Developing Racial-Cultural Competence: A Call to all therapists

What comes up when you read the words “race and culture”? For most its likely to be people descended from the global majority (PoGM), such as African or South Asian people and their ubiquitous experiences of racism and systemic discrimination. While these are often central concerns, they can hide much of the scope, awareness, and depth of a subject, which can be applicable to all clients, even those with similar or white cultural backgrounds (18). In this article I hope to go under the surface, with a few examples, of why race and culture core competence is a vital competency for all therapists, supervisors and trainers, and what it means in practice.

‘Race’ means the categorisation of people into groups primarily based on skin tone

Culture means shared or common set of values, beliefs, rituals, social norms with a social group e.g. ethnic group, social group, nationality, individual (worldview)

People of the Global Majority (inc Mixed) whose heritage is from Global South (non-European) heritage

Race & Culture are Universal : Worldviews, identity and positionality

First, everyone’s worldview is influenced by race and culture (4,9), whether values and beliefs, language, faith, social norms of behaviour, or a sense of being a part of a collective racial-cultural group. Race and culture are embodied within, and give rise to our sense of identity, regardless of cross-cultural relationships. Therefore, race and culture can be a source of suffering, loss, conflict and pain as well as a positive source of home.

Second, the racial-culture perceptions of how both therapist and client see themselves in the here-and-now have been socialised through intergenerational, historical, current and personal events. Therapy is often seen as a microcosm of the world; its effects such as racial and cultural bias, intergroup anxiety, negative relationship dynamics within or cross racial groups can be reproduced in the room. Therapists need to recognise that the work does not occur isolated from larger events in society; they need to be aware of the socio-political forces that affect both therapists and clients’ lives.

Third, (9, 4), healthy personality development includes awareness of our relationship with the construction of race. Racial identity theory provides an evidential frame within which we can consider the meaning of race and culture in our internal and external world, including in relationships and between racial groups.  For example, white identity development (11) describes states of personality development going from being unaware, complicit, or externalising the problem of race, to being self-aware, reflective, and reimagining anew their individual and collective identity. These processes allow for the possibility of an improved relationship with the self as well as others. All these development processes are vital for personal development and thus working effectively with clients (9, 4).

Fourth, race and culture are a consideration in every aspect of therapy whether it is research, theory, assessment, relationship, presenting problems, or even the construction of therapy itself (4). This is prioritised so much that culture is often considered superordinate (17) to therapy as it, too, is culture bound. As an example, if a woman of colour has an eating disorder and the effects of race and culture are not the considered it could lead to discounting vital aspects of the work, such as the effects of being racialised or fitting into the cultural norm of ‘fit and thin’. Further, say the therapist needs to engage the family in support of the client, but doesn’t understand the cultural meaning of mental health; much of the client’s cultural context could be missed. Similar examples could be given for a whole range of presenting problems such as trauma, stress, anxiety and depression. Therefore, race and culture should not be an aside to therapy, but a foundational element of theory alongside other universal theories such as relationship patterns, childhood family experiences, psychosocial development, attachment theory or even empathy.

The following Case Study can be used to demonstrate these points:
Case study [this could perhaps be a separate box/panel alongside the main copy]

Addison is a woman: “This race awareness training has triggered unknown feelings in me as a White woman with a partner of African heritage. I can see the differences in how my family treat her compared to everyone else. I notice how even strangers would greet her differently, like an afterthought. And I’ve been wondering why. I want to respect my own culture, but I feel ashamed. I also want to respect my partner’s culture, and not take over and make sure I do the right thing by her and her children. But I don’t know how. Am I taking over and assimilating everyone into to my world? Things don’t feel right, especially as we seem to be bickering so much about family”.

What racial-cultural exploration could be relevant here? for example. Does Addison feel that aversion to her partner is due to her family’s attitudes towards race, culture and/or sexual diversity? What is driving Addison’s conflict and feelings of shame about her white cultural identity? How do race and culture differences impact the family unit as well as the relationship? Do misunderstandings and even lack of race awareness between the couple cause difficulties? Is there a power struggle to have each other’s cultural preferences affirmed and adopted? What are the implications for raising a child within a transracial household? And what parenting style will they adopt under these circumstances? Further, ethical dilemmas may also arise in consideration of (for example) the client’s expression of cultural prejudice or the implication of the therapist’s inadvertent preference towards their own culture. Will the therapist be an agent of assimilation or provide true autonomy?

