5 Ways to be a Culturally Responsive Therapist

By: Dr. Jessica Jackson 

The death of George Floyd has brought discussions of racism to the forefront of America, and ultimately into the therapy room. For many clinicians, discussions of racism, discrimination, and/or the role that race plays in our daily lives has come up in therapy sessions. If it hasn’t happened yet, it will.

Our clients do not live in bubbles and are not exempt from the current social and political climate, especially people of color. Sue & Sue (2012) put it best, “…counseling and psychotherapy do not take place in a vacuum, isolated from the larger sociopolitical influences of our societal climate” (pg. 91).

I’ve received many questions and took part in many discussions with colleagues about how to help BIPOC (Black, Indigenous, People of Color) clients, specifically Black clients. My answer: practice cultural humility and culturally responsive therapy.

Moving beyond cultural competence to cultural humility and responsiveness

Cultural competence is a phrase I am sure has popped up in recent discussions you’ve had with your colleagues. For many of us, cultural competence is what was taught in graduate school. It was the standard for discussions of diversity for years in psychology. Cultural competence was a term that came into prominence in the early 1980s thanks to Derald Wing Sue. Culture competence is model of developing skills, knowledge and self-awareness to be more effective in working with diverse populations. While cultural competence is an important start; I encourage you to think and reflect deeper.

The American Psychological Association Race & Ethnicity guidelines and increased multicultural emphasis in training programs have helped the field of psychology evolve beyond just possession of knowledge and skills of other cultures — moving from a way of doing to a way of being. More and more we recognize that our cultural identity and that of our client are both salient aspects of the therapy dynamic (American Psychological Association (2003). Cultural humility and cultural responsivity are building blocks to understanding our clients and the cultural context that shapes their distress, building blocks that help us provide needed support on a deeper level.

Davis et al. (2011) breaks down humility into intrapersonal humility and interpersonal humility. To practice cultural humility, we must have both an accurate view of ourselves and respect for others without an attitude of supremacy or superiority.

Cultural humility is a continuum of:

1. Inward self-awareness,
2. Outward valuing of others and
3. Upward growth. (Hook et al. 2013).

Culturally responsive therapy is responding to and making room for the client’s culture in the therapeutic process. This may look like:

• Asking questions about their family’s cultural background and beliefs,
• Asking about their use of emotional expression, and
• Learning their perspective of their symptoms, even if it’s unrelated to the presenting problem.

As therapists, we cannot be culturally responsive if we have not first worked on developing cultural humility.

Developing cultural humility: the pre-work

Cultural humility is a mind-set shift and a career-long commitment. For those looking to get started on this journey, here are three skills you can begin working on. I call this the pre-work, the work that should happen on your own time before you enter the therapy room.:

1. Self-awareness – Engage in self-reflection and self-understanding to develop an accurate view of self. Take the time to reflect on how your different social identities (e.g. religion, sexuality, generation, acculturation, socioeconomic status, education, ethnicity etc.) have influenced your worldview. Engage in reading, dialogues, workshops etc. that help you have a better understanding of your privileges, biases and values.
   
2. Valuing of others – Be curious! Demonstrate a willingness to learn from others around you (e.g. colleagues, clients, friends etc.) and respond from a place of genuineness and authenticity. It’s okay to not know everything, in fact, admitting ignorance and asking questions is a cornerstone of humility. A caveat to this point is to be careful that you are not placing the responsibility on clients to teach you about their culture. There is a difference between asking someone to teach you about racism and asking to learn their experience of racism. Finding the balance is necessary.
   
3. Growth – Remember, practicing cultural humility is a process. This is not a skill that we build overnight, but a continuum of continuing learning throughout our careers as clinicians. Push through discomfort and anxiety related to cultural conversations and enter conversations acknowledging that you may not feel your best throughout the conversation.

How to be a culturally responsive therapist

Once we have engaged in the pre-work, we can then focus on building on our increased self-awareness to foster empathy for clients. Culturally responsive therapy requires this empathy to truly understand and conceptualize how the client’s social identities interact and influence the client’s perception of their distress.

I have outlined five tips for doing culturally responsive work in the therapy room:

1. One-size doesn’t fit all – Be mindful of how client’s social identities interact to make them unique. Appreciate individual differences and approach clients with an understanding of and respect for the client’s needs and cultural values. Be open-minded and recognize that there are multiple ways of viewing the world.
   
