Keywords

In the field of applied psychology, there have been a recent emphasis and even a requirement to employ what has become known as “culturally sensitive” or “culturally competent” practices in all professional services (e.g., Betancourt, Green, Carrillo, & Owusu Ananeh-Firempong, 2016; Griner & Smith, 2006). This movement was built upon two different constructs that are central to these efforts, “cultural sensitivity” and “cultural competence.” Cultural competence, although variously defined, has been characterized with a three-dimensional model (Chu, Leino, Pflum, & Sue, 2016), consisting of (1) a therapist’s cultural awareness and beliefs; (2) knowledge of a client’s cultural background, worldview, and therapy expectations; and (3) the development of cultural skills (Sue, Arredondo, & McDavis, 1992; Sue et al., 1982; Sue, Zane, Nagayama Hall, & Berger, 2009). Cultural sensitivity , again diversely defined, has been characterized as the “awareness of how cultural variables may affect the treatment process” (Sperry, 2010, p. 316). A purported claim for the necessity of cultural sensitivity and cultural practice is that clients who experience culturally insensitive behavior report a variety of adverse psychological reactions (e.g., feelings of being insulted, disconnectedness, uncomfortableness, even trauma). These psychological reactions, in turn, are considered to either interfere with the professional services being delivered or result in needless and unwanted side effects (e.g., weak rapport or ability to relate/connect with the therapist; see Sue et al., 2009).

To address these potential concerns, the cultural competence movement has taken a number of steps in an attempt to prevent or remediate these potential problems, including mandating coursework in professional curricula, requiring test items for licensing in some states, and influencing the professional standards and ethical codes of various mental health organizations. It is interesting to note that some of these standards, but not all, also recognize negative psychological reactions may possibly be exhibited by minority clients, especially related to discussions of cultural differences. For example, the National Association of Social Workers’ Standards and Indicators for Cultural Competence in Social Work Practice (2015) suggests that cultural competence entails the development of “skill and confidence to engage in and facilitate difficult conversations about cultural differences” (p. 49). The usage of the word “difficult” suggests that there is a reasonable likelihood that a client might feel some level of discomfort or some other negative psychological reaction, perhaps even with a culturally competent provider, as there may be no avoiding some level of “difficulty” in these complex conversations. While this standard appears to imply that the culturally competent provider should attempt to minimize the client’s level of discomfort, this standard still appears to recognize the possible shortcomings of such efforts.

This chapter will examine some of the assumptions and assertions of the cultural competence movement in relation to clients’ reported experience of negative psychological reactions and explain the problems with these, including the issues with reliability and validity of self-reports, lack of clarity of concepts related to key psychological reactions such as “uncomfortableness,” lack of discernment between levels of adverse experiences/impairment, whether the effects of the listener are always relevant, utilization of cultural competence to combat egregious behaviors/values, pseudo−/problematic attempts at relating to culturally diverse clients, whether cultural competence results in positive psychological reactions, and the lack of empirical support for the causal pathways that are assumed.

Case Example #1

To illustrate what cultural competence experts would view as being culturally incompetent behaviors, let’s consider a case example: Anderson, an African American male, arrives to therapy 15 min late. He states that he was late because he was being profiled by cops and was pulled over for speeding, though he was not going faster than the drivers around him. He spends 10 min of the therapy session stating that he was only pulled over because of his race and was unrightfully stopped. He continues, stating that African Americans are often mistreated by the police and it is hard being an African American with so many racists in the USA. Anderson’s therapist, a white female, tells Anderson he should not assume it was because he was African American and that white people get mistreated by police officers too, so it is not a racial matter. Anderson becomes upset and states that his therapist does not understand him and should not compare the African American experience in the USA to that of whites. He leaves the session early and is visibly upset as he walks out yelling that he does not trust white therapists because they don’t understand African Americans.

In this example, a cultural competence expert would likely view the therapist’s actions as being culturally incompetent. It would be argued that a culturally competent therapist would have acknowledged the oppression and prejudice African Americans have historically experienced. The therapist would not have challenged the client’s assertion that he was unrightfully pulled over or that African Americans get mistreated by police officers. It would be concluded that this therapist’s behavior caused such understandable negative psychological reactions (i.e., upset, distrust, being misunderstood) in the client, which is inappropriate and avoidable on the part of the therapist. However, it could be that the therapist was trying to assess the client’s core beliefs and help the client better understand whether him being pulled over was warranted or if his perceptions of being profiled were in fact true. Suppose the client is constantly in a state of anxiety and assuming he will be targeted by any white person he encounters, and this is a recurring theme in therapy. This cognitive schema could be exaggerated and not serving the client well. His exaggerated beliefs could be a target in therapy and reasonably rebutted by the therapist who perhaps comes from a rational emotive therapy orientation. However, such challenging of beliefs is prohibited in therapy by those in the cultural sensitivity movement when these beliefs are related to cultural factors, such as race. It is posited that by challenging the idea that minorities are oppressed in ways that they describe, a therapist will automatically cause a strong negative psychological reaction in the client and harm the therapeutic relationship. However, challenging inaccurate core beliefs is a common part of many forms of therapy, such as cognitive behavioral therapy, so should cultural competence standards forbid such practice?

