Race

Race is a culturally determined method of categorizing people by physical characteristics such as skin color, facial structure, eye color, and hair texture. The biological determinants and distinctions of race are not always clear. Indeed, racial constructs and categories have varied over time and across cultures within a single time period. Nevertheless, it is important to recognize the role of race. Many individuals and communities identify strongly with their race or are forced by others to be characterized by their perceived race. Without a doubt, racial “lenses” can play a significant role in problematic biases and prejudices, thus representing potential components of the kulturbrille effect from either side of the interviewing dyad.

Ethnicity

Ethnicity has been described as reflecting the cultural aspects of language, social patterns, and practices.⁴ In the “Cultural Formulation” section of the DSM-5, this reflection is given substance as follows:

Ethnicity is a culturally constructed group identity used to define peoples and communities. It may be rooted in a common history, geography, language, religion, or other shared characteristics of a group, which distinguish that group from others. Ethnicity may be self-assigned or attributed by outsiders. Increasing mobility, intermarriage, and intermixing of cultures has defined new mixed, multiple, or hybrid ethnic identities.⁵

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013). American Psychiatric Association. All Rights Reserved.

In this regard, a variety of ethnic groups may be present within a single race depending upon factors such as geographic origin. By way of example, the ethnic identification of Hispanics born in South America, Central America, Mexico, and Cuba, are generally distinctive, and these distinctions are important to each ethnicity although they are often perceived as being the same race. Moreover, factors such as nationality can play a role in ethnicity, such as what it means to be American, French, or Chinese. Combinations of ethnic backgrounds are increasingly common, as described by La Roche:

For example, a woman who has lived all her life in the United States and whose father was Filipino and mother Latino could identify herself as “Filipino American” or “Latino-Filipino” or other combinations at different times. It is also important to note that a person can identify himself or herself as Latino (ethnically), but be perceived as black because of her or his skin color (racially).⁶

Ethnic biases and predispositions can play a major role in kulturbrille effects.

Definition of “Cultural Competency”: More Complicated Than It Looks

A variety of definitions have been proposed for the term “cultural competency,” from definitions focusing upon an individual clinician’s actual everyday competence to definitions that address the term from the more abstract perspective of organizations and fields of practice (social work, clinical psychology, medicine, nursing, education, and business). In this chapter we will focus primarily on what it means for an individual clinician to be culturally competent. A good place to start is with a definition by Sue and Torino.

Cultural competence is the ability to engage in actions or create conditions that maximize the optimal development of the client and client systems. Multicultural counseling competence is achieved by the counselor’s acquisition of the awareness, knowledge, and skills needed to function effectively in a pluralistic democratic society (ability to communicate, interact, negotiate, and intervene on behalf of clients from diverse backgrounds) and on an organizational/societal level, advocating effectively to develop new theories, practices, policies, and organizational structures that are more responsive to all groups.⁷

From the perspective of defining cultural competence regarding individual clinicians, it is the first part of this definition that warrants our greatest attention. Sue and Torino’s definition is clearly person-centered, emphasizing the goal of maximizing the client’s functioning. They clearly indicate that gaining knowledge (about the characteristics of the client’s culture if different from our own) is valuable.

In this regard, an ever-increasing and sophisticated knowledge about the specific details, nuances, customs, rituals, communication rules, and biases of our patients’ cultures is sometimes referred to as “cultural literacy.” We will devote significant time in this chapter to understanding how to utilize cultural literacy to engage patients more effectively, to recognize important cultural and cross-cultural stresses that might be negatively impacting on our patients, and to mobilize collaborative treatment planning.