Morphing therapy to the client’s racial-cultural context

Understanding the client’s personal beliefs and attitudes, spirituality, communication needs and their cultural context can help therapists to adapt their approach, interventions and therapeutic responses. Adaptation may or may not be about their ‘race’ but their cultural context.

For example, within a client’s cultural context, silence or a non-directive approach may be considered non-caring rather than empathic (8). Another example I can give you from my own experience is where a therapist wanted me to hand money over at the end of the session directly into their hands which, from my cultural perspective, is seen as rude. For interventions, the therapist could consider healing practices that are inclusive of the client’s own cultural values such as prayer, rituals, and arts.

When understanding and responding to the client’s description of their world we need to be mindful of differences in cultural meaning, such as boundaries, duty, age-based respect, love or forgiveness. For example, teaching clients to be assertive in order to hold boundaries may not be an appropriate way of helping a client where respect for elders is highly valued (3). Therefore, working relative to your client’s culture could mean reappraising your internal understanding of taken for granted constructs as a way of truly meeting the client in their world.

These examples serve to highlight how the therapeutic relationship could jar, aspects of client’s world could be missed, and incongruent responses provided in contrast to the client’s worldview. Racial-cultural difference needs to be considered rather than assumed even if the client appears white.

Working with racism and intersections of discrimination

Much research has been done on the effects of mental and physical health due to accumulative, traumatic and daily forms of racism, which shows that discrimination can have a profound impact on stress and resilience, and can contribute to poor health (1, 14, 16).

Therapists need competence to work with racism, including internalised racism and colourism, so that clients can work on their difficulties in a contained environment, free of negative or retraumatising experiences which could be triggered, however unintentionally, by the therapist (6, 3, 4). This work may also include helping clients to evaluate the meaning of their life experiences from childhood to the present day through the lens of racial and cultural psychosocial development and discrimination.

Learning should emphasise systemic forms of discrimination too. The therapist will need to develop personal critical awareness skills to consider racial and intersectional forms of discrimination. Consider this example from a woman of colour in her workplace:

“My colleagues [White] at work don’t support me and I notice I get left out a lot at events and don’t get backed up when I need it. I feel I’m the only one. I feel so anxious every time someone is going to judge my performance! I need to find a way to get rid of this anxiety. I feel such a failure”

We can help clients to consider the workplace environment which could, at least in part, be contributing to her difficulties, and shift the problem (the client’s self-blame) to include the workplace. For example, is this about the client’s race and gender, where she feels her views are continually dismissed, ignored, or appropriated? Racialised clients often get into a cycle where they dismiss their intuitive feelings, but rather continually question it as, “Is it true or is it me? It wasn’t intentional. Maybe I’m being too sensitive”. (17). Understanding that the effects of racism aren’t only in overt acts of racism (10).

Social Justice & Inclusion

We can think about social justice practices in a number of ways, in helping clients, within our own practice or sphere of influence, within our profession such as within equality, diversity and inclusion (EDI) work, and of course within our communities and the world.

Clients may want to address unfair treatment within their environment. Taking action could lead to healthier outcomes for the client (5), and could provide a source of meaning to their experience. Helping a client find their voice could be the most important part of their healing and self-development. Clients may wish to carefully consider their actions and responses, so therapists need to educate themselves on strategies such as education, calling in and out and in helping clients understand the balance between risk, reward and self-care.

In the previous example, of the woman of colour struggling in the workplace, she may reflect:

After learning strategies to call out/in I’ve learnt to take a stand while considering my own care. I realised there were things I could do. I found some others who actually wanted to do the heavy lifting. It’s like I found another family rather than being alone. I’m also trying be a good ally for others in the workplace. You got to pay it forward.”

