Culture-centered counseling
November 22, 2021
By Lindsey Phillips
The 2020 census revealed a growing multiracial U.S. population, with the number of people who reported multiple races increasing from 2.9% in 2010 to 10.2% in 2020. Part of this increase stems from changes the U.S. Census Bureau made to the questions about race and ethnicity to more accurately capture the shifting demographics of the nation’s population. These changes included removing the word origin on the instructions for the Hispanic ethnicity question, because this term can mean different things to different people, and adding write-in response areas for the question about racial identity.
The counseling profession could also benefit from rethinking the way it approaches diversity and multiculturalism. Most of its foundational theories and approaches, such as psychoanalysis, cognitive theory and cognitive behavior therapy, were developed by white men, leading many counselors to ask whether these approaches still meet the needs of an increasingly diverse and multiracial clientele.
Answers to these questions are not easy or straightforward. Some counselors want to revise or adapt these foundational counseling theories to make them more inclusive, while others argue it’s time to make room for more culture-centered theories or even create new ones.
The thought of adapting traditional forms of counseling to make the process more appropriate for culturally diverse populations bothers Derald Wing Sue, a professor of psychology and education at Teachers College, Columbia University, because “it almost assumes that no societies or other groups ever had anything like counseling or psychotherapy,” he says. Instead, he argues the mental health field should broaden its understanding of Indigenous and non-Western help-giving networks.
Broadening the theoretical perspective
“All theories of counseling and psychology represent worldviews, primarily ones from the developer of that theory,” says Sue, the author or co-author of several books and articles on multiculturalism, including Counseling the Culturally Diverse: Theory and Practice and Race Talk and the Conspiracy of Silence. Rational emotive behavior therapy, for example, stems from Albert Ellis’ view that problems reside in the cognitive realm. In turn, these theories “represent worldviews that define normality [and] abnormality, what is therapeutic [and] what isn’t therapeutic,” Sue says. “So, the first objective is for therapists and systems of counseling and psychotherapy to deconstruct their worldviews.”
Sue also argues that theories of counseling and psychotherapy should encompass an understanding of the social-political dynamic that affects the counseling situation. Many clients come to counseling with a worldview that is intimately linked to their status as a member of a marginalized group and the social-political dynamics surrounding that status, he notes.
“Therapists often don’t understand that in their work, they may be encouraging clients in a forced compliance to assimilate and acculturate [and] to do things the white, Western way,” he says. “A liberated form of helping is one that recognizes strongly the social-political element and is unafraid to include that as part of the counseling session and structure that is going on.”
Although many theories of counseling and psychotherapy attempt to do this, they have done it in a way that is not well integrated in terms of the system of counseling, he adds.
In addition, Sue, co-founder of the Asian American Psychological Association, points out that counseling theories typically study only one aspect of the human condition: the behavioral self, the feeling self, the cognitive self, etc. But human beings contain more depth; they are also cultural, political and spiritual beings, which traditional counseling can often overlook.
Culture-centered counseling theories such as liberation psychology, relational-cultural theory and critical race theory begin to address some of the gaps in more traditional counseling approaches. These theories have basic tenets that counselors can use as a foundation for how they interact with clients, says Regina Finan, an American Counseling Association member whose research interests include multiculturalism and social justice.
One tenet of critical race theory, for example, is that race is a social construction with real-life implications, she notes. Critical race theory asks people “to stretch and expand themselves, and bracket all the things they think they know and understand as ‘right’ and ‘true’ [about race and racism] and make space for things that they can’t understand because they haven’t lived it,” Finan says. “But isn’t [making space for clients’ experiences] what we are trained as counselors to do? … We just don’t always talk about it in terms of race, sexual orientation, gender identity, religion and all these pieces.”
Even if counselors have never experienced depression or anxiety themselves, they don’t doubt that their clients have, says Finan, an assistant professor of counselor education at the University of West Georgia, and they set about educating themselves on those issues. That is what equity-centered theories are asking counselors to do, she stresses.
