In recent years, the importance of cultural training in the education of psychologists has been particularly emphasized (American Psychological Association, 2003). However, clear guidelines for cultural training have not been established. As a result, internship sites vary significantly in their notions of what makes cultural training effective (Brooks, Mintz, & Dobson, 2004; Constantine & Sue, 2005; Magyar-Moe et al., 2005).
Two approaches to cultural training in internship have been identified. First, didactic approaches focus on teaching facts about specific cultures. Research suggests that a didactic approach may improve self-awareness (Brown, Parham, & Yonker, 1996). However, this approach has limitations. For example, it is impossible to provide training on all cultures and, furthermore, research on many cultures is not available (Canady et al., 2011). Second, the “cultural roadmap” approach involves teaching interns a process of how to learn about specific cultural groups, rather than facts about cultural groups. In this approach, interns first gather general information about a particular cultural group. Next, interns meet with community representatives and groups of community members and, finally, develop a project using the information learned to serve the cultural group studied (Canady et al., 2011).
In contrast to these approaches, the cultural training at The National Asian American Psychology Training Center at Richmond Area Multi-Services, Inc. (RAMS) provides an alternative approach to cultural training for its interns. This approach is consistent with the relational and intersubjective psychoanalytic orientation of the internship’s training. In these approaches, the advent for change in therapy is the relationship between patient and therapist. In exploring the interactions and subjective experiences of the patient within this relationship, therapeutic change occurs, and the patient is able to process their own past and present experiences of self and other in relationship. Thus, the therapist him/herself is a vital tool in the therapy, and self-awareness is critical in being able to utilize the self effectively. Given this emphasis on the relational elements of the therapeutic relationship, this model for cultural training focuses on helping interns identify their own cultural biases and identify how these biases impact their clinical work.
Cultural competency has been defined as “the ability to work effectively across cultures in a way that acknowledges and respects the culture of the person or the organization being served” (Hanley, 1999). Although it was developed less than two decades ago, the construct of cultural competence has quickly become an important part of graduate training in psychology (Furlong & Wight, 2011). Cultural competency training programs are intended to help individuals and institutions to increase their proficiency in understanding, accepting, and working with culturally different individuals. In fact, evidence suggests that educational interventions intended to improve cultural competency are capable of positively impacting the knowledge, attitudes, and skills of health professionals (Beach et al., 2005).
At the same time, the construct of cultural competency has received some critique. For example, Furlong and Wight (2011) have argued that instead of pursuing cultural competency as an “add on” to graduate education, critical awareness that involves the interrogation of received knowledge and lifelong reflection on one’s own ideological and cultural commitments should be emphasized. From this point of view, critical awareness involves at least two components: (a) working on the principles of “curiosity” and of “informed not knowing” and (b) regarding “the other” as a mirror upon which we can see the outline of our own personal, professional, ideological, and cultural profile. This critique is entirely consistent with the intersubjective psychoanalytic orientation of the internship’s training, which recognizes that the meaning of our own experience can only be understood in the context of relationship.
The notion of cultural humility provides a touchstone for the cultural investigation conducted by the interns throughout the training year. Originally developed by Tervalon and Murray-Garcia (1998), cultural humility is founded on the recognition that providing culturally competent mental health services is impossible unless the provider possesses cultural humility. According to Hunt (2001), cultural competency training has made the mistake of focusing on traits that describe certain cultural groups and developing treatments based on these traits. This approach to training overlooks the dynamic nature of human beings (Hunt, 2001). Culture is not static and the expression of one’s culture is largely influenced by one’s larger context. To attempt to predict a person’s behavior based on a cultural label is a watering down of both individuality and culture. In addition, in this approach the mainstream culture remains unexamined and maintains its status as “normal,” the standard by which other cultures are examined (Hunt, 2001).
Tervalon and Murray-Garcia (1998) as well as Hunt (2001) propose that cultural competency must be rooted in cultural humility, which involves a continual process of reflection of one’s values and biases. The goal, according to Hunt, is not “cultural competence,” which is a moving target as culture constantly changes. Instead, each clinical encounter must be followed by intentional self-reflection on one’s reactions, feelings, beliefs, assumptions, and values. The ultimate goal is self-awareness, and respect and recognition of each individual’s cultural values within the therapeutic dyad.
