● Living between cultures : Living between cultures is another factor that links marginalization to SDH. Although the boundary or margin separates the dominant and peripheralized groups, incomplete integration leads to a person or group that lives between cultures. Incomplete integration creates a situation where a person or group relinquishes characteristics of the marginalized group in order to bond with the dominant society, but is unable to do so. Examples of living between cultures are the ways of life of most immigrants, migrant farm workers, and other vulnerable groups. People living between cultures tend to live in areas characterized by limited employment and educational opportunities (Baah et al., 2019). ● Creation of vulnerabilities : Vulnerabilities are created by the cumulative impact of the creation of margins and living between cultures. Vulnerability is defined as a state of being exposed to and unprotected from health-damaging environments (Baah et al., 2019). Marginalized groups often do not receive the same access to societal resources such as high- quality education, healthcare, housing, or equal access to voting as those groups that are not marginalized. The marginalization of oppressed groups prevents The concept of cultural humility was first discussed in the medical world to better understand and address health inequities and disparities (Duncan, 2019). The concept has evolved to include ideas related to the creation of a broader and more inclusive society by acknowledging the intersectionality that exists across domains of diversity. Unlike the concepts of cultural and multicultural competency, which focus on gaining knowledge about cultural groups differing from the individual’s own with the hopes of better understanding those cultures and thus better meeting the needs of different groups who enter counseling, cultural humility focuses on the cultural context 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 Attending to diversity Given the vast diversity within the U.S., both healthcare professionals 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 professionals 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.
them from having a voice and helps to sustain the status quo in the U.S. in which White, economically well-off, and able-bodied individuals control access to social, economic, and political power. Healthcare Consideration : Healthcare professionals should recognize the power imbalances that result from oppression, privilege, and marginalization and work to correct the imbalances within the delivery of mental and behavioral healthcare services and within the broader institutional and societal context. Self-Assessment Quiz Question #6 When discussing themes related to marginalization, the concept of being exposed to and unprotected from health- damaging environments is referred to as: a. Creation of margins. b. Living between cultures. 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). 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 anxiety.” 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 multidimensional 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).
c. Vulnerability. d. Boundaries. COUNSELING WITH CULTURAL HUMILITY
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