For example, a Black client might have panic attacks whenever they get pulled over by the police. A counselor could choose to use cognitive behavior therapy to help this client because it has been shown to be an effective treatment for panic attacks. But the counselor could also approach this situation using the lens of critical race theory, Finan says. This lens can help situate the client’s fear as rationale within the broader systemic context of police brutality and racial bias. Being culturally aware will help the counselor broach this issue with the client and remind them that the problem is a systemic one, not something that is “wrong” with them.
Broaching the topic is important, Finan adds, because although the counselor may find that there is a specific fear associated with the client’s race, it is also possible that the client fears getting in trouble. Ultimately, the counselor has more information, and then they can work together and use appropriate techniques to help the client manage the panic attacks and explore the concerns underlying the attacks.
Unlike many traditional counseling theories, Black existentialism asks counselors to broaden their perspectives and sit with the knowledge that there are multiple truths and experiences, notes Linwood Vereen, an associate professor of counseling at Shippensburg University of Pennsylvania. In the article “Black existentialism: Extending the discourse on meaning and existence” (published in The Journal of Humanistic Counseling in 2017), Vereen, an ACA member, and his colleagues explain how Black existentialism aims “to merge both individualistic and collectivist representations and dimensions of the respective self, in such a manner that the real and constructed selves are intricately bound with the social circumstances human beings find themselves situated within.”
This theoretical approach challenges counselors to find ways of applying this notion of individual existence to clients who live and operate within communities, he adds.
Doralis Coriano Ortiz, an ACA member and licensed clinical professional counselor in Illinois, acknowledges that theories that are more culturally centered can provoke uncomfortable feelings for some counseling professionals because these theories often challenge what they have been taught in the U.S. educational system. These theories often force counselors to confront the racist origins of counseling and psychology and the ways they have appropriated and repackaged Indigenous practices, she says.
Taking a culture-centered approach
Culture-centered theories acknowledge that people are affected not just by interpersonal relationships but also by larger systems, notes Finan, the Association for Multicultural Counseling and Development (AMCD) vice president of multiethnic, multiracial and transracial adoptee concerns. This view allows counselors to broaden the context for clients, helping them realize that the counseling relationship involves more than just the counselor and client; it’s about the counselor’s and client’s lived experiences, which are embedded in their families’ lived experiences, as well as privileges and marginalized experiences, she says.
If a client is struggling with how racism or poverty is affecting them, Finan suggests that the principles of critical consciousness and liberation psychology can be used to engage the client in a conversation about how systemic and historical oppression can shape them. She may have clients complete a family genogram to unpack the role that racism plays in their life. Clients can go back as far as they are able in their family tree, thinking about the experiences that their family had with racism, how that shaped them then and how it continues to shape the client today.
The goal of this exercise is to help clients clearly understand the systemic nature of racism and realize that these experiences are not their fault, says Finan, co-author of a book chapter on intersectionality in Introduction to 21st Century Counseling: A Multicultural & Social Justice Approach. (The book is co-edited by ACA President S. Kent Butler.) In addition, this strengths-based approach seeks to center the resilience and characteristics of individuals, which in turn can be used to reject deficit narratives created by oppressive systems, she adds.
Monica P. Band, a licensed professional counselor and clinical supervisor who owns the private practice Mindful Healing Counseling Services, with offices in Washington, D.C., and Manassas, Virginia, also highlights how systemic factors affect her clients’ mental health. For example, she has worked with several women of color who were struggling with impostor syndrome. Some counselors may be tempted to focus on changing the client’s thoughts and behaviors around being an “impostor” without first considering context, Band says, but then they are leaving out a large part of the problem.
“While the experiences of impostor syndrome are not unique to BIPOC [Black, Indigenous and People of Color] folx, the experience takes on a different tone, and cultural influences must be considered,” Band explains. “Most spaces are not created for [this client]; in fact, they often actively exclude her and, historically, have been meant to exclude her via legislation or social norms. So, some of the discomfort that the client is experiencing is not about her ‘not being enough’ but an appropriate and natural reaction to systems which have defined her as ‘not enough,’ and the client has internalized harmful narratives like this.”