Nevertheless, in the above definition of cultural competency, Sue and Torino metacommunicate an implicit warning that cultural literacy alone does not define cultural competence. True competence is not merely the acquisition of knowledge about our clients’ cultures; it is also an “awareness” and a “set of skills.” A variety of experts have emphasized that cultural literacy alone – although clearly useful – is not the foundation of cultural competence.^8–11 Indeed, an interviewer could be culturally illiterate about a patient (know very little about a patient’s culture) and still be culturally competent with the patient. Moreover, I have seen clinicians who are clearly culturally literate about their patients (know a great deal of details about their patients’ cultures), who, in my opinion, were culturally incompetent. Cultural literacy is important, but it should not be over-emphasized, for it is never adequate. Fields points out that, “Not only is knowledge of cultures insufficient to work with culturally diverse clients, but developing a complex understanding of every culture is challenging, if not impossible. It is unlikely that a clinician will possess a high level of expertise on more than a few cultural groups.”¹²

Another major reason that attendings, professors, and trainees must be careful not to over-emphasize cultural literacy is the fact that such an over-emphasis can create an atmosphere in “diversity training” that becomes precariously close to stereotyping. In this regard, the unwary interviewer may be predisposed to immediately assume that they know the personal characteristics of a particular patient because they are quite familiar with the patient’s culture. Consequently, the interviewer will immediately implement a set of interviewer behaviors based upon the standard characteristics of the patient’s culture. Ho has described this as creating a situation in which trainees are taught to interview in such a fashion that they are “culture-specific” as opposed to being “client-specific.”¹³ Paradoxically, in such situations, the diversity training has trained the interviewer to be less interested in the uniqueness of the person beneath the culture and more interested in categorizing the patient as a “cookie-cut” representative of the culture in question.

By way of illustration, a White or Asian clinician who has learned that people in a Hispanic or Latina/o culture tend to stand more closely to each other during conversation than would be normal in a typical White or Asian dyad, may immediately decide to initially approach such a patient at a closer interpersonal distance, so as to match the patient’s cultural proclivities. Unfortunately, the patient, who is presenting in an emergency room, happens to be a Hispanic patient who is acutely paranoid, a psychological state being triggered by a first episode of schizophrenia. Such a patient might require four times the interpersonal space of a non-paranoid White or Asian patient during a conversation in order to feel comfortable and safe. By stereotyping the Hispanic patient along supposed cultural norms, the clinician has inadvertently encroached upon the patient’s intimate space, potentially triggering not only acute disengagement but also the potential for defensive violence.

In this regard, Sue has suggested the useful principle of “dynamic sizing.”¹⁴ In dynamic sizing, one recognizes that effective cultural literacy often provides a clinician with a sound understanding of the common characteristics that many patients from a specific culture may share, but it adds an important caveat. The interviewer must remember, and subsequently determine, whether or not this unique individual has characteristics that are idiosyncratic or at significant variance with his or her culture of origin. One size does not fit all.

It is also important to remember that each person embodies a dynamic, potentially shifting culture. We are all cultures “on the move,” psychologically speaking. With the advent of the web and social media, a culture can shift with a rapidity before unknown in the history of civilization. Moreover, the power of a single individual or a small group of people to impact on a culture worldwide is quite extraordinary in this wired age. On an innocuous level, an individual could post a video of a dance move on YouTube that, if it went viral, could become part of the pop culture overnight throughout the world. On a more disturbing level, a terrorist group can attract individuals to join its ranks (even changing the individuals’ ethnic identity) with a single website from 6000 miles away.

In the last analysis, the secret to cross-cultural interviewing is not so much understanding the culture of the person sitting before us as it is recognizing that each person before us is a unique culture. Interviewers aware of this uniqueness step into their offices with both the compassion of a psychologist and the curiosity of an anthropologist. Borrowing from Zen philosophy, the culture of each patient must be explored with the humility of a beginner’s mind. It does not mean that we cannot pull upon our hard-earned familiarization of cultural distinctions (cultural literacy). It does mean that we cannot rely upon those distinctions to be present in the person before us.

