Lawrence Rubin: I want to thank you very much, Usha, for being with us today and sharing your time and expertise with our audience of psychotherapists.
Usha Tummala-Narra: Thank you for inviting me.
Towards a Definition
LR: Multicultural competence seems to have become somewhat of a buzzword in the field of counseling and psychotherapy, defined differently by different clinicians; but since it’s the nexus of your own clinical and research work, can you tell our readers what you think it is and what you think it isn’t?
UT: Indeed, there’ve been many different definitions. I arrived at cultural competence from a psychoanalytic perspective. Given that, I think of multicultural competence as a way of understanding, a way of engaging with sociocultural context and how it shapes interpersonal processes as well as intrapsychic life and extending into the therapeutic relationship. How do the sociocultural context and dynamics that are evident in broader society get mirrored in the relationship between the therapist and the client? So, cultural competence to me looks at the various layers of an individual’s life, both intrapsychically and interpersonally.
LR: Irvin Yalom talks about the therapeutic relationship as a microcosm for the client’s interpersonal world, so I’m wondering if what you’re saying is that a
multiculturally competent clinician strives to build a connection with the client’s broader contextualized experience.
UT: That’s certainly a part of it. I think the other piece is the person of the therapist in terms of their own socio-cultural history. This includes their own history of social oppression – what they find as positive and identify positively with in terms of their cultural background, their religious background or linguistic background. It’s about how all those sets of cultural and socio-cultural experiences shape the therapist and their subjectivity and how that in turn interacts with the subjectivity of the client. There’s this kind of interaction between multiple cultural worlds happening regardless of who we’re working with therapeutically. And this is not specific to working with clients from a particular socio-cultural background, but rather I see it as broader than that. It’s about engaging our broader context within the therapeutic relationship.
And so for me, cultural competence isn’t a specialty, it’s just part of professional competence. I just really see it as a regular part of psychotherapy.
LR: So, it’s more than just two people coming together, but it’s almost like two worlds coming together in the therapeutic encounter.
UT: Yes, that’s right.
Revealing Full Personhood
LR: Traditional therapeutic practice, particularly dynamically-informed practice, is built upon the premise of therapeutic neutrality; so how can a clinician bring their full contextual personhood into the relationship with a client and still be faithful to the ethics and the tenets of psychotherapy?
UT: That’s a great question. We should consider what neutrality actually looks like and feels like for the client. We’ve been socialized as therapists to put everything about ourselves to the side so that we’re not imposing our agenda onto the client. And so, therapists have this idea that “if I was to initiate a discussion about race or culture or gender, that it’s really my personal wish that’s being filled in some way, or my personal longing to engage in those discussions rather than the client’s needs and what might be actually helpful to the client.” But in fact, what I have found is that so many clients in fact need to talk about issues of race and culture and religion but have been told all their lives in one way or another that they shouldn’t. As a result, people’s experiences of racism are often kept hidden, are kept silent, and are more often spoken about within somebody’s home or with a circle of friends.
But, we should consider that psychotherapy is actually a place where we can talk about things that we have been told not to because therapy is not an ordinary conversation, as Freud himself pointed out. For me, then, we must think about what’s not being spoken about when we neglect to address issues of sociocultural context and background. If we’re not talking about something like social class and how it impacts our clients, then perhaps neither will our clients. I don’t see those particular issues as being separate from what may be going on internally for a person – what they might be struggling with. I just see the two as quite intertwined in terms of a person’s suffering and conflicts and relational issues. They’re very intertwined for me.
LR: It’s interesting how you’re saying that people who differ from the so-called mainstream are taught to be invisible, to homogenize themselves and hide the rich context of their life. And the same seems to go for therapists who are taught to blend into the background, to neutralize the rich cultural, racial, gendered, religious aspects of themselves so they may be fully available. But you’re also saying that both client and therapist need to step out of that invisibility and reveal themselves to each other.
UT: Yes. If we’re interested in exploring a full range of experience within our client’s lives, then we must actually explore all of those different aspects of our own life. And I don’t see how we can separate the individual from their context. One other thing that comes to my mind is how we might even from the very start think about developmental history. When we do an intake assessment and ask questions about a person’s development, we typically ask questions about their family, school experiences, work and health history – things of the like. But we tend not to ask more specific cultural, racial and contextual questions like, was the family struggling financially, did they have resources in the community, what was it like growing up in this particular family?