She advises counselors to be cautious and avoid pathologizing the client’s distress and instead be active in observing the client’s lived experiences. “When believed, narratives associated with impostor syndrome like ‘I am not good enough’ or ‘I shouldn’t/don’t deserve to be here’ continue to perpetuate the oppressive nature of impostor syndrome by attacking the client’s self-concept,” Band says. “It is our goal as culturally competent counselors to call out and normalize these narratives by providing a broader, historical understanding for our clients by decolonizing and deconstructing their intersecting cultural identities with them.”
First, Band would normalize the client’s complex feelings of shame and pressure to succeed around being an “impostor,” and she would remind the client that the feelings associated with being an impostor, counterintuitively, helped the client survive in oppressive spaces at one point in her or her ancestors’ lives. “When I say surviving oppressive spaces, what I mean is to adapt and assimilate,” she explains. “At some point in history, BIPOC folx learned that in order to survive physically and emotionally, sometimes it was necessary to make oneself smaller, to not be seen, to not take up space, to not be [themselves] — in other words, oppress [themselves] and adapt to the legislation that has excluded [them] from these spaces.”
When these individuals enter spaces where they don’t feel like they belong or that don’t have many people with similar cultural backgrounds or lived experiences, Band continues, they begin to ask themselves, “Is this a mistake? Should I be here? Why am I here? It doesn’t feel safe.”
When Band and the client step back and begin to deconstruct the perspective of belonging considering this context, the client can then grieve the lost opportunity that resulted from intergenerational trauma and inequitable systems. The client can also learn to intentionally respond to these systems rather than react out automatically, Band adds.
“Counselors must contextualize these harmful narratives [and] understand and focus on the history as a source of strength,” Band argues. “The client has autonomy in choosing these narratives as their own once they build conscious awareness. The client and [counselor] then can build upon the strength, energies and spirits of [the client’s] ancestors as motivation and reflection. The counselor is not just working with that individual client in front of them on that couch; they are working with the ancestors and traumas the client brings with them.”
Liberation psychology means redirecting pathology away from individuals and onto systems that create environments where it is not possible for someone to be healthy, says Sarah Sevedge, a licensed mental health counselor in private practice who also holds a doctorate in counseling psychology. LGBTQIA and BIPOC clients have come to see Sevedge because of anxiety, depression and trauma — issues that can stem, she says, from the fact that they live in rural, conservative areas that may be antagonistic toward their identities. Sevedge realizes that the larger societal and systemic issues affecting her clients’ mental health work against their ability to be fully healthy, but often her clients view their mental health issues as personal failures.
“So many clients look at mental health issues as if something’s wrong with them — they’re anxious, they’re depressed,” Sevedge says. She reminds them not to be upset with their bodies for responding appropriately in unhealthy environments. “If you have high levels of anxiety in an oppressive context, then your body is functioning properly; you’re not the problem,” she explains. “But we don’t always look at it that way.”
Sevedge also tries to create a brave space within the oppressive environment by not being neutral about the oppression and validating her clients’ experiences. She believes clinicians must be willing to step into a therapist-activist role in the community and actively engage in the larger social dialogue on diversity and multicultural issues. Counselors can do this, she says, by attending Pride and Black Lives Matter events, participating in discussion groups about these topics, and integrating inclusive symbols into their practice (e.g., Pride flags, anti-racist and religious-inclusive artwork). Counselors can also refer clients to peer groups and other social support networks that share similar struggles to help them form community.
Coriano Ortiz, a bilingual psychotherapist at Live Oak, a psychotherapy group practice in Chicago, often works with first-generation college students of color who attend primarily white institutions. So, if a client tells her that they have anxiety and don’t think that many people like them at school or can relate to their experiences, she doesn’t encourage them to challenge this “irrational thought.” That would only gaslight their experience, she says. Instead, she explores possible systemic issues that could be causing the client to feel this way. She asks questions such as “When did you first feel like others didn’t like you?” and “How is the transition from home to college going? Are you making friends?” These questions quickly reveal the underlying issues at play and help clients realize that their beliefs are not irrational and can be an understandable reaction to white supremacy.
