Category: Latino/Hispanic

From Cultural Competence to Cultural Humility & Equity

Posted on by Psychotherapy.net Team

What if traditional notions of “cultural differences” in clients have been misleading? The over-representation of children of color in the welfare system is more about policies and institutions that fuel disenfranchisement, and less about cultural attributes.

Despite being a cherished ideal in psychotherapy for decades, the term “cultural competence” has become increasingly flawed. It has poorly accounted for the power dynamics present not only in psychotherapy, but also in broader institutional and healthcare settings. It has also overlooked social injustice and contextual and structural influences essential to someone’s “culture.”

“Cultural competence” was coined by anthropologist James Green in 1982, and then disseminated to the fields of social work, psychology, psychotherapy and counseling. It is based on classifying culture by race and ethnicity. It has emphasized prior assumptions of cultural difference among ethnic groups. These classifications easily stereotype people, dismiss key intragroup differences and areas where they don’t apply, and consider culture as a monolith. This overlooks the reality that there are often more within-group than between-group differences among many categorized in certain groups. For example, the classification of “Asian” can overlook differences between Cambodian, Korean, and Japanese.

Becoming “competent” in someone else’s culture is not only insufficient, but largely untenable, especially if we have never been immersed in it. “Culture” is too nuanced for psychotherapists to “master.” Essentializing culture has become a disparaging form “otherizing,” and risks colluding with the power of the dominant group. The “other” focus also implies that default is White, and “others” as non-white, non-cisgender, non-English-speaking, non-Christian, non-heterosexual, etc.
Notions of competence are most flawed because they overlook the dominant status of the White group, the status quo of power over marginalized groups, and depend on overly formulaic prescriptions about how to do therapy with “them.”

“Cultural humility” is a promising replacement. It acknowledges the fluidity of culture and pushes individuals, communities, and institutions to scrutinize social inequities. Humility acknowledges differences in power and challenges injustice and related barriers at the broader levels outside of the client’s immediate social web. The shift from competence to humility is from an expert stance of understanding “others,” to emphasizing accountability in addressing institutional barriers that impact marginalized clients. For instance, the oil fracking in Colorado in neighborhoods with low-income Latinx communities is associated with negative health outcomes. Low-income communities also tend to be more dangerous, less sanitary, and less resourced. This is not a reflection of cultural characteristics.

“Cultural equity,” like humility, examines institutions and systems of subordination across and within cultures. Equity specifically examines the relations between power, privilege, oppression, family, and communal life. While competence aims merely to learn a group’s history, values, and attributes; humility and equity strive to reduce oppression and injustice. While competence stresses sheer self-awareness, encouraging practitioners to be more comfortable with differences, humility and equity add thorough assessment to the inherent power disparities in therapist-client relationships. Competence has also focused primarily on race or ethnicity, deemphasizing other germane disparities, such as SES, disability, sexual orientation, and gender identity.

Ana, age 18, an excelling student, has a mother from Guanajuato, Mexico, and stepfather from San Diego who is currently in jail for drug-related charges. Her mother brought her here at 9-years-old to escape Ana’s violent father, a policeman who muscled his power to block her and Ana from protection. Ana and her mother have no nearby relatives. She applied for DACA status in 2013. She came to therapy feeling depressed, barely able to get out of bed or attend school for 2 weeks. Despite acceptance into UCSD, her dream university, she was unable to access financial aid due to her legal status.

We explored her situation as being privileged growing up speaking English with a native-born step-father yet subjugated as an undocumented immigrant with temporary DACA protection. We attended to her persistent fear about her status. I humbly acknowledged that it’s impossible for me to have a complete understanding of how culture and systems of injustice impact her although I have lived in Mexico and had a Mexican partner. I recognized how my privilege as a graduate-level educated and White male US citizen may blind me from certain crucial aspects of her experience. We collaboratively strived to decrease the inherent power differential between us by encouraging her feedback throughout therapy.

In response to mentioning that the term “Latinx” is gaining popularity because it emphasizes inclusion, she self-identified as Chicana to convey pride in her dual heritage. We then discussed the unjust disparity in financial access despite her academic merit. From researching in-session, we learned an empowering loophole: a co-signer may help her access aid, something her high school’s career center did not know, and reached out to nearby clergy who presented her predicament to the community to secure a co-signer.