Dean has described this approach to cultural diversity as developing an awareness of our “lack of competence” and a “not-knowing position.”¹⁵ I also like the expression of Dyche and Zayas that we should move with a “respectful curiosity.”¹⁶ Arguably the single most important interviewing principle in this chapter is that to reach a deeper understanding of a patient’s culture and cultural priorities, never assume, always ask. When he is referring to his work with the Latina/o population, Gallardo emphasizes this principle, writing, “Client self-report always supersedes textbook knowledge or the therapist’s own experiences with the Latina/o culture.”¹⁷

We are now left with an important unanswered question: If cultural literacy is useful but not sufficient in order to be culturally competent, what are the specific attitudes and skills sets, alluded to by Sue and Torino, that we must nurture and mobilize?

Towards a Third Culture

Cross-cultural work can be viewed as the study of how two people from differing cultures enter an interviewing room and either ultimately clash, mix, or resonate with one another as determined by their cultural moorings. The task of cross-cultural awareness then becomes one of acknowledging the potential differences between the two cultures that shaped the two entities in the room – the clinician and the patient – with the goal of creating a resilient understanding between these two parties. This task can be clarified, and its goal more likely to be achieved, if one realizes that a rather unusual cultural process is unfolding in every interviewing room. It is a phenomenon that is quite intriguing, but often goes unacknowledged. A third culture is being born.

No interview room exists in which there are only two cultures mixing. There is always a third – the therapeutic alliance. This third culture, the therapeutic alliance itself, will be unique to every interviewing dyad. It is a culture that literally disappears as the patient and the clinician leave the confines of the office, although both parties’ actions between sessions may be impacted by its rules and conditions. (For example: When is it appropriate to call or text the clinician? Will therapeutic tasks or homework be completed or not completed? Will confidentiality be respected or not? Is it okay for the clinician to look at the patient’s profile on Facebook and vice versa?) At times, it is a culture that exists for exactly 50 minutes and then disappears forever (a triage intake at a community mental health center). At other times, it is even shorter in duration (a 20-minute emergency room interview).

To me, no matter what its length or context, when trying to maximize the effectiveness of the first encounter, the lens of cross-cultural interviewing is often most clarifying when it is focused upon the collaborative process of creating this third culture. Ultimately, the success of cross-cultural training is not the creation of a clinician who can recognize cultural differences, but the creation of a clinician that can collaboratively forge new cultures when such differences arise.

I believe this new focus is what Andrew Fields is intimating when he talks about the importance of the “cultural exchange” that occurs in a therapeutic dyad. He reminds us that, whether in an academic forum or within a clinician’s office, effective cross-cultural exchange demands that the clinician always remember that “defining culture and cultural interaction is a complex and ever-changing phenomenon.”¹⁸ In this light, the third culture that we co-create – the therapeutic alliance – is ever-changing.

There is no doubt that this third culture will shift its rules, accommodations, and goals throughout the subsequent sessions of ongoing therapy if undertaken. It is also true that the most powerful characteristics of this third culture may very well be sculpted in later sessions than during the initial encounter. On the other hand, attending to the initial forging of the third culture during the first encounter is of particular significance. It often determines whether there will even be a next encounter.

In his illuminating article on creating the therapeutic alliance with Latina/o patients, Gallardo poignantly emphasizes this point by drawing upon an old adage that can be paraphrased along the lines of, “You need to be invited into someone’s house before you can help them to rearrange the furniture.”¹⁹ Patients need to feel culturally safe with us before they will invite us to collaboratively explore and rearrange their intimate memories, fears, defenses, and problematic behaviors.

As a co-creation of the clinician and the patient, it is valuable to acknowledge that the success of the therapeutic alliance is not entirely dependent upon the clinician, although its failure may frequently originate in the clinician’s misguided actions or absence of actions caused by a lack of cultural awareness. A vibrant cross-cultural exchange, with bilateral resonance, will ultimately depend upon the actions of both its authors.