Humility is a dispositional character trait, and in order to grow in cultural humility, engagement in a process of exploration of one’s attitudes, biases, and values is foundational. Holmes (2012) argues that the model of cultural competency training our field espouses is biased toward surface-level training. As a result, she argues, there is a discrepancy between what the therapist knows about cultures and what the therapist does in session (Holmes, 2012). What one knows cognitively must be processed, and the transformation to becoming a culturally competent therapist must be fostered within a training model that espouses deep-level changes (Holmes, 2012; Hunt, 2001). The training model that we present in this paper attempts to fill this gap of deep-level transformation among therapists toward greater multicultural competence and awareness.
The training model
The development of clinical sensitivity to culture and diversity is a central feature of the APA-accredited pre-doctoral internship training program at The National Asian American Psychology Training Center at Richmond Area Multi-Services, Inc. (RAMS). This training consists of two parts. First, the three pre-doctoral interns meet for a weekly cultural process group with the program’s training director, Dr. Alla Volovich, with the intention of exploring and discussing each of the intern’s cultural experiences. During the first half of the training year, with the help of the training director and other interns, each intern identifies a particular cultural bias believed to be impacting clinical work. During the remainder of the year, each intern uses the cultural process group as well as individual supervision and independent research to explore that bias. Second, at the end of the year, interns present their research in a written paper, as well as in a lecture given to clinic staff and trainees.
The cultural process group involves exploring one's own culture with other group members, receiving support and feedback throughout this process, and eventually choosing and presenting on a topic of interest related to personal cultural biases. In this context, culture is construed in the broadest sense as describing the ways of living developed by groups to meet their biological and psychosocial needs. In most cases, culture includes patterns of thought, behavior, language, customs, institutions, and material objects (Leighton, 1982). When thinking about culture, it is important to differentiate between its superficial, readily apparent aspects and those that exist on a deeper level.
The iceberg concept of culture offers a framework for understanding culture that is divided into three tiers: (1) high or surface culture, (2) folk culture, and (3) deep culture. Using the metaphor of an iceberg, Weaver (1986) suggests that much of culture is outside conscious awareness. While surface and folk culture are readily apparent, they are limited manifestations of deep culture. Within this framework, deep culture includes the foundational elements of a culture, including its metaphysics, epistemology, and logic. One aspect of deep culture is worldview. Worldviews consist of one’s attitudes, values, opinions, concepts, thought and decision-making processes, as well as how one behaves and defines events (Sue & Sue, 1999).
The cultural process group provides an opportunity for interns to gain increased awareness of the deep aspects of their individual culture and to learn about the deep aspects of one another’s cultures. Drawing on the influence of intersubjective psychoanalytic thought, interns are able to increase their awareness of the deep aspects of their own cultures by recognizing its immediate impact on fellow participants and directly experiencing how cultural beliefs shape interpersonal encounters. Within a framework of cultural humility and critical awareness, ongoing self-disclosure, support, and confrontation allows interns to find a place in which they can explore the meaning of their own and each other’s cultural differences. Over time, interns develop an increased capacity for cultural self-formulation insofar as it impacts countertransference dynamics in clinical work.
The following encounter in the cultural process group occurred about four months into the training year and illustrates the concepts that we have discussed above.
Wooldridge: I'm still not sure what we are doing here.
Prasad: Even now? After you talked about what a powerful impact growing up in the South had on you?
Wooldridge: Yeah, but I'm unclear of what that has to do with the everyday. When I look at Carissa, I don't see her as being Indonesian. I just see Carissa as Carissa. I mean she's human, like me and you and everyone else.
(Long, uncomfortable pause)
Volovich: Carissa, you have a look.
Dwiwardani: I'm thinking of how to say it...I know you mean to make me feel accepted in some way by saying that, but it hurts me to hear you say what you said. It makes me feel unseen, like you've taken something important away from me.
Wooldridge: I'm sorry. I didn't mean to do that.
Dwiwardani: I know you didn't, but that was how it affected me.
Prasad: It's like colorblindess. People think it makes everyone closer somehow, but it actually creates distance. It disallows a part of you—your culture—and it feels pretty awful.
Wooldridge: I wouldn't have thought that.
In writing this paper, we each reflected on this particular encounter that occurred almost two years ago. We reproduce each of our reflections on this encounter verbatim.