Similarly, therapists, supervisors and trainers can contribute to equality within their own practice or organisation, for example, undertaking training, connecting with communities across cultures, and making services visible to diverse heritage clients. For organisations, competence is a starting point for EDI work, especially for organisational leadership and service owners who set the tone of the organisation. For training providers, competence will help them attract diverse students, improve their diversity curriculum and improve the training experiences of diverse heritage students. For researchers, it could include clarifying the racial-cultural context of their research as well as conducting more research on the experiences of diverse heritage clients specifically.

By joining the dots between individual practice, the client’s world, and our profession we can then get a sense of how we connect to structural issues, such as higher rates of mental health detention for black people, as well as mental health diagnoses such as psychosis and schizophrenia (5). We all need to consider how competency scaffolds improve individual, professional, and structural outcomes.

Developing awareness

RACE competency will not only give you competency within the therapeutic space, but will also help you to develop confidence within yourself, reduce race anxiety (17), and be able to begin applying yourself in the world, for example in education and relationships.

Racial identity theory (4, 11) helps us to understand that racial awareness and competency skills are part of healthy personality development. This has huge implications, such as in early years child development and education. Here is an example; would you know the right thing to do?

I felt really embarrassed when my [White] child pointed out my black friend’s different skin. I’m not sure if I did the right thing by just joking about it rather than addressing it. What was I supposed to say?

Knowing yourself from a racial-cultural perspective allows you to become aware of how much the formation of your experience is based on your lived-in culture(s), its values, expectations, and norms. For example, someone may ask how much of their conflict comes from what it means to be successful in the world.

Race awareness can help you in numerous settings within family, work and social settings, including developing cross-cultural relationships, gaining more confidence in talking about race and diversity as well as learning skills to be in solidarity when racialised incidents occur. By developing and acting you will be helping change to happen.

Relational depth
Having a deeper understanding of Race and culture will no doubt help in building the therapeutic relationship, because confidence can assure clients of the therapist’s ability to help. This correlates with research which shows that outcomes are improved and clients helped where the therapist has a higher levels of race awareness, regardless of their racial group identity (4).

The therapist needs to consider the relationship throughout, but particularly during the initial contracting phase and in building the relationship (9), as early dropouts with diverse heritage clients are more likely (9). It’s important that the therapist understands the potential for racial-cultural processes and power dynamics which could be barriers in the relationship.

Without competence there a higher risk of the therapist to jarring the relationship (9) because of not understanding the deeper meaning of language and non-verbal behaviour. These experiences could reinforce the pre-fractured social group relationship, whereas its anthesis, may be particularly important in helping a client find their voice, as well as in experiencing an individual restorative relationship.

Broadened knowledge of human understanding

A broader and deeper understanding of human experience allows us to further develop and refine our theory, research and practice base. By considering aspects of experience that we may have missed, such as cultural communication styles, social impact, ethnic discrimination, personality development, methods of healing and intergroup anxiety, we broaden and deepen our knowledge base, which should all lead to better outcomes for all. This knowledge base also needs to include the impact of various forms of group discrimination on the client, as there are likely to be many group ethnic experiences which cause clients to suffer, such as due to their heritage, spiritual beliefs or white otherness.

Revisiting Ethical practice

I hope by now you will recognise that race and culture core competence needs no further justification against ethical practice. Further, evidence for diverse heritage clients is clear: they are less likely to access therapy, less likely to have good outcomes, not be represented in practice, and more likely to have negative experiences of therapy or even harm (6,13).

Ethical practice requires therapists to value and respect the rights and dignity of clients, work in consideration of their cultural context, and to provide fair service provision (2). By gaining competence we are reflecting values of the profession such as “justice”, “duty of care”, “beneficence” and “help” rather than upholding a status quo (11a). Clients will be truly respected if they can bring their whole selves because of the therapist’s ability to work effectively with race and culture. How can we value the client’s dignity and respect in the room if we don’t afford them the opportunity to bring their whole selves? How can we help put out the fire?

Have I convinced you to develop more race and culture competence?

Mamood Ahmad

Web: learn.tadf.uk , tadf.co.uk

References

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