If a patient is immersed in deeply rooted prejudices against the perceived culture of the clinician, no matter how culturally sensitive the interviewer’s efforts may be, the alliance may fail. Sometimes psychopathology may interfere. A patient experiencing a paranoid first episode of schizophrenia may hold all Asian, Black, Hispanic, Native American or White interviewers in contempt, depending upon the nature of the patient’s delusional framework, without regard to how talented the efforts of the clinician might be. In contrast, a patient with an openness to cultural dialogue may help foster a powerful third culture that may even provide the interviewer with new vistas of insight and opportunity. Sometimes, inadvertently, it is the clinician who grows more than the patient with regard to cultural awareness in successful exchanges. In the last analysis, an interview is, as Comas-Diaz comments, a “dance of pluralism.”²⁰ Both dancing partners play pivotal roles in its creation.

From a cross-cultural perspective, we can now more accurately view the initial clinical interview as including an interpersonal process of cultural exchange that is actively evolving over the course of the first 50 minutes. In this process, the two participants are co-creating a third culture – their therapeutic alliance – that is a unique culture to them. To return to the words of Alan Moore in our opening epigram, “A world grows up around me. Am I shaping it, or do its predetermined contours guide my hand?” Like the situation of Moore’s fictional character who is appraising who shapes whom in a culture, the third culture of the therapeutic alliance “grows up around” the patient and the interviewer. It eventually envelops and shapes the interactions of its own creators. Like Moore, we can wonder who is doing the shaping here – the interviewer or the interviewee? Truth be told, both hands are doing the shaping. And, in return, the therapeutic alliance becomes a third hand that impacts on the thoughts, feelings, and behaviors of each of the co-participants of the interview as it proceeds.

As one of the most highly acclaimed of graphic novelists, Alan Moore knows a thing or two about the creative process and the making of fictional worlds. His metaphor seems to fit our cross-cultural work quite nicely. It is now time to arrive at a name for our interviewing approach that captures its essence succinctly as it would be applied in the everyday world of clinics and inpatient units.

Culturally Adaptive Interviewing

Although still in its infancy, much work has already been undertaken on the cultural adaptations of treatments.^21,22 In other words, how does one adapt the basic principles, techniques, and strategies of a specific evidence-based therapy such as cognitive–behavioral therapy (CBT) when used with patients from different cultures? It should be borne in mind that the original empirical research that launched many therapeutic modalities was often done primarily with narrowly recruited subjects (such as college students, a primarily White or Black population, a specific nationality or ethnic group). Guillermo Bernal and his colleagues concisely summarize the importance of work related to the cultural adaptation of therapies as follows, “Cultural adaptations may make it possible to go beyond the one-size-fits-all approach and move closer to the ideal of providing effective psychotherapies for all individuals, contextualized in terms of cultural values, language, socioeconomic status, gender, and preference.”²³

As evidenced by the title of our chapter, one can also apply the term, “culturally adaptive” to the initial interview. Indeed, I believe it is useful to do so. The term seems to inherently embrace the principles we have discussed thus far. Rather than suggesting the static goal of creating a culturally competent interviewer, it emphasizes that cultural competence is a life-long process, not a short-term achievement. From a training perspective, one can operationally define cultural competence by delineating what characteristics of the interviewer will be present when the interviewer is displaying “culturally adaptive interviewing”:

From a cross-cultural perspective, the goal of graduate training whether in psychiatry, social work, clinical psychology, nursing, counseling or other mental health professions is the development of clinicians who consistently attend to the ongoing cross-cultural currents of the initial interview as it proceeds, whose expertise must be enhanced and re-applied in each interview in an ongoing fashion. Such an interviewer is gently yet keenly aware that a third culture, the therapeutic alliance, is being co-created by the patient, the clinician, and the cultures that have shaped, and are still shaping, each participant. Both patient and clinician are actively making adaptations. The interviewer recognizes it is his or her responsibility to foster this adaptive process to the very best of his or her abilities, to create an interpersonal environment where the patient feels welcome, respected, and safe to share whatever thoughts and feelings come to mind.

