider a situation in which a conflict occurred in your everyday life. For this exercise, it does not have to be an example from a therapy session—it can be any example of a conflict that comes to mind. It could be an argument you had with a romantic partner, a disagreement with a friend, or something that happened with a client. Once you have a conflict in mind, write a few sentences describing it and what happened. Then reflect and journal about the following questions, which are designed to provide you with a context for understanding how a conflict might be identified, as well as the steps you could take to attempt to repair a conflict, if you choose to do so.

When the situation occurred, how did you know you were in the midst of a conflict? What were the signs and signals that indicated a conflict was happening? Did you notice anything happening in the other person or yourself? Were you aware of any physiological reactions happening in your body? What thoughts and feelings came up for you? What was your immediate and default reaction? Did you attempt to try and resolve the conflict? Why or why not? How did the conflict resolution process go? What parts of the process were effective, and what parts were not effective? Were you able to resolve the conflict? Why or why not?

Next, we would like you to reflect and journal about some questions designed to increase your humility about the situation and the conflict. First, write a few sentences describing the conflict from the point of view of the other person. Now take some time and compare and contrast (a) your description of the conflict and (b) the description of the conflict from the point of view of the other person. What was similar about the two descriptions? What was different? What was it like to consider the other person’s point of view?

It may have been difficult to write a thorough description from the point of view of the other person. We have greater access to our experience—especially painful feelings—than we do to the other person’s experience. Often, we might make up a story about what the other person is thinking or feeling or what their motivations may have been. Our story may or may not be true. Think back to the conflict. What information about the other person’s point of view would have been helpful for you to know when dealing with the conflict? What questions would you have liked to ask? Is there anything about your interactions with the person that may have conveyed a sense of arrogance on your part? If you had the chance to do it over, how could you have engaged in a more humble manner?

Cultural Ruptures and Microaggressions

Many ruptures have cultural underpinnings. We refer to these cultural misunderstandings or hurts as cultural ruptures, and they have the potential to disrupt the working alliance if they are not addressed and worked through. A cultural rupture occurs when clients perceive that an aspect of their cultural identity was targeted or implicated in an offense. A type of cultural rupture that has received a great deal of scholarly attention involves microaggressions (Hook, Farrell, et al., 2016; D. W. Sue et al., 2007). Microaggressions are offenses that are often largely invisible to the people that commit them but that occur regularly within society due to the prevalence of stereotypes and cultural norms that form “normal” prejudice and discrimination. Microaggressions in therapy occur when tensions, strains, and ruptures that occur in the relationship between therapist and client are related to cultural messages conveyed by the therapist (Owen, Imel, et al., 2011). Microaggressions negatively affect clients’ perceptions of their therapists’ level of cultural humility (Hook, Farrell, et al., 2016) and therapy outcomes (Owen, Tao, & Rodolfa, 2010).

The next exercise provides concrete examples of the kinds of behaviors that clients may experience as racial microaggressions. In Table 6.1, we present examples of racial microaggressions in Column 1 and possible interpretations of those statements in Column 2 (examples from D. W. Sue et al., 2007). For example, if a therapist asks a question such as “How long have you lived in this country?” a client could interpret it to mean that the therapist does not think the client is a United States citizen. This is an example of a statement that many Asian Americans hear regularly, and it reflects a stereotype of Asian Americans as perpetual foreigners. Read through the table and consider how seemingly innocuous statements can signal an underlying prejudice or bias.

Take some time to reflect and journal about your experiences reading through the statements. What did you think of the list of statements that could be interpreted as microaggressions? Did you have any reactions while reading them? Were you surprised by any of the statements on the list? Have you made any of the statements on this list (or statements like them) to your clients? If so, your motivation may not have been to offend, but can you see how certain statements—when heard over and over again across relationships and contexts—could make someone feel increasingly invalidated or marginalized?

D. W. Sue et al. (2007) described three types of microaggressions. Microassaults involve explicit and intentional acts of racism, prejudice, or discrimination (e.g., referring to someone as “colored”). Microinsults are more subtle, often unconscious messages that put down an individual’s cultural group (e.g., asking a person of color, “How did you get this job?”). Microinvalidations are messages that deny the experience of a cultural group (e.g., claiming to be “colorblind,” which denies the racial experience of people of color). Of the three forms of microaggressions, clients are most likely to perceive microinvalidations and microinsults their therapists express in the form of dismissive messages about their cultural heritage or through culturally inappropriate interventions (Burkard & Knox, 2004; Neville, Lilly, Duran, Lee, & Browne, 2000; Salvatore & Shelton, 2007; Shelton & Delgado-Romero, 2011).

As therapists, we can engage with the scientific literature on microaggressions to increase our sensitivity to the repeated slights individuals from marginalized groups experience within society, which can increase our awareness of and responsiveness to clients. We might not expect it, but microaggressions do occur in therapy. For example, in a college student sample of racial and ethnic minority students seeking counseling at a college counseling center, 53% of clients reported they had experienced at least one microaggression over the course of their therapy experience (Owen, Tao, Imel, Wampold, & Rodolfa, 2014). In a community sample of racial and ethnic minority adult clients, 81% of clients reported they had experienced at least one microaggression over the course of their therapy experience (Hook, Farrell, et al., 2016).

The purpose of the next exercise is to help you think about and understand how microaggressions might show up in therapy. On the basis of data from focus groups looking at the experience of African American clients in therapy, Constantine (2007) identified 12 categories of racial microaggressions that might occur in therapy. We list each category, along with its definition and an example, in Table 6.2.

What do you think of the categories of racial microaggression that can occur in therapy? Looking back on your work with clients, have you committed any of the microaggressions on the list? Which microaggressions do you think you are most likely to commit in therapy? Why do you think you are more likely to commit certain microaggressions than others?

The microaggressions described in Table 6.2 focus on race, but people also experience microaggressions for other cultural identities (e.g., gender, sexual orientation, disability or ability status, religion) and their intersection with each other (e.g., women of color). One way to start to learning more about the different types of microaggressions is by examining the professional literature on microaggressions for various cultural identities. On the basis of conversations happening in professional communities, authors have given examples of more commonly occurring offensive behaviors. For example, Shelton and Delgado-Romero (2011) interviewed lesbian, gay, bisexual, and queer (LGBQ) individuals who experienced microaggressions in therapy and identified seven themes: (a) assuming that sexual orientation is the cause of all presenting issues, (b) avoiding and minimizing sexual orientation, (c) attempting to overidentify with LGBQ clients, (d) making stereotypical assumptions about LGBQ clients, (e) expressing heteronormative bias, (f) assuming that LGBQ individuals need psychotherapeutic treatment, and (g) warning about the dangers of identifying as LGBQ. Gender microaggressions against women in therapy have also been described (e.g., encouraging women to be less assertive; Owen et al., 2010). However, some microaggressions are highly contextual and can change over time. Looking at Table 6.2, can you think about common slights you have observed regarding other cultural identities?

Becoming more aware of microaggressions is a process that involves caring about other people and learning to think accurately about and empathize with their experience. For example, last year, Donnie had a Jewish colleague tell him what it was like to raise his son within a predominately Christian culture. This was not new information per se, but Donnie experienced the next December and the focus on the Christmas holiday in a whole new way. The colleague’s description of his experience echoed in Donnie’s mind as he entered various spaces. He thought about what it would be like for his family. Donnie remembered stories his colleague told him about his son feeling left out. Conversations about inclusive language regarding religious holidays had a different kind of traction in Donnie’s heart and mind.

If cultural ruptures are not effectively repaired, they can undermine the working alliance and lead to poor outcomes with clients. For example, when clients experienced more microaggressions in therapy, they reported a weaker working alliance with their therapist (Constantine, 2007; Morton, 2012; Owen, Imel, et al., 2011; Owen, Tao, et al., 2014). Clients experiencing more microaggressions in therapy also reported lower levels of psychological well-being (Owen, Imel, et al., 2011) and less satisfaction with therapy (Constantine, 2007). Experiencing microaggressions in therapy even sets the stage for more negative therapeutic interactions in the future. For example, clients who reported more microaggressions in therapy said they were less likely to seek therapy in the future (Crawford, 2011).

Case Example: Juan and Jessi

In this next exercise, we consider a case example of a cultural rupture or microaggression that might occur in therapy. This example is intended to help you consider some ways you might improve your ability to detect cultural ruptures or microaggressions within the therapy context.