Wooldridge: Although cultural competency was emphasized during my graduate education, at the beginning of my pre-doctoral internship I was deeply ambivalent about whether that emphasis had been beneficial to me in my clinical work. Notably, I was nonetheless drawn to pursue my pre-doctoral internship at the National Asian-American Psychology Training Center at RAMs, Inc., a training program well-known for working with immigrant populations and its concomitant emphasis on cultural competency.
In hindsight, I attribute my ambivalence about cultural matters to early experience. I grew up in Mississippi, an area of the United States well-known for its history of racial and cultural strife. An African-American nanny was a central figure in my childhood, someone to whom I was deeply attached. Even as a child I had a nascent recognition that my nanny was, somehow, regarded as fundamentally different from me both by my family and the larger social milieu. In reaction to the painful emphasis on difference I experienced then, I now tended toward a denial of difference, both in others and in myself.
Around the fourth month of internship, an interaction that was both difficult and enlightening occurred during the cultural competency seminar. Although our training cohort had been remarkably cohesive throughout the year, the cultural differences between us were beginning to make themselves known. More importantly, perhaps, my difficulty acknowledging the importance of these differences was becoming evident. As we discussed the interpersonal process between us, I said, “Carissa, I don’t see you as Indonesian. I see you as a human being.” This naïve comment launched a long discussion, extended over many weeks, through which I came to see that my comment left Carissa feeling unseen and misunderstood. Equally important, I began to understand how my own developmental process had led me to deny cultural difference both in others and in myself. In time, I was able to increasingly acknowledge this previously denied aspect of myself and, therefore, to acknowledge its existence in others. Unsurprisingly, this had a significant impact on my clinical work.
Dwiwardani: When Tom stated that he did not see me as Indonesian—that he simply saw me as a person—I was stunned. While colorblindness is not a new concept to me, I was quite surprised at how it affected me directly when someone—not just someone, but a friend and colleague— exhibited it so bluntly toward me. As I reflected on the hurt I felt, I realized that I felt unseen, that a big part of me was being overlooked. The context of our friendship made it confusing, too. I was certain that Tom is a friend who cared for me, but why this hurtful overlooking of who I am? It did not seem to make sense.
As I began to voice my experience to Tom, I sensed openness on his part to hear how his comment affected me, and this was the beginning of a deeper understanding of myself—how colorblindness affects me, and growth in my learning of how to address it interpersonally. This experience taught me that cultural awareness of oneself and of others must happen in a relational context. If Tom were not a friend and colleague, if he had been just a stranger to me, it would have been easy to dismiss him entirely. The relational context forced me to wrestle with the complexity of the interaction, to put the complexity into words, and to experience receptiveness in Tom's reaction, all of which were healing to our relationship.
Prasad: When I heard Tom say the words “I just see you as a human,” I felt my blood pressure starting to rise. I was angry not only for what Tom said, but for all of the many times that kind, well meaning people, even friends, had made me feel either unseen or ashamed of my culture. My thoughts jumped to when my closest friend told me that the music to which I danced sounded like an alarm going off but that she meant no offense, or the many times in Wisconsin that people said that race and ethnicity had no impact on how they saw others while they argued that affirmative action was reverse racism. These interactions made me feel misunderstood and angry, but I could not experience that anger without anyone to help me hold it, so I internalized it at first, and later processed it in the displacement in college by studying neo-colonialism in the context of Latin America.
In graduate school, I read everything about microaggressions and racism that I could, and began to understand its impact on me, but before I was able to process these interactions during internship, I did not realize that I took the many cues that people did not want to see my cultural self and would prefer if I were an acultural being; I did not recognize that I, like my parents, had complied with this given our social context and fear of rejection should we confront these interactions. Even now, when I find myself in homogenous setting where I am the “other,” I feel isolated, and when I find myself among Indians, I feel less Indian than I should, sometimes attributing my shame about this to others around me and sometimes recognizing negative judgment from others who rejected my parents’ relatively liberal stance and their inter-caste marriage.