In the following pages we will see how this operationalized definition brings the three components of Sue and Torino’s definition of cultural competence to life via the practical application of attitudes (awareness of potential engagement and treatment opportunities and issues related to differences in culture between the interviewer and the interviewee), knowledge (cultural literacy), and skills (interviewing strategies and techniques for gracefully exploring cultural beliefs of importance to the patient, as well as techniques for transforming cultural roadblocks if encountered). We will also spend considerable time exploring the complex and ongoing clinician self-examinations that are necessary to allow these three elements of culturally adaptive interviewing to be effectively utilized. We shall examine the types of questions, statements, verbal and nonverbal behaviors, and conscious and unconscious perceptions that can increase the likelihood that the multicultural dance of pluralism, described by Comas-Diaz, will be a successful one.

Intersectionality

We will begin our foray into the mystery of cultural identity not in the hands of a noted mental health professional nor on the pages of an esteemed mental health journal. We will begin with a concept coined by a lawyer interested in social justice.^25,26

Near the end of the 1980s, Kimberle Crenshaw, J.D., introduced the term “intersectionality.” Although a bit abstract sounding, it is about an all-too-human phenomenon: prejudice. Of course, the issues surrounding prejudice had been discussed by psychologists, sociologists, and anthropologists for decades, especially racial and ethnic prejudice. What made people take particular note of Crenshaw’s concept of intersectionality was an important detail delineated by Crenshaw. It was a detail that too often was under-emphasized in the literature. A single human being could be the target of multiple prejudices, and these multiple prejudices might create exponentially more difficult hurdles. To better understand the pain and challenges facing any oppressed individual, one needed to better understand the amplifying damage done by these multiple aggressions.

Crenshaw was particularly interested in exploring the difficulties of Black women who were the victims of domestic violence. She highlighted that these women of color were the targets of oppression, domination, and discrimination both because they were female and because they were Black. To understand their struggles, one needed to address both of these discriminatory parameters separately and then in a combined fashion. The question became one of, “How did these two different prejudices amplify one another?” For example, a Black woman who was physically and/or or sexually assaulted by her husband (as engendered by sexism) may be more hesitant to call the local police for some members of the police force (primarily White in composition) had gained a reputation for demonstrating psychologically and/or physically abusive behavior towards Blacks (as engendered by racism).

With such a patient, let’s examine how clinician misinterpretations could arise during the initial interview if the ramifications of intersectionality were not being considered by the clinician. Hearing during the history that the patient had not contacted the police on several occasions after experiencing episodes of intimate partner violence, a clinician – unaware of the intersectional reality of the patient’s life – might mistakenly perceive that the patient was overly dependent (the patient’s lack of police contact being misinterpreted as caused by a need to stay with the male partner no matter what the circumstances) or was lacking in problem solving skills (lack of police contact being misinterpreted as not being able to recognize that a call to the police could be a means for engaging help). Both of these perceptions by the naïve clinician are patently false. The patient was merely being wise, considering the forces of intersectionality at work in her life. Crenshaw outlined numerous other examples of such situations. Intersectionality would prove to be an innovative perspective that would have significant ramifications outside the field of law, especially in the fields of social psychology, mental health, and cross-cultural studies.

Over time, as is the case with many innovative principles, it was found that the concept of intersectionality could be broadened to provide useful insights in a variety of circumstances.^27–30 Although it was originally designed, and is still extremely useful, for analyzing oppressive factors, intersectionality can also shed light upon the numerous cultural factors that shape all of us, including not only negatives (such as oppression) but also positives (such as compassion). Prilleltensky and colleagues point out that “wellness cannot flourish in the absence of justice, and justice is devoid of meaning in the absence of wellness.”³¹