Juan identifies as a 20-year-old gay, Latino, cisgender man. He is currently in his third year as an undergraduate student at a large university in the northeastern United States. Juan grew up in a devoutly Roman Catholic household and a relatively conservative community. Consequently, Juan has only disclosed his sexual orientation identity to his friends and select family members. In addition, Juan has only recently begun to date men. Before college, he had one relationship with a man, but this relationship was not disclosed to others.

Now that Juan is living in a more metropolitan area that is more affirming of his sexual orientation, he is beginning to explore his sexuality. Although Juan is excited about dating, he also struggles with his own internalized homophobia and a fear of rejection. To help address these concerns, Juan decided to attend counseling. Early in therapy, Juan’s therapist, Jessi, who identifies as a nonreligious, White, cisgender woman, disclosed to Juan that she identifies as lesbian.

After a few months of therapy, Juan and his therapist have been able to explore his trepidations about dating, and he is feeling more and more comfortable exploring his dating prospects in the city. However, Juan also began to share an additional perceived challenge about dating, namely, racism. He shared with his therapist that he sometimes feels uncomfortable at gay bars and restaurants because he is often the only Latino man present and sometimes the only visible person of color. These feelings of discomfort have sometimes led Juan to avoid going out.

When Juan broached the topic with his therapist, Jessi replied, “Come on, don’t play the race card. You know you just need to get out there.” Juan did not directly respond to his therapist’s comment, and the session continued, seemingly without incident. However, Juan was deeply hurt and angry with his therapist. He talked little for the remainder of the session and “just wanted to get out of there.” There is some evidence that microaggressions that occur in the context of a therapy relationship where there is an identity match—in this case both Juan and Jessi identify as sexual minorities—may be more impactful to clients (Hook, Farrell, et al., 2016). Juan returned to therapy the following week and the subsequent week before not showing up two additional times and eventually terminating with his therapist. He never told her exactly what happened.

This scenario clearly depicts a microaggression (i.e., invalidation of Juan’s race or ethnicity). Furthermore, Juan’s therapist never addressed the incident with him, and he did not feel comfortable bringing up the topic with her. Spend some time thinking and reflecting on this case example. What was your initial reaction to the therapist’s comment? Although Juan never confronted his therapist, what indications did he provide to his therapist that a rupture had occurred? What do you think the therapist could have done in this situation to address the microaggression?

This example illustrates why it is important to show interest in and discuss clients’ cultural identities throughout the course of therapy. Perhaps if Juan’s therapist had explored all of Juan’s salient cultural identities early in the therapy process, the issue of ethnicity could have been more fully explored and validated. This may have created an environment in which this particular microaggression could have been avoided altogether. At the very least, asking about Juan’s ethnicity would have acknowledged Juan’s multiple cultural identities in ways that would have made them more present and understood by the therapist.

Perhaps with a stronger foundation of trust, Juan would have felt more comfortable challenging his therapist’s statement or sharing his feelings about the microaggression. That being said, this is not by any means Juan’s responsibility. It is our responsibility as therapists to develop a strong working alliance, to do our best to avoid committing cultural ruptures, and to address them if and when they do occur. In this instance, Juan’s silence and subsequent no-shows were strong indicators that something was amiss. These also could have been opportunities for his therapist to intervene.

REPAIRING CULTURAL RUPTURES

Now that we have discussed some strategies for identifying cultural ruptures in therapy, we want to discuss how to repair them when they do occur. Although cultural ruptures are likely to undermine the working alliance if left unaddressed, taking steps to repair the rupture has the potential to rebuild the working alliance, perhaps even resulting in a stronger alliance and a deeper bond than before the rupture occurred. Next, we discuss four aspects of repairing cultural ruptures: (a) dealing with defensiveness, (b) cultivating an environment in which the client can disclose cultural ruptures, (c) getting client feedback about cultural ruptures, and (d) putting together a cultural rupture repair action plan.

Dealing With Defensiveness

First, by definition, microaggressions are subtle and ambiguous statements that typically result in confusion, discomfort, and frustration. Accordingly, it can be difficult for therapists to recognize they have committed a microaggression. If they do recognize the offense, it can be difficult to accept that one has perpetrated such an offense. Defensiveness is a common and expected reaction. It is important, then, to anticipate this possible reaction and consider ways we might respond differently. One thing that is difficult about perpetrating microaggressions is that there are always several perspectives of the offense. Microaggressions usually evoke a dynamic in which the offended person feels devalued or invalidated by some aspect of the interaction, but the perpetrator sees the behavior as innocuous or benign. If the offended person does confront the event, the perpetrator’s response is often to clarify, justify, or defend their behavior and perspective.

Granted, it might be easier to own one’s responsibility for committing a microaggression if the offended person always communicated about offenses using “I language,” excellent emotion regulation, and positive engagement. This might be a legitimate request to make of a romantic partner, asking them to learn to address conflict in ways that make a productive conversation about conflict most likely. However, as therapists, we should aspire to practice interpersonal skills that will help us respond to microaggressions effectively even when the client’s response leads us to feel highly defensive and insecure. It is not the client’s job to take care of our feelings; however, it is (literally) our job to attend to theirs. The purpose of the next exercise is to provide a microaggression self-talk plan that can help you plan for and quickly reduce defensiveness when it arises.

Think of an example of a microaggression you have committed with a client. If you cannot think of a specific offense, think about a microaggression from Table 6.2 that would likely make you feel defensive if you were accused of committing it. Also, think of some of the contextual factors that might make it particularly difficult to respond in an open and nondefensive manner, such as how the confrontation occurred, your relationship with the offended person, the cultural identity of the client, or your personal state of mind (e.g., high stress).

Under high strain, it is difficult to reduce defensiveness, but we would like you to develop a plan for self-talk that will help you to reduce defensiveness in the midst of a conflict situation. Write two or three phrases that might help you shift gears, engage with cultural humility, and put clients’ needs first, rather than attending to your own needs to justify yourself. For example, what could you say to yourself to validate and honor your experience of the event without needing to invalidate the client’s experience of the offense? What are some things you could say to yourself that would remind you to explore and honor the client’s perspective and experience?

Cultivating an Environment in Which the Client Can Disclose Cultural Ruptures

As noted in the example of Juan, sometimes clients do not choose to disclose when they have experienced a microaggression in therapy. Thus, it is important to cultivate an environment in which clients feel safe to bring up offenses. In the previous chapters, we discussed several strategies that therapists can use to help make the therapy room a safe place where clients are more likely to feel comfortable bringing up cultural offenses if they occur.

It would obviously be great if we never committed an offense that would cause a cultural rupture with our clients, and we believe that none of us would want to do that intentionally. At the same time, worrying too much about committing a cultural offense or microaggression within a therapy session is not likely to be helpful. Being too self-focused and worried about making mistakes likely distracts and detracts from other positive behaviors that can strengthen the bond between therapist and client. A better strategy may be to direct one’s energy toward establishing a supportive and trusting working alliance and making it a regular practice to check in with clients about how they are experiencing the relationship, including any possible offenses or ruptures. Mistakes are a normal part of life, and it is likely that you will make some cultural mistakes with your clients because you are an imperfect human who is learning and growing in your development as a therapist. If you have done the personal and relational work with your client to make the therapy room a culturally safe place before the offense occurs, you will likely be able to hear your client’s feedback and respond effectively.

One of the most difficult aspects of repairing cultural ruptures and microaggressions is that we are unlikely to receive accurate feedback from our clients unless we cultivate the kind of environment in which they are willing to take substantial risks to repair the relationship. In this exercise, we would like you to consider some of your personal relationships and the degree to which you feel comfortable addressing conflict with different individuals with whom you are in relationship.

First, in what kinds of relationships are you least likely to confront minor to moderate offenses when they occur? What are some of the qualities of these relationships that make it more difficult for you to think that it is worth confronting hurts? Next, think of the relationships in which you are most willing and able to address hurts and offenses when they occur. What qualities of that person or relationship make it easier or more likely for you to disclose when moderate or minor shifts occur in the relationship? After reflecting on these questions, write down 10 qualities of a therapeutic environment or relationship you think would facilitate client disclosure of a cultural rupture or microaggression.