Clinical work will not always specifically be about race, gender or culture, Finan adds. Sometimes a client’s presenting issue is just about depression or anxiety, but counselors should be open to listening for when culture does play a role, she asserts.
Decentering whiteness
Band, an ACA member who serves on ACA’s Anti-Racism Commission, and Coriano Ortiz are intentionally decentering whiteness in their practices by asking their white clients some of the same questions that are often asked of clients from BIPOC communities.
Counselors “don’t [typically] ask white people the same questions we ask people of color,” Band says. “Some of that’s for good reason because the trauma experienced historically is felt and experienced to a greater degree by BIPOC. Counselors want to be respectful of these differences in lived experiences by acknowledging and discussing race, ethnicity and various marginalized identities within the counseling session. However [this focus] often exclude[s] accountability for white people and their lived experiences. For example, by counselors not asking how white people feel about certain sociopolitical events, they are at risk of preserving white supremacy within the space. We can so readily talk with BIPOC folx on how it feels for them as a member of their community in relation to — insert a sociopolitical event — but asking white people the same is uncommon.”
One of Band’s office locations is near the U.S. Capitol. So, in the aftermath of the Capitol insurrection on Jan. 6 — an event she believes illustrates a buildup and continuation of hate and violence toward marginalized communities — she asked all of her clients what it was like for them to see those events unfold. She got some culturally humbled responses from her white clients. One admitted they had not considered how, as a white person, this event could also affect them.
“They didn’t think about it because white is the default,” Band stresses. “Right now, white is seen as a monolith; it’s created that way because that’s how white supremacy maintains power. … So, if you don’t ask white people what does that mean for them as white people, then we’re not going to begin to break through the identity development that needs to occur.”
This simple question allowed Band’s white clients to become more self-aware and to pause and consider how they are also a part of the community, and it challenged them to reconsider their own privilege and accountability, she says.
“Most of the white clients I work with mean well, and they are deeply empathetic to BIPOC communities, which is why most of their focus is on how that makes others — i.e., BIPOC folx and their families — feel when they are shot, targeted and taken advantage of by the system,” Band says. “They do not focus on how they enable an inequitable system. But the truth is we all must look at our own role in these systems.”
Coriano Ortiz also makes a point to ask her white clients about their cultural background. They frequently respond by saying, “I’ve never thought about it” or “I didn’t realize I had a culture.” She often eases them into this discussion on cultural identity by asking what their holiday traditions look like. This question helps them consider the diversity within white culture, which may be rooted in German, English or Swedish cultures, for example.
Counseling resources often focus on how to work with BIPOC communities but not on how to work with white people, notes Band, AMCD vice president of Asian American/Pacific Islander concerns. She hopes that as more BIPOC counselors enter the field, the focus will be not just on ways to treat these communities as “others” but also on ways to help BIPOC mental health professionals. This means there will need to be more trainings on how to work with white clients and supervisors and within predominantly white counseling programs, she points out.
Allowing for other viewpoints
People often equate good mental health with having a positive self-concept or strong self-esteem, says Manuel Zamarripa, a licensed professional counselor supervisor in Texas. But this leaves out the collectivist piece of mental health.
“The [counseling] field is built on a foundation of individualism,” he says. “There’s nothing wrong with individualism … [but] we need a balance in worldviews as well.”
When counselors encounter clients who come from a different worldview, they tend to describe the other viewpoint as a deficient version of their own worldview, says Zamarripa, a dean of counseling at Austin Community College District. Instead, he stresses the importance of seeing these different pieces as two positive, healthy and beneficial ends of a continuum.
For example, a counselor who values autonomy may believe that their client is struggling with self-worth because they don’t have healthy boundaries with their family. Although the client also values autonomy, they place a higher importance on community. If the counselor approaches this from an individualist viewpoint, they may think the client is being difficult, Zamarripa says. But if the counselor understands that both worldviews are positive and healthy, then they can help the client find a solution that honors the client’s values.