***

Cultural competence is not merely a set of skills and techniques acquired through hard work. While competence emphasizes knowledge acquisition, humility and equity stress responsibility at individual and institutional levels. While competence would imply that problems come from lack of knowledge or awareness, humility and equity recognize power differentials, and call for action and changes in attitudes about diverse clients and the broader forces that subjugate them. Clients from disenfranchised communities have less access to quality services, a lack of linguistically and culturally appropriate services, financial barriers, scarce time, and limited knowledge of resources available to them.

If you want to lead and effect change for clients, a technical and knowledge-based competence focus will not suffice. Training in humility building and equity appreciation are the keys to building improved relationships between therapists and clients. We begin to make a key difference when we attend to the equitable distribution of resources and confront unjust politics, practices, and policies, and examine how they influence one’s “culture.”

Resources

Almeida, R., Hernandez-Wolfe, P., & Tubbs, C. (2011). Cultural equity: Bridging the complexity of social identities with therapeutic practices. International Journal of Narrative Therapy & Community Work, (3), 43.

Fisher-Borne, M., Cain, J. M., & Martin, S. L. (2015). From mastery to accountability: Cultural humility as an alternative to cultural competence. Social Work Education, 34(2), 165-181.

Therapy with Latinx DACA Clients and Their Families: A Therapist’s Primer

Posted on by Psychotherapy.net Team

A DACA Primer

Many therapists are unfamiliar with the Deferred Action for Childhood Arrivals (DACA) program and have little experience serving clients and families with DACA status. I lived in Mexico City for almost 3 years, earned my masters degree there, speak Spanish, and have worked with many immigrant families over the last six years, and thus I feel a civic duty to share my experience and knowledge with the psychotherapy community.

DACA is a temporary protected legal status (TPS) created by the Obama Administration in 2012 to protect children from deportation after arriving without legal authorization (usually with undocumented parents). I use the word “undocumented” instead of “illegal,” because “I believe that no human is illegal”. We don’t call a 14-year-old driver “illegal,” or a 17-year-old drinker either. Language matters; we want to use inclusive, respectful and empowering language—after all, as therapists, language is our primary tool to promote healing and change.

There are roughly 800,000 DACA recipients in the U.S. (not including the additional 300,000 who are eligible but don’t have DACA status), approximately 75,000 of whom reside in California, and around 40,000 in San Diego. Most are Latinx, have undocumented parents and have migrated in search of safety and economic opportunities unavailable in their countries of origin. You can also use the term “DACA-mented” to describe the unique experience many DACA-mented folks experience of feeling like a foreigner—unable to access government assistance such as student loans or the vote, yet simultaneously feeling like the U.S. is the only place to call home because most DACA recipients grew up here. It is very important to be aware of how the individuals and families with whom you work self-identify. For example, I have a few female clients who have told me that although they appreciate the term “latinx,” they prefer “Latina” instead to emphasize their pride in being female.

To make matters more complicated for families of DACA status, on September 5, 2017 the Trump Administration canceled the DACA program. Although current recipients can still renew their status every 2 years for $495 plus legal fees, no new applications are being accepted. There is currently no guarantee of permanent residence or citizenship as DACA status only provides a social security number, authorization to work, and a driver license. The future of DACA remains undecided in two pending Federal court cases. Added to this, a majority of DACA recipients have parents who are undocumented, which is terrifying for them given the increasing anti-immigrant sentiment and recent increases in ethnic profiling, detainments, raids, distressing executive orders, and deportations.

Resilience

Clearly this population is at risk and needs competent, knowledgeable and supportive mental health practitioners. DACA families commonly face poverty-stricken households and neighborhoods, PTSD, agoraphobia and depression, and other psychological distress emanating from family separation, and a realistic fear of leaving the home for fear of deportation and societal discrimination. Our job as therapists is to educate, understand, heal and help manage the numerous traumas related to fearing for their own and their family’s future. The exclusionary and dehumanizing messages, xenophobia, and ethnocentrism rampant in the current political rhetoric has contributed to the hyper-vigilance and fear this population faces daily. It’s vital that these families attribute their pain mainly to the adverse events and unjust immigration circumstances instead of to themselves personally. More crimes are committed against undocumented and DACA families than by them. They live and contribute to society the same way that legal citizens do—working, studying and paying taxes. Yet they aren’t afforded the short or long-term security of citizenship, which can be so easily taken for granted. We can’t afford to ignore that one’s immigration and legal status, which in many ways form the bedrock of identity, have become so politicized on the national stage at the expense of the individual caught in the rhetoric.