Prioritizing Cultural Identities: A Framework for Simplifying the Complex

As we have described, over the course of a lifespan, each patient and each clinician is sculpted by numerous cultural factors including race, sex, gender identification, sexual orientation, religious beliefs, political beliefs, social perspectives, family beliefs, socioeconomic factors, degrees of social acculturation during processes such as immigration, and cultural beliefs regarding body habitus, physical attractiveness, and the presence of mental and/or physical impairments. The clinical concept of “prioritizing cultural identities” postulates the following precepts (note that they are primarily viewed from the perspective of the fashion in which the patient’s prioritizing cultures may impact on the therapeutic alliance; but they are equally applicable to the clinician’s prioritizing cultural identity, a process we will examine in detail in a subsequent section of this chapter):

We will find that the concept of prioritizing cultural identities (as well as the concept of intersectionality) will help us to better understand a variety of cross-cultural issues and opportunities in the following pages. An appreciation of these concepts fosters an attitude of respect for the dynamic uniqueness of the individual, described earlier as being one of the foundations of effective culturally adaptive interviewing. It can also help a clinician to more rapidly understand what appears to be a confusing interaction with a patient and, from this position of understanding, more effectively address the concerns of the patient.

Clinical Illustration of the Impact of Prioritizing Cultural Identities

The concept of prioritizing cultural identities serves a variety of additional useful purposes. For instance, it can decrease cultural stereotyping and “culture-specific” versus “client-specific” interviewing, while reminding us, during the interview itself, of the value of dynamic sizing. To illustrate its power, let us look at the ramifications of prioritizing cultural identification with the initial engagement process.

It could be stereotypically assumed that an African American patient being interviewed in a culture such as the United States where the White culture has historically functioned in an oppressive fashion, would be more at ease with a Black interviewer. At times this is definitely true. At other times, it may not be true, and this type of disparity is nicely explained by the concept of prioritizing cultural identities.

By way of illustration, let us picture that the African American patient in question is a 24-year-old male who in childhood and adolescence had received more than his fair share of racial discrimination. We shall call him Shane. Throughout most of his life, he has strongly identified with his Black heritage. It is his most consistent cultural identity. When he enters the room, he notices immediately that the clinician is White. One might assume that he would be more comfortable, and perhaps better served, by being assigned a Black therapist. But such is not necessarily the case.

After a cursory glance around the room, a genuine smile and warmth enters Shane’s demeanor, as he comments, “Thank God.” The conversation continues as follows:

Here we have seen that the power of the patient’s identification with a fellow veteran has over-ridden his Black identity as being his immediate primary cultural identification during this initial interview. As his history would have it, his life had been saved by a White soldier who had thrown himself on an improvised explosive device (IED) in order to save several fellow soldiers including the patient at hand. Context is everything. The interview is occurring in a Veterans Administration (VA) Hospital. If Shane had entered that room for the first time and saw a Black therapist sitting there who was a civilian employee of the VA, I believe it is highly unlikely that we would have seen Shane embrace his therapist with such a sigh of relief, despite both men being of the same race.

But what if the patient was not a Black man but a Black woman? What if the patient had experienced considerable sexism while in the military, or even sexual assault? Might she not prefer a female civilian therapist to a military therapist, no matter what the color of the therapist’s skin? In such an instance, her identification as a woman might over-ride her identification as a veteran or, indeed, her racial identification (i.e., she might prefer a civilian White female therapist to a Black male therapist who was a vet).

At this juncture, with definitions of culture, race, ethnicity, intersectionality, and prioritizing cultural identities under our belt, we are better equipped to begin a more thorough exploration of interviewing strategies and techniques that can help us to create productive cross-cultural interviews. Let us begin with the most basic of foundations – engagement and the creation of the third culture, the therapeutic alliance. In addition – having acknowledged the problems arising from an over-emphasis upon cultural literacy – we can now effectively explore the power of cultural literacy to enhance engagement when appropriately utilized.

As we become more familiar with different cultures, I believe that we find our clinical work more exciting and gratifying. The diversity of human beings is indeed fascinating in its complexities and distinctions. But we are not in the room to enhance our own intellectual curiosity, nor our sense of wonderment. We are in the room to help the patient.

