Practicing cultural humility

Privilege is invisible to those who have it.” This pithy statement from sociologist Michael Kimmel reflects the state of research on privilege and also calls attention to the importance of counselors raising self-awareness about how privilege affects their work. A general consensus exists among counselors that they need to be aware of their own privilege and need to be multiculturally competent. These aims can be rendered inert, however, in the absence of a conceptual framework and process that guide counselors to embody cultural responsiveness within counseling sessions.

The Multicultural Counseling Competencies (MCCs), a ubiquitous model in counseling, address three main domains:

• Counselor knowledge about different cultures and cultural perspectives
• Counselor skills to utilize culturally appropriate approaches
• Counselor awareness of their own and their clients’ cultural heritage and the influence of culture on attitudes, beliefs and experiences

This tripartite, developmental model, developed by Derald Wing Sue and colleagues, has for several decades provided a foundation in counseling for how cultural competence is conceptualized, pursued and evaluated. In this article, the acronym MCCs is used to refer to this model. (Note that the Association for Multicultural Counseling and Development endorsed the Multicultural and Social Justice Counseling Competencies in June 2015. These competencies, which were also endorsed by the American Counseling Association Governing Council, revise the MCCs.)

Although the value of the MCCs in terms of counselor development is evident from research and counselor support, they have limitations related to counseling outcomes and the interpersonal process that unfolds between the counselor and the client in sessions. Specifically, outcome research connected to the MCCs has been based largely on counselors’ self-reports of their own levels of multicultural competence. Such evaluations suffer from self-assessment bias and do not capture the client’s experience. The few studies that have examined counselor multicultural competence from both the counselor’s and the client’s perspective have found that counselors typically view their own multicultural counseling competence much higher than clients view the counselor’s multicultural counseling competence. In other words, counselors often have an inflated view of their own multicultural competence in comparison with the client’s view.

This gap in perceived competence is concerning, in part because counselors’ beliefs about their general level of multicultural competence influence their behavior. Specifically, when counselors think they are high in multicultural counseling competence, they are less likely to put effort toward growing in this domain. Likewise, they are less attuned to responses from clients that might indicate the counselors are not as multiculturally competent as they think. Although the MCCs are useful for counselor development and self-evaluation, a more process-oriented framework is needed to address in-session multicultural processes and counselor multicultural competence from the perspective of the client.

With this in mind, multicultural orientation (MCO) offers an empirically supported model for counselors to understand how individual clients experience the multicultural dimension of counseling in the sessions. This article describes a framework for counselors to increase their multicultural counseling effectiveness, privilege the voice of clients and make the counselor’s own invisible privilege a little more visible.

Multicultural orientation

MCO consists of two major domains: the client’s perception of the counselor’s level of cultural humility, and the degree to which the counselor addresses culture and cultural opportunities in the session.

In the words of Joshua Hook and colleagues, cultural humility refers to the counselor’s “ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client.” Cultural humility contains intrapersonal and interpersonal dimensions. Intrapersonally, cultural humility encompasses counselors’ openness to accepting that their own cultural identities and experiences will limit their perspective and awareness in understanding the cultural experiences of others. The interpersonal dimension of cultural humility involves an “other-oriented” stance that includes openness, respect, consideration, humility and interest regarding the client’s cultural identity and experiences.

Cultural opportunities refer to moments in counseling sessions when counselors are presented with opportunities to address and focus on the client’s cultural identity. For example, a cultural opportunity may emerge in a session when a client of a marginalized racial group discusses depression that is linked to being treated unjustly in the workplace. This presents an opportunity for the counselor to explore potential discrimination and the client’s cultural identity.

An essential feature of MCO is that it is rooted in the client’s perspective. Specifically, counselors need to understand the degree to which the client perceives the counselor to be expressing cultural humility and the degree to which the client thinks the counselor seized on or missed cultural opportunities in the session.

Multicultural counseling outcomes

Despite several decades of calls for counselors to develop multicultural competence, scant research exists to demonstrate that counselors’ self-rated multicultural competence is related to counseling outcomes. This is partly because counselors’ self-evaluations of their multicultural competence, while important for self-reflection and understanding and guiding counselor development, do not address clients’ views of their counselors’ competence levels. Emerging research on MCO demonstrates that adopting an interpersonal stance that is focused on cultural opportunities and cultural humility has a positive effect on client outcomes and offers a practical framework for cultural engagement with clients in sessions.

