Suraji Wagage, Ivy Kwong, and Renetta Weaver
The Equity Issue

Why Therapists Say Cultural Safety Is Essential in Mental Healthcare

When Hurricane Ida hit New Orleans last year, Jasmin Pierre had to leave her home for the sake of her safety. Due to this natural disaster, she ended up at a shelter in Alexandria, Louisiana, as her father was not around to help her like he usually did during hurricane season. By the time she arrived there, she was in a state of mental health distress, so she stated this to the team at the medical station at the shelter.

While she denied any active plans to hurt herself, she knew that she needed help to get through the night before she could make her way to the airport to fly to Texas. Instead of a good night's rest when she most needed it, a police officer snuck up on her while asleep, and the next thing she knew, she was handcuffed and taken to a psych ward.

With such an awful experience, it is easy to grasp why she created The Safe Place app to support Black people with mental health. Unfortunately, not everyone gets it, as Pierre has been accused of reverse racism by white people for prioritizing Black communities. Undeterred, she says, "Those messages only prove why the app is needed. The last two years have been a lot with the pandemic. In 2022, it has almost 20,000 downloads."

Thankfully, some therapists share Pierre's perspective, which informs their practice. Here is what they have to say about the need for cultural safety in psychotherapy.

Providing Equitable Services

Psychotherapist, Ivy Kwong, LMFT, says, "Cultural competency is not a gold checkbox. This operates on a continuum. I love culturally safe services in terms of the mental health profession maturing as a service as there are so many levels to this."

Kwong further explains that clinicians need to uncover their own biases, develop more awareness around their own thinking, and be aware of their privilege. "Ultimately, you don't want it to be a hierarchy, but the power dynamic is already present," she says.

By taking this approach, Kwong conveys how therapists can acknowledge that clients are the experts of their own lives. "Cognitive-behavioral therapy (CBT) may be limited compared to the healing practices of those that you are working with," she says.

As an Asian American woman who mostly serves Asian American and Pacific Islander (AAPI) communities, Kwong describes how CBT may only skim the surface of what her clients need, which is why she encourages a more collaborative approach to therapy.

Unfortunately, Kwong has often heard from AAPI clients who have been traumatized by white therapists. "We have differences and we should want to improve our ability to have hard conversations, to understand how we can best serve our clients," she says.

Kwong explains, "If we are willing to be uncomfortable, to make mistakes, and be willing to be transparent, so much healing can happen in the relationship if there's a willingness and ability to deconstruct these systems in the therapy session."

Having been threatened with a lawsuit by a white therapist for trying to educate her, Kwong is aware of how power operates in the mental health field even among professionals when race differs, which is why she is committed to cultural safety.

Ivy Kwong, LMFT

If we are willing to be uncomfortable, to make mistakes, and be willing to be transparent, so much healing can happen in the relationship if there's a willingness and ability to deconstruct these systems in the therapy session.

— Ivy Kwong, LMFT

Not Like Flipping a Switch

Licensed clinical psychologist, and co-founder and director of the Center for Cognitive Behavioral Therapy and Mindfulness, Suraji Wagage, PhD, JD, says, "The idea of cultural competence has never sat well with me. Competence is an all-or-none concept: you are either competent or you are incompetent."

While such a framing may appear like flipping a switch from incompetent to competent, Wagage instead explains, "Becoming culturally aware or having cultural humility is a lifelong process, not a flipped switch. No one wants to say they are culturally incompetent, so everyone says and believes that they are culturally competent."

In this way, Wagage notes, "Admitting to being culturally incompetent also feels uncomfortably akin to admitting to being racist or at least racially insensitive, which no one wants to do. This creates an unfortunate situation where, as a field, we pay lip service to cultural competence while believing we have already achieved it."

Wagage shares how she has witnessed an arrogance in the field as psychologists are expected to understand the workings of the psyche and the ins and outs of implicit bias, stereotypes, and prejudice, so we believe we have transcended these pitfalls.

Suraji Wagage, PhD, JD, licensed clinical psychologist

Becoming culturally aware or having cultural humility is a lifelong process, not a flipped switch. No one wants to say they are culturally incompetent, so everyone says and believes that they are culturally competent.

— Suraji Wagage, PhD, JD, licensed clinical psychologist

Instead, Wagage clarifies, "Psychologists believe we are qualified to show others how to be more aware and recognize biases, but I think this creates an enormous blind spot to our own issues and prejudices. We are susceptible to the same biases as everyone else, but our profession can make us feel pressured to presume we are less biased."

In nearly a decade of postgraduate education and training in psychology, Wagage explains that she learned a great deal about how to treat a variety of disorders, but little, outside of autodidacticism, about how to treat a variety of people. She notes, "The presumed perspective was white, American, able-bodied, middle-to-upper-class, and heterosexual."

Wagage highlights, "There have been many recent cultural movements (Black Lives Matter, MeToo, Health at Every Size, LGBTQIA+ movements, to name a few) raising awareness of how detrimentally we as a nation have excluded other perspectives for centuries and how deeply discrimination can be ingrained."

By recognizing that people are treated differently based on characteristics like race/ethnicity, gender, sexuality, disability, religion, and socioeconomic status, Wagage notes how certain individuals may be more likely to face adverse settings or experiences that shape thoughts and emotions in ways not often acknowledged.

