Engaging clients with cultural humility.

Hook, Joshua N.

As a young counseling psychologist, I entered a field that had a heavy emphasis on multicultural competence. I was taught the importance of developing (a) self-awareness of my own cultural background and experiences, (b) knowledge about the various cultural groups that comprised the clients I worked with, and (c) counseling skills for working with clients from various cultural groups (Sue et al., 1982). The ethics code of my profession prioritized respect for people's rights and dignity, including respect for cultural differences (APA, 2002).

At the beginning of my training, I engaged with diversity issues (and clients from different cultural backgrounds) with a combination of interest and fear. I think my interest in multicultural counseling and diversity issues was related to the reasons I chose to pursue psychology in the first place. I am naturally curious, and have always been interested in people and their backgrounds, including their families and broader cultural upbringing. So the idea of connecting with and trying to understand individuals who had different worldviews than I did was exciting.

On the other hand, I also experienced fear around diversity issues. I was scared about offending clients, and saying the wrong thing due to my inexperience. I grew up in a suburb of Chicago, and had limited experiences with diversity in my neighborhoods and schools. I went to college at a large state university that was diverse; however, the large size of the university made it easy for me to surround myself with friends who looked and thought similarly to the way I did. Graduate school was the first time that I engaged more intimately in relationships with individuals who were markedly different from me culturally.

Throughout my graduate training and early professional career, I had a series of professional and personal experiences that led me to engage deeply in the multicultural counseling discussion. For example, when I first attended graduate school, the advisor that I planned to work with was on sabbatical, so I worked closely with an African American faculty member for two years, which focused my early research on issues related to race-related stress and minority mental health and well-being. In one of my graduate courses, I was tasked with interviewing a prominent counseling psychologist, and I had a deeply moving discussion with Joseph Ponterroto, who is a White male and a leader in the multicultural counseling movement. One of my best friends from the church I attended in graduate school came out as gay, which prompted me to wrestle with the topic of religion and sexual orientation, and to figure out what I believed about that issue.

One byproduct of joining a community that deeply values diversity and multiculturalism was that I began to see myself through other people's eyes--I was the face of the oppressor and I had to come to terms with this. I remember a class in which we were discussing first impressions of each other, and an African-American student remarked that I reminded her of everything she disliked about my undergraduate institution (which she had also attended). At the time, I was surprised, not understanding why she had reacted to me in this manner. However, looking back, I recognize that I did harbor negative attitudes toward other racial groups that I had little experience with, and I did not openly acknowledge my position of privilege. Throughout graduate school (and partly because of my interactions with that student), I became increasingly aware of my privilege as a White, male, heterosexual, middle-class, Christian. I became convinced that to have integrity as a Christian, I had to integrate back into my identity the subtle ways that I had been desensitized to privilege and oppression. For example, I had to own that Christians have done great good, but we have also colluded in major forms of oppression. I am still working to hold this tension--that my faith holds a potential for both participating in God's redemptive work, as well as joining with dehumanizing forces in the world.

In spite of my anxiety and discomfort, I continued to engage with diversity issues in my professional and personal life. I think this was an important step for me. Because of the anxiety and discomfort, there was a part of me that wanted to avoid the tough conversations and check out. There was a part of me that wanted to go back and surround myself with individuals who supported the same exact worldview that I had growing up and was comfortable with. But another part of me knew that I couldn't go back. This journey of continued engagement in diversity and multicultural issues was difficult, but it was one that I absolutely had to continue in order to be a Christian who engaged others and the world with integrity.

When I accepted my first faculty position at the University of North Texas, I was asked to teach the graduate course in Multicultural Counseling. My anxieties about culture and diversity issues resurfaced. I didn't feel like an expert in this area. I didn't feel as if I had figured everything out yet. And I was going to be asked to teach, engage, and lead discussions on some of the most difficult and controversial subjects in our field. I was nervous.

The class went well, better than I expected. Paradoxically, part of the reason that I think the class went well is that I didn't pretend to have all the answers, and I didn't set up the expectation that my students should get to a place where they had all the answers. Instead, I told my students that my primary goals for them were to (a) become aware of and explore their own cultural upbringing, including their blindspots and biases, and (b) become lifelong learners in the area of multicultural counseling and diversity issues. In a sense, I shifted the goal from competence to humility.

Defining cultural Humility

This shift aligned with a problem I had experienced with the concept of multicultural competence as I had gone through my graduate training in counseling psychology. Namely, the idea of competence invokes the idea of getting to a certain end point where one is sufficiently proficient. It has the connotation of arriving at a place where one is deemed competent. I don't think that is the best way to think about training in multicultural counseling and diversity. In fact, I think it is dangerous to think we have somehow arrived in regard to understanding individuals and groups who are different from us. That stance sets many people up to try to hide their limitations instead of owning and leaning into them as a normal part of growth. To prop up our sense of competence, we are more likely to make false assumptions about individuals who are different. Viewing myself as always in process of leaning into my areas of discomfort seems to lower my defensiveness and open me up to new learning. I find this focus on an open and humble stance much more helpful than a focus on how well I'm doing, which stirs up perfectionistic strivings that tend to interfere with my ability to be present and receptive to clients' needs.