Research in 2016 by Jesse Owen and colleagues found that cultural opportunities had a significant influence on client outcomes. Specifically, researchers examined the perspectives of racial and ethnic minority clients on “missed cultural opportunities” in sessions and the relationship of these missed opportunities to client outcome. Missed cultural opportunities were evaluated by client report on a scale to assess the degree to which the counselor missed opportunities to discuss important cultural factors in the session.

Findings revealed that client improvement and increased wellness at the end of counseling were strongly negatively correlated with missed cultural opportunities. That is to say, as missed cultural opportunities increased, client improvement decreased. Clients experienced better outcomes in counseling when they perceived that their counselor responded to in-session opportunities to address cultural factors. These opportunities are the moments in session when counselors either engage in a culturally responsive way with clients regarding their cultural identity or they miss the opportunity.

In addition, several studies have demonstrated the positive effects of cultural humility on the therapeutic alliance and client outcomes. Instead of assuming that they are high in multicultural competence based on their own self-evaluations, counselors who are high in cultural humility typically engage in collaborative, open exploration with clients regarding their cultural identity as a salient factor in treatment.

Indeed, two recent studies by Owen and colleagues found a strong positive correlation between the client’s perspective of the counselor’s level of cultural humility and client outcomes. Essentially, when clients viewed their counselors as high in cultural humility, those clients experienced much more improvement in counseling than did clients who viewed their counselors as lower in cultural humility.

Cultural humility also mitigates the impact of missed cultural opportunities. Put another way, when counselors miss important cultural opportunities in the session, the negative effects of these missed opportunities on client outcome are neutralized if clients see their counselors as being high in cultural humility.

Implications for counseling

Understanding the role of culture in counseling is a challenging and multifaceted endeavor. Despite the complexities, some distinct themes have emerged regarding the benefits of MCO when significant counselor-client cultural differences are present.

As already mentioned, client perspectives of the two domains of MCO (cultural humility and cultural opportunities) are good predictors of client outcomes. There are also several overlapping themes from this research that suggest why MCO influences client outcomes. These themes suggest that the MCO model can help counselors:

• Reduce the frequency and impact of microaggressions committed in counseling sessions
• Effectively utilize dynamic sizing in sessions
• Create a culture of feedback with clients

Microaggressions in counseling

Overt forms of discrimination based on race, sex, age, sexual orientation and many other identities have a long history in the United States and still persist today, but a more subtle and pernicious form of prejudice manifests in microaggressions. According to Sue and colleagues, microaggressions can take at least three different forms:

• Microassaults (e.g., purposeful actions of discrimination such as name-calling)
• Microinsults (e.g., subtle communications that demean a person’s cultural identity)
• Microinvalidations (e.g., subtle communications that negate a person’s cultural reality, such as displaying colorblind attitudes or telling a person of color that you don’t see color)

Microinsults and microinvalidations generally fall outside of the perpetrator’s conscious awareness. People of privilege frequently view these microaggressions as banal, trivial and not a source of harm for the recipient. However, in addition to promoting stereotypes, microaggressions often cause frustration, anger, low self-esteem and physical health problems for recipients. Although counselors take multicultural counseling courses in which they explore their own biases, research indicates that counselors commonly and unwittingly commit microaggressions toward minority clients.

At least four published empirical studies in the past 10 years have examined the role of microaggressions in counseling. Microaggressions have been found to be associated with weaker working alliances, fewer sessions attended and poorer counseling outcomes. The percentage of racial and ethnic minority clients who reported experiencing microaggressions in counseling in these studies ranged from 53 percent to 81 percent. The most common microaggressions committed by counselors included declarations of colorblindness, avoidance of discussion of cultural issues and denial of their own prejudices.

Mental health professionals commonly commit in-session microaggressions, despite generally having good intentions. Privileged counselors are unlikely to notice when they commit microaggressions in counseling and frequently lack awareness of the untoward effects of these subtle slights.

Several important research findings are instructive regarding in-session microaggressions. Namely, counselors who are viewed by clients as being culturally humble commit fewer microaggressions than do counselors who are viewed as lower in cultural humility. Additionally, when counselors who are high in cultural humility (as viewed by the client) do commit microaggressions, the negative impact of these microaggressions is lessened. A separate study found that the negative effects of microaggressions were mediated when the counselor addressed and discussed the microaggression that occurred. Thus, cultivating cultural humility can help counselors reduce the frequency and impact of inadvertently committing microaggressions and learn to recognize, discuss and attempt to repair microaggressions that they do commit.

