Aspects of Culturally Competent Care That We Don’t Talk About (But Need To)

I recall sitting across from my school counselor and feeling somewhat relieved that she came to the United Arab Emirates from the same country as I had, India. How else would she have understood when I said, “My mom doesn’t let me make any decisions…ever,” unless she’d experienced it herself?

Looking back, I realize that any counselor, irrespective of nationality, would have understood; teenagers complaining about having no control over their lives is practically universal. However, there are other experiences that aren’t as widely-shared — experiences that are more culturally-specific and connected to identity.

Identity is largely informed by internalized values, beliefs and attitudes that we receive from our communities (families, schools, religious institutions, etc.). This self-concept cannot simply be shed when entering a therapy room; it determines how we view ourselves and our external world. Accordingly, our identities impact how we view mental health conditions, treatment and relationships with practitioners.

As a result, a positive experience in therapy is dependent on a mental health care practitioner’s cultural competence — their ability to appropriately respond to our unique social, spiritual, economic and political experiences. There are many aspects of culturally competent care, but one, in particular, is often overlooked in our increasingly globalized world: practitioners must be prepared to work with clients from different countries with vastly different cultural practices.

The Consequences of Non-Culturally Competent Care

When practitioners are not fully equipped to incorporate patients’ complex backgrounds into a session or treatment plan, they risk several adverse outcomes; specifically, the misdiagnosis of clients with non-Western cultural backgrounds and a low percentage of returning clients.

According to a 2017 study, misdiagnosis can be attributed to practitioners’ understanding of “normal” versus “abnormal” — a concept that is, arguably, culturally specific. For example, a patient entering into a “trance” or “state of possession” is considered normal in some South-Asian cultures; however, a patient in a similar state in a Western context might be diagnosed with schizophrenia.

This lack of cultural understanding can also lead to high dropout rates among certain groups. For example, in a 2016 study addressing effective therapeutic engagement for Hispanic/Latinx people, participants voiced “a general mistrust of a Eurocentric-based mental health settings.”

Overlooked Components of Cultural Competence

One factor in offering culturally competent care is practitioners’ understanding of the patient-therapist power dynamic. In clinical settings, Western patients tend to view the therapist-client relationship as equal- likely due to their upbringing in an environment valuing autonomy. However, patients from Eastern societies may view the relationship differently. Eastern cultures, place a heavy emphasis on following a guru-disciple dynamic, meaning that in a therapeutic setting, a patient would view a practitioner as occupying a “higher” position. This understanding may impact the effectiveness of a therapist’s treatment plan.

Research has demonstrated that techniques, such as Socratic questioning — a method that encourages the patient to take an active role in therapy — is more effective with Western clients. Meanwhile, patients from Eastern societies prefer to follow the guidance and recommendations provided by their therapists. Thus, in order to be more effective when working with non-Western clients, mental health practitioners should consider assuming the role of teacher/leader as opposed to that of a partner.

Another intervention technique that therapists use frequently is journaling homework. Journaling one’s thoughts and feelings, a cognitive task, has been proven to be beneficial to Western clients. However, Eastern clients are often hesitant to engage with this type of work. Some voiced concerns that the therapist would judge them and their work. Others didn’t benefit from journaling work because the technique addressed emotional, rather than physical, symptoms — and research suggests that Eastern clients are more inclined to present with somatic symptoms Thus, a hesitance to journal can be attributed to a limited vocabulary for describing emotional expressions, as often, they would prefer to use somatic metaphors to explain their emotional states.

A more helpful way to engage Eastern clients would be providing work that is similar to, or in line with, the client’s cultural values, preferred forms of expression, etc. For example, a 2015 study found high engagement when Pakistani clients were provided homework that involved working with beads, a cultural form of prayer.

How To Move Forward

The practice of psychotherapy is a dynamic process and is adaptable in nature. While practitioners in the West have shown interest in modifying therapies to better incorporate the backgrounds of patients from other regions, there is still a long way to go.

An important first step in developing culturally competent care is conducting more research on people with mental health conditions across cultures and further engaging with existing literature on the subject.

On a smaller scale, practitioners must commit to assessing patients’ cultural background in addition to their presenting symptoms and adapting their treatment accordingly.

Surabhi Roy, a mental health advocate, holds a bachelor’s degree in Psychology with Management and is pursuing a master’s degree in Clinical Psychology.