It is important to note that there is no research that provides direct information about the kinds of psychological reactions, the frequency of these, how these may vary by minority status or other personal variables, or exactly what occasions minority clients might experience these reactions with behavioral health professionals who are not “culturally competent.” Further, there is no research to show the degree to which cultural competence training eliminates or reduces the likelihood or intensity of these adverse psychological reactions. The question also remains as to what does cultural sensitivity look like? At no point are professionals ever told what specific behaviors they need to exhibit to prevent these negative psychological reactions in their clients. Without this research to form a factual basis for these efforts, the cultural competence movement is built based on the various stereotypes of diverse groups and their reactions and assumes that, without such training (however unclearly defined, see Benuto, Casas, & O’Donohue, 2018), a professional will harm clients, particularly minority clients, either by not being as effective as possible or by unnecessarily causing negative psychological reactions in these clients. Also, interestingly, the culturally sensitive movement seems to be relatively sanguine about causing negative psychological reactions in majority clients or professionals, as there is very little effort in this movement related to avoiding similar adverse reactions when these individuals hear claims associated with the majority culture’s alleged sexism, homophobia, racism, or other problematic behaviors (see O’Donohue, this volume). The question also remains as to when, if ever, the effects or psychological reactions on the listeners (i.e., client) are relevant in the clinical context. The next section will address this issue.

Are the Effects on Listeners Relevant?

Applied psychology is supposed to be a scientific discipline (McFall, 1991). Science evaluates propositions not by their effects on listeners but by other properties pertaining to the claim itself—is the claim falsifiable, is it clearly stated, has the claim been tested, what is the quality of these tests, what is the cumulative quality of the evidence in support of these, are there data that falsify the claim, and so on. Never are these propositions in a scientific worldview evaluated by the effect these have on the listener. To do so would be a radical shift from normal rational appraisal of claims. For example, whether the earth rotates around the sun (heliocentric view of the universe) or the sun rotates around the earth (geocentric) is evaluated by astronomic evidence—not whether it can make certain people feel less important.

As such, in a scientific orientation, the effect of a claim on the listener is neither a necessary or sufficient property of a problematic evaluation of an utterance. Saying someone is offended by x doesn’t entail that the utterance is false, unwarranted, or otherwise problematic epistemically. Thus a listener’s adverse psychological reaction is not sufficient, nor is it necessary property, that the claim is problematic. The statement “all humans are completely wonderful” may not offend anyone, and in fact it may make many feel good, but the claim is still false—thus offense or a positive reaction is not a necessary property of a problematic proposition.

As O’Donohue (this volume) pointed out, it may be the case that the sort of claims of most interest to the cultural competence movement are not empirical claims but ethical/normative ones. This is important to note because ethical/normative claims are evaluated differently than empirical claims. “It is your duty not to lie” is evaluated differently than “centipedes live an average of 2 years.” The latter requires systematic empirical evaluations to evaluate its truth—the former does not. However, again, ethical claims are not evaluated by their effects on individuals. One may feel bad when one hears it is your duty not to lie, but if this is in fact a duty, these adverse psychological reactions are not evidence for the falseness of the duty.

Further, the major domain in which the effects on others are taken into consideration—and given the weight that cultural competence gives to it—is the domain of manners and etiquette. One often claims, for example, not saying “goodbye” upon leaving a social situation is problematic as it can make people feel bad. Not waiting until all are served before eating can make others at the table feel uncomfortable. Does cultural competence then become essentially a domain of professional manners? More evidence of this is also the claim that others will not only be offended by bad manners, but they will typically think ill of the “bad mannered”—something that is also occurring in this domain. If one is culturally insensitive, one will “offend” others, and others usually will think of one as sexist, racist, homophobic, etc. However, this is not likely the case, though cultural competence implies this is so.

Cultural Competence to Combat Egregious Behaviors/Values

One way of justifying the goals of the cultural competence movement is by stating that it is intended to promote a professional environment that does not tolerate usage of racial epithets, stereotypes, hate speech, speech suggesting violence toward minority, actual discriminatory practices, and other egregious behaviors. The American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (2002) states that:

Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status, and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices. and accept differences between their own values and those of their clients. (p. 4)

However, there is a general consensus that this prejudicial behavior is wrong in any context, not just the professional setting. This is a moral duty of all individuals, including behavioral health professionals, and it is important to note that this is independent of whether the listener experiences a negative psychological reaction. Therefore, cultural competence standards are not necessarily needed to combat such egregious behaviors, as it is implied in all contexts that such behavior is not appropriate—there has been no research indicating a significant likelihood that an entering first-year student in a psychology doctoral program , let alone experienced therapists, would believe, for example, that using racial slurs in therapy is appropriate.