Getting Client Feedback About Cultural Ruptures

Now that you have a better sense of the type of environment you would like to create to enable client feedback about cultural ruptures and microaggressions, we turn to how you might go about actually obtaining feedback after a cultural rupture has occurred. In the previous chapter, we discussed several strategies for obtaining formal and informal feedback on how clients think therapy is going. These strategies are important because they communicate your interest in investing in the relationship, as well as your openness to being responsive if there is something that would improve the client’s experience.

One strategy some of us have implemented in the clinics where we have worked is to have clients fill out a brief weekly measure of their therapy experience, including their perceptions of the working alliance during that week’s session. The therapist can look at these data and see a graph of the working alliance with each client each week. One simple strategy for identifying cultural ruptures is to examine the alliance scores each week and look for dips in ratings of the working alliance. A dip in working alliance could indicate a cultural rupture or strain in the relationship. If this does occur, therapists can think about whether they may have done something to contribute to it, or they could check in with clients to see whether anything happened in the previous session that may have caused distance or strain in the relationship.

If your clinical setting measures working alliance on a regular basis, spend some time and review the alliance ratings for all your clients each week. Do you notice any dips in the working alliance ratings for any of your clients? If so, did anything happen the previous week that may have contributed to a strain in your relationship? If nothing comes to mind, it might be a good idea to check in about this with your client the next week.

Perhaps you do not work in a clinical setting that regularly keeps track of client ratings of the working alliance. How might you check in with your clients during a session to get feedback on how they are feeling about therapy or whether any cultural ruptures have occurred? The following are some examples of in-session language that could be helpful here. For example, during the initial session, you might say something such as the following:

“I want to be sure we are on the same page throughout this process, so if there is anything that arises that does not seem to fit for you or you find off, I hope you can share those concerns with me, and I might just check in about that from time to time, if that’s OK.”

“I want this place to be a safe place where you can talk about your beliefs and values, and if there are any moments when you feel that might not be the case, please let me know.”

The following are some examples to get feedback from clients in ongoing sessions. For example, near the end of a session, you might say:

“I just wanted to check in with you about how things are going in our sessions.”

“Are we on the right path here for addressing your goals?”

“Has there been anything we have discussed that isn’t sitting right with you?”

“I know we have been discussing important issues over the past session, and we talked about [a specific cultural issue]. I wonder how you felt that conversation went?”

Get together with a friend or colleague and practice asking some questions to get feedback about the working alliance, cultural misunderstandings, and cultural ruptures. As you are practicing, take note of what kind of language feels natural to you. Check in with your discussion partner and get feedback about how you came across. Did you feel comfortable asking for feedback? Did you come across as defensive in any way? What could you adjust, either in your body language, tone of voice, or choice of words, to present as more culturally humble?

Cultural Rupture Repair Action Plan

Finally, because culturally humble therapists acknowledge their limitations and understand they have the proclivity to make cultural mistakes (and that making such mistakes is a normal part of the therapeutic process), they ought to respond to cultural ruptures and microaggressions in therapy in such a way as to increase the likelihood of forgiveness, compassion, and reconciliation. For example, culturally humble therapists are likely to make more effective other-oriented apologies than therapists who are not culturally humble, which is likely to lead to higher levels of forgiveness and reconciliation. Many of you know intuitively how to do this, but some ways of dealing with ruptures are more effective than others. Next, we discuss a plan—based on research on forgiveness and reconciliation—that can help you clarify the important elements of an effective response to cultural ruptures.

In this exercise, we walk you through how to develop an action plan when a cultural rupture has occurred in therapy. To make this plan more concrete, we return to the example of Juan introduced earlier in the chapter. Juan’s therapist did not address the incident and may not have even been aware that a rupture had occurred at all, but for the purposes of this exercise, let us suppose she became aware she had committed a microaggression toward Juan. What could she do if she wanted to acknowledge the microaggression and attempt to repair the cultural rupture? What steps would she take? The following plan of action integrates what we have discussed in this chapter.

Step 1: Check in with yourself. How are you feeling about the cultural rupture? When you think about what happened, do you feel sad, scared, or angry? What feelings come up when you think about addressing the cultural rupture with your client? What are you feeling toward the client right now?

Step 2: Consider your client’s perspective. Put yourself in your client’s shoes. How do you think the client is feeling about you, your relationship, or the therapy process? What do you think your client would want regarding the resolution of the cultural rupture? What action would be in their best interests? One strategy to help take your client’s perspective is to think of a situation in which a person who held a position of power in their interaction with you said or did something that was invalidating of your experience. How did that feel? What steps could they have taken to repair the rupture? Did they do anything to exacerbate the problem?

Step 3: Clarify your motivations. What could be the reasons for addressing the cultural rupture? How do you think addressing the rupture could help you and the client reconnect? An important consideration is to remember that, as therapists, it can be tempting to explain how what we said was “right” and defensible—we might even be able to put a theoretical conceptualization behind our comments. If you feel a pull to do this, it might be a good time to stop, assess, check in, and explore your need to be “right,” rather than empathic. However, if your motivation is to help you and your client reconnect and restore the working alliance, your motivations may be in a better place. Remember, the focus here is on your therapeutic mistake or misstep. As therapists, we are in the position to honor our clients’ cultural heritage.

Step 4: Consult. Sometimes if we are struggling to decide whether and how to address a cultural rupture in therapy, it is a good idea to consult with a supervisor or colleague. Take some time to talk through what happened, as well as your proposed course of action. Be open to feedback.

Step 5: Acknowledge the incident or rupture. When acknowledging the cultural rupture, use “I” statements, take responsibility, and clearly state your interpretation of the rupture. For example, in the case of Juan’s therapist, she could have said, “I think I just said something that was hurtful and invalidating of your experience.”

Step 6: Invite your client to share their perspective and feelings. It is important to create a safe space for your client to share their perspective of the cultural rupture. Also, remember that a client may not feel comfortable doing this immediately. As with any conflict, it can take time to process an incident and clarify one’s thoughts and feelings. Thus, be patient and leave the door open for future dialogue. You may also ask for permission to revisit the issue in the not-too-distant future.

Step 7: Apologize. Apologizing for a cultural rupture is critical and requires the very focus of this book—cultural humility. Apologizing requires vulnerability and a willingness to admit you made a mistake. Apologizing is a means of honestly owning and taking responsibility for our actions. When a rupture has occurred, we have to acknowledge our role in the rupture. An effective apology involves more than just saying, “I’m sorry.” Good apologies involve certain ingredients, including (a) making a statement of the apology, (b) naming the rupture, (c) taking responsibility for the rupture, (d) expressing your feelings and emotions about what happened, (e) addressing the emotions of your client, and (f) making a commitment to do things differently in the future (Kirchhoff, Strack, & Jager, 2009).Think about a current or past client with whom you committed a cultural rupture or microaggression. Spend some time putting together a rupture repair action plan. Think, reflect, and journal about each step. If this is an issue you are having with a current client, try working through the last three steps with the client. Take notice of what worked well and what things you could improve on in the future. If this was an issue with a past client with whom you no longer have a relationship, get together with a friend or colleague and practice working through the last three steps with them. As you are practicing, take notice of what worked well and what things you could improve on in the future. Check in with your discussion partner and get feedback about how you came across. Did you feel comfortable bringing up the cultural rupture and making an apology? Did you come across as defensive in any way? What could you adjust, either in your body language, tone of voice, or choice of words, to present as more culturally humble?

Ineffective and Effective Apologies

The final step of the rupture repair action plan, making an effective apology, is so critical for facilitating relationship repair that we would like to spend some additional time providing science-informed training on the elements of a good apology. Remember the main components of a good apology described in the previous section (Kirchhoff et al., 2009). In the following exercise, you have the opportunity to apply this information to some apology examples.

Next, we provide three examples of ineffective apologies. Now that you understand the ingredients of a good apology, see whether you can (a) identify what was wrong with the ineffective apology and (b) turn these ineffective apologies into effective apologies that are likely to generate empathy and willingness to risk relationship repair on the part of your client.

Ineffective apology: “I’m sorry, but I think maybe you’re being a little too sensitive.”

What was wrong?

_________________________________________

Effective apology:

_________________________________________

Ineffective apology: “I don’t know what I did to upset you, but I’m sorry.”

What was wrong?

_________________________________________

Effective apology:

_________________________________________

Ineffective apology: “I’m sorry you took it that way. It’s not what I meant.”

What was wrong?

