What Is Cultural Competence?
Consistent with the definition of MCT, it becomes clear that culturally competent healers are working toward several primary goals (American Psychological Association, 2003; D. W. Sue et al., 1992; D. W. Sue et al., 1998). First, culturally competent helping professionals are ones who are actively in the process of becoming aware of their own values, biases, assumptions about human behavior, preconceived notions, personal limitations, and so forth. Second, culturally competent helping professionals are ones who actively attempt to understand the worldview of their culturally diverse clients. In other words, what are the client’s values and assumptions about human behavior, biases, and so on? Third, culturally competent helping professionals are ones who are in the process of actively developing and practicing appropriate, relevant, and sensitive intervention strategies and skills in working with their culturally diverse clients. These three attributes make it clear that cultural competence is an active, developmental, and ongoing process and that it is aspirational rather than achieved. Let us more carefully explore these attributes of cultural competence.
Competency 1: Therapist Awareness of One’s Own Assumptions, Values, and Biases
In almost all human service programs, counselors, therapists, and social workers are familiar with the phrase “Counselor, know thyself.” Programs stress the importance of not allowing our own biases, values, or hang-ups to interfere with our ability to work with clients. In most cases, such a warning stays primarily on an intellectual level, and very little training is directed at having trainees get in touch with their own values and biases about human behavior. In other words, it appears to be easier to deal with trainees’ cognitive understanding of their own cultural heritage, the values they hold about human behavior, their standards for judging normality and abnormality, and the culture-bound goals toward which they strive.
As indicated in Chapter 1, what makes examination of the self difficult is the emotional impact of attitudes, beliefs, and feelings associated with cultural differences, such as racism, sexism, heterosexism, able-body-ism, and ageism. For example, as a member of a White EuroAmerican group, what responsibility do you hold for the racist, oppressive, and discriminating manner by which you personally and professionally deal with persons of color? This is a threatening question for many White people. However, to be effective in MCT means that one has adequately dealt with this question and worked through the biases, feelings, fears, and guilt associated with it. A similar question can be asked of men with respect to women and of straights with respect to gays.
Competency 2: Understanding the Worldviews of Culturally Diverse Clients
It is crucial that counselors and therapists understand and can share the worldviews of their culturally diverse clients. This statement does not mean that providers must hold these worldviews as their own, but rather that they can see and accept other worldviews in a nonjudgmental manner. Some have referred to the process as cultural role taking: Therapists acknowledge that they may not have lived a lifetime as a person of color, as a woman, or as a lesbian, gay, bisexual, or transgendered person (LGBT). With respect to race, for example, it is almost impossible for a White therapist to think, feel, and react as a racial minority individual. Nonetheless, cognitive empathy, as distinct from affective empathy, may be possible. In cultural role taking, the therapist acquires practical knowledge concerning the scope and nature of the client’s cultural background, daily living experience, hopes, fears, and aspirations. Inherent in cognitive empathy is the understanding of how therapy relates to the wider sociopolitical system with which minorities contend every day of their lives.
Competency 3: Developing Culturally Appropriate Intervention Strategies and Techniques
Effectiveness is most likely enhanced when the therapist uses therapeutic modalities and defines goals that are consistent with the life experiences and cultural values of the client. This basic premise will be emphasized throughout future chapters. Studies have consistently revealed that (a) economically and educationally marginalized clients may not be oriented toward “talk therapy”; (b) self-disclosure may be incompatible with the cultural values of Asian Americans, Hispanic Americans, and American Indians; (c) the sociopolitical atmosphere may dictate against self-disclosure from racial minorities and gays and lesbians; (d) the ambiguous nature of counseling may be antagonistic to life values of certain diverse groups; and (e) many minority clients prefer an active/directive approach over an inactive/nondirective one in treatment. Therapy has too long assumed that clients share a similar background and cultural heritage and that the same approaches are equally effective with all clients. This erroneous assumption needs to be challenged.
Because groups and individuals differ from one another, the blind application of techniques to all situations and all populations seems ludicrous. The interpersonal transactions between the counselor and the client require different approaches that are consistent with the client’s life experiences (Choudhuri, Santiago-Rivera, & Garrett, 2012; Ratts & Pedersen, 2014). It is ironic that equal treatment in therapy may be discriminatory treatment! Therapists need to understand this. As a means to prove discriminatory mental health practices, racial/ethnic minority groups have in the past pointed to studies revealing that minority clients are given less preferential forms of treatment (medication, electroconvulsive therapy, etc.). Somewhere, confusion has occurred, and it was believed that to be treated differently is akin to discrimination. The confusion centered on the distinction between equal access and opportunities versus equal treatment. Racial/ethnic minority groups may not be asking for equal treatment so much as they are asking for equal access and opportunities. This dictates a differential approach that is truly nondiscriminatory. Thus to be an effective multicultural helper requires cultural competence. In light of the previous analysis, we define cultural competence in the following manner:
Cultural competence is the ability to engage in actions or create conditions that maximize the optimal development of client and client systems. Multicultural counseling competence is defined as the counselor’s acquisition of awareness, knowledge, and skills needed to function effectively in a pluralistic democratic society (ability to communicate, interact, negotiate, and intervene on behalf of clients from diverse backgrounds), and on an organizational/societal level, advocating effectively to develop new theories, practices, policies, and organizational structures that are more responsive to all groups. (D. W. Sue & Torino, 2005)
This definition of cultural competence in the helping professions makes it clear that the conventional one-to-one, in-the-office, objective form of treatment aimed at remediation of existing problems may be at odds with the sociopolitical and cultural experiences of the clients. Like the complementary definition of MCT, it addresses not only clients (individuals, families, and groups) but also client systems (institutions, policies, and practices that may be unhealthy or problematic for healthy development). Addressing client systems is especially important if problems reside outside rather than inside the client. For example, prejudice and discrimination such as racism, sexism, and homophobia may impede the healthy functioning of individuals and groups in our society.