In this regard, increases in cultural literacy that can be valuable in enhancing engagement can unfold in one of two ways – acquired and discovered. Acquired cultural literacy refers to learning about differing cultures by reading about them, interacting with community members from them, talking with other clinicians who are familiar with the culture, and utilizing the web as a rich arena for encountering cultures other than our own. Note that in acquired cultural literacy, none of the learning occurs during the actual clinical interview with our patients. In contrast, with discovered cultural literacy, something spontaneously arises in the clinical interview that results in the interviewer discerning a cultural nuance previously unknown to him or her. Both types of cultural awareness can be useful in the initial engagement process as well as in ongoing therapy.

Acquired Cultural Literacy

Whether one is in a psychiatric residency or in a graduate program, clinicians will find themselves working with patients of a differing culture from themselves. It is not possible to practice without interfacing with other cultures. These interfaces may occur when there are immediately obvious distinctions between the interviewer and the interviewee (race, sex) or when there are potentially hidden distinctions (sexual orientation, religious beliefs, political views). In addition, during both training and subsequent careers, as clinicians move about their own country – or immigrate to a foreign country – it is not uncommon for them to move to an area in which they encounter unfamiliar cultures.

For instance, a clinician might move to a rural setting from an urban one, where the distinctions may transcend race and sex. There can be marked differences in culture between a White patient from a major metropolitan center such as Washington DC who is interviewed in a private practice and a White patient in a poverty-stricken area of rural Arkansas who is interviewed in a community mental health center. Clinicians may find themselves working with people who have recently immigrated (or have escaped from a place of aggression as might be experienced with a move to the Minnesota area where both a large Hmong population and a large Somali population settled years ago when fleeing genocidal violence in their homelands).

In a different light, the cultural differences may reflect that the clinician has had a limited personal exposure to specific cultures, such as an interviewer who has had limited exposure to poverty or knows few, if any, individuals in their personal upbringing who have been addicted to heroin or involved in gangs or prostitution. Or the cultural unfamiliarity may be specifically related to upbringing (and cultural preference) such as an interviewer raised as a Christian fundamentalist who may have little familiarity with the lesbian, gay, bisexual, and transgender (LGBT) community or an interviewer raised in a progressive household who may have little, if any, personal familiarity with Christian fundamentalism (never had a friend or colleague who was a fundamentalist).

No matter what the situation, once a clinician has become aware that he or she will be working with people from a culture with which he or she is unfamiliar, it is useful to read and learn as much as possible about the new culture. The innovative work of the Sommers-Flanagans comes to mind, and I highly recommend reading their chapter on interviewing in a multicultural world.³³ This self-enrichment is both enjoyable and potentially quite useful in subsequent clinical work. In such situations, I also strongly recommend talking with clinicians who have been working effectively with people from the cultures commonly seen in your respective clinic or hospital setting, for they will have many insights that might not be readily available from books, journals, or the web.

As we saw in earlier chapters of this book, cultures can vary in a variety of fashions including: methods of greeting, eye contact, preferred interpersonal space, comfortableness with sharing intimate details, use and recognition of emotional states, beliefs in healing, cultural norms with regard to family ties and methods of rearing children, etc. The list is extensive. Being familiar and comfortable with such differences can help the interviewer to positively engage rapidly. It can also help the interviewer to avoid equally rapid disengagement or misinterpretation as we discussed in the opening example of our chapter where problematic kulturbrille effects may occur between a Native American and a person of another culture over differences in the approach to time and timeliness.

Cultures generally have idioms or “turns of phrase” that are unique to the culture. In addition, there may be an underlying cultural heritage of myths, literary references, or religious associations that have powerful meanings to patients and can be used to enhance engagement. For instance, if a patient spontaneously presents as devoutly practicing the Jewish or Christian faith, it is likely that the patient is familiar with the Book of Job from the Old Testament. In this story, as a reflection of his trust in his god, Job shows a remarkable acceptance of life’s traumas, from the loss of loved ones to ruination of his finances and the onset of hideous boils and medical illness. In the initial interview with such a patient, the well-timed comment, “You have certainly shown the patience of Job. I’m impressed with your resilience. Where do you think your strength has come from?” may be powerfully engaging.