_________________________________________

Effective apology:

_________________________________________

Case Example: Deanne and Mary

To make the information on rupture repair and apology more concrete, we consider another example of a microaggression in therapy, as well as the therapist’s attempt to apologize and repair the cultural rupture. Consider the following therapy example between Deanne, a 48-year-old, White, heterosexual, cisgender female therapist, and Mary, a 30-year-old, White, heterosexual, cisgender female client. Mary sought therapy to address her depressive and anxious symptoms after her partner’s recent extramarital affair. Therapy initially went well. Mary felt a strong connection with Deanne, and she was able to process the feelings of loss, anger, and hurt that she experienced following the affair.

During the 10th session, Mary shared with Deanne that she was feeling angry with God and not feeling connected at church anymore. Instead of exploring the topic, Deanne moved on, missing something Mary viewed as an important disclosure. Mary did not address what happened at the time, but she felt unsettled with Deanne after that. Mary had questions about what happened. Was Deanne religious and offended that she felt upset at God? Was faith not that important to Deanne, so she just did not understand it or want to talk about it? Mary felt herself shutting down.

Deanne did not know what exactly was happening between her and Mary. But she did notice a shift in their relationship during that session. For example, Deanne noticed that Mary seemed a bit short and guarded with her responses. Mary seemed more irritable and sad than usual. Deanne tried a few open-ended questions to get things moving, but the therapy remained stuck, and she started to feel anxious and unsettled too. Something was off in their relationship, but she did not know what to do. Deanne decided that in their next session, she would try to address what was happening with Mary, with the hope of gaining insight and repairing the relationship if necessary.

Deanne:  Mary, I’ve noticed that something seemed different the last time we met and also today. In prior sessions, you shared things on your mind freely, but now you seem more cautious.

Mary:  Yeah, I guess so.

Deanne:  [Sitting in silence, but expressing interest and caring.]

Mary:  Well, I’ve been thinking a lot about last session. I felt like maybe you didn’t understand where I was coming from.

Deanne:  [Feeling anxious, with her mind racing, so she reminds herself to stay engaged and nondefensive, even though she feels like pulling back.] Something happened last week that is related to how you feel today. Can you tell me what happened?

Mary:  Well, I was talking about how terrible everything has been. Most of the session felt fine, but then I started talking about some of the struggles I have had lately with my religion. You know, feeling angry at God.

Deanne:  Ah, yes, I remember that. Yes, something did seem to shift. What was going on with you then? I can tell this is a hard conversation, but I’m so glad you are willing to have it with me.

Mary:  Well, you just seemed uncomfortable, and I didn’t know what that meant. All of the sudden, I felt very self-conscious. I realized I didn’t know anything about your faith background, or even if it’s OK to ask. I wasn’t sure if I offended you, or you just didn’t see how important this was to me, but I just wanted to curl up into a ball and hide.

Deanne:  Ah, Mary, I think I am starting to see. You didn’t quite know what it meant, but what you shared about your spiritual life was really important, and I didn’t seem to get it. Worse than that, you didn’t know how to interpret the fact that I just moved on to something else. I am so sorry, Mary. I see now that was very painful. I could tell this was really important to you, and there was a lot of pain behind your statement. To be honest, I wasn’t quite sure what you needed from me. I realize now you may have needed more support and engagement. Is that right?

Mary:  Yes! I had no idea how to put words to all that I was feeling. I wanted you to help me untangle the complex feelings I was having. Instead, we just moved on [starting to cry]. I felt so alone.

Deanne:  Mary, I wish last week had gone so differently, but I am so glad to have another chance to revisit this issue. We can absolutely talk about your spirituality. Would you like to talk more about how you are feeling about God and your church now?

What is your initial reaction to this dialogue? How did Deanne know that a rupture had taken place? What steps did she take to invite feedback from Mary about the rupture? Do you consider what happened to be a microaggression? When Mary shared what had happened and how she felt, how did Deanne respond? How did Deanne acknowledge the rupture? How did Deanne invite Mary to share her perspective and experience about the rupture? How did Deanne apologize for the rupture? Did Deanne incorporate all the elements of a good apology? If you were the therapist in this situation, how would you have responded to Mary?

Conclusion

Building and maintaining a strong working alliance is essential for effective therapy. However, we are not perfect, and sometimes we make mistakes. These missteps can sometimes take the form of microaggressions or cultural offenses or ruptures. It is essential to try to minimize committing cultural offenses in our work with clients, but we also need to also create an environment in which clients feel safe to address cultural ruptures when they do occur. If we can have open and honest discussions with clients about cultural ruptures, we may be able to work to repair the relationship when a rupture occurs. In the next chapter, we discuss difficult situations in which therapists experience cultural value conflicts in their work with clients.

Chapter 7 Navigating Value Differences and Conflicts

We hang on to our values, even if they seem at times tarnished and worn. . . . What else is there to guide us?

—Barack Obama, The Audacity of Hope: Thoughts on Reclaiming the American Dream

Josh: When I met with Sharon for the first time, I noticed right away there were some differences in our cultural identities. She was a 46-year-old, African American, cisgender woman, working two part-time jobs to make ends meet. She was a single parent with four children between the ages of 12 and 25 and two small grandchildren, all of whom lived with her in government-subsidized housing. I was a mid-20s, White, cisgender, male graduate student. I was an only child who grew up in a suburb of Chicago, and I was single with no children.

She was in treatment for alcohol dependence. Therapy seemed to progress reasonably, but at times we struggled to connect with each other, and some of our struggle had to do with the value differences and conflicts between us. For example, Sharon placed a high value on her family. She valued her children and grandchildren over almost anything. At the time, I struggled to fully support this value. I thought that many of Sharon’s stressors were linked to her family members, some of whom I judged were making poor decisions and taking advantage of her financially.

But I had to come to terms with the fact that I held a different set of values than Sharon. They were not completely different. Family was important to me as well, but other values, such as independence, education, and self-actualization, sometimes took precedence. For example, I was OK with moving far away from my family to attend graduate school. When deciding on schools, I got accepted to a school close to my home, but I almost viewed the proximity as a negative because I wanted to move away and explore something new.

I could tell these value differences sometimes got in the way of our therapy work together. I could feel myself wanting Sharon to be more independent and set better boundaries with her children, especially the ones who were adults themselves. I thought that some of these relationships were part of the stress that was leading Sharon to drink. Sharon agreed that her family was causing her stress. She knew her older children were making bad decisions that were negatively affecting her health and well-being. But she was not willing to draw a hard line or boundary with them (e.g., tell them they either had to pay rent or leave). Maintaining her family relationships and taking care of her children and grandchildren were her highest priorities, and because I was coming from a different place and had a different set of values, I had a difficult time understanding her perspective. For our therapy to be effective, I would have to recognize the value differences between us but honor and prioritize her values. I had to see whether there was a way forward in treatment that worked within her value framework.

Cultural Humility and Navigating Value Differences and Conflicts

The purpose of this chapter is to explore ways to navigate situations in which you experience strong value differences or conflicts between yourself and your client. One of the more challenging aspects of effectively engaging with cultural identities in therapy occurs when our personal values conflict with the values of the client we are trying to help. We each have a set of values—the things we consider to be “good,” “right,” or “desirable.” Values are important to therapy because they help frame our ideas of what positive mental health and well-being look like. These values help frame the collaborative goals that we develop with our client. What does the client hope to gain from therapy? What does the client want their life to look like as a result of therapy? These therapy goals are all affected by one’s values about what it means to have “good” mental health. In this chapter, we cover three important aspects of working with value differences and conflicts: (a) exploring your values, (b) recognizing when a value difference or conflict occurs, and (c) addressing the value difference or conflict in therapy.

EXPLORING YOUR VALUES

What is it about values that makes it difficult to engage with someone who has a different set of values? According to Graham and Haidt (2010), core values bind people together into close-knit groups, but they also lead to conflict and tension with other individuals and groups who may not share our core values. When we share our core values with others, it provides a sort of “glue” for our relationships. Think about your closest friends and family members. Think about the groups to which you are strongly committed. It is likely you share at least some core values. Perhaps shared values are what brought you together in the first place. However, even though core values draw people together, they can also lead individuals and groups to have negative reactions toward outgroup members who do not share their cherished values. To the extent that we use core values to identify who is on “our team,” it is similarly easy to view others who do not share our core values as the “other,” outside of our care and concern.