It can be so important to ask about the immigration history not only of the client and their immediate family, but of the extended family. Deep and culturally-informed questions can be so valuable like, was there any bullying related to racism or to sexism or homophobia? These are the kinds of questions I think that could extend what we already do, but into a realm that considers the fact that development is occurring in multiple contexts and that we ought to know and learn about what’s happening in those contexts, especially for kids. But also for adult patients, who have been internalizing all sorts of things as a function of being in and living through those contexts.
Becoming Culturally Competent
LR: It goes back to what we talked about before—the need to de-neutralize the relational encounter with our clients. What are some of the challenges that you’ve seen clinicians deal with, or that you want to caution clinicians to be careful of?
UT: Actually, something you said pointed to part of my response to this in that I don’t see cultural competence as necessarily an outcome, but as a process. It’s a journey, as you say. And I think one of the things that clinicians are challenged with is this idea that somehow cultural competence only relates to certain outcomes related to people of color, or people holding some kind of minority status, rather than this being relevant to all people of all backgrounds. And so, I think that an important challenge to overcome is the assumptions we make about what is cultural competence and who it is relevant for. If we don’t see it as relevant to all of us, then it becomes a situation for certain people at certain times rather than thinking more broadly. I also don’t see it as only a professional endeavor, but a personal endeavor as well, because if we are not learning to listen to issues of context and culture in our everyday lives, then it’s very difficult to know how to listen for that in our professional work. So, to think that we just need a set of competencies to apply in a technical way in the therapeutic relationship, that’s really not what I think of as cultural competence. To me that’s a mechanical way of being rather than investing the self into the work.
LR: A more fluid way of living multiculturally rather than simply turning on the multicultural switch when in therapy! What do you see as some of the blind spots clinicians may have in working with the “other,” basically someone who’s different from yourself in any regard?
UT: I think that’s a great way to phrase it because so much of the time, the assumption or presumption in our literature is that the clinician is white, and the client is the racial minority person or something like that. Whereas certainly in my case, it might be reversed or there are two racial minority people in the room. So, you can have any combination. I think one blind spot may have to do with our human tendency to overgeneralize about groups or our conceptions about certain, if not all, socio-cultural groups. It is the notion that if someone is affiliated with or identified with a particular group, then they carry certain characteristics or that they have this or that particular set of values. I do think it’s important to have some working knowledge about the history of different cultural groups and a good working sense of that. To me, those form just a beginning framework, a beginning sense, rather than a story or rather than really understanding what belonging to that particular cultural group means for and feels like to the person.
Everybody has a unique experience of their own culture or their own religion or belonging to a particular racial group or being multiracial. I think this is why for me, a psychoanalytic perspective is particularly well-suited to this line of inquiry, because it does allow us to think about experiences that are deeply embedded in relationships, within early life relationships, but also throughout one’s lifespan and one’s evolving relationship with the broader context as well.
Another blind spot that comes to mind has to do with working with somebody who is, in some way, of similar background and making an assumption of sameness, which can get in the way of differentiating ourselves from the other. This is the flip side of overgeneralizing about the other, sort of more about merging – two people whom you think might be similar in some dimension which may not necessarily be true.
LR: Overgeneralizing about the other and undergeneralizing about someone we perceive to be like ourselves or with whom we share certain demographics. Like me working with a white Jewish male and not inquiring into their whiteness, Judaism or their maleness and as a result, missing out on a lot of potentially good information about what it is like for them.
UT: And sometimes the clients are making assumptions about the therapist, too. So, you might hear a client say, “Oh, you know what it’s like to be Christian,” or biracial, or gay? And I could say, “Well, I know what it’s like for me, but I’m still learning about what it might be like for you and trying to understand that more.” And certainly, with some of my white clients, I routinely ask about their ethnic background. I will ask them to describe it. Some of these clients will say, “Well, I’m just white you know; that’s just who I am.” And to me it always reflects how we’re socialized around race, particularly in this country, to believe that some people don’t have a history beyond just being white. So any previous family history is really kind of disavowed, which people may actually have a lot of complicated feelings about.
LR: And if we don’t allow that into the conversation, then it just continues to be a force of oppression. Just out of…
UT: Disavowal of some kind.
Bearing Witness
LR: Along these lines, what have you learned about social oppression, racism and trauma in working with immigrants and refugees that could help our audience of therapists along their own journeys towards multicultural awareness and competence?