Second, cultural competence can be seen as residing in three major domains: (a) attitudes/beliefs component—an understanding of one’s own cultural conditioning and how this conditioning affects the personal beliefs, values, and attitudes of a culturally diverse population; (b) knowledge component—understanding and knowledge of the worldviews of culturally diverse individuals and groups; and (c) skillscomponent—an ability to determine and use culturally appropriate intervention strategies when working with different groups in our society. Box 2.1 provides an outline of cultural competencies related to these three domains.
Box 2.1 Multicultural Counseling Competencies
1. Cultural Competence: Awareness
1. Moved from being culturally unaware to being aware and sensitive to own cultural heritage and to valuing and respecting differences.
2. Aware of own values and biases and of how they may affect diverse clients.
3. Comfortable with differences that exist between themselves and their clients in terms of race, gender, sexual orientation, and other sociodemographic variables. Differences are not seen as deviant.
4. Sensitive to circumstances (personal biases; stage of racial, gender, and sexual orientation identity; sociopolitical influences; etc.) that may dictate referral of clients to members of their own sociodemographic group or to different therapists in general.
5. Aware of their own racist, sexist, heterosexist, or other detrimental attitudes, beliefs, and feelings.
2. Cultural Competence: Knowledge
1. Knowledgeable and informed on a number of culturally diverse groups, especially groups with whom therapists work.
2. Knowledgeable about the sociopolitical system’s operation in the United States with respect to its treatment of marginalized groups in society.
3. Possess specific knowledge and understanding of the generic characteristics of counseling and therapy.
4. Knowledgeable of institutional barriers that prevent some diverse clients from using mental health services.
3. Cultural Competence: Skills
1. Able to generate a wide variety of verbal and nonverbal helping responses.
2. Able to communicate (send and receive both verbal and nonverbal messages) accurately and appropriately.
3. Able to exercise institutional intervention skills on behalf of clients when appropriate.
4. Able to anticipate the impact of their helping styles and of their limitations on culturally diverse clients.
5. Able to play helping roles characterized by an active systemic focus, which leads to environmental interventions. Not restricted by the conventional counselor/therapist mode of operation.
Sources: D. W. Sue et al. (1992), and D. W. Sue et al. (1998). Readers are encouraged to review the original 34 multicultural competencies, which are fully elaborated in both publications.
Third, in a broad sense, this definition is directed toward two levels of cultural competence: the personal/individual and the organizational/system levels. The work on cultural competence has generally focused on the micro level, the individual. In the education and training of psychologists, for example, the goals have been to increase the level of self-awareness of trainees (potential biases, values, and assumptions about human behavior); to acquire knowledge of the history, culture, and life experiences of various minority groups; and to aid in developing culturally appropriate and adaptive interpersonal skills (clinical work, management, conflict resolution, etc.). Less emphasis is placed on the macro level: the profession of psychology, organizations, and the society in general (Lum, 2011; D. W. Sue, 2001). We suggest that it does little good to train culturally competent helping professionals when the very organizations that employ them are monocultural and discourage or even punish psychologists for using their culturally competent knowledge and skills. If our profession is interested in the development of cultural competence, then it must become involved in impacting systemic and societal levels as well.
Fourth, our definition of cultural competence speaks strongly to the development of alternative helping roles. Much of this comes from recasting healing as involving more than one-to-one therapy. If part of cultural competence involves systemic intervention, then such roles as consultant, change agent, teacher, and advocate supplement the conventional role of therapy. In contrast to this role, alternatives are characterized by the following:
· Having a more active helping style
· Working outside the office (home, institution, or community)
· Being focused on changing environmental conditions, as opposed to changing the client
· Viewing the client as encountering problems rather than having a problem
· Being oriented toward prevention rather than remediation
· Shouldering increased responsibility for determining the course and the outcome of the helping process
It is clear that these alternative roles and their underlying assumptions and practices have not been historically perceived as activities consistent with counseling and psychotherapy.
