Cultural Competence, Inequality, and Psychotherapy Process
What is Cultural Competence in Psychotherapy?
Cultural competence refers to a care provider’s ability to deliver effective, evidence-based interventions to clients from racial, ethnic, class, cultural, gender, sexual orientation, and other diverse populations.
In psychotherapy, cultural competence involves building a relationship of mutual trust in which client and clinician can explore the presenting problem, build a collaborative therapeutic relationship, and identify interventions and tools for addressing the problem that are culturally relevant.
Research suggests that establishing strong therapeutic relationships can be impacted by societal inequalities across difference. However, addressing those tensions as they come up in the therapeutic relationship is associated with better outcome, and higher likelihood clients will stay and complete treatment.
Inequality and Trust
Research on wealth inequality tells us that as inequality rises, so do negative outcomes such as anxiety, self-harm, substance misuse, child maltreatment, and poverty (Wilkinson & Pickett, 2009; 2019).
The ability to trust and understand others has been found to be a mediator of the relationship between inequality and adverse outcomes, which opens the door to examining how core psychological processes of attachment and identity are impacted by social, political and economic forces.
Another factor that impacts the ability to empathize with and trust those who are different from us are stereotypes. Research shows that as inequality increases, so do highly pernicious and ambivalent stereotypes about those seen as different or with less power. Stereotypes impair understanding and corrode cohesion in communities (Fiske, 2018).
What is Attachment Theory and How Does it Affect Psychotherapy?
Attachment theory explains how we achieve closeness, security and intimacy with others in order to meet our needs. It also addresses the stories we tell ourselves about how other people think and feel, and also, how they think and feel about us, based on our early childhood experiences.
Closely tied to attachment theory is the work of Peter Fonagy on “mentalization” and Howard and Miriam Steele on “reflective functioning.” These terms refer to our ability to think about what other people are thinking, feeling and what their intentions are.
Research shows that when clients are able to form a trusting, secure relationship with therapists who are understanding and open to them, psychotherapy is likely to be more effective. A secure therapeutic relationship, then, involves attachment processes that are both universal and cross-cultural, while also sensitive to social influence.
What We Are Doing
I am currently surveying the research on cultural competency, inequality, and attachment in order to develop a nuanced, multi-systemic model of why psychotherapy works, and how both issues of attachment and social justice are critical to clinical efficacy.
Current models of cultural competency emphasize the recognition of cultural differences, which sometimes leads to a lack of clarity as to how psychotherapy works, and how addressing social and cultural issues are important for good outcome.
It might mean that secure and trusting therapeutic relationships require not just empathy, but also the therapist’s ability to reflect about their clients as both individuals with their own psychology and developmental history, and as members of intersecting groups in society.
If we can better understand how individual psychotherapy is impacted by broader systems of inequality, we will better able to not only identify effective mechanisms of change, but also how psychotherapists can serve as change agents and public policy advocates.