UT: The journey I’ve had has been an incredible one. I feel very grateful for the opportunity to have learned from the people I’ve worked with in therapy. They have been an incredible resource in transforming my understanding of immigration and trauma. One of the things that I have learned along the way is how incredibly complicated the process of immigration is psychologically.
Immigration is rife with hope and optimism and resilience, but also with deep separation and loss. And the ways that people reconcile this are unique to that individual and depend on so many different factors. It depends on their families, the quality of their relational life, their own personalities and what they bring to those relationships. It also very much depends on the traumatic experiences, the support they’ve received and the willingness of people to listen to them and to hear their perspectives. So much of what’s happened in more recent years, certainly since Trump’s election, is we have enormous anxiety among immigrants and refugees.
This anxiety is not only about status, the fear of deportation and separation from loved ones, but also related to the underlying anxiety that immigrants have always felt around not belonging and not being wanted. You know, feeling as though one must find other ways to sustain the self. And that’s been important for me to understand and bear witness to. So, listening to the stories of immigrants and refugees is not just about hearing what happened, but about witnessing and bearing what is happening now and what has happened in the past. There’s tremendous transformation that occurs across the lifespan for immigrants and refugees, as well as developmental points and junctures where their kids and their grandkids are also challenged. And that itself transforms one’s own experience of what it means to be an immigrant or refugee. So, there’s a lot that we still have to understand and learn and research. Actually, I think about these changes that occur as a function of time and cultural shifts and political context and social oppression – all those things.
LR: On a more personal level, if I may, how has or is being an Indian, Hindu female, informed your own multicultural journey as a clinician and a researcher?
UT: Well, certainly it informs a great deal of my whole self, which you know, I bring to my work as well. I immigrated to the United States when I was seven years old from India and grew up first in New York City and then in New Jersey and then moved to Michigan. And we traveled around quite a lot while growing up in the US as well. So, I think that one of the things that stood out to me in that process of adjusting to being in America was how incredibly resourceful my family as well as people in my community — my Indian community, the Hindu temple — were. We really found ways to take care of each other and be very present with each other in one sense. And yet in another way, people also have difficulty talking about painful losses and traumas, so there was this really interesting paradox within the community where I grew up.
I think it’s true for many communities that there’s this sense of cohesion and an incredible connection that feels positive that brings a great deal of strength for people. And yet at the same time, when there are issues of trauma such as violence in the home, racism, sexual abuse, or political oppression that people might have faced prior to immigrating, these things become much more complicated to talk about openly and become stigmatized. So, I became increasingly interested in figuring out what can we do about that and why is that the case? A lot of what I do in my research and in my practice has to do with trying to figure out those gaps and try to make mental health care more accessible to people who typically wouldn’t seek it out or who may not trust the typical mental health professional to understand their context, their values and their families.
I think anything that’s not considered mainstream American is not necessarily considered positive or normal in some cases or normative. People within immigrant communities have a lot of concerns. Racial minority communities as well.
I have concerns that if an immigrant sees a therapist, are they going to be seen as abnormal, or are their families going to be devalued? Is their culture going to be devalued in some way because of the very theories that we use to conduct psychotherapy? And so, there’s a lot of concern around that for people in addition to around providers’ not having awareness of the impact of trauma or the impact of emotional suffering on individuals and families. This is one way I think about my own journey interfacing with and guiding my professional life and is clearly very important to me.
A Different Worldview
LR: What are the elements of the Indian and Indian American worldview that psychotherapists need to understand?
UT: I think there are some common shared elements. But I think that it’s also important to point out that, as you say, there isn’t one worldview. Somebody may say something like, “what’s it like to be an Indian person?” Well, you can ask a million Indian people and you’ll hear different things about what that means. So, I would say that there’s no one thing that’s definitive. There are many things, but I will try to narrow it down to a Hindu Indian perspective — but again, it depends on how much a person identifies with a particular religion or a particular ethnicity, and even a region within India and language, all those things.
One of the things that comes to mind as a common or a shared element of Indian culture is the ways in which families interact with each other. There is traditionally a respect for older members of a family, in a way — a deference.
And this leads us to think about conflict within families. While there is the tradition of deference to older members of the family, younger members may want to do something that’s not approved of by the older members, but they may then go ahead and do it. But in this instance, they tend to avoid speaking about the conflict. So, there are ways of communicating that are more culturally accepted or valued.
