Peggy Loo, PhD on Feb 27, 2023 in Treatment Orientation
One Size Can’t Fit All
Until the last few decades, it was commonly accepted that theories about ideal psychological functioning are universal. After all, aren’t we all humans? Isn’t an anxiety disorder the same regardless of who the person is? Yes and no.
As the field of psychology grows and diversifies in representation, more psychologists are pointing out that while there are universally shared experiences, our various identities (i.e., age, generation, ability, diagnosis, religion, race, ethnicity, class, sexuality, indigenous heritage, nationality, gender, etc.) shape how we will go through those moments. There is no one-size-fits-all experience, even if there are aspects of an experience that resonate with many.
Our social identities determine all aspects of our lives. There are identities that may change over a lifetime (e.g., immigration status, class, religion), ones that remain stable, others that may be invisible (e.g., neurodivergence) or assumed — sometimes inaccurately (as can be the case for Multiracial people). Everyone has multiple identities, and the overlap and interaction of these identities creates a unique lens for your life experiences (e.g., a middle class, queer, Multiracial, older adult).
Multicultural Psychology in Mental Health Care
There’s also increasing awareness that no one psychological theory can speak to all and no therapy approach works for everyone. The canon of psychology theorists referenced in every Psychology 101 textbook (often cisgender, heterosexist White men in an American or European context) had to do what all theorists do: develop ideas from personal experience, value systems, and observations. Some came up with valuable theories that are taught in psychology graduate programs today.
But of course they (and their theories) have biases and blindspots when it comes to defining what’s most important to focus on in mental health and therapy. Some biases come from being from a specific place and generation; some blindspots come from areas of gender and racial privilege. Other limitations come from not fully considering how their theories land when you cross international borders or when globalization and immigration changes the makeup and mental health needs of our neighbors and communities. Mental health care must be adapted to the social context, needs, and identities of each person, which highlights the importance of multicultural psychology.
In the last few decades, the need for multicultural psychology has grow; it’s now a mandatory part of training programs. A watershed moment, APA’s Committee of Accreditation declared cultural diversity to be a key component in graduate training in 1986 (APA, 2002), fundamentally changing the way that graduate programs taught emerging mental health professionals that now make up the psychology workforce. As a result, newer generations of trainees accept that the identity differences between us profoundly matter in terms of how we define and practice quality mental health care.
When therapists don’t tailor the way we listen, respond, and work, the transformative and healing potential of therapy becomes a space of invalidation and even colonialism. While there’s been progress in the mental health field, we have a lot of work to do. To this day, psychology training programs vary widely on how much multicultural training they provide graduate trainees, with some programs offering a single course while others have all courses grounded in a multicultural orientation.
Multicultural Competency in Therapy
The American Psychological Association provides a starting definition of multicultural competency as “the ability to understand, appreciate, and interact with people from cultures or belief systems different from one's own” (DeAngelis, 2015). A common understanding is that multicultural-competent therapists have a combination of self-awareness, broad cultural knowledge, and a skill set that allows them to provide interventions in a sensitive manner (Sue, 1992). This definition has been expanded to discuss domains of privilege and marginalization in one’s identities. It also includes the introduction of a socioecological paradigm encouraging reflection on diversity through multiple levels: the intrapersonal, interpersonal, institutional, community, public policy, and global (Ratts et al, 2016).
Yet researchers are recognizing that multicultural competency is a difficult thing to measure (Jones et al, 2013). There is inconsistent connection between multicultural competency training and what happens in sessions, and there are even discrepancies between therapist and patient perceptions of multicultural competency (Davis et al, 2018). Psychologist Pamela Hays points out, “This may be because competence implies an end goal that can be definitively measured and met, whereas in reality, measuring such a construct is quite difficult, due in large part to the complexity of identity. How does one assess [multicultural competency] given the enormous range of cultural influences and identities?” (2022, p.7.) Hays wonders if there is such a thing as partial multicultural competency or population-specific competency. Is anyone ever fully competent, and does it really matter if a therapist rates themselves as multiculturally competent but their patient doesn’t?
Great questions — and I don’t have the answers. What I do know is that all licensed mental health professionals are required every few years to enroll in continuing education and training. There is a mandate in nearly every professional field to be a lifelong learner. You are deemed competent enough upon completing a standard of education, training, and supervised clinical practice — and then you are required to further your professional competency your entire career. Similarly, I think there should be a baseline of multicultural competency — but it only serves as a starting point, not an ending point.
Why “Multiculturally Responsive?”
I’ve started to think of multicultural competency like literacy. You can learn to read and write, and you need some fundamental knowledge and skills to be considered literate. But being literate doesn’t mean that you’re well read. It doesn’t mean that you comprehend what you’re reading or that your writing is clear and effective. Just because you read very capably in one genre, doesn’t mean you are automatically “competent” in other genres. An academic peer-reviewed journal article is different from poetry. Technically, I can read both — but I know next to nothing about poetry and wouldn't pretend otherwise. The truth is, even if you’re an avid reader and a good writer, there’s always more ways to grow. That’s why I deeply appreciate the concept of multicultural responsiveness.
Three Characteristics of Multicultural Responsiveness in Therapy
Multicultural responsiveness is relational.
Being responsive to someone as a whole person isn’t simply knowing a lot of accurate things about their identities — it is reflecting on that knowledge in the service of creating a connected relationship. Being responsive is an attentive reply. It’s inherently process-oriented, it only makes sense in an interpersonal context, and it centers the goal of attunement. Strong responsiveness only occurs after many back-and-forth interactions, resulting in a fuller, more fine-tuned connection.
Being responsive is fluid.