Jonathan Haidt and colleagues presented a model for organizing values based on five moral foundations (Graham et al., 2011; Haidt, 2013). The model is not a comprehensive list of values or virtues but rather attempts to describe some of the foundational considerations people use to evaluate what is right and wrong. First, some individuals place a high value on harm and make moral decisions based on whether a person or other living thing is hurt. Second, some individuals prioritize fairness and make moral decisions based on equality and justice. Third, some individuals stress loyalty and make moral decisions based on a commitment to one’s team, tribe, or group. Fourth, some individuals place a high value on authority and make moral decisions based on the ordered, hierarchical system of which they are a part. Finally, some individuals prioritize purity and make moral decisions based on avoiding pathogens and contaminants. In general, liberal individuals have profiles that prioritize the moral foundations of harm and fairness, with a lower emphasis on loyalty, authority, and purity. In contrast, conservatives tend to prioritize all five moral foundations equally (Graham, Haidt, & Nosek, 2009).

To successfully navigate value differences and conflicts, you must first understand and acknowledge how you judge right from wrong, which is closely linked to your cultural background and worldview. Having an accurate sense of yourself culturally (including your values) is a core aspect of cultural humility (Hook, Davis, Owen, Worthington, & Utsey, 2013). One important way to get a sense of the value differences or conflicts you might experience in therapy is to complete a measure that can help give you insight into your core values.

Next, we provide a measure of values: Exhibit 7.1, the Moral Foundations Questionnaire (MFQ; Graham et al., 2011). The MFQ is based on the theory we described earlier in this chapter; namely, there are five moral foundations that people use to make decisions about right and wrong (i.e., harm, fairness, loyalty, authority, and purity). For our purposes, this model provides a language for beginning to think and talk about your core values, as well as what types of value conflicts you might expect to experience in your work with clients.

RECOGNIZING A VALUE DIFFERENCE OR CONFLICT

In some of your therapeutic relationships, your values will likely line up (for the most part) with those of your client. For example, the client might be depressed and want to reduce the depression and become more satisfied with their life (perhaps falling under the harm/care domain). You might value life satisfaction as well, and thus therapy moves forward without a deep consideration of your values. Your values are congruent with those of your client, and thus therapeutic goals are easily set, and therapy moves forward with relatively few incidents.

But in other therapeutic relationships, you might get the sense that there are some value differences or conflicts between you and your client. We started this chapter with one such example. Josh’s client strongly valued family and connection, whereas Josh strongly valued independence and boundaries. There was a difference here (perhaps a smaller emphasis on loyalty and respect for authority), and it was a bit of a struggle for Josh to find a way to support the client and her values. But there are other examples as well. Maybe you strongly value equal rights for lesbian, gay, bisexual, and transgender (LGBT) individuals but have a religious client who is struggling with guilt and shame associated with her same-sex attraction. You believe that part of the reason for her guilt and shame is due to involvement in a religious community that labels her sexual attractions as bad and sinful, and you would like her to become more free and open with her sexuality. But your client places a high priority on her religious values regarding sexuality and would like you to help her adjust her behavior to be consistent with those values. This represents a value conflict. How do you move forward in a way that honors and respects your client’s values?

Or perhaps you strongly value independence and pursuing your personal goals and dreams. Your client is attending school in the United States but grew up in a family with strong collectivistic family values. Your client’s parents have several specific goals for your client—make straight As, get into medical school, become a doctor, get married and have children to carry on the family name, and so forth. Your client is struggling because she strongly values her family and wants to make them proud but is not sure she even wants to be a doctor. She feels conflict between her wants and desires and the desires of her family. Because you strongly value independence and pursuing your goals, you want the same for your client, and you find yourself encouraging her in this direction. But in doing so, are you respecting your client’s values or pushing your agenda for her?

Examples of Value Differences and Conflicts

To begin thinking about value differences and conflicts, we describe some hypothetical scenarios that might elicit a reaction from you on the basis of your personal set of values. For each hypothetical scenario, imagine you are the therapist for each of the clients described. Think about what values you hold that apply to this particular client situation. Think about whether there might be a value difference or conflict between you and the client. Read each of the following brief client descriptions and then answer the subsequent questions designed to help you clarify your values and reactions to the conflict:

Case 1. Sid is a 45-year-old, White, heterosexual, cisgender father of two. His daughters are aged 16 and 20. He is a widower. Recently, Sid was charged with sexually abusing his daughters. The abuse allegedly began a year after his wife’s death, when the girls were 12 and 16. Sid has been court ordered to attend counseling.

What personal values do you hold that apply to this client situation?

Do you foresee any value differences or conflicts that might come up between you and this client? If so, briefly describe the value difference or conflict.

Case 2. Eliza is a 33-year-old, White, cisgender woman who has recently begun a lesbian relationship with her neighbor, Kathy. This is Eliza’s first relationship with a woman. She has always been attracted to women, but she married her husband, John, immediately after high school. They have a son. Eliza is still married to John, but she intends to ask for a divorce and move out of state with Kathy to begin a new life. Eliza decided to attend therapy to help her get up the nerve to carry out her plan.

What personal values do you hold that apply to this client situation?

Do you foresee any value differences or conflicts that might come up between you and this client? If so, briefly describe the value difference or conflict.

Case 3. Frankie is a 27-year-old, White, heterosexual, cisgender man in a relationship of 4 years. He came to therapy to address issues of substance use. In his fifth session with you, Frankie discloses that he has contracted a sexually transmitted infection (STI) and has not told his girlfriend. He states that he is not totally surprised about his STI status given that he has unprotected sex with other women every few weeks. He shares that he thinks these other sexual contacts prevent his relationship with his girlfriend from feeling dull and monotonous. Frankie does not feel that this topic is relevant to his work in therapy and would like to keep the focus on his desire to be less dependent on alcohol and other drugs.

What personal values do you hold that apply to this client situation?

Do you foresee any value differences or conflicts that might come up between you and this client? If so, briefly describe the value difference or conflict.

Case 4. You are working with a family that recently emigrated from India. The family was referred to therapy by child services because the parents refused medical treatment for their daughter’s seizures. Emergency room doctors have become familiar with the family because of the daughter’s multiple emergency admissions. The hospital contacted child services because the little girl’s condition is worsening and will continue to do so unless she receives medical care. Through an interpreter, you can glean that the reason the family is refusing medical treatment is religious.

What personal values do you hold that apply to this client situation?

Do you foresee any value differences or conflicts that might come up between you and these clients? If so, briefly describe the value difference or conflict.

Take some time to think and reflect on your responses to each of the hypothetical scenarios. Of the four, which one elicited the strongest reaction from you? Which scenario tapped into your values the most? For which scenario did you foresee the greatest chance of a value difference or conflict between you and the client? Which scenario do you imagine being the most difficult for you to work with? As you consider this challenging scenario, what feelings come up for you (e.g., sad, angry, scared, happy, excited)?

Describing Value Differences and Conflicts

When we are working with clients, we might sometimes experience a value difference or conflict but struggle to put words to our experience. It is important to be able to talk about value differences and conflicts so we can process them, either individually or with a colleague or supervisor. In the following exercise, you have an opportunity to describe the value difference or conflict you experienced in the previous exercise.

Think back to the previous scenario that you felt represented the strongest value difference or conflict for you. Think about the strong feelings that the conflict evoked in you, such as confusion, anger, or sadness. Take 5 minutes and journal about your feelings regarding this value difference or conflict. Just write whatever comes to mind, without trying to censor. Try to focus on your deepest thoughts and feelings about the value difference and conflict. What is it about this value difference or conflict that brings up strong feelings in you? What feelings are triggered by this case? If you run out of things to write about, that’s OK—just keep writing whatever comes to mind. After you finish writing, read back through your journaling and make a note of what values seem to be at stake for you. See whether you can describe at least two values that are at odds with you as a result of considering work with this case.

Emotions in Value Differences and Conflicts

The process of recognizing value differences and conflicts can be difficult to navigate and may involve strong emotional reactions. Emotions play an important role in navigating value differences and conflicts. According to Haidt (2013), we do not primarily process morals or values with the analytical part of us. Instead, we have a tendency to make gut-level decisions about morals or emotions and then search for evidence to support our gut-level decisions. In other words, we may have an initial reaction of “good” or “bad” and then try to figure out why we react in this way. Because they play such a powerful role in morals and values, it is important to be able to put words to the emotions you are experiencing. According to emotion-focused theory (Greenberg, 2004; Pascual-Leone, Andreescu, & Greenberg, 2016), the process of verbalizing emotions is a key strategy for enhancing self-regulation and the ability to respond effectively to real-life situations.