My colleagues and I have defined cultural humility as having both intrapersonal and interpersonal components (Hook, Davis, Owen, Worthington, & Utsey, 2013). On the intrapersonal level, cultural humility involves an awareness of the limitations in our ability to understand the worldview and cultural background of our client. On the interpersonal level, cultural humility involves a stance toward the client that is other-oriented, marked by respect and openness to the client's worldview. In our research on cultural humility and therapy outcomes, we have found that cultural humility was viewed as important by potential clients, and perceptions of cultural humility by clients in therapy were positively related to (a) developing a strong working alliance with the therapist and (b) actual improvement in therapy (Hook et al., 2013).

In my research and teaching, I stress the importance of humility to the multicultural counseling discussion. That said, I think the concepts that have been historically stressed by the multicultural counseling movement (i.e., self-awareness, knowledge, and skills) are important as well. I strive to continue to learn and be a well-informed psychologist about diversity issues, and I encourage my students to do so as well. And I believe that an awareness of oneself and one's cultural background is an important prerequisite for understanding one's blindspots, biases, and limitations (an important aspect of humility). But I always want to pair the knowledge and skills I accrue with humility. For example, the aspect of culture that I probably know the most about is religion/spirituality. However, no matter how many papers I have written about religion and mental health, or how many clients I have seen with religious issues, each client is new and different, and there are limitations to my ability to understand my particular client's cultural background and experience. And because of these limitations, I improve my ability to connect with my client if I engage with humility.

What does engaging clients with cultural humility look like in practice? Perhaps it would be easier to start by describing what cultural humility is not. First, cultural humility is not making assumptions about the client based on his or her cultural background. Related to this idea of making assumptions, cultural humility is not trying to make it seem like I understand the client's experience (when I do not), or even assuming that I know a lot (or anything) about the client's particular cultural experience. Second (and this is important), cultural humility is not thinking that my worldview is superior to the client's, regardless of my training or what I "know" to be true.

In explaining what cultural humility is, I will likewise discuss two broad categories. First, cultural humility involves an interest and exploration of the client's worldview. The culturally humble counselor is genuinely interested in learning more about the client's cultural background and experiences, and asks questions or requests clarification when uncertain. Second, cultural humility involves a respect and openness to cultural differences. In other words, the culturally humble counselor is genuinely open to the possibility that the client may have a different worldview than the counselor, which may result in disparate goals for counseling. The culturally humble counselor doesn't have a rigid picture of what the client should look like to be "healthy" or "functional;" rather, the counselor works with the client in the context of the client's worldview and goals. The client's worldview and goals take precedence.

Practicing cultural Humility

Practicing cultural humility can be difficult, especially in situations in which the client's worldview and goals are markedly discrepant from the worldview and goals of the therapist. For example, an African American female therapist strongly committed to advocacy for women's rights and reduction of racial disparities may struggle when working with, for example, White male clients who are politically conservative and committed to traditional or patriarchal gender roles. Or a strongly religious therapist may struggle deciding how to handle clinical issues that are related to strong religious convictions (e.g., sexual ethics, abortion, contraception). How can therapists work to develop cultural humility in their work with clients who have different cultural backgrounds?

First, therapists can work to develop cultural humility by becoming more aware of their own cultural worldviews, biases, and blindspots. Awareness is key. If I am not aware of my cultural worldview, I may inadvertently think of my worldview as "normal" or "right," and fail to respect the fact that my client may have a different worldview. For example, both of my parents obtained graduate degrees. When I was growing up, the expectation was that I would do the same. It seemed "normal." However, after exploring my own cultural background and family upbringing, I realized that education was a huge value that was stressed in my upbringing. That is my value, but it is important to recognize that it may or may not reflect the worldview of my client. In my multicultural counseling class, I have each student complete a family tree and write a paper describing their family and the beliefs and values that were passed down by their family of origin. When discussing and sharing the values of their family, students often realize that values they consider to be "normal" are actually not universally shared by others.

Second, therapists can work to develop cultural humility by consistently placing themselves in situations that stretch them to engage with individuals who are culturally different from them. Worthington (1988) presented a model of working with religious clients in which he posited that both therapists and clients have "zones of toleration" in regard to value differences. In other words, we each have space around our beliefs, values, and worldview in which we can comfortably develop a strong working relationship with a client who is different from us. In his model, Worthington focused on religious values, but I believe that the model can be expanded to apply to any type of cultural difference. Based on Allport's (1954) social contact hypothesis for improving relationships between different racial groups, I believe that therapists can expand their zones of toleration by having positive contact with individuals from different cultural backgrounds.