Coriano Ortiz also considers clients’ cultural backgrounds and their intersecting identities before determining the best treatment approach. A common client she sees is a woman of color who assumes a caregiving role in her family because she is the eldest daughter. Approaching this client’s issue with an individualist mindset would only cause more harm, Coriano Ortiz notes, because the client’s goal is not to disconnect from her family. The client loves her family and wants to be with them even though some of their expectations can be a source of stress for her. So, the client needs an approach that values her collectivist culture while also helping her find a way to alleviate the stress and anxiety caused by a caregiving role that was imposed on her at a young age because of the parentification that often happens to girls of color, she says.
Coriano Ortiz draws on the client’s cultural values by talking about the importance of community care. She asks the client, “If you are always taking care of others, are you allowed to take care of yourself as well?” Then, they discuss how the client can show her family that she also has needs and how being vulnerable and willing to access help from her family, friends and community will ultimately create a more balanced community care dynamic. The client comes in talking about community care, Coriano Ortiz says, but sometimes she needs help realizing that receiving care herself is a part of that.
Some of Coriano Ortiz’s clients also blend their spiritual practices, such as limpias (spiritual cleansing), espiritismo (spiritism), Santería (an Afro-Caribbean religion) and other practices common in Latin America, with therapy. If a client comes in talking about recently getting a limpia, she will ask, “What were you cleansing away during your limpia?”
“Spiritual beliefs and cultural traditions for those seeking to reconnect with their ancestral wellness practices are important to process in therapy as a valid way of sustaining mental health,” says Coriano Ortiz, co-chair of Reclamation Collective, a nonprofit that helps people who are navigating religious trauma and adverse religious experiences.
Zamarripa, with Jessica Tlazoltiani Zamarripa, co-founded the Institute of Chicana/o Psychology in Austin, Texas, and developed Chicana/o/x affirmative therapy — an approach that assumes the centralizing of culture and that a positive perception of one’s cultural background will be facilitated in therapy. When working with Latinx clients, he incorporates the “pillars of brown wellness” — identity, family and spirituality — as a means of integrating cultural relevance into the therapeutic space.
Zamarripa also uses the four elements of nature (earth, wind, fire and water) as a way for his clients to reconnect with Indigenous practices. When doing grounding techniques, he invites clients to leave the session and find an area outside where they can take off their shoes and stand in the grass for a few minutes. Then they can let what they were talking about in session flow from them into the earth. “It allows us to appreciate more the importance of nature, the importance of the elements,” he says. “It can teach some clients something new, and for those clients that are marginalized … who have heard this in their family but they don’t practice it, it can help them culturally reconnect.”
Counselors can also draw on narrative therapy and storytelling, which has been a part of Indigenous cultures for years, Coriano Ortiz notes. During her graduate school program, where she specialized in Latinx mental health, she learned about cuento therapy, an intervention that was implemented in Brooklyn, New York, with Puerto Rican children. This therapy integrates Puerto Rican stories or folktales into therapy for children. Cuentos are a big part of Puerto Rican culture, she says. They serve as a way for children to learn lessons, feel hopeful about healing if they’ve gone through adverse childhood experiences, draw from the knowledge of their ancestors, and stay connected to their culture for those who have migrated from Puerto Rico to other parts of the world. This therapy allows children to read stories that are culturally congruent to their own experiences, which helps them build rapport with the counselor and the adults who are part of their support system. Eventually, these clients create their own life story as a way of healing.
Preparing counseling students
Finan believes that counselor education and counselor trainings should help equip clinicians to use a culture-centered approach in their work and engage in difficult dialogues about diversity and social justice. However, from her perspective, many counseling programs aren’t doing enough. “We are asking people to engage in really challenging conversations without preparing them to do it,” she says.
To address this issue, she piloted a counselor training workshop using Sue’s Race Talk and the Conspiracy of Silence as a framework for discussing all types of isms and social justice work in counseling. The book provides practical advice on why and how to have difficult conversations about race.
Band suggests counselor education programs help students begin to think about their own identities and biases by having them create positionality statements, which require individuals to consider how differences in social position and power have shaped and continue to shape their identities and access. The exercise asks students to describe their early life experiences of feeling “different,” “othered” or privileged, including the thoughts and emotions they experienced at the time and how they make sense of themselves now.