These realizations did not come in therapy or in other contexts of self-exploration but were possible because of the training that I received at RAMS through the interactions like the one shown above. I had a space to work out my thoughts and feelings, which were at times incredibly painful, with the support of a supervisor and colleagues. Equally important, I had the opportunity to support my colleagues in processing their own experiences without the high level of conflict that I have witnessed in other conversations about race, ethnicity, and culture. This experience fostered dialogue and patience, and the interaction between Carissa and Tom allowed me to let go of some of the anger that I had held on to. It gave me hope that people can understand what it means to be different from the norm if they have the patience and support of others. This patience and support was possible because we knew and cared about each other and because we sat down for at least an hour a week to talk about culture.
This illustration of an encounter in the cultural process group illustrates one group member (TW) moving from cultural naïveté toward a place of increased cultural humility and curiosity about both his own cultural experience and the other’s. Although this did not involve learning facts about a particular culture, it nonetheless dramatically influenced his future clinical work and sense of identity as a cultural being.
In fact, this transition can be mapped according to a developmental model of cultural competency (Mason et al., 1996). This model consists of five stages: (1) cultural destructiveness, (2) cultural incapacity, (3) cultural blindness, (4) cultural precompetence, and (5) cultural competence. In brief, cultural destructiveness is a stage in which individuals and groups are unable to acknowledge the importance of cultural differences. In the cultural incapacity stage, cultural differences are provided with neither a positive or negative valuation and, therefore, ignored. In the cultural blindness stage, cultural differences are seen as inconsequential and of no importance. In this stage, being “color-blind” is desirable. In the cultural precompetence stage, individuals acknowledge the need for cultural competence and attempt to correct harmful practices. In the cultural competence stage, individuals learn to value cultural differences.
In the illustration we have provided, TW can be seen as moving from a stage of cultural blindness, in which cultural differences are seen as irrelevant, toward a stage of cultural precompetence. As the process group continued throughout the year, so did this development.
Finally, the encounter brought forth several aspects of deep culture present in members of the process group. For example, TW recognized that one aspect of his own culture consisted, with a few notable exceptions, of minimizing the importance of cultural difference. In this way, the complex feelings associated with being a member of the “majority” culture could be bypassed. SP recognized a parallel bias in herself to discount the value of her own cultural experience given that she internalized others’ assumption and desire for colorblindness, and CD learned to voice her reactions to colorblindness and gained a deeper and experiential understanding of the impact of colorblindness. Thus, each intern grew developmentally through this experience.
The model that we propose does have its limitations. In order to have a successful group, there must be a facilitator who is attuned to cultural issues, cares about the topic, and has adequate training to manage in-depth discussions. In addition, there is a need for enough diversity in the training group to allow for lively discussion and counterpoints and also a need for the group to not consist of two sides of a historical trauma without any other members to mediate the intense emotional valence.
Because one’s culture cannot fully be separated from self and family, it is innately emotional, such that transference and countertransference often emerge during the group, and can be difficult to contain. This is particularly apparent in the context of an internship program that requires ego strength and a consolidated self in order to manage the rigors of training. This model of cultural competency training, however, requires interns to deconstruct themselves in cultural terms. This can result in emotionally charged interactions and distress at times if interns choose to self disclose and engage in the process fully. This requirement of self-disclosure is also a limitation in that participants may have difficulty feeing comfortable self-disclosing to peers about their own experiences. We feel as though this is necessary given the difficulty of finding other venues to engage in this level of discussion around culture. Because most therapists themselves have not undergone extensive training around issues of culture, interns’ personal therapy often does not provide adequate support and knowledge to hold a patient in the process of working through personal culture.
In addition, although not included in the scope of this article, we believe that a two-pronged approach to cultural training is indicated. The two facets of this training involve both the in-depth reflection and relational interactions described in this article, as well as research about one’s culture of origin in the form of readings and consultation with others to gain knowledge from an external perspective.
In this paper, the authors have attempted to present a training model on multicultural competence that is directed toward promoting a cultural awareness that goes beyond a cognitive knowledge of others’ cultures. The cultural competence training model at the National Asian American Psychology Training Center’s predoctoral internship program at RAMS, Inc. was presented. The model is carried out over a period of the internship year, during which the interns meet weekly in a group with the internship Training Director. Along with working on individual cultural competence projects, the interns engage in a process of cultural awareness development and exploration in the weekly group meeting. An illustration of a process that took place in the group was presented, as well as interns’ reflections on the process. Limitations of this model of training were also presented. The training model presented is one that is directed toward a deep-level transformation within a relational context. This model, we believe, increases the therapist’s level of comfort with discussions of cultural dynamics in therapeutic contexts and sharpens therapists’ sensitivity to cultural nuances presented in various therapeutic contexts.
