Cultural Competence and Bias

Painting of faces and hands

As therapists, we recognize our ethical obligations to know and acknowledge the limits of our training and skills. We know that our expertise grows over time with experience and supervision, training, reading, dialogue and further training. These activities contribute to our mastery of specialized areas, methods or skills. But what about cultural competence? How do we become culturally competent? Does it just happen naturally or is there something we need to do?

I think of cultural competence as an evolving set of attitudes, knowledge, skills and awareness that supports my ability to relate to “other-ness” or the unknown in myself and those around me. Other-ness can also be thought of as experiences, ideas, practices, beliefs, and so on that I do not identify with, believe, do practice, or endorse. In thinking about cultural competence, I focus on my connection to other-ness. For me, it is less about achieving a level of proficiency as measured or defined by someone else and more about an ongoing process of refining the skills, attitudes and awareness practices that support my capacity to relate to and work with other-ness in myself and others.

In developing expertise in an area of practice, I might study, write and do research to deepen my knowledge base. In mastering a treatment model, I study concepts, clinical vignettes and research. I also practice basic skills (or interventions), learn to identify patterns or signals and seek out supervision to help me perceive and respond to what I cannot yet completely behold, understand and articulate.

In cultivating cultural competence, I rely heavily on my ever-changing ability to develop new attitudes and relationships as well as the capacity to use my awareness in new ways  to relate to ideas, practices, identities and other information I may not yet fully understand. I challenge myself to identify places where I am blocked from understanding or relating, instead of glossing over them and using my privilege to ignore or forget the experiences of others I do not in that moment connect to. Developing attitudes and growing awareness sometimes means exposing myself to and relating to people, practices and ideas that may feel foreign to me. It may mean looking at deeply held beliefs and subtle biases that are not easy to identify or that are embarrassing or troubling. This can be a very difficult process!

Everyone Has Bias
One of the reasons the process of cultivating cultural competence is so difficult is bias. None of us want to have prejudices or biases but they are inevitable. In our work at LifeWorks Psychotherapy Center supervising and training therapists, we begin with the premise that every therapist, and in fact everyone, has bias. Bias starts with our experiences and the information we gather in life and gets filtered thru our identity and culture. Some of our biases are known to us, while others may be unknown or hidden.

Every therapist, no matter their identity or background, has bias. We define bias as anything (for example, any idea, belief, opinion, reaction or emotion) that limits one’s capacity to relate to another as whole and equal, or that which creates a tendency to marginalize aspects of another’s experience.

Therapeutic bias, if unexamined, can hinder or even endanger the therapeutic relationship but it can also be a looking glass into experience that can enlighten, deepen and transform our connections to our clients.

Observations from Our Practice
In our practice, at LifeWorks, we work with diverse clients, who identify across a variety of religions, genders, sexualities and relationship constellations, including: lesbian, gay & bisexual (39% of clients); trans, queer and genderqueer (13%); non-monogamous and polyamorous (40%), and clients who are kink and/or BDSM-identified (23%). And many clients endorse more than one of these identities.

A recent informal sampling of therapists in our practice revealed that approximately 25% of their clients had explicitly indicated that they had had previous therapy experiences where their therapist’s bias regarding kink or non-monogamy was an obstacle to their care or hindered their experience in therapy. In our recently reported research (See: “Social and therapeutic challenges facing polyamorous clients,” Sexual and Relationship Therapy, Henrich & Trawinski, 2016), 50% of clients identifying as polyamorous had seen therapists that they felt lacked cultural competency or were biased. Participants in that study reported that therapists were uninformed about polyamory, or biased toward monogamy.

Even therapists who themselves identify as marginalized in some way—for example, those who are LGBTQ, kinky, non-monogamous or polyamorous—may have subtle or not so subtle biases about the groups with which they identify. These biases may show up in therapists as reservations, judgments, concerns, worries about their clients or as strident beliefs, one-sidedness and even extreme positive regard. Neither being inside or outside a given community offers immunity from bias towards that community (or towards any other). Our experience and research confirm that bias affects us all.

Emphasizing Wholeness
Our work on bias is shaped by the concepts and methods known as process-oriented psychology or processwork. Developed by Arnold Mindell and others, processwork is both a depth psychotherapy paradigm and a phenomenological approach to working with human problems that emphasizes wholeness, the flow of experience and awareness and the importance of all points of view. Mindell coined the term “deep democracy” to describe the idea that all voices are important to the well-being of the whole.

Using process-oriented methods and awareness, we have been teaching psychotherapists—and learning ourselves—to detect and identify bias, unfold its meaning, and learn to relate to aspects, attitudes and behaviors of clients that they may find difficult, disturbing or troubling. In our experience, therapist bias is often a reflection or expression of some quality or trait that the therapist tends to marginalize or overemphasize in themselves. Something important, and often subtle or outside of awareness, may need to be known or understood better, and can be uncovered by looking closely at spontaneous or troubling reactions and perceptions.

From our perspective, it is probably impossible to get rid of bias entirely, but we have found that it is possible to embrace and transform therapist bias into something that enhances the capacity to experience and support clients’ wholeness. It takes time and practice to develop the skills, awareness and attitudes that support the capacity to learn and grow from our bias—and in so doing, to increase our ability to understand, relate to our clients and to support their process of change.

There is no quick fix that we are aware of.  In our experience, the awareness and transformation of therapist bias is more like a lifelong endeavor.

This article was first published as a blog in 2015. In 2016, LifeWorks Launched the Green House, an in-house training program that provides post-grad therapists with opportunities to develop their cultural competence with the clients we serve, as they develop their identity as therapists, learning about their unique strengths and how to use themselves effectively in the client relationship. We are currently training our third cohort and will soon be accepting applications for the 2019 Greenhouse cohort. To learn more about this exciting training and mentorship program, visit the Green House.

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About Cindy Trawinski, Psy.D., Dipl. PW

Cindy Trawinski is a licensed clinical psychologist, a Diplomate in Process-oriented Psychology (also known as Process Work) and a certified Imago Relationship Therapist. She is a founding partner of LifeWorks Psychotherapy Center and North Shore Psychotherapy Associates and has offices in Skokie, IL. Cindy is the former CEO of the Process Work Institute, in Portland, OR and a member of the International Association of Process-oriented Psychology (IAPOP), in Zurich, Switzerland. Cindy is a frequent speaker on topics including: Diversity and Multicultural Issues; Sex Positivity; Rank & Power; Therapist Bias; and Polyamory.