Although this discrimination can gradually erode physical and mental health for families of DACA status, it’s crucial to recognize and appreciate the resilience that I have witnessed in my clinical work with this is population. Even though health settings tend to focus mainly on the risks and deficits associated with DACA, undocumented and mixed-status families, Latinx DACA recipients and their families, have in my experience been a strong group of people. “Latinx DACA and mixed-status families tend to be hopeful about a better future”, even given the current political climate. Immigration scholar and professor Dr. Carola Suárez-Orozco at UCLA refers to this as “immigrant-optimism.” They also tend to value education and have a robust work-ethic—many are excelling in schools and in their jobs. Moreover, these families tend to be closely-knit and extremely affectionate, loving and supportive, a major sign of strength. Unfortunately, this has been periodically pathologized as “enmeshment” by Western-oriented therapists and other practitioners who are not as knowledgeable about cultural norms and sociopolitical contextual variables affecting our clients.

The resilience doesn’t end there; DACA recipients often benefit from the advantages of being bilingual, binational, and bicultural, which is correlated with increased employability, cognitive flexibility and enhanced capacity for perspective-taking. I have witnessed immense cultural pride, religious and spiritual strength and social support within this population. There is also a present-time orientation—contrasted with the greater emphasis on past and future in the U.S. that helps affected families enjoy and appreciate their time together and to stay closely knit and loving, despite the fear of uncertainty always lurking in the background. Understandably, DACA recipients have reported that “coming out” publicly has been tremendously difficult; many parents coach their children to be furtive with their immigration status for protection and unity. This appears to be very appropriate given the associated risks of “going public.”

Consistently witnessing these families strive, grow stronger, wiser, and more resilient as time passes and therapy progresses, has not only encouraged me to continue this work but has also instilled a sense of vicarious resilience within me. As I mindfully reflect, I feel that I have grown stronger and wiser personally and professionally from continually seeing these families do so time after time. I owe this vicarious resilience to this population’s courage in their work with me. Next, I’ll share a brief snippet of my work with one family. I’m eternally thankful to this family for allowing me to share their story, of course with their identities concealed.

Sergio

Sergio, age 17 and a DACA recipient since 2013, was brought to therapy by his parents, Tina and Jorge, who were concerned that he hadn’t been sleeping or eating well, had been struggling academically, worrying excessively and had become increasingly nervous and irritable. His parents brought him to California when he was 11 months old in search of better economic opportunities. They hired a “Coyote” to cross from Tijuana—fortunately, they were neither abused nor robbed en route which are very common occurrences.

After a careful assessment, Sergio met the diagnostic criteria for Adjustment Disorder with Anxiety. Jorge, his father, had been suddenly detained by ICE (Immigration and Customs Enforcement) when walking from the car to a restaurant where he had planned to dine with his wife and Sergio’s two siblings. Jorge was detained for the night and released in the morning. Sergio remembered experiencing a panic-filled and sleepless night following his father’s detention. Although Jorge was detained only briefly, a court date for the following year was scheduled at which time his deportation would be decided. This only added to his son’s sense of impermanence and anxiety. We don’t currently know the extent to which Jorge’s previous DUI contributed to his arrest or will factor into the court’s impending decision regarding his status. I have collaborated with Jorge’s lawyer in documenting what I considered would be an adverse impact of deportation on Jorge’s family.

Sergio has shared that he constantly worries about “having to be the man of the house” and having to help raise his younger brother and sister if his father is deported. He also worries about his own future in the country since the DACA program was rescinded last year. Because Sergio is old enough to understand and psychologically strong enough and high-functioning, we have collaborated on a “family preparedness plan.” Fortunately, Sergio’s family is closely-knit and resourceful and has supportive relatives in the area who have lent his family money to cover Jorge’s legal fees. Sergio also speaks English and Spanish, a big plus when he enters the job market, and has maintained a 3.84 GPA up to his senior year in high school. We have discussed the traumatic nature of his father’s arrest along with the wider socio-political injustice and hateful rhetoric that have contributed to his symptoms; shifting the narrative from believing something is wrong with him to his anxiety being a normal response to abnormal circumstances. Together, we have highlighted the strengths he’s developed from coping with this uncertainty. We also review mindfulness strategies to embrace the here-and-now, so that he may sleep better, and utilize EMDR to reprocess the horror that periodically torments him from that day.