While it is important for therapists to have a body of knowledge of diverse cultures, identities, and groups (ranging from their own to others), how this information is made useful in a therapy session can’t be prescriptive. This knowledge is also ever-expanding. Being responsive means appropriately adapting across situations. It is always malleable unique to a specific therapy relationship.
Responsiveness is dynamic.
There is room for growth and movement as a therapy relationship moves forward. We become more responsive with time and interaction. Maybe more importantly, there’s room for some of the inevitable questions, fumbles, or challenges inherent to developing any close relationship.
Spoiler alert: Therapists aren’t perfect. We are also multicultural beings, with our own identities, worldviews, and blindspots — which is why I think overemphasizing the word "competency" can unrealistically imply therapist mastery or infallibility. Being responsive means we are committed to action-oriented growth, whether that is checking in, clarifying, reconnecting, taking ownership, or evolving.
Characteristics of Multiculturally Responsive Therapy
When you experience feeling seen and heard by someone, there’s often a lot that goes into that. It’s big and small things. It could be the words said, the way they were said, a feeling of warmth and care, undivided attention, gentle eye contact, follow-up questions that demonstrate understanding, the sense that sometimes there are no words but there’s comfort or solidarity in being together, etc.
Similarly, there’s no one thing that determines multicultural responsiveness. Instead of giving a singular definition and being reductionistic, here are three qualities of multiculturally responsive therapy:
1. Ongoing curiosity and conversation about who you are as a multicultural being.
Are there opportunities to explore and discuss the identities that matter to you? Are questions asked, or are you expected to take the lead?
Is this an ongoing dialogue throughout therapy (versus only being part of the first intake session)?
Do you feel comfortable sharing about all parts of who you are? If not, is there exploration of how to encourage greater sharing? When you do share something about your identities, are you met with validation and openness to further conversation or a change in subject?
Is there space for you to reflect on the effect of your identities on your experiences or how it may shape your mental health needs?
2. Openness to exploring multicultural dynamics in the therapy relationship.
Is there space for your therapist to acknowledge themselves as a multicultural being or recognize that all therapist-patient relationships are cross-cultural? Even if you and your therapist share many similar identities, is there affirmation of what you share and appreciation for what may be different?
If and when clumsy moments happen, are they handled responsibly, with respect, intention, and care? Have you ever silenced a part of yourself to keep it moving?
Are there opportunities for feedback about this part of your therapy relationship, and have you ever tried giving any?
Part of creating opportunities for responsiveness is being honest when something feels off. If there is an area that you’re not sure whether or not your therapist understands you, don’t bypass the moment. Take the brave step and ask.
Part of developing a trusting relationship with anyone is navigating uncertainty about whether or not you’re on the same page. Doing so may become a chance for dialogue, or it can be clarification that you may need to reevaluate your therapy experience. Either way, it’s helpful to know. (Caveat: This does not apply to moments that are clearly prejudicial and disrespectful.)
3. Adapting therapy to who you are and your value system.
I’m passionate about BIPOC mental health, and I see a lot of adults of Asian descent ranging in age, ethnicity, acculturation, immigration status, and Multiracial/bicultural identity. I’m a millennial woman who was born and raised in the US, so I’ve been deeply steeped in Western cultural ideas about feelings.
I also have over a decade of psychology training that often views crying with someone as an intimate, breakthrough moment that signals trust. I am a psychologist who believes emotional catharsis in session can be powerful. Relatedly, I’ve learned to associate minimized facial expressions as a sign of emotional defense.
However, I’m also a second-generation Asian-American raised by immigrant parents — parents whose cultural norms for emotional expression were very nuanced. There was a whole host of invisible rules as to when, where, and with whom it was appropriate to be that demonstrative. So I understand and inherited both ways of being.
If I project a Western-American expectation of emotional expressivity on all of my patients, I can easily misconstrue a lot in sessions. Someone’s cultural display rules (i.e., internalized ideas about appropriate emotional expression in social contexts) may discourage showing particular emotions or result in unexpected facial expressions in certain contexts. It’s important to know this isn’t the same as being unfeeling or psychologically unaware. It’s entirely possible to be deeply feeling something without showing it. In this situation, it’s important that people aren’t misjudged or pathologized for what may be a culturally-normative behavior — even if it isn’t typical for everyone. On another note, how are we to categorize therapists? Are we authority figures, peers, coaches, elders, healers, allies, teachers? Yes, and no, and sometimes. You can see how complicated social norms for relating can become. It highlights how important open dialogue is to avoid assumptions and respect cultural values.
Does It Feel like Therapy Becomes Increasingly Tailored to You as a Whole Person?
Is there space for your cultural values to be discussed, honored, and integrated into therapy (e.g., what expectations exist, how sessions are structured, what’s a comfortable way to relate, who takes the lead, what are actual signs of respect, discomfort, or trust)? Does it feel as though someone else’s values are being imposed onto you and your life?
I’ve spent a lot of time thinking about multicultural responsiveness. It’s something I care deeply about and think is an essential ingredient for empathy, which means that it’s a non-negotiable part of what makes good therapy.
American Psychological Association. (2002). Guidelines and principles for accreditation. Washington, DC: Author.
Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., ... & Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89.
DeAngelis, T (2015, March). In search of cultural competence. https://www.apa.org/monitor/20...
Hays, P. A. (2022). Addressing cultural complexities in counseling and clinical practice: An intersectional approach. American Psychological Association.
Jones, J. M., Sander, J. B., & Booker, K. W. (2013). Multicultural competency building: Practical solutions for training and evaluating student progress. Training and Education in Professional Psychology, 7(1), 12.
Ratts, M. J., Singh, A. A., Nassar‐McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28-48.
Sue DW, Arredondo P, McDavis R. (1992). Multicultural counseling competencies and standards: a call to the profession. J. Couns. Dev. 70:477–486