Cite This Article
Wooldridge, T., Dwiwardani, C., & Prasad, S. (2014). Cultural training in internship: A relational model founded on cultural humility. Psychotherapy Bulletin 49(3), 19-26.
American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58(5), 377-402. DOI: 10.1037/0003-066X.58.5.377
Beach, M. C., Price, E. G., Gary, T. L., Robinson, K. A., Gozu, A., Palacio, A., Smarth, C., et al. (2005). Cultural competence: A systematic review of health care provider educational interventions. Medical Care, 43(4), 356–373. DOI:10.1186/1471-2458-6-104
Brooks, B. L., Mintz, A. R., & Dobson, K. S. (2004). Diversity training in Canadian predoctoral clinical psychology internships: A survey of directors of internship training. Canadian Psychology, 45(4), 308-312. DOI: 10.1037/h0088237
Brown, S. P., Parham, T. A., & Yonker, R. A. (1996). Influence of a cross-cultural training course on racial identity attitudes of White women and men: Preliminary perspectives. Journal of Counseling and Development, 74(5), 510-516. DOI: 10.1002/j.1556-6676.1996.tb01902.x
Canady, B. E., Rivera, M., Gerdes, J., Ford, A., Johnson, K., & Nayak, N. (2011). Cultural roadmap: Developing cultural learning strategies during internship. Training and Education in Professional Psychology, 5(1), 30-37.DOI: 10.1037/a0021856
Constantine, M. G., & Sue, D. W. (2005). Strategies for building multicultural competence in mental health and educational settings. Hoboken, NJ: John Wiley. DOI: 10.1037/0022-0188.8.131.52
Furlong, M., & Wight, J. (2011). Promoting “critical awareness” and critiquing “cultural competence”: Towards disrupting received professional knowledges. Australian Social Work, 64(1), 38-54. DOI: 10.1080/0312407X.2010.537352
Hanley, J. (1999). Beyond the tip of the iceberg: Five stages toward cultural competence. Reaching Today’s Youth: The Community Circle Of Caring Journal, 3(2), 9-12.
Holmes, D. (2012). Multicultural competence: A practitioner-scholar’s reflections on its reality and its stubborn and longstanding elusiveness. The Register Report, 8(1). Retrieved September 8, 2014, from http://www.nationalregister.org/pub/the-national-register-report-pub/spring-2012-issue/multicultural-competence-a-practitioner-scholars-reflections-on-its-reality-and-its-stubborn-and-longstanding-elusiveness/
Hunt, L. M. (2001). Beyond cultural competence: Applying humility to clinical settings. Religiously Informed Cultural Competence, 24, 134-136.
Leighton, D. L. (1982). As I knew them: Navajo women in 1940. American Indian Quarterly, 6(1-2), 34-51.
Magyar-Moe, J. L., Pedrotti, J. T., Edwards, L. M., Ford, A. I., Petersen, S. E., Rassmusen, H. N., & Ryder, J.A. (2005). Perceptions of multicultural training in predoctoral internship programs: A survey of interns and training directors. Professional Psychology: Research and Practice, 36(4), 446-450. DOI: 10.1037/0735-7028.36.4.446
Mason, J. L., Benjamin, M. P., & Lewis, S. A. (1996). The cultural competence model: Implications for child and family mental health services. In C. A. Heflinger & C. T. Nixon (Eds.), Families and the mental health system for children and adolescents: Policy, services, and research (pp. 165-190). Thousand Oaks, CA: Sage Publications.
Pedersen, P. (1994). A handbook for developing multicultural awareness (2nd ed.). Alexandria, VA: American Counseling Association.
Sue, D., & Sue, D. (1999). Counseling the culturally different: Theory and practice (3rd ed.). Hoboken, NJ: John Wiley & Sons, Inc.
Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125. DOI: 10.1353/hpu.2010.0233
Weaver, G. (1986). Understanding and coping with cross-cultural adjustment stress. In R. Paige (Ed.), Cross-cultural orientation: New conceptualizations and applications (pp. 137-167). Lanham, MD: University Press of America.