“It’s essential to emphasize that therapy has significant limitations if wider sociocultural and political influences are not considered in the work”. No therapy can resolve the uncertainty of Jorge’s future in this country with its increasingly strict immigration policies. Helping families talk about injustice in therapy is a step toward effectively managing it. In fact, Sergio shared helpful information with his community such as the app Migrawatch for warnings of any future raids in real-time, which we agree has helped his anxiety symptoms. As Sergio’s therapist, I know that symptom management isn’t enough and realize the importance of opening a dialogue with him and other such clients. I also consider it crucial to share my personal commitment to progressive politics and public advocacy of immigrant rights that have helped Sergio and his family embrace their resilience, and that will hopefully challenge the injustice in his own community.

Therapeutic Tips

Here are some practical tips I hope will be helpful in your own practice if you have the privilege of working with clients like Sergio and his family. Additional information can be found in the article Ten Psychotherapeutic Considerations to Assist Young Undocumented Latinx by LaRoche, Lowy & Rivera(1)

  • Remind them in the informed consent that disclosing their status, is never part of your mandated-reporting requirements, and unwaveringly commit to confidentiality.
  • Shift problem-saturated narratives around DACA and U.S. immigration-policy toward resilience.
  • Emphasize their many strengths alluded to above; use them as assets in treatment-planning.
  • Help families create a “preparedness plan” in the event that a member is suddenly deported, and capitalize on other aspects of their lives that they can control in the here-and-now. This can include appointing guardianship for children and referring families to the “Toolkit for DACA Families” by Chavez-Dueñas and Ademes(2). Be careful that although this helps by increasing a sense of power/control, these can initially foster anxiety. The same is true for rehearsals of the plan or confrontation with officials. DACA families have the constitutional right to “remain silent” and contact their lawyers in response to police, ICE, or immigration officers.
  • Use a genogram to help families understand the current makeup of their transnational extended family. Unlike the generic caucasian nuclear family, Latinx families often include non-blood relatives, who should be included in the “preparedness plan.”
  • Check your assumptions; don’t assume they speak Spanish because their parents brought them here from Latin America.
  • Speaking and learning some Spanish is always a plus.
  • Be bold; don’t only have the LGBTQ pride flag in your office but have the butterfly symbol to show your support for this population.
  • Remind them that Title IX prohibits discrimination based on ethnicity, nationality, or race for organizations that receive federal funding; DACA recipients arguably are included.
  • Since these families don’t leave their homes because everything is fine in their native countries, it’s vital to know why they left and their immigration story, which is likely to reflect trauma and separation, and help clients understand and overcome trauma from these adverse experiences.
  • Encourage families to use the app Migrawatch to see if a raid is taking place
  • Know the limitations of weekly therapy in helping families cope with intense and chronic immigration stressors and societal discrimination.
  • Collaborate with a multi-disciplinary group of lawyers and medical doctors.
  • Use your privilege! Utilize your civic rights to advocate (a good therapist is always a good case manager) and censure deleterious deportation policies through organized protests and rallies, and calling local politicians or elected officials. As therapists, I believe we have a civic duty to advocate for this community and promote sociocultural transformation. As therapists, we cannot be quiet or neutral in the face of the numerous injustices this population faces.

In the words of Dr. Martin Luther King, “In the end, we will remember not the words of our enemies, but the silence of our friends.”

1 https://www.researchgate.net/profile/Martin_La_Roche/publication/322255405_Ten_Psychotherapeutic_Considerations_to_Assist_Young_Undocumented_Latinx/links/5a4e832a458515e71b085836/Ten-Psychotherapeutic-Considerations-to-Assist-Young-Undocumented-Latinx.pdf

2 https://icrace.files.wordpress.com/2018/05/final-immigrant-parent-toolkit.pdf