2. Consider how your values, worldview, upbringing, etc. may influence your client’s perception of, rapport with, or trust in you. – Conceptualization and diagnosis often go hand in hand. Consider how your client’s behaviors and decisions may be guided by their cultural values and beliefs.
   
3. Ask yourself, are you being tolerant, inclusive or integrative? – Consider culture at each step of the appointment, from advertising for clients to the termination session with a client. Tolerance is acknowledging there are differences between you and your client. Inclusivity is asking them their social identities and cultural background and considering it in your conceptualization. Integration is all of the above and having office décor reflective of different cultures or having intake forms/screeners in multiple languages. The goal in culturally responsive therapy is demonstrating integration. Georgetown University’s National Center for Cultural Competency has a checklist available to self-assess the inclusiveness of your practice.
   
4. Acknowledge what is happening in the world outside of the therapy room – Even if your client does not bring it up, it’s okay to open the door for the discussion. They may be waiting to see if you’re comfortable bringing up a certain topic (e.g. racism, police brutality etc.). Asking a client how they are holding up with everything happening this week (note what’s been in the news or all-over social media etc.) is a general way to make it clear you are open to the conversation. Keep in mind, acknowledging a topic does not mean that it has to be the focus of treatment, but could be helpful in establishing rapport.
   
5. Don’t make assumptions – Ask clients how they identify. Don’t assume, based on your client’s outward appearance, that they don’t want to discuss certain topics OR that they relate to specific topics. We all have fallen prey to stereotyping. Work on being intentional about not generalizing based on prior knowledge or prior experience with similar clients. For example, with the current COVID-19 pandemic, some Black American clients may be more focused on grief or financial concerns than racism. That’s not to say racism may not be important to them but may not be what’s most affecting them in session. In this case acknowledging the racism that is occurring may help the client feel more comfortable addressing the other concerns.

Barriers to being a culturally responsive therapist

As you practice these skills, be mindful of common barriers that may get in our way:

1. Fear
2. Lack of preparedness for emotionally charged conversations
3. Feelings of inadequacy
4. Politeness protocol, and
5. Colorblindness.

For example, fear of saying the wrong thing often goes along with feeling incompetent, especially when addressing a topic, you don’t normally discuss. It’s okay to name this anxiety in the therapy room, as long as the intention is to communicate, “I might get this wrong, but I’m willing to take the risk to create a necessary space for my client.” What is not okay is not doing the self-work or preparing for the discussion and expecting the client to educate you in session.

It’s helpful to give yourself time before the session to prepare and reflect on what you want to say. Jumping into this conversation without thoughtfulness or intentionality could disrupt the rapport, the opposite of the goal.

Lastly, I challenge you to push past colorblindness and politeness protocol. Telling a client that you do not see color is essentially telling them that you do not see the totality of who they are. It is not polite, it not good etiquette, it is not a compliment. If you feel the pull to tell a client you do not see color, I encourage you to pause and reflect on why that may feel safer for you.

We all make mistakes. Even when we have the best of intentions to support our client’s and meet them where they are, we can still get in our own way. There is simply no way to know it all, but we can communicate to our clients that we’re ready to listen and meet them where they are to support them.

Remember, cultural humility is being comfortable admitting what we don’t know. Leaning into this uncomfortableness has the potential to lead to deeper, richer connections with clients; making it well worth the effort.

Dr. Jessica Jackson is a counseling psychologist with a private practice in Houston, TX. She has provided mental health services in correctional facilities, university counseling centers, high schools and healthcare settings.

Jessica is a 2019 recipient of Society of Counseling Psychology, Section for Ethnic & Racial Diversity Outstanding Service to Diverse/Underserved Communities Award. Jessica is an alumna of the APA Council of National Psychological Associations for the Advancement of Ethnic Minority Interests (CNPAAEMI) Leadership Development Institute Fellow.

As a practitioner-scientist -advocate, her research focus has primarily centered around barriers to outpatient treatment, culturally competent clinical practice, race-related stress and racial trauma.

Connect with Dr. Jackson on Twitter, Instagram, or her website: www.drjlauren.com.