Cultural Humility and Cultural Competence
Can anyone ever be completely culturally competent in working with diverse clients? Are the awareness, knowledge, and skills of cultural competence the only areas sufficient to be an effective multicultural helping professional? The answers to these questions are extremely important not only to the practice of counseling/therapy, but to the education and training of counselors and therapists. The answer to the first question is an obvious “no.” It is impossible for anyone to possess sufficient knowledge, understanding, and experience of the diversity of populations that inhabit this planet. Indeed, those who have developed and advocated multicultural counseling competencies have repeatedly stressed that “cultural competence” is an aspirational goal, that no single individual can become completely competent, and that the journey toward cultural competence is a lifelong process (D. W. Sue et al., 1992; Cornish et al., 2010).
With respect to the second question, it appears that the dimensions of awareness, knowledge, and skills may be necessary, but not sufficient conditions to work effectively with diverse clients. Other attributes, like openness to diversity (Chao, Wei, Spanierman, Longo, & Northart, 2015) and cultural humility seem central to effective multicultural counseling (Gallardo, 2014). The concept of cultural humilitywas first coined in medical education, where it was associated with an open attitudinal stance or a multicultural open orientation to diverse patients, and found to be quite different from cultural competence(Tervalon & Murray-Garcia, 1998). The term has found its way into the field of multicultural counseling, where it also refers to an openness to working with culturally diverse clients (Hook, Davis, Owen, Worthington, & Utsey, 2013; Owen et al., 2014). But exactly how does it differ from cultural competence and what evidence do we have that it is an important component?
Cultural humility appears more like a “way of being” rather than a “way of doing,” which has characterized cultural competence (Owen, Tao, Leach, & Rodolfa, 2011). In the former, we are referring to the virtues and dispositions inherent in the attitudes that counselors hold toward their clients, while the latter refers more to the acquisition of knowledge and skills used in working with clients. The attitudinal components of respect for others, an egalitarian stance, and diminished superiority over clients means an “other-orientation” rather than one that is self-focused (concern with one’s expertise, training, credentials, and authority). Recall again the therapeutic encounter between Dr. D. and Gabriella. When asked by Gabriella whether he could understand what it’s like to be Latina, and the unique issues she must cope with, his response was “Of course I can” and “I’ve worked with many Latinos in my practice.” In many respects, the definition of cultural humility is humbleness; thus therapists acknowledging that they may be limited in their knowledge and understanding of clients’ cultural concerns may actually strengthen the therapeutic relationship. Dr. D.’s response, however, suggests he is self-oriented (“I am the therapist and I know best”), while cultural humility would entertain the possibility that the therapist may not understand. A therapeutic response that would indicate cultural humility would be: “I hope I can, let’s give it a try, okay?” Hook et al. (2013) make the following observations about cultural humility:
Culturally humble therapists rarely assume competence (i.e., letting prior experience and even expertness lead to overconfidence) for working with clients just based on their prior experience working with a particular group. Rather, therapists who are more culturally humble approach clients with respectful openness and work collaboratively with clients to understand the unique intersection of clients’ various aspects of identities and how that affects the developing therapy alliance. (p. 354)
Although cultural humility may appear difficult to define and measure, researchers have been able to begin construction of an instrument to quantify it (Hook et al., 2013; Owen et al., 2014). In a therapeutic context, cultural humility of therapists was (a) considered very important to many socially marginalized clients, (b) correlated with a higher likelihood of continuing in treatment, (c) strongly related to the strength of the therapeutic alliance, and (d) related to perceived benefit and improvement in therapy. Thus cultural humility as a dispositional orientation may be equally important as cultural competence(awareness, knowledge, and skills) in multicultural counseling and therapy.
Social Justice and Cultural Competence
Recently, the Multicultural Counseling Competencies Revision Committee of the American Counseling Association (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015) has presented an important draft document, Multicultural and Social Justice Counseling Competencies (MSJCC) that proposes to revise the multicultural counseling competencies devised by D. W. Sue et al. (1992). As indicated in Chapter 4, at the heart of the revision is integration of social justice competencies with multicultural competencies. Acknowledging that multiculturalism leads to social justice initiatives and actions, they propose a conceptual framework that includes quadrants (privilege and oppressed statuses), domains (counselor self-awareness, client worldview, counseling relationships, and counseling and advocacy interventions), and competencies (attitudes and beliefs, knowledge, skills, and action).
Perhaps the most important aspect of the proposed MSJCC is seen in the quadrants category, where they identify four major counseling relationships between counselor and client that directly address matters of power and privilege: (1) privileged counselor working with an oppressed client, (2) privileged counselor working with a privileged client, (3) oppressed counselor working with a privileged client, and (4) oppressed counselor working with an oppressed client. In other words, when applied to racial/ethnic counseling/therapy, various combinations can occur: (a) White counselors working with clients of color, (b) counselors of color working with White clients, (c) counselors of color working with clients of color, and (d) White counselors working with White clients. Analysis and research regarding these dyadic combinations have seldom been addressed in the multicultural field.