Exhibit 7.2 lists some key moral emotions. Take a look at the list and think back to your experience when you read the scenario in which you expected to have a large value difference or conflict with the client. What are the key emotions that came up for you as you read the scenario? What emotions do you think you might have to work through to work successfully with this kind of client?

After thinking about the scenario in which you had a value conflict and identifying the underlying emotions, discuss this scenario with a colleague you trust. First, listen and ask questions to see how the other person thinks about the different values that are in tension. If you decide to share your perspective on the scenario, try to create a collaborative tone that makes it easier for you and your colleague to connect at a deeper, more vulnerable level.

Experiencing value differences and conflicts in your role as therapist is inevitable. Sometimes these value differences will be small, and it will be easy to negotiate and get on the same page as your clients. Other times, however, the value differences will be large, and it will seem impossible for you and your client to get on the same page. It may feel like you are between a rock and a hard place. One course of action seems to violate your values; another course of action seems to violate the client’s values. Even the most mature and healthy therapist will experience value differences or conflicts with their clients. A core part of every person’s cultural identity is their sense of right and wrong—and therapists are no different. Thus, we will not pretend that it would be possible or desirable for therapists to avoid completely ever having value differences or conflicts with their clients. Instead, we want to help you develop practical guidelines and strategies for managing situations in which your most cherished values are different or conflict with the values and expectations of the client.

Case Example: Paula and Robert

Consider the following therapy example between Paula, a 51-year-old, Puerto Rican, bisexual, cisgender, female therapist, and Robert, a 50-year-old, African American, heterosexual, cisgender, male client. Robert is attending therapy to get help with his drinking problems. In the last year, he was fired from his job for showing up to work drunk, and he was convicted of driving under the influence. Robert also believes his drinking problems contributed to his divorce several years ago and his estrangement from his two adult children. Paula, an experienced addictions therapist, has begun to work with Robert using an eight-session cognitive behavioral protocol focused on developing more adaptive ways of coping with stress other than drugs and alcohol. The following is an excerpt from their fourth session.

Paula:  OK, let’s begin by checking in about the previous week. How many drinking days did you have and how many drinks per drinking day?

Robert:  Honestly, it was kind of a tough week. I think I drank 3 days. Two days weren’t so bad—about four beers each day. But Friday night I kind of lost it—I drank most of a 12-pack.

Paula:  OK, so 3 drinking days and about 20 drinks in total. That’s actually quite a bit of improvement from when we started, so I want to honor you for that. What do you think went well?

Robert:  Well, I still had those 3 days, so I’m not feeling as good about those days. But I would say I’m feeling more hopeful than before, you know, that I could actually quit for good. Between my sessions with you and my AA meetings, I feel like I’m doing a lot of work, so that feels good.

Paula:  So it sounds like you’re feeling more hopeful, and you’re putting forth quite a bit of energy on your counseling. And maybe there’s the support piece too—through your counseling and your meetings?

Robert:  Yeah, that’s right. Support is key for me. A lot of times when I’ve tried to quit in the past, I’ve been pretty much on my own.

Paula:  We haven’t talked about your AA meetings before. What are those like for you?

Robert:  It’s just nice to be around a bunch of people who are trying for the same goal, you know? I’m trying to quit, and they are too. So there’s kind of this environment of accountability. Not like they look down on you if you had a drink, but there’s some people who have been sober for years—it’s pretty inspiring. And then there’s the higher power aspect of it as well. I haven’t been able to give up drinking before, and I’ve been trying for the last 20 years. So I do think I’m powerless to change on my own, like they say.

Paula:  OK, well, I’m glad you have people to support you besides what you are getting in therapy. The main topic for the session today is developing a plan to deal with relapse when it occurs.

Did you have any reactions as you read the dialogue between Paula and Robert? Did you notice any clues that a value difference or conflict was occurring? If you did notice anything, what made you think a value difference or conflict might be occurring? If you were Paula, how might you have addressed this with Robert?

Next, let us assume that Paula is committed to a harm-reduction model of working with clients who struggle with substance abuse problems. Suppose that she believes that the AA model, with its focus on abstinence and submitting to a higher power, is problematic and inconsistent with what she is trying to do in therapy with Robert. If you were Paula in this situation, how might you address this value difference or conflict with Robert? And how would you do so in a culturally humble way?

Regulating emotions that arise when discussing value differences and conflicts takes practice, so once again, see whether you can find a colleague whom you trust but who might have a different perspective on this case example. It is a simple behavior—but ask for a different perspective. Listen more than you talk. If you share, practice what we call a movement intervention. State what your initial reaction was. Then share with the other person that their perspective has changed how you understand things and explain how. Then see whether they offer an additional reaction. Most likely, you will not be able to resolve completely your ambivalence or dissonance and reach complete agreement, which is OK. You are two different people, and it is natural to have different perspectives and points of view. You could practice communicating about the difference, but see whether you can do this in the most disarming way possible, showing that the relationship is more important to you than being right. For example, one idea is to share the part of you that is still thinking or struggling. Share with your colleague that you will continue to explore other perspectives—or at least learn to sit better with the dissonance. Perhaps acknowledge impatience or other feelings you have related to ambiguity. Conflict does not have to create distance. If two people remain vulnerable and seek to build emotional trust, these interactions can deepen a relationship.

ADDRESSING THE VALUE DIFFERENCE OR CONFLICT IN THERAPY

Some scholars have discussed ways in which therapists might engage clients about values and value differences. For instance, Worthington (1988) developed a model for how therapists might engage with clients about religious values. Worthington posited that religious clients were likely to hold values associated with the authority of religious individuals, the authority of scripture, and ingroup norms (note the similarity to the binding foundations within moral foundations theory, including authority, loyalty, and purity). Outside clients’ specific value positions they had a zone of toleration in which they could comfortably engage with individuals who held values that were different from theirs. Some clients had zones of toleration that were quite narrow, whereas others had zones of toleration that were quite large. Therapists likewise held religious values associated with the authority of religious individuals, scripture, and ingroup norms, as well a zone of toleration in which they could comfortably engage with individuals who held values that were different from theirs. Worthington theorized that clients and therapists could develop a strong therapeutic relationship if their particular value positions were within the others’ zone of toleration.

Although Worthington (1988) focused on religious values, we believe this model can be extended and applied to any value conflict you might experience with a client. Clients have a range of value positions on various topics. For example, one client may be strongly committed to values such as conservative politics, opposition to abortion and gay marriage, commitment to family, and patriarchal gender values. Another client may be strongly committed to values such as liberal politics, immigration reform, Catholic religious beliefs, and criminal justice reform. A third client might be strongly committed to values such as equal rights for LGBT individuals, collectivism, and egalitarian gender roles. Each client is likely to have a zone of toleration for these values. Likewise, therapists have their value positions and zones of toleration. Effective therapy occurs at the overlap of the client’s and therapist’s zones of toleration. Cultural humility is critical for therapists to expand their zone of toleration (Woodruff, Van Tongeren, McElroy, Davis, & Hook, 2014).

There are several possible steps to intervention when you recognize a value difference or conflict between you and your client. Cultural humility involves prioritizing the cultural perspective and worldview of your clients, and this includes their values (Hook et al., 2013). We believe clients have the right to self-determination, even if their values, goals, or view of what “mental health” looks like differ from your own. So ultimately, when value differences or conflicts occur, the values that should take precedence are those of the client. Cultural humility will help you navigate this process and deal with your internal reactions to these differences.

Empathy and the Empty Chair Technique

To understand and prioritize your clients’ values, you have to be able to truly empathize with your clients, their experience, and their worldview. You might experience the following with a client: You notice a value difference or conflict, and you know that you should be experiencing empathy for the client’s perspective, but try as you might, the empathy just is not there. The empty chair technique, with roots in gestalt therapy (Perls, Hefferline, & Goodman, 1951), is a powerful intervention for helping individuals work through ambivalence and gain deeper levels of cognitive and affective empathy. The intervention is designed to help you develop greater awareness of the perspective of another person.

