building trust:
the importance of cultural competence

alexa southall

After years of navigating through my own mental health journey I decided that I wanted to try seeing a therapist. I thought this would improve my willingness to speak about the things I was feeling and would be a way to take control of my mental health. I prepared for all the things that might come with starting therapy, like dealing with the stigma, telling my family and trying to open up to someone I had never seen before. What I didn’t anticipate was how difficult it would be to find a mental health practitioner I felt like I could relate to and someone who could understand my unique experiences as a mixed woman of Mexican and African-American descent. I was stunned to discover that only 4 percent of all psychologists are Black. Of all mental health clinicians, only 12 percent are people of color. These statistics are just small numbers that are representative of a much larger issue. Since its establishment, the mental healthcare system has failed to equitably provide treatment to minorities and despite many efforts to close this gap, a clear disparity continues to persist. In order to properly serve the needs of minority communities, there must be more representation within the mental health field.

Critical psychiatry of course shares an urgency to dismantle the DSM. However, while mad scholars condemn the DSM, and psychiatry more generally, for pathologizing lived experience, CP averages and abstracts away lived experience entirely, all in the name of objectivity. On this basis, I argue that CP research is both inaccurate and unjust. Writing as an autistic, neurodivergent researcher with lived experience of depression, anxiety, C-PTSD, childhood adversity, and more, I will critique CP on epistemic grounds: these models are at best inaccurate and thus will not advance understanding. More importantly, I will critique CP on ethical grounds: by failing to consider the lived experience of mad/neurodivergent individuals, CP research is invalidating and therefore unjust. I will describe the ethical issues of the research and data practices used in CP, and why objectivity is a myth. Looking forward, I will outline how we might shift away from CP toward a more liberatory, user-led research agenda that centers lived experience.

A racist past

Fundamentally, the fields of psychology and psychiatry have always been culturally ignorant towards minorities. As a result, people of color are often misdiagnosed, mistreated and ignored in their attempts to receive equitable health care. Created in the early 19th century, ideologies such as scientific racism, or the belief that racism is justified because people are biologically more developed based on their race, have been instilled since the beginning of psychiatric development. Further, the influence of these beliefs have yet to be erased and continue to affect our mental health system today. These disparities have created mistrust between people of color and the mental health system, further contributing to high rates of stigma and misinformation in minority communities. When we consider cultural competence and its importance as it relates to mental health reform, we must stay attentive to the fact that cultural competence targets a much greater and structural problem within the mental health system: racism. Cultural competence is not just about trying to bridge the gap between minorities and mental health treatment, but about fundamentally changing the way we offer mental healthcare to include and consider the experiences and struggles of people of color that have not previously been evaluated.

How to address the lack of diversity

To create more equity in the mental health system we must work to improve the amount of representation and diversity within it. In order to do this, we must close the current disparities between minorities and non-minority communities. A man named Steven O. Roberts conducted a study titled,“Racial Inequality in Psychological Research: Trends of the Past and Recommendations for the Future” that emphasizes the lack of minority representation in clinical psychology studies. He said, “If we are to eradicate racism from our society we need to eradicate it from our science.”

Making it approachable

Minority communities have some of the highest rates of stigma and opposition to mental health topics. The inability to afford treatment and a lack of knowledge on where to find mental health services are among the top reasons that people do not seek mental health services. This same stigma that keeps minorities from engaging in mental health discussion is also what prevents them from becoming licensed psychology workers. To combat this, we should work to raise awareness among minority communities by making treatment options and resources inclusive of diverse representation. The mental health field is also less financially appealing to those with lower socioeconomic status because of the many years of schooling and training required. By incentivising the mental health field with grants, scholarships and other financial support, more people who are interested in mental health but cannot currently afford it will have more opportunities.

Increase representation

Making sure to have a diversity team or board in an administration helps to ensure that different cultures are being properly construed and effectively acknowledged. These teams should be looked to for input on current protocol and advice for possible improvements. By increasing diversity within a space to more accurately depict the diversity of the surrounding community, people will have an easier time finding someone who can fit their needs and someone they can trust.

Focus on the bigger picture

Oftentimes, research conducted or data collected regarding minority mental health is used to quantify how prevalent an issue is among a community and how it compares to other communities. While this information is important, it is also important to gather information on why disparities between communities may exist as well as how effective different approaches in fixing them are. In a clinician setting, this may look like identifying the most prevalent barriers between clients and mental health treatment and what strategies are most effective.

