With the “Occupy” movement in full swing, I’ve had the opportunity to engage in multiple conversations about privilege and identity politics, and their impact on both grassroots political organizing and my work as a therapist.  These conversations keep bringing me around to the question, what does it mean to be a culturally competent, socially-engaged therapist.

For many therapists, cultural competence “training” amounts to one course in graduate school in which we learn things like “some clients might not feel comfortable with eye contact”, or “some clients might feel affronted by a clinician who doesn’t reciprocate a hug”.  In more “sophisticated” trainings, dialogues include some discussion about how it is important to acknowledge our differences in the therapy room with our clients.

Cultural competency training often ends up being more about the concrete details of “difference”, than about the process of negotiating the complexities of living with and being in open, curious, accountable dialogue about the ways our differences impact how we show up in our relationships.

Recently, I had a client* say that in over twenty years of being in therapy with different therapists, she was never able to talk about the impact of social context on her experience.  Everything had to be “personal”, which meant not talking about racism, sexism or classism and the ways she felt impacted by those dynamics.

This client, a woman of color, had been raised by white parents.  Her whole life, she had lived with people who had denied the reality of her experience as a person of color in a predominantly white community.  Her therapists were supposed to create safe spaces for her to be known, to explore her life story, and to begin to heal from the “crazy-making” experience of never being seen or understood for who she really was.  Yet, because race and culture were off limits, her therapists had been unable to stop themselves from re-enacting one of the fundamental traumas of this woman’s story: the denial of the significance of her identity as a person of color.

I like to think that psychotherapy has come a long way since the days of therapists trying to be totally objective observers.  Most therapists realize that it’s not really possible to be invisible, and that our histories and our life experiences deeply impact our interactions with clients.

For example, when I, a therapist of African descent, am sitting across from a white man who is talking about how anxious he feels because his children have befriended some black kids at school, and he would prefer it if his children befriended white kids because he thinks they’re “safer”, history and socio-cultural context are in the room for both of us.  My job as a therapist is definitely not to be neutral about that.  After all, he is choosing to tell me, despite (or perhaps because of) our differences.  That, in and of itself, is significant.

Over time, we learn that race and racism are significant for him too: that he is as terrified by his own racism as he is by the African American children at his children’s school, and that he is grateful to be heard and challenged, and to have a place to sort through the complexities of the cultural trauma of living with white (and male) privilege.

For another client, it is an acknowledgement of the fundamental ways that oppression distorts and confuses us, that liberates her from the deadening depression she has lived inside of for over a decade.  I tell her:

“You are not crazy; you are impacted by the world in which you live, and for some of us, after a time, the weight of it is too much.  Then, there you are, five years later, struggling to get out of bed, unable to work, wondering what happened to your life.  Part of what oppression does is it makes you feel crazy.  We challenge someone on their sexism or their racism, and they ridicule or just dismiss us.  We listen to our co-workers call women “cunts” or describe people of color in demeaning ways, and then, if we don’t have a solid support system, or we’re just feeling particularly vulnerable, we find ourselves feeling crazy for feeling angry… or for not quite being able to think straight.  That is cultural trauma.”

This woman was diagnosed with Major Depressive Disorder, and that was right for her.  We don’t have to throw out what we know about treating depression, to incorporate an understanding of the impact of cultural trauma into our work.  However, if we do not get curious about how social context impacts one’s ability to process and respond to those experiences, to access resources, and to access one’s internal resilience, or if we do not acknowledge the reality of what it means to live inside of an oppressive social context, then we are only doing part of the work and failing our clients.

I had my first panic attacks while training as a therapist in an all white (except for me) cohort at a mostly white agency, and while being the only African American in my graduate school program.  It took a year and a half after leaving those programs to stop having flashbacks and nightmares about my experiences over the two years I was there.  I was diagnosed with Post-Traumatic Stress Disorder (which was accurate).  However if my therapist had been unwilling to acknowledge the precipitating “event” as being the socio-cultural context of my training environments, and if she hadn’t been willing to acknowledge the ways that some of those socio-cultural dynamics might still be playing out between us in session, the treatment (even with some of the somatically-oriented treatments “designed” to work directly with the nervous system, and bypass the relational system) might have failed.

This is why it is crucial that therapists undergo ongoing, depthful therapeutic training that encourages us to sit deeply with our own histories and struggles around these issues.

These are not beginning “diversity 101″ conversations.  This is a life long practice, a skill that gets developed over time.  It’s about understanding that we are living it all, right now, together, in the therapy room.  Our differences are shaping us, the ways we interact, what we say and don’t say, what we let ourselves know about ourselves and about each other.

The dialogue always includes who we are and where we’ve been, whether we acknowledge it or not.  So why not start learning how to acknowledge it?  It starts when we acknowledge that we don’t know, that we can’t know all there is to know.  We have to begin with a willingness… to be vulnerable with our clients and with ourselves, to be wrong, to be challenged, and to be moved by the complexities of our journeys.

*Therapy is always confidential.  Client descriptions are composites of many stories and experiences, and all identifying characteristics have been changed or eliminated.

Tags: Cross-Cultural Therapy, Cultural Trauma, Culturally Competent Therapy, Intercultural Counseling & Psychotherapy, Mental Health, Social Justice & Psychotherapy, Traumatic Stress