In the typical empty chair intervention, the individual sits in one chair and talks to another person (or perspective, such as a part of oneself) who sits in an “empty chair.” The person then switches seats and talks from the other person’s perspective. The individual alternates back and forth between perspectives. Then, after the activity, the facilitator often helps the individual process what the experience was like and consolidate any insights gained. We use this technique in the next exercise. (Ideally, you would complete this activity with a colleague or supervisor observing.)

If you are currently seeing clients, choose a current client with whom you are experiencing a value difference or conflict. If you are not currently seeing clients, choose a past client or one of the hypothetical scenarios described earlier in the chapter. Use the empty chair to talk to yourself from the vantage point of the client. Try to consider potential aspects of your client’s cultural or family history that may have contributed to their way of being and value position. Also, consider any current extenuating circumstances in your client’s life that might be at play.

Take some time to think and reflect on the empty chair exercise. Did anything come up for you? Did you experience any insights about your client’s behavior or values? If you completed this activity with another person, discuss what your experience was like and any insights gained.

If you allowed yourself to participate fully in the exercise, you might have noticed some resistance on your part to truly being willing to understand and prioritize your client’s values relative to your own. Try to notice these feelings of resistance, honor them, and then see whether you can set them aside. The goal of this exercise is to understand that if we can move past our judgments of a person, we may be able to identify points of understanding, which can lead to additional points of connection. This is empathy. We are trying to walk in another person’s shoes with less judgment. It is through empathy that we can begin to bridge our value difference or conflict. We do not need to agree with the behavior, actions, or values of the other person, but it is important to mitigate our tendency to link behavior we view as objectionable with our view of the person’s character and value.

Adapted Empty Chair Technique

Next, we adapt the empty chair technique to take advantage of your colleagues who may have a better sense of what your client may be experiencing. When therapy involves substantial cultural differences, you may need additional support to engage clients and their values with empathy.

Recruit a colleague or supervisor to help you with this exercise. Discuss with your discussion partner the client with whom you are working. Also, tell your discussion partner about the value difference or conflict you are experiencing with your client. Now, instead of you speaking from the other perspective (as you did in the empty chair technique), invite your discussion partner to speak from the client’s perspective. If you can, complete this activity with two or three colleagues to gain a variety of perspectives.

Spend some time reflecting on your experiences. Did anything stick out to you as important regarding your cultural exchanges with your colleagues? Did your colleagues offer any perspectives on your clients and their values that you had not thought about previously? Did they offer any perspectives on the value difference or conflict that you had not thought about previously? Did you experience more empathy or less empathy for your client following these cultural exchanges? Do you feel more or less able to prioritize your client’s values relative to your values following these cultural exchanges?

Addressing Value Difference or Conflict in Therapy

Although it is an important first step to understanding and prioritizing your client’s values throughout the therapy process, there may be times when it is a good idea to address the value difference or conflict in therapy. For example, you might have a discussion about your value difference with your client. This kind of discussion may lead therapy in a new direction or help the client consider other options or goals. Also, there may be times when you feel the value difference between you and your client is too large, and you feel unable to support the client in their values and goals. If this occurs, referral may be an option. However, as you become a more culturally humble therapist, our hope is that you would be able to work with and support a wide range of clients (and their accompanying sets of values).

The following are some practical steps for increasing your cultural humility about value differences and conflicts. First, you can work to identify your core values, like you did at the beginning of this chapter. Second, you can gain self-awareness for what it feels like when you are faced with a value difference or conflict. This involves learning and gaining insight into your areas of cultural countertransference, which occurs when you have personal reactions to clients based on your cultural history, values, or experiences. Cultural countertransference can occur with clients both within (i.e., intraethnic countertransference) or outside (i.e., interethnic countertransference) your cultural group (Roysircar, 2004). Third, you can develop self-regulation skills and engage in the challenging work of cultivating a more secure belief that you can explore different values without losing a sense of integrity. Fourth, you can develop habits of daily life that regularly require you to continue to learn and grow from individuals and groups who hold values that are different values from yours.

When thinking about how to address value differences and conflicts in therapy, an important first step is to have a general sense of some of the different ways therapists may try to address or cope with value differences or conflicts during a therapy session. Some of these strategies are more effective than others. However, gaining a basic understanding of the possible strategies and outcomes can provide you with a language for describing how you engage with value differences and conflicts when they occur in therapy.

The following are possible strategies for dealing with value differences and conflicts when they arise in therapy:

Immobilization. The therapist becomes fixated on the value difference or conflict and associated emotions (e.g., anger, anxiety) and is unable to progress with the client in therapy or seek help.

Antagonism. The therapist and client become at odds regarding the value difference or conflict, and/or the therapist in the position of power imposes their values on the client.

Distraction. The therapist engages in self-distraction to avoid the value difference or conflict and also redirects the client from the source of the value difference or conflict.

Ethical bracketing. The therapist attempts to bracket their values, empathize with the client, and provide ethical and effective therapy.

Collaborative discussion. The therapist can have an open and honest discussion with the client about the value difference or conflict they are experiencing, with the goal of moving forward in a mutually agreed-on direction.

Referral. The therapist and client cannot bridge the value difference or conflict in a way that leads to effective work, and they collaboratively decide that it is in the best interest of the client to work with a therapist who can provide better support for the client’s values.

Take some time and reflect on your experiences thus far in therapy. When you have experienced a value difference or conflict with a client, what is your typical way of responding? How would you like to respond when you experience a value difference or conflict with a client? Which responses reflect a high level of cultural humility? Which responses reflect a low level of cultural humility?

Develop a Value Hierarchy

We discuss ethical bracketing and collaborative discussion in more depth later. First, however, we want to highlight that it may be helpful to learn the skills of this chapter while focusing on more manageable value differences and conflicts before moving on to your most difficult and possibly even traumatic value differences and conflicts (e.g., working with sexual violence perpetrators if you have experienced sexual harassment or violence yourself). This concept is called scaffolding (Wood, Bruner, & Ross, 1976)—working within your current abilities before trying to expand them.

According to the zone of proximal development (Vygotsky, 1978), people tend to learn best when they work on new skills that are appropriately challenging but not too far outside their current abilities. Applied to the work of navigating value differences and conflicts, some value differences or conflicts may feel too difficult to work through at that moment. That is OK. It can be helpful to work on a more moderate value difference or conflict first to learn and practice the necessary skills. Then, once you get more comfortable with the skills involved, you can move on to addressing more challenging value differences and conflicts. In this next exercise, we help you identify a value difference or conflict that may represent a manageable place to begin.

Make a list of at least three of the most salient value differences and conflicts you have experienced in your work thus far. If you cannot think of a good example from your clinical work, think about an example from a close relationship (e.g., friends or family). Put these topics in order from most difficult to least difficult. This is a value hierarchy of value differences and conflicts you have experienced. Identify the third most difficult item on your value hierarchy sheet. Work through the following activities with this value difference or conflict. If you feel up to it, you can work through the process again with your second most difficult item and your most difficult item.

1. Describe the value difference or conflict using value language.

2. Identify the moral emotions you are having in the midst of the value difference or conflict.

3. Use the empty chair technique to cultivate empathy.

4. Use the adaptive empty chair technique to obtain additional perspective from others.

Ethical Bracketing

In this section we discuss ethical bracketing and collaborative discussion in more detail. It is important to note that in some cases, it may not be possible for a beginning therapist to engage in these techniques, and more immediate action (e.g., referral) may be required to protect the client’s welfare when a major value difference or conflict occurs. We each have limits in our ability to navigate value differences and conflicts. If there is a client who holds a value position that is truly outside your zone of toleration, it is important to recognize this and seek to refer the client to a therapist who is better able to support the client and the client’s values. There is a balance here. It is important to recognize that there are situations in which a referral is the best option, both for the therapist and client. However, it is also important to be willing to push yourself to work with clients who may be outside your comfort zone because this is the best way to grow and develop into a therapist who can be effective working with a wide range of clients.

When considering issues of referral due to value differences and conflicts, supervision and consultation are of utmost importance. A defining feature of value differences and conflicts is that the feelings that come up are often negative, and without some resolution, the value difference or conflict will likely make productive therapy difficult. So, what do we do? How do we work with the feelings that come up? The first step is to consult, whether that is in the context of supervision or with a trusted colleague. This step is crucial. It allows you to process what you are thinking and feeling with a trusted third party and get a second opinion about whether you should try to push yourself to address this value difference or conflict or whether referral is in the best interests of the client.