Dynamic sizing

The concept of dynamic sizing, as articulated by Stanley Sue in 1998, refers to counselors’ adaptable skills regarding when to generalize cultural knowledge or norms about a client based on cultural identity versus when to individualize. For instance, in their training, counselors gain cultural knowledge about particular groups. For example, “Native people perceive direct eye contact as disrespectful” or “Asian people are collectivistic, not individualistic.”

Such statements may reflect cultural norms and general group characteristics, but dynamic sizing entails the counselor’s ability to know when and how to generalize cultural information about a client in a way that applies to the individual and is not simply stereotyping. My own experience working in Alaska Native health clinics was illuminating in this regard. Specifically, two Alaska Native clients independently pointed out to me that they believed the “direct eye contact is disrespectful” concept was a residual effect of their ancestors being taught to be submissive by white colonizers. Thus, they did not endorse avoidance of direct eye contact in sessions and explicitly preferred more maintained eye contact with me than did some other Alaska Native clients.

MCO provides a conceptual framework that promotes dynamic sizing because it takes an interpersonal stance that focuses on elements of cultural identity and cultural opportunities in the counseling session that are deemed salient by the client. Specifically, MCO guides counselors to understand cultural norms and characteristics but not to view these elements as fixed variables. Instead, this interpersonal stance promotes understanding how culture informs each client’s life from the client’s perspective.

Creating a culture of feedback

Counselors with privileged identities are often unaware of the impacts a lack of privilege can have on marginalized and oppressed populations. In counseling sessions, this privilege frequently manifests through unconscious biases. Well-meaning counselors frequently do not recognize when unconscious biases or microaggressions occur because these are, by definition, unconscious.

Given this reality, it is important that counselors create a culture of feedback. This involves providing space for clients to feel safe and open to explore topics such as discrimination, systemic inequality, microaggressions and their lived experiences of marginalization. More to the point, the MCO model pushes counselors to embrace the fact that these manifestations of inequality (discrimination, microaggressions, etc.) are not something that clients experience only “out there” in the world. These manifestations frequently occur in counseling sessions too. Even well-intended, thoughtful counselors can inadvertently commit microaggressions, engage in stereotyping or exhibit poor cultural awareness, thus setting back or severing the therapeutic bond with clients. MCO helps counselors create a climate of trust and safety in which they can engage clients in difficult dialogues to better understand their perspective.

Putting it into practice

The MCCs and MCO share some broad, overlapping aims of increasing culturally responsive counseling services, reducing disparities and their negative effects, increasing counselor awareness of their biases and reducing these biases. Both models point toward a few central (but certainly not exhaustive) steps to take outside of counseling sessions to increase counselors’ overall multicultural competence. In addition, MCO emphasizes what counselors can do within sessions to increase their overall multicultural competence.

Out-of-session recommendations

• Assess your level of multicultural competence by honestly completing the Multicultural Competencies Self-Assessment Survey (MCSA) developed by Manivong Ratts.
• Follow a four-step process toward increasing multicultural competence based on the MCSA. These steps involve assessing your areas of need, defining objectives based on what you learned from the MCSA, designing a plan to meet the objectives and evaluating your success.
• Engage in intentional cultural self-exploration related to counselor development. For instance, address questions such as: How does my cultural identity and privilege limit my ability to see or understand lack of privilege and marginalization? What are my gut reactions to clients who have different cultural backgrounds than my own? How do I create space for or welcome clients to explore their cultural identities? How open am I to my clients’ feedback about my level of cultural competence and cultural responsiveness?
• Educate yourself about microaggressions, including the types that counselors commonly commit. Because microaggressions are the behavioral manifestation of beliefs and attitudes, the process is not as simple as telling oneself not to commit microaggressions. However, when practiced in conjunction with evaluating your own privilege, learning about marginalized populations and taking a stance of cultural humility, you can improve your skills in noticing microaggressions and making the necessary repairs.
• Don’t conflate biases or committing microaggressions with being a bad person or a bad counselor. Like everyone else, counselors absorb and internalize cultural messages and stereotypes communicated through the media and broader culture. Accepting your own imperfection around cultural biases is essential to maintaining a growth mindset, developing cultural humility and benefiting from a new awareness that emerges over time. Denying your own biases and microaggressions will cause them to persist.
• Read some peer-reviewed articles and engage in ongoing professional development regarding MCO, the MCCs, cultural humility and microaggressions in sessions.

 

In-session recommendations

Although the MCCs and MCO share general aims, their paths to increasing multicultural competence are quite different. In many ways, they are complementary.

The MCCs guide counselors toward developing specific knowledge, skills and awareness through personal work done outside of counseling sessions. For example, the MCCs provide counselors a framework for examining their biases, exploring the influence of their own cultural identities, assessing their multicultural competence for areas of strength and weakness, and developing culturally responsive intervention skills.

