_________________________________________________________ Cultural Humility in Behavioral Health
within America that marginalizes and oppresses some groups of people, while privileging and empowering other groups of people (Foronda et al., 2016). The overall defining premise of cultural humility is that humble individuals “have an accurate view of self” and “are able to maintain an interpersonal stance that is other-oriented rather than self-focused, characterized by respect for others and a lack of superiority” (Hook et al., 2013, pp. 353–354), and includes the four essential elements of self-reflection and self-critique, respectful partnerships, lifelong learning, and institutional accountability (i.e., addressing and changing power imbalances and institutional practices that are not respectful to a diversity of clients and that uphold current patterns of oppression). In short, “cultural humility takes into account the fluidity and subjectivity of culture and challenges both individuals and institutions to address inequalities. As a concept, it challenges active engagement in a lifelong process (versus a discrete endpoint) that individuals enter into with clients, organizational structures, and within themselves” (Fisher-Borne et al., 2015, p. 171). ATTENDING TO DIVERSITY Given the vast diversity within the U.S., both healthcare profes- sionals and counselors must develop cultural humility as they work with individuals whose life experiences vary in myriad ways based on many intersecting dimensions of diversity. A primary component of cultural humility is self-awareness. As a healthcare professional, completely exploring one’s own identity is of utmost importance. It is through knowing and understanding oneself that counselors and healthcare profes- sionals can uncover their beliefs, values, and—moreover—their implicit biases. Consider the following scenario: Trinh, a 17-year-old first-generation American of Hmong decent, is graduating first in her high school class. Her school counselor has encouraged her to apply to top-level colleges, several of which are hours from home. When Trinh asks about some nearby colleges, the counselor simply tells her that they are “well below her abilities,” even though one is highly regarded. She is accepted by the top-level colleges to which she applied, including two Ivy League schools. Despite generous financial aid packages, Trinh does not accept offers from any of these schools. Now that it is past the deadline to apply to the local four-year colleges, Trinh decides to go to the local community college and live at home. Her counselor tries to persuade Trinh to reconsider one of the Ivy League schools. Trinh tells the counselor that she needs to stay home to help care for her younger siblings and translate for her parents during doctors’ visits. The counselor engages Trinh in a role play to help her tell her parents that she needs to make her own decisions and go away to college.
Although school counselors do want their students to succeed, what underlying values might have clouded the counselor’s judgment when working with Trinh? Trinh had given the counselor signals that she was not ready to move hours away when she asked about local colleges. Perhaps the counselor, working from a belief that individualism is preferred, ignored these clues, hoping not to play into Trinh’s “separation anxi- ety.” If the counselor had viewed her client as being both Trinh and her family, rather than only a young woman needing to be more independent, she could have worked with the family to make a decision that addressed both Trinh’s needs and those of her family. By ignoring Trinh’s cultural background and her sense of responsibility to her family, the counselor could not help in an informed way. As this case demonstrates, clients come from a larger multidi- mensional context that pervades all aspects of their lives but is often invisible to them, much like water in a fish tank is to the fish until the water is removed (Parker & Fukuyama, 2007). Some have suggested the metaphor of an iceberg to describe culture: The “objective culture,” or the small, observable part of the iceberg, consists of institutions such as “education, government, the law, religion, and artifacts like art, music, foods, customs, and holidays,” whereas “subjective culture,” the larger, hidden portion of the iceberg, is composed of “language (verbal and nonverbal), meaning of time and space, values and morality, definitions of reality and perception, ways of thinking and knowing, myths and legends, death and afterlife, and universal existential human needs” (Parker & Fukuyama, 2007, p. 14). Understanding subtleties in cultural differences, expectations, and worldviews can be further complicated when differences in language or interactional patterns enter into the therapeutic process as well. Implicit bias is defined as an unconscious and unintentional bias (van Nunspeet et al., 2015). Individuals may not be aware of their implicit biases (Byrne & Tanesini, 2015). These biases are the result of combinations of factors, including an individual’s early experiences and learned cultural biases. In fact, indications of precursors for these biases actually show up quite early in development. Thus, ongoing critical self-reflection that acknowledges the exis- tence of implicit biases within everyone is necessary. Repeated and evolving processes of self-reflection make healthcare professionals’ implicit biases explicit and, therefore, subject to examination and change (Byrne & Tanesini, 2015; Fitzgerald & Hurst, 2017). In addition to understanding their own implicit biases, healthcare professionals, especially those from domi- nant societal groups (e.g., White, heterosexual, male), need to explore their own racial, ethnic, sexual, and class identity. Individuals from dominant cultural paradigms often consider themselves without racial, ethnic, sexual, or class identity as they have privilege; their identities are considered the norm. However, without deep exploration of intersecting aspects of personal diversity, it is difficult to understand oneself and where biases might insert themselves into healthcare profes- sionals’ relationships (Fisher-Borne et al., 2015).
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