Now, we return to the strategy of ethical bracketing. Kocet and Herlihy (2014) defined ethical bracketing as

the intentional separating of a counselor’s personal values from his or her professional values or the intentional setting aside of the counselor’s personal values in order to provide ethical and appropriate counseling to all clients, especially those whose worldviews, values, belief systems, and decisions differ significantly from those of the counselor. (p. 182)

Ethical bracketing can provide an initial stance that protects therapist from imposing their values too strongly on the therapy process; however, therapists who use ethical bracketing may sometimes experience a lack of integrity unless they can achieve a greater level of emotional integration. As we discussed earlier, value differences and conflicts are associated with intense emotional responses. Consequently, it is important to consider exercises that can help you attend to your emotions and cultivate empathy during ethical bracketing.

The following model provides a cognitively based set of strategies for helping therapists (a) consider how their personal values may influence their clients and (b) ethically manage this potential for harm or coercion (Kocet & Herlihy, 2014). The intention is to gain cognitive perspective to be able to tolerate the ambiguity and potential distress that can result from dissonance between your personal values and those of the client. The approach delineates five steps, which involve engaging increasing levels of professional support:

1. Immersion. Therapists immerse themselves in self-reflection about the value difference or conflict they are experiencing.

2. Education. Therapists educate themselves on the nature of the value difference or conflict.

3. Consultation. Therapists consult their professional ethical codes and literature on best practices.

4. Supervision. Therapists obtain supervision and consistent consultation when applying ethical bracketing to the value difference or conflict.

5. Personal therapy. Therapists can consider personal therapy to identify their barriers and biases to working with a particular client or presenting concern.

Spend some time thinking and reflecting on the strategy of ethical bracketing. Have you ever used this strategy in your work with clients? Was it possible for you to separate your personal values from your professional values when navigating a value difference or conflict? What about this was most difficult for you? When you were engaged in ethical bracketing, were you able to get the outside support (e.g., consultation, supervision, personal therapy) you needed? How did this outside support help you in your ethical bracketing process?

Collaborative Discussion About Values

In addition to ethical bracketing, sometimes it can be helpful to have a discussion about value differences or conflict with your client. Admittedly, the appropriateness of these kinds of discussions may depend on your theoretical orientation. The four of us have been influenced by interpersonal theory (e.g., Teyber & McClure, 2011), which views the interpersonal dynamics and interactions between therapist and client as an important source of both conceptualization and intervention. Thus, we tend to be relatively more willing to self-disclose our feelings and reactions and talk about what is happening in the therapy room.

Case Example: Barbara and Alex

Consider the following example of Alex, an 18-year-old, Latino, heterosexual, cisgender man attending his first semester of college. He decided to go to therapy to address various depressive symptoms and difficulty adjusting to college. At this point, he had seen his therapist, Barbara, a 26-year-old, White, heterosexual, cisgender woman, for two sessions at the university counseling center. Alex, who was raised in a devoutly Catholic family, recently had sex while under the influence of alcohol. Alex feels a great deal of shame and guilt related to this recent behavior. Barbara, who identifies as spiritual but not religious, is struggling to support Alex’s beliefs and even finds them problematic. Specifically, she is concerned that his feelings of shame and guilt are potentially damaging to him. After consulting with her supervisor, Barbara decided to look for opportunities to have a collaborative discussion with Alex about their values in the next session.

Alex:  I still feel so ashamed for what happened. If my family knew what I did, they would be so disappointed in me.

Barbara:  It sounds like there is a very clear rule that you broke related to sexuality.

Alex:  Yes, I was supposed to wait until I was married to have sex. Instead of doing that, I waited until my first time getting drunk and woke up next to some stranger. I was so stupid. I don’t even remember what happened, but I don’t think we used protection. I feel so dirty.

Barbara:  I’m noticing that you are saying some very harsh things to yourself: “stupid,” “dirty.” In addition to your family, I also get the sense that this affected your spirituality. Is that true?

Alex:  Yes, it did. I went to church last week, but I felt numb. I felt like an outsider, like I no longer fully belonged. It was so painful. I tried to pray, but it felt like I was just talking to myself. I have no idea what to do next. I wish I could turn back time, but I’ll never be able to get my innocence back.

Barbara:  Alex, as we discussed in our first session when you asked, I am not a religious person. But I’d really like to understand your values around religion and sexuality, so I can better support you. It sounds like you have a strong sense that you have done something very wrong. Is that right?

Alex:  My feelings certainly say so. My family and church have always had very clear rules about sex. I just wish the pain would go away. If I could change my values, I would. I’ve tried before, but anytime I push the limits, it feels like my conscience is right there. I feel so worthless and sinful. I’ve confessed to my priest, but I still feel terrible inside. That’s part of the reason I came here.

Barbara:  Alex, I can tell you are dealing with a lot. Your religious identity is very important to you but also changing. And what you did last week felt like it changed you too, and you’re not quite sure how to move forward from here.

What is your reaction to the dialogue between Barbara and Alex? What value differences or conflicts did you notice during the dialogue? Do you think it was a good idea for Barbara to bring up the value difference she noticed between her and Alex? In your view, was Barbara able to affirm Alex in his values about religion and sexuality, even though she held a different set of values? How do you think you would have navigated this value difference if you were Alex’s therapist?

The goal when having a collaborative discussion about value differences and conflicts is to explore the difference or conflict, learn from it, and find a way forward to work collaboratively toward the client’s goals. The collaborative discussion involves naming and exploring the value difference or conflict with the client. The client and therapist can discuss the value difference or conflict and the ways in which it may affect the therapy relationship and process.

It is important for therapists to engage with cultural humility throughout this process. This involves, first, listening to clients and trying to understand their perspective. There may be some important information the client can offer regarding the value difference or conflict that could move the conversation forward in an important way. It is also important for the therapist to prioritize the client’s values and perspective. Ultimately, clients have a right to hold the values they prioritize, and it is not our job to change their perspective. However, just as we might learn new information from the client’s perspective, it is possible that clients may benefit from hearing our perspective on the value difference or conflict.

Finally, therapists should be open about possible ways forward. Your theoretical orientation may provide some guidance in understanding the nature of this dynamic and the degree to which engaging the value difference or conflict in therapy is likely to lead to positive outcomes. It may be that, following the discussion, the client may decide that they would be best served by a referral to a different therapist. More likely, however, you will be able to find a way forward that honors and respects the client’s values and perspective. It also is likely that both the therapist and client may benefit from having an open and honest discussion about the value difference or conflict.

If you are currently seeing clients, choose a current client with whom you are experiencing a value difference or conflict. If you are not currently seeing clients, choose a past client or one of the hypothetical scenarios at the beginning of the chapter. Recruit a colleague or supervisor to help you with this exercise. Have them play the role of your client. Practice having a collaborative discussion about the value difference or conflict you are experiencing. It is OK if this conversation feels a bit awkward at first—you will feel more comfortable with practice. After the discussion, check in with your discussion partner and ask for feedback. Did they feel as if their cultural perspective and values were honored and respected, even though the discussion centered on the value difference? How could you have engaged differently in order to lead a more productive conversation about the value difference or conflict? What was the end result of your conversation?

Value Hierarchy Revisited

Return to your value hierarchy. Previously, you worked through a series of steps from describing the value conflict to participating in an adapted empty chair technique. Now we would like you to revisit your value hierarchy and incorporate the more recent activities.

Again, list your values conflicts from most to least challenging. Identify the third most difficult item on your value hierarchy sheet. Work through the following activities with this value difference or conflict. If you feel up to it, you can work through the process again with your second most difficult item and your most difficult item.

1. Consult with a colleague or supervisor about this value difference or conflict.

2. Practice ethical bracketing.

3. Practice having a collaborative discussion about the value difference or conflict.

Conclusion

Navigating value differences and conflicts with clients can be a difficult process. This may be especially true if these value differences and conflicts involve cherished values that are core to your personal cultural identity. Navigating these value differences and conflicts also has the potential to change who you are as a person because you must learn to clarify and integrate conflicting values in a novel way. Although the process can be difficult, it can also lead to tremendous growth. Confronting and navigating value differences and conflicts forces us to examine (and perhaps change) our most strongly held values. Our encouragement is to engage in these situations with hope and expectation. You will likely come away from these interactions changed and enriched.