Wagage explains, "Our responsibility as therapists is to listen to individuals with an open mind, not make assumptions, and validate clients' experiences. We must educate ourselves about the history of treatment of different groups to understand these contextual factors, while also gaining understanding from our clients' experiences and being aware of the beliefs that we bring into the relationship."

In her experience, colleagues' culturally unsafe practices often stem from an unwillingness to discuss cultural identity with clients, particularly regarding race/ethnicity. "Many providers don't touch it for fear of saying something wrong. This does our clients a disservice because many clients won't bring up issues that they feel their therapists don't want to discuss or will not understand," Wagage says.

Being a Minority Therapist Can Bring Insight

Neuropsychologist and faculty member at Columbia University, Sanam Hafeez, PsyD, says, "Even basketball professionals have to undergo some level of cultural competency training. Several organizations offer that on an ongoing basis in-house and through larger bodies such as associations. It is both the therapist's and their employer's responsibility to remain updated and diligently seek out such education."

Hafeez explains, "As a BIPOC psychologist, I am aware that my cultural sensitivity does not expand to include every group. Those therapists who feel they cannot connect or provide truly sensitive services must refer patients out as needed to those who can." 

When in a position to provide a teachable moment, Hafeez seizes the opportunity to educate and inform. "I teach and train and am often asked about my bilingual skills as well as being a minority (woman, Pakistani-American, Muslim, immigrant), all not such traditionally associated with the old male, white psychologist image," she says. 

Sanam Hafeez, PsyD, neuropsychologist

As a BIPOC psychologist, I am aware that my cultural sensitivity does not expand to include every group. Those therapists who feel they cannot connect or provide truly sensitive services must refer patients out as needed to those who can.

— Sanam Hafeez, PsyD, neuropsychologist

In her experience, Hafeez notes that several patients shared that they stopped seeing their therapist after the BLM movement because they felt they could not connect. "Patients reported that they felt a lack of empathy, leading them to withdraw from their therapist. I have heard the same from other groups but most overwhelmingly with those who felt strongly about Black Lives," she says. 

Hafeez explains, "In some ways, it highlighted and brought out the sensitivities that had remained hidden for so long. It made more people seek therapy in a most precocious and difficult moment. Patients and clients wanted to feel understood and accepted and therapists were not truly prepared for such a wave of collective psychological need." 

If a therapist does not meet one's needs by connecting with one on a human level, or empathizing with some of one's values or concerns, Hafeez recommends that one may choose to move on. "You’re wasting precious time and will not feel as committed to the therapeutic process. It is also okay to tell your therapist openly, candidly, and respectfully how you feel and see if the therapist can make a change," she says. 

In that way, such disclosure from a patient about unmet cultural needs may prompt therapists to seek out additional training to serve clients better. Hafeez recommends that such therapists learn from BIPOC colleagues, and listen to the patients or the population they serve. "Ask for training from your local chapters, including the more widely available online seminars and continuing education credits," she says.

Cultural Factors Can Impact Outcomes

Certified bariatric specialist, and neuroscientist, Renetta Weaver, LCSW-C, says, “It is about living in spaces where the subliminal message is I’m not seen or that the way I’m being seen is through the restricted lenses of other people’s stereotypes. And that is how I felt for many years living in my body as a Black overweight woman who was given the medical diagnosis of obesity with a culturally biased measurement of BMI."

Weaver reflects on "not being seen, not feeling heard, or feeling understood because after experiencing a number of adverse childhood experiences (ACEs), and crying every day starting in my 8th-grade classroom, no one acknowledged me. When my mother took me to the doctor to address my rapid weight gain, none of them asked what had been done to me, or if I was suicidal, which I was." 

While the term cultural competency often assumes taking a class in diversity means professionals know what is best for their clients, Weaver embraces intentional cultural sensitivity, which allows her to use her awareness that each client has a unique cultural story that is shaping the way they experience their life. 

By this, Weaver explains, "Cultural sensitivity allows us to get out of the way and invite our clients to share and release the burdens that their inner parts are carrying, while practicing with cultural humility allows us to hear how our parts are getting in the way."

Given her personal experience navigating bariatric surgery, Weaver worries about those patients who are deemed less than ready for a much-needed procedure, as it may stem from a limited understanding of the impacts of culture, trauma, etc.

Renetta Weaver, LCSW-C

Cultural sensitivity allows us to get out of the way and invite our clients to share and release the burdens that their inner parts are carrying, while practicing with cultural humility allows us to hear how our parts are getting in the way.

— Renetta Weaver, LCSW-C

Weaver notes, "Emotional eating is like any other addiction and that relapse is a part of recovery. Old habits are had to break and the habit of turning to food to cope with stress is a cultural norm for trauma survival. It’s a very young protective behavior that has nothing to do with laziness, lack of motivation or willpower." 

Trauma changes the brain and many in the bariatric community experience this, according to Weaver. "I hope that reading this changes someone’s cultural perspective towards people who live in larger bodies. I hope we stop mislabeling people with obesity for continuing to engage in eating patterns that helped them to survive," she says.  

Weaver explains, "Having a culturally-informed practice is what encourages clients to come back because you understand them and treat them with cultural attunement. They can intuitively see, sense and feel that in their being because emotional eaters are highly sensitive and often scanning their environment for safety."

In addition to her continued expansion of the Safe Place app to provide much-needed support for the mental health of Black communities, Pierre says, "I do work with the Congressional Black Caucus because the suicide rates for Black youth have skyrocketed. We are trying to get money for research and mental health resources, because even in the school system, the counselors are traumatizing these Black children."