From a Hindu perspective, there’s also a belief in Karma, or a belief in the inevitability of suffering in human life. This is very interesting to me because it parallels psychoanalysis in a particular kind of way in that there is an acceptance of the fact that suffering happens and that there’s value in bearing suffering, at least to a certain extent in service of others, in service of a greater good. So, this feeling of being a part of something greater than yourself or bigger than yourself is something that I think a lot of Indians more broadly, but certainly Hindus, tend to value as well.
These are a couple of more common types of shared elements. There’s also a third thing I could highlight, which is a different sense of ideology around parenting. Parents are typically pretty involved in their children’s lives throughout their lifespan. The Hindu Indian notions of parenting don’t necessarily follow the same developmental lines of being 18 and going to college or being 21 and experiencing a definitive separation from the family. And so, in a lot of Indian families the separation may happen later, or it may take a different form in some other way later in life. So, that can look a little bit different from Western notions of parent involvement. And sometimes it’s extended family too, like aunts and uncles who play a significant role in the attachment and separation experiences within families.
Sitting with Suffering
LR: Along these lines of differences in worldview, I understand that in Hinduism, as in some other religions, suffering for the greater good is seen as a virtue, as aspirational. Western psychotherapy, in contrast, seems bent on eliminating suffering, resolving irrational thoughts, helping the person to regulate themselves, helping the person to change their behaviors so they don’t suffer. And even though the third wave of cognitive behavior therapy incorporates mindfulness and acceptance, do you still see a tension between traditional Western psychotherapies that are designed to eliminate suffering and therapeutic orientations that embrace suffering for growth?
UT: To see some type of suffering as a normative part of life feels very aligned to me with the reality of what I see every day. But the idea that somehow to live a happy, fulfilled life you must eliminate all suffering, just doesn’t add up. I think it’s sort of a setup for people to actually feel even worse, and it creates more suffering because there’s a way in which this expectation creates the unrealistic expectation that one should never feel bad or one should never have negative experiences. And in fact, we all do and we all will and that’s sort of a foundational idea. So, I do see it as a problem of trying to eliminate the suffering as quickly as possible rather than trying to understand what’s happening. I do see that as a big tension.
LR: I wonder then if Western psychotherapists need to be aware of the intrinsic pressure of our models to sanitize living. An example, perhaps, is our seemingly uncomfortable relationship with death, dying and grieving. We remove people to facilities. We don’t talk about death. We have special grief counselors, which is okay, but what about conversations in families around loss and death? I worry that many therapists in our audience may be too caught up in that need to sanitize and cleanse the person of suffering.
UT: I think we probably feel some pressure to have to relieve people of how bad it feels. And I understand that. And of course, there are certain situations where that suffering is so overwhelming that we do need to help and relieve people. But if it’s something that is a natural part of a loss or separation that happens, we can help people to bear those and know that they will come through it. And so, you’re certainly instilling hope. But you’re not also giving this false hope that somehow everything will be fine after this. Because in fact, it often isn’t, you know?
LR: I wonder if therapists working with refugees and immigrants who have been trafficked, tormented or brutalized simply find it so hard to be in the presence of someone who’s suffered that they try purge them (and themselves by association) of their suffering? Or might some therapists simply not be cut out to work with these clients for reasons related to countertransference?
UT: I do think there are certainly some types of suffering that feel too much to bear for therapists, but that varies for each of us. Some things are going to just feel harder. And perhaps it’s because we’ve been through something similar or that we just don’t want to imagine, you know, and bear witness to that. And certainly, that happens. I’m thinking also of situations where a therapist may not know what to do with that suffering, so they minimize it or push it aside.
LR: Ignore it.
UT: Ignore it. I’m thinking of a situation where clients will talk about experiences of racism at the workplace or at school and wonder within themselves, was that racism? Was that why I feel so badly?
LR: It goes back to something we were talking about earlier in the conversation — core competencies of a clinician who is aspiring to cultural competence. So maybe we should add to this conversation the willingness and ability to sit in the presence of pain, someone else’s pain, our own pain, and bear witness to it — to embrace it, to allow it into the conversation. And in doing so, honor the client who has been oppressed, who’s been trafficked, who’s been marginalized, who’s been hunted.