Thus, I believe it is important for therapists to consistently put themselves in situations in which they engage with individuals who are culturally different, especially in areas that tap into our personal biases or blindspots. For example, in my class I have students pick the aspect of diversity that they are most uncomfortable with, and construct a project around that topic. Students do research on best practices for therapy with that type of client, and also interview a person from that cultural group and do an immersion experience with persons from that cultural group. For example, one student struggled with negative attitudes toward older adults, and designed an immersion experience at a community center where he befriended several older adults and asked about their experiences. Another student noted that she had negative attitudes toward African Americans, and interviewed an African American neighbor about her cultural background and experiences. Often students report that this experience was powerful in helping them to understand members from that cultural group in a more nuanced way. Stereotypes are often broken, and students are able to form connections with members from a cultural group in a way that they had not viewed as feasible in the past.

For the Christian therapist, I believe that struggles with cultural humility have the potential to be exacerbated, especially if the differences in worldview or values tap into the religious convictions of the therapist (Hook & Davis, 2012). When differences in worldview or values tap into our religious convictions, it may be more difficult to engage with humility because the value difference is no longer just viewed as a matter of difference in cultural background but rather as going against the therapist's sense of what God wants or what is true. For example, depending on one's values, a Christian therapist might have difficulties supporting a client wanting to embrace a gay identity, divorce one's spouse, or pursue a different religious path. Thus, for the Christian therapist, I believe that it is especially imperative to be aware of one's worldview, and the ways in which it may conflict with the worldview of the client. Professional practice dictates that when value conflicts exist, the beliefs, values, and goals that must take precedence are those of the client (Gonsiorek, Richards, Pargament, & McMinn, 2009).

I have found that engaging with cultural humility is often the glue that holds the alliance with a culturally different client together, even if the therapist is anxious or makes blunders. The focus on humility rather than competence also allays pressure that is often felt by beginning therapists who have a strong need to "get it right" and "not make mistakes." I still recall a client I saw who was from a cultural background that I had zero experience working with. At the end of our intake session, I checked in with the client and asked how he felt about the session, and if he felt comfortable scheduling for the following week (I generally do this at the end of most intake sessions). He said yes. The following week, after our session I asked again how he felt about the session, and if he felt comfortable scheduling for the following week (I generally do not do this at the end of most counseling sessions; I believe my unconscious decision to ask this question again reflected my anxiety about my inexperience with this particular client and his background). He again said yes, and asked whether I felt comfortable scheduling for the following week. I said yes, acknowledged my lack of experience and anxiety, and said I was committed to learning and working with him moving forward. Looking back, this ended up being one of my most rewarding clients, and I think a big part of our bond was my ability to engage his cultural background with humility.

References

Allport, G. W. (1954). The nature of prejudice. Reading, MA: Addison-Wesley.

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073.

Gonsiorek, J. C., Richards, P. S., Pargament, K. I., & McMinn, M. R. (2009). Ethical challenges and opportunities at the edge: Incorporating spirituality and religion into psychotherapy. Professional Psychology: Research and Practice, 40, 385-395.

Hook, J. N., & Davis, D. E. (2012). Integration, multicultural counseling, and social justice. Journal of Psychology and Theology, 40, 102-106.

Hook, J. N., Davis, D. E., Owen, J., Worthington, E. L., Jr., & Utsey, S. O. (2013). Cultural humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychology, 60, 353-366.

Sue, D. W., Bernier, J. E., Durran, A., Feinberg, L., Pedersen, P., Smith, E. J., & Vasquez-Nuttall, E. (1982). Position paper: Cross-cultural counseling competencies. The Counseling Psychologist, 10, 45-52.

Worthington, E. L., Jr. (1988). Understanding the values of religious clients: A model and its application to counseling. Journal of Counseling Psychology, 35, 166-174.

Joshua N. Hook

University of North Texas

I would like to acknowledge the generous financial support of Fuller Theological Seminary / Thrive Center in concert with the John Templeton Foundation, Grant No. 108 (Intellectual Humility in Religious Leaders), as well as the John Templeton Foundation (Grant No. 29630, The Development, Validation, and Dissemination of Measures of Intellectual Humility and Humility; Grant No. 14979, Relational Humility: An Interdisciplinary Approach to the Study of Humility). The opinions expressed in this publication are those of the author and do not necessarily reflect the views of the Fuller Thrive Center or the John Templeton Foundation.

Correspondence regarding this article should be addressed to Joshua N. Hook, Ph.D., Department of Psychology, University of North Texas, 1155 Union Circle #311280, Denton, TX 76203; joshua.hook@unt.edu

Joshua N. Hook, Ph.D., is Assistant Professor of Counseling Psychology at the University of North Texas, where he teaches Positive Psychology and Multicultural Counseling. He is a licensed clinical psychologist in the state of Texas. His research interests focus on humility, religion/spirituality, forgiveness, and multicultural counseling. He can be reached at joshua.hook@unt.edu .