However, the final word on the overall cultural competence of a counselor rests in the perspective of each specific client. In other words, “Does this client experience me as culturally competent?” As found repeatedly in the counseling research, the client’s perspective on a number of important elements of counseling is often more strongly associated with counseling outcomes than is the counselor’s perspective. This holds true for core predictors of outcome such as empathy, the therapeutic alliance and multicultural competence/responsiveness. Thus, putting MCO into practice involves establishing an interpersonal stance of cultural humility and a willingness to explore cultural opportunities that are relevant to the client.

With this in mind, some in-session recommendations follow.

• Reconceptualize your multicultural competence to include an emphasis on privilege and power in relationships, especially regarding their effects in the therapeutic relationship. Counselors often think through the lenses of their theoretical orientations in sessions (existential, cognitive behavior therapy, Gestalt, etc.). Work toward adding culture and privilege to the lenses that you intentionally consider in sessions.
• Begin by acknowledging, during the informed consent process, the cultural differences between you and the client that the client may (or may not) see as important. Do this by acknowledging, explicitly, your potential lack of awareness of the client’s cultural experiences. For example, “You shared at the beginning of our first session today that you identify as a transgender person, and I know that many transgender people experience discrimination. If this is your experience, then I really want to ensure that I am aware and sensitive to the effects of this. Even though I try to understand clients’ experiences, I may unintentionally miss something that is really important in this area. As a person who is not transgender, I may have blind spots about your experience, but I will work hard to overcome these. If at any point it seems that I am missing or misunderstanding something about your experience in this regard, then I really welcome your comments on this.”
• Acknowledge your biases or the microaggressions you commit in session, either when you notice them yourself or when your clients point them out. Clients might point these out indirectly, so be sensitive to nonverbal or subtle verbal cues that indicate the client may feel devalued in some way. If you think you might have committed a microaggression in the session but are not sure, check with the client. Depending on the level of severity, this might involve a simple question to the client about your concern regarding something you said or did. In the case of more egregious microaggressions, you might need to discuss it with the client in more detail and apologize for your lack of awareness.
• Develop a culture of feedback, beginning with the first session and continuing throughout. Although clients are not responsible for teaching counselors about their cultural identities, counselors cannot possibly have complete understanding of how culture influences a particular client. A general example of creating a culture of feedback is as follows: “It is really important for me to make sure that I understand your perspective in our sessions. For instance, although I know some things about your cultural background, I may not fully understand at times how this impacts your life and relates to challenges that have brought you to counseling. I welcome your thoughts about anything you think I may not be getting in our sessions about you, your values or your cultural experiences. I really welcome your feedback.”
• Near the end of each session, check in with clients about the therapeutic alliance and the cultural dimension of counseling in that session. For example, “Before we end today, I want to ask about how things were for you in our session. How did you feel about our session today? Did I seem to understand things from your perspective? Were there certain things that I missed or misunderstood regarding how culture plays a role in what we discussed today?” Counselors can also ask scaling questions here. For instance, “How would you rate our session today on a scale from 1 to 10, specifically regarding how well I understood the influence of your cultural background in what we discussed today? I would really like your honest feedback about this. If you have feedback that seems negative in some way, I welcome that, and it won’t hurt my feelings.”

Summary

MCO cannot be scripted or manualized, but its central features include communicating respect, practicing humility, being receptive to acknowledging one’s own biases when they occur and practicing culturally inclusive engagement that resonates with clients. An essential element of cultural humility is nondefensiveness around one’s own lack of awareness or demonstrations of incompetence. Thus, before encouraging client feedback, counselors need to be clear about how willing and able they are to receive this feedback with humility.

Cultural competence is not adequately defined by counselors’ self-perceptions of competence. Rather, it is determined by how their clients — especially marginalized clients — view the counselors’ capacity and willingness to understand the cultural forces that influence clients’ lives. Comprehending clients’ subjective cultural experiences and acknowledging our own cultural blind spots in the process are central to cultural humility. This interpersonal stance can help counselors improve client outcomes, honor the cultural experiences of clients and clarify the effects of counselors’ own privilege.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Sidney Shaw is a core faculty member in the clinical mental health counseling program at Walden University, a certified trainer for the International Center for Clinical Excellence and a workshop presenter. Additional information on multicultural counseling and other counseling topics is available at sidneyleeshaw.wordpress.com. Contact him at sidneyleeshaw@gmail.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.