UT: You’re right. You’re mentioning situations of extreme trauma like trafficking that feel, in some way, so foreign to so many people, as though it’s happening out there somewhere. And in fact, it’s happening in our own neighborhoods and in our own microcosms. I think that it speaks back to that earlier point we touched on which has to do with our own personal investment in these issues. If we don’t take the time to learn about what’s happening to people within our broader society, then it’s going to be very hard to listen for these experiences.
LR: You speak about our broader society. I worry that some psychotherapists consider our broader society maybe a few states away, or “all the way” out to the Coast. But when you expand the definition of “our broader society” to humanity beyond borders, then it’s really a commitment to considering that there but for the grace of Allah or Brahma or Yahweh, go I — that we are all potential sufferers.
UT: Yes.
LR: I wonder if certain therapists would actually benefit from working with such clients and to consider doing so to be a gift of enlightenment for them. A potential gift of the opportunity for awareness and growth.
UT: I think it’s so pivotal to growth as a human being and as a therapist. It’s transformative when you listen to people’s stories from various places and contexts; it is unbelievably transformative.
Final Thoughts
LR: Given that patriarchy and the masculine worldview have historically infused psychotherapy and religion, how does male privilege impact the practice of psychotherapy for you? What are some of the learning lessons we need to learn?
UT: It’s a big framework kind of question. When I think about male privilege more broadly, I see it in the context of our traditional theories that I think hold so much weight over how we think today. I don’t think, oh, well these were some of the older theories or theorists and that was a long time ago. But in fact, I think about how we’ve all been and continue to be socialized under certain models of thinking. In the research world, for example, there is still a valuing of a certain type of research which is quantitative and includes randomized clinical trials as the gold standard. Only certain types of methodologies fall under that umbrella, whereas qualitative research such as case studies are actually more feminized and seen as less valuable. Storytelling and listening and witnessing and participatory action research, which is not valued as highly as quantitative research, is really rooted in community psychology and feminist psychology.
So, I’ve been really interested in using the feminized methodologies and rethinking the issue of being privileged, how it applies to our research paradigms and ultimately to our clinical practices. You know, what narratives and whose narratives are being privileged, and why? Not to say that there isn’t value in all these different paradigms. I see great value and I learn a great deal from each of them, but I do think that the issue of male privilege brings up a broader question about privilege in terms of what therapies are available to different communities. I think about what research is considered to be gold standard and acceptable, and how that all translates to public welfare and people’s wellbeing. I think there are many ways to challenge the status quo in terms of that.
LR: A dichotomy between quantitative and qualitative as masculine and feminine. It seems that the newer therapies are much more relational, inter-psychic, narrative and contextual than the traditional therapies. This makes me wonder about you as a psychotherapist. When a client walks into a room with you, a Hindu, Indian female, what can they expect from you based on the intersectionality of you, of your Usha-hood?
UT: When someone comes to me for psychotherapy, I think they can expect someone who is really interested, curious about their life, about their perspective, how they make meaning of things in their life, and what’s important to them. And I want to hear their story. I want to know who they are as fully as I can know them and as they will let me know them. I want them to understand that we’re all vulnerable in some way or another, but also that being in psychotherapy itself can feel really precarious and that I understand that. I hope to make it a space where they can connect with as much of themselves as they can and make decisions that feel more fulfilling.
LR: So, you are curious, and you are caring, and you are contextual, and you are collaborative.
UT: I would say so, yeah. That’s what I try to be.
LR: Well, it’s about the journey, not about the destination. Right?
UT: True. Very true.
LR: Do you have any questions of me before we stop, Usha?
UT: I have one question. I am curious about how you’re finding this mode of interacting with your audience and what you’ve been learning from that.
LR: This mode of communication, the interviews I conduct, is the pinnacle of the work I do for Psychotherapy.net, because each interaction expands me as a teacher, clinician and as a person. Learning from some of the experts in the field, those who are passionate and committed has ignited my own passion and commitment to learn and grow. It has also made me painfully aware of my biases and limitations, but also of my gifts and strengths. It has made me all the more sensitive to stories, to context, and to the importance of deeply felt personal experiences. I hope that answered the question.
UT: It does and very much aligns with how I’m experiencing you. So, I just want to say that. It’s really been lovely to talk to you.
LR: Same here, Usha. I hope we can speak again.
UT: Me too.
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