Similarly, Bernal and colleagues describe the use of dichos when working with a Latina/o population. Dichos are cultural sayings, aphorisms, and proverbs based upon a Latina/o sense of heritage and community. The use of such phrases may be of value not only in the initial interview but as a tool for culturally adapting ongoing interventions such as cognitive–behavioral therapy.³⁴ On a cautionary note, it should be emphasized that the use of culturally resonating myths, literary references, or dichos should only be employed by an interviewer who is truly familiar and comfortable with their use. When used without such a genuine resonance by the interviewer, their use can be seen as disingenuous, superficial, or insulting.

Many cross-cultural differences in communication are general in nature. An awareness of such ubiquitous cultural norms and social etiquette can help clinicians to avoid potentially disengaging gaffs. For instance, Lisa Aronson Fontes, in her outstanding book, Interviewing Clients across Cultures: A Practitioner’s Guide, describes how pointing with a finger in many Asian countries including India, China, Indonesia, and the Philippines is viewed as being impolite. With this knowledge, an interviewer would know that it is inadvisable, in an initial meeting with a family from one of these countries, to point to a specific family member to speak.³⁵

Other cross-cultural nuances may be quite specific to unique situations yet could result in surprisingly significant miscommunications if not understood. In the same book, an example first delineated by Okawa provides a striking example of this phenomenon. Okawa describes how a Cameroonian asylum seeker might relate that every morning while imprisoned, he was taken out of his jail cell for a “morning coffee.” Sounds like a surprisingly pleasant social custom for a prison environment, unless one is familiar with the fact that the phrase “morning coffee” is a slang euphemism for the practice of prisoners being taken from their cells to be brutally beaten as a form of torture in the early morning hours.³⁶

This last example highlights a point we made earlier in the chapter. It is not feasible to know all of the cultural nuances of every culture. No matter how much acquired cultural literacy an interviewer obtains, there will be interviews in which the interviewer encounters an unfamiliar cultural nuance. Moreover, we have already seen that every person is, in reality, a unique culture. Unexpected reflections of this cultural uniqueness are unavoidable.

Before closing this section, I would like to emphasize a point made earlier, that although books and articles offer rich resources for acquiring cultural literacy, fellow clinicians and fellow trainees are often invaluable resources. One of the things I would recommend doing when first moving into a clinical environment in which one is working with patients from unfamiliar cultures, is to seek out at least two supervisors or clinicians who are comfortable with the nuances of the cultures in question. Sit down with them and tap their knowledge. Asking these colleagues questions such as the following (in no special order) can be enlightening:

1. “What are some of the cultures and ethnic groups that are common here?”

2. “Are there any minority populations here of which I might not be aware?”

3. “Are there immigrant populations here?”

4. “Are there racial or ethnic tensions here of which I need to be aware? (including issues of trust/mistrust between marginalized communities and dominant ones as well as such issues between differing marginalized communities, which can be equally intense.)”

5. “Are there gangs here and what are the tensions amidst the gangs?”

6. “Are there tensions between the police force and any racial or ethnic groups in the community?”

7. “Are there specific street drugs that are particularly popular here?”

8. “What are the slang names of the common street drugs here?”

9. “What is the typical high-end daily use of these drugs: bag of heroin, five bags of heroin, a bundle (ten bags) etc.”

10. “With regard to suicide, are there particular words or approaches that are best used for sensitively raising the topic?” If so, one can modify approaches such as the Chronological Assessment of Suicide Events (the CASE Approach; described in Chapter 17) to fit more effectively with the culture in question. Such issues are equally pertinent to other sensitive topics such as sexuality, incest, or domestic violence.

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