Cultural competence in psychotherapy

Despite increasing investment in neurobiological approaches, psychotherapy remains a crucial intervention in psychiatry with wide application for diverse patients, conditions and contexts. However, to have maximum accessibility and impact, psychotherapy must be delivered by culturally competent practitioners and health systems. Cultural competence involves three broad sets of issues: a) pragmatic – recognizing and addressing cultural and linguistic differences is essential to guide clinical assessment and negotiation of the goals, methods, process and progress of psychotherapy; b) conceptual – psychotherapy needs to mobilize changes in psychological functioning and adaptive strategies that fit the resources of individual patients and their social world; this may require rethinking the mechanisms and modalities of therapy; and c) ethical – psychotherapy conveys particular concepts of the person that may be at odds with the values or ways of life of particular cultures and communities. This cultural proselytization may be intentional or inadvertent for the therapist, and desired or unwanted by the patient. In either case, it may be liberatory and empowering or disruptive and undermining of individual’s adaptation and social integration. Cultural competence in psychotherapy requires knowledge, attitudes and skills for context-sensitive assessment and intervention1. This includes a general framework for thinking about cultural identity and difference, language and communication skills, and specific knowledge about the cultural background, lifeworld and communities of patients. Older notions of culture as constituting distinct, homogeneous and self-contained social systems have given way to more dynamic views of culture as hybrid local worlds and extended transnational networks that afford individuals multiple strands to their identities and multiple niches they can inhabit to realize their capabilities and adapt to challenges. This requires a more dynamic approach to assessing and integrating cultural dimensions into clinical case formulation and psychotherapeutic intervention2. Generic cultural competence makes use of tools such as the DSM-5 Outline for Cultural Formulation and the Cultural Formulation Interview, which provide a place to start in basic assessment3. However, psychotherapy requires more nuanced understanding of local idioms, social contexts, life predicaments and possibilities. Given the great variation within and across cultural communities, clinicians need a general attitude of humility and openness to foster a collaborative process of inquiry and mutual learning. In addition to competence and humility, the complementary construct of cultural safety recognizes that the effort to mobilize psychological resources to heal must consider the ongoing structures of inequity in which patient and therapist are embedded. There is a long tradition of research on cultural variations in healing practices and psychotherapy4. This has identified processes of change and sharpened our understanding of how the mechanisms of psychopathology and psychotherapy are influenced by culture. Putatively universal processes in healing and psychotherapy include expectancy effects, cognitive reframing and restructuring, meta-cognitive self-regulation, and relational learning5. While these processes can be described in abstract terms, they take specific forms in each culture, and require appropriate models and metaphors to evoke or mobilize. Moreover, cultures may favor particular mechanisms of coping and adaptation. Culture can then influence psychotherapy in multiple ways: a) shaping the cognitive-emotional loops that constitute or contribute to mental disorders; b) articulating shared and divergent experiences and modes of expression and communication; c) determining the ways in which modes of self-construal, coping and adaptation are enacted to yield positive effects for the sufferer and others in their social world; d) establishing norms of behavior and expression that set thresholds for pathology; and e) determining the social niches or ways of life that provide pathways for recovery6. The narratives of suffering and healing that are the basis for self-understanding and the medium of therapeutic transformation in psychotherapy are rooted in cultural concepts of the person. Much of current psychotherapeutic theory and practice rests on individualistic notions of the person that emphasize autonomy and independence. Alternate cultural concepts of the person may be characterized as sociocentric, emphasizing the embedding of the individual in interdependent social relationships; ecocentric, linking the person to the environment; or cosmocentric, recognizing relationships with ancestors or a spirit world7. Each of these versions of self and personhood is elaborated in indigenous or ethno-psychologies, along with specific notions of health and illness. Each provides ways of structuring the self and potential targets for intervention. The pattern theory of self suggests that embodied experience, narratives of the self, and modes of active engagement with the social world are configured in ways that may result in pathology but that also offer opportunities for transformation8. The metaphors of psychological theory – both its formal constructs and everyday uses to explain or rationalize behavior – draw from these cultural concepts of the person and cultural ontologies. So too do our notions of distress, dysfunction or disorder. But other metaphors also come into play. Thus, illness may be seen as a breakdown in biological machinery (“broken brain”), a dysfunction in information processing or computation, deficient learning or lack of skill, traumatic memory, weak will, or a snarl of psychological conflicts that reflect internal struggles or interpersonal tensions and contradictions. Other metaphors drawn from different ontologies may provide ways to rethink the form and content of psychotherapy to better fit cultural systems of meaning and social contexts. Culturally adapting existing therapies can increase their acceptability, uptake and effectiveness9. Adaptation ranges from minor changes in language or framing of activities to more fundamental shifts in the ways problems are conceptualized and processes are mobilized to achieve a desired outcome. Recognizing cultural difference can lead us to enlarge our models of psychotherapy to include different frameworks and practices. In recent years, we have seen this with the emergence of therapies that borrow from Buddhist or other contemplative practices. There is great potential for creative development of therapeutic methods that build on shared and distinctive features of the cultural constitution of the self. To do this, we need to continue to develop our understanding of cultural variations in the self and the poetics of illness and healing4.

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