Nonetheless, increasing the number of mental health clinicians of color is not the only way to improve mental health services; we can also work to ensure that the mental health professionals who are currently in the field are culturally competent.

What is cultural competence, and why is it important?

Cultural competence takes into consideration aspects of a culture such as language, customs, values, and beliefs and then evaluates the ability of a professional to effectively provide a service within the range of the cultural beliefs or needs of a patient. More loosely, cultural competence is the ability to adjust standard treatment or care to more directly and effectively assist someone based on their cultural needs or experiences. Cultural competence requires a clinician to draw connections between a person’s culture and how those cultural aspects could affect someone’s mental health.

When I am in therapy, I want to feel heard and validated in my experiences. I want to be able to speak about struggles as they relate to my culture without fear that the person I’m speaking to won’t understand what I’m talking about. When we encourage people to talk about their mental health we are asking them to be vulnerable. That vulnerability is something we must address with competence and an assurance that it will be properly addressed.

How can we increase cultural competence?

Know yourself

In order to be culturally competent you must be able to identify the personal beliefs and implicit biases you hold. By identifying these beliefs you can assess where your cultural beliefs come from and how they might differ from others.You can take this 5-minute Implicit Association Test that can reveal possible racial biases. This test alone will not determine every possible implicit bias but it is a good place to start before self-reflecting on your beliefs.

Know others

Cultural competence is a continuous learning process that mental health professionals must continue to manage. To improve the amount of culturally competent clinicians, more professionals must work to develop thorough knowledge regarding different cultures and experiences.This can be done through different diversity workshops. If it’s not available already, it’s a good idea to host training within a department or workplace so that more clinicians have access to diverse resources. You should work to find people of color who can speak on their own experiences with cultural competence and build discussion among clinicians about what they interpreted the key takeaways to be. Diversity training can sometimes further perpetuate negative stereotypes and biases, but by putting people of color at the forefront and encouraging open discussion to include several perspectives, you can ensure that you are providing training that is valuable and effective.

Cultural competence is not about knowing everything about every culture. Instead, cultural competence is about being open to new perspectives and acknowledging that clients may have a different viewpoint you never considered that may need to be further discussed or researched. At the end of the day, every person is unique in their experiences and the beliefs that they hold. While it is important to consider the microaggressions, stereotypes and oppression that a specific cultural group may have faced, it is important not to assume a person’s perspective solely because of their cultural background. By doing this, you are further contributing to existing stereotypes.

Put it into practice

On an individual level, there are many things that you can do to become more culturally competent. Culture should be something that is discussed and not held back on. For this reason, you should ask open-ended questions so that people can share their own cultural perspective without feeling confined to a specific belief. You can also create a survey for clients or other clinicians to recognize their understanding of cultural competence and what it means to both the client and the clinician.

There are many aspects of culture and each will affect a person differently. For example, the experiences of a man will be different than the experiences of a woman solely because of their gender identities. The experience of an Asian woman will be different from the experiences of a white man because of their ethnic background and gender identity. To help assist in this process, it is a good idea to compile resources that are specific to different cultures and backgrounds so that clients can receive more support that understands their unique experiences.

The importance

For years, mental health advocates have been working to close the disparities between mental healthcare and minorities. People of color with a mental disorder seek mental health resources at a significantly lower rate than white counterparts. With such a small number of people of color seeking mental health resources, it is integral that those that do seek treatment, receive treatment that properly addresses the unique experiences and cultural differences that people of color face. Research demonstrates that people of color are more likely to stop therapy as a result of cultural insensitivity. By ensuring a cultural understanding among clinicians and proper representation of minorities, we are building the trust between the mental health field and people of color that is often lost.

Culture encompasses a vast amount of diversity. People are not only distinct in their racial or ethnic background, but also in their gender, sexual orientation, religion and socioeconomic status. A combination of these factors will make the experiences and beliefs of each individual very different; however, what is important is that a mental health clinician seeks to understand the possible effects of all of these aspects and build a relationship with their client that encourages meaningful discussion about those experiences.

Culture plays a big role in the way we perceive the things around us. This is why cultural influence is an ongoing discussion with my mental health professional and in my community. Our unique experiences and perspectives are what make us special and we should work to build a system that supports those differences instead of trying to suppress them.

Alexa Southall is a high school student and mental health activist. Inspired by lived experiences, she advocates for mental health awareness through the use of writing and public speaking. Alexa also founded her school’s mental health club to encourage discussion about mental health on her school campus. She plans on studying health policy and law in hopes of creating systemic change in the mental health field. She’s on Instagram @alexa_southall.

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