As stated in the Multicultural and Social Justice Counseling Competencies, privileged and oppressed identities are contextual and socially constructed, Band notes, so this exercise highlights how someone might hold privilege in one area but may be considered a minority and experience micro- or macroaggressions in another. A positionality statement does not simply ask students to list out their identities or privileges, she says. It asks them to recall others’ reactions to them during times when they felt “different,” “othered” or privileged and how they responded to those interactions.
With this approach, Band stresses the importance of having students not just write their statements but also share them with the class because it makes the experience more transformative. “This exercise is often deeply emotional because it is detailed and there is a storytelling or narrative aspect to it,” she adds. “It has the potential to be very cathartic.”
Vereen, editor of The Journal of Humanistic Counseling and past president of the Association for Humanistic Counseling, still teaches traditional theory from names such as Sigmund Freud and Alfred Adler in his counseling classes. But he says he does this more as a way of helping students learn from the past and figure out where the theories do and do not apply today.
For Vereen, theory serves as a learning tool to get counseling students to think about what they would do with a client, not what Adler or another theorist would do. And then he pushes them to consider the current relevancy of these theories by asking, “Now how do you step outside of this [theoretical] framework to then be a better helper to the student or client you’re working with? … [How] does what Adler’s saying [still] apply to the work that you’re doing? And in what way does it impact the relationship that you have with this student or client?”
Vereen recently restructured one of his graduate exams to help students see the practical application of theory. Rather than giving them a multiple-choice exam on theoretical concepts, he had the students work in groups to discuss ways to apply certain theories to client cases.
One group explored mental health implications for a pregnant teenager who had been emancipated. They looked up state statutes and thought about ways this young woman might get lost in the system. Then they considered the mental health impacts of carrying a pregnancy to term when it was not her choice, their role as her counselor, possible theoretical approaches they might use, and the ways these approaches did or did not address the client’s needs.
Sue says that his counseling psychology program does a good job of teaching counseling students the importance of social justice. At the same time, he acknowledges it does “a bad job of arming them with the strategies and techniques to bring about change and … of immunizing them against the resistance they are going to encounter.” Often, when counselors attempt to introduce a multicultural framework to an organization or agency, they are told that the strategies they want to use don’t align with the standards of practice or ethics codes that have been established there, he explains.
Sue recounts how one of his former students finished the graduate program excited to be a school counselor. When he noticed that underrepresented students rarely came to his office at the school where he was hired, he decided to go to them instead. He went outside and played basketball with these students, which led to some great discussion about their mental health. But the head counselor said that his actions were unethical and violated school policy. This exchange left Sue’s former student feeling discouraged.
“It does no good for any of us to become culturally competent when the very institutions that employ us punish us for it,” Sue says.
In his latest book, Microintervention Strategies — What You Can Do to Disarm and Dismantle Individual and Systemic Racism and Bias, Sue provides strategies people can use to combat the micro- and macroaggressions that target marginalized groups.
An evolving profession
Vereen challenges his fellow counselors to ask themselves a question: “If we continue to operate in the ways that we always have, are we then moving toward being unethical as a profession because we are not advancing what we’ve done to more holistically support the people and communities that we purport to be providing good work for?”
Sue says there is no one culturally appropriate way to maintain a good system of healing. Instead, to become culturally competent, he urges mental health professionals to work toward four main objectives:
Being aware of our own worldviews, values and assumptions about human behavior.
Understanding the worldviews of those who differ from ourselves.
Developing culturally appropriate intervention strategies and engaging in actions that positively affect the client’s environment.
Recognizing the systemic factors at play that directly and indirectly affect the policies and practices governing the mental health professions.
Culture-centered theories are “about how we view the world and how we conceptualize who we are in the world and [who] our clients and our students [are],” Finan says. “These are foundational ways of understanding what it means to be a 21st-century counselor. If we don’t … start using some of these theories to enhance our ability to connect with, understand and support clients and students, then we’re not growing with the profession. We’re not evolving.”