While blatant prejudices are clearly counterproductive to the therapeutic process, current cultural competence standards leave room to assert that other behaviors may cause a significant impact. For example, if a Mexican-American client is hesitant to continue with treatment because his/her culture does not support receiving mental health treatment, a clinician could try to educate the client about the positive outcomes of therapy and help the client make an informed decision. While this is intended to benefit/educate the client and to motivate them to engage in treatment to improve their life, it may be misconstrued as culturally insensitive to suggest a client disregard their cultural values. The client might feel invalidated or conflicted by the therapist’s behavior or even that the therapist’s behavior was culturally insensitive. The therapist could be accused of invalidating the client’s values and culture when they are instead trying to provide an avenue of reducing distress in the client and assisting them with making the choice of whether it is beneficial to engage in therapy. This example also begs two questions: (1) who decides what is or is not a “cultural” variable or issue, and (2) even if this dispute of what constitutes as being a “culture,” where is it validly argued that so-called “cultural” issues are sovereign? A gang member in therapy may claim that it is “cultural” to take revenge on another gang member by killing him. Should the therapist therefore accept this belief simply because it stems from a so-called cultural practice? Additionally, motivational interviewing, which is an empirically supported practice in behavioral health (Vader, Walters, Prabhu, Huock, & Field, 2010), is sometimes intended to make people uncomfortable or experience distress (cognitive dissonance) through having them recognize differences in their behavior and their goals (Miller, 2010). Doing so helps motivate clients to make changes in their behaviors, as a means to achieve their stated goals. However, by creating even a minimal level of distress or discomfort in the client, it also provides the opportunity for a client or another to claim that unwarranted culturally insensitive behavior occurred that created the negative psychological reaction .

Types of Negative Psychological Reactions

One commonly feared reaction to “culturally incompetent” practices is claims about the feeling of “uncomfortableness”—though it is unclear what exactly this encompasses. Utterances are of the ilk: “That made me feel uncomfortable .” “I am not sure that I am completely comfortable with you saying that.” Another commonly used term to explain one’s negative psychological reaction although perhaps on the other end of the spectrum of seriousness is “trauma” or being traumatized. Again, statements could be along the lines of “When you did X, I felt traumatized”; or “Your failure to do Y made me feel traumatized”; or “When you mentioned Y, that was a trigger that caused me to reexperience my traumatization.” This is somewhat related to the recent focus on “trigger warnings” as both prudent and necessary. According to the American Psychological Association (2008), trauma encompasses strong psychological sequelae (e.g., horror, terror, or helplessness) in a response to rape, natural disasters, or other catastrophic events that may cause injury or death in oneself or others. Other constructs used to label clients’ negative psychological reactions include reported feelings of invalidation, dismissiveness, or being misunderstood. However, despite these potential negative psychological reactions, there are many issues with using these constructs as labels for such responses, primarily, that a negative psychological reaction, such as uncomfortableness or invalidation, is likely brief and far from being considered clinically significant.

First, there is a lack of operationalization of these adverse psychological reactions in the cultural sensitivity context, and, consequently, the terms can be commonly misused or used with significant variance . Relatedly of course these cannot be precisely measured as clarity in definition is a prerequisite for valid measurement. Is uncomfortableness a physiological response—or at least does this have a somatic component? Is it purely an emotional reaction? Is it unidimensional or multidimensional? Are there different kinds and levels of uncomfortableness? What magnitude of uncomfortableness is of concern—any? Can such uncomfortableness be multiply determined (e.g., caused by the therapist’s comment but also caused by other factors such as the clients’ own negative stereotypes about others)? Instead of parsing through these issues, cultural competence advocates instead use ill-defined labels such as “uncomfortable” to advance the position that a wrong was done and such ought to be prevented or perhaps the speaker ought to be punished.

Further, given that trauma encompasses intense psychological responses, such as horror, nightmares, and hypervigilance, even if the therapist said something related to culture that caused some sort of negative psychological reaction in the client, it seems unlikely a psychological reaction would reach the magnitude of being considered a traumatic event. To illustrate the difference in severity that would need to be demonstrated, we will refer to the canonical definition of reactions to trauma contained in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for post-traumatic stress disorder (PTSD), which is defined as “the development of characteristic symptoms following exposure to one or more traumatic events” (American Psychiatric Association, 2013, p. 274), including:

  1. A.

    Exposure to actual or threatened death, serious injury, or sexual violence directly experiencing the traumatic event(s), witnessing, in person, the event(s) as it occurred to others, learning that the traumatic event(s) occurred to a close family member or close friend, and/or experiencing repeated or extreme exposure to aversive details of the traumatic event(s)

  2. B.

    Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: (1) recurrent, involuntary, and intrusive distressing memories of the traumatic event(s); (2) recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s); (3) dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring; (4) Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) and/or; (5) Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

  3. C.

    Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: (1) avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) and/or; (2) avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

  4. D.

    Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: (1) inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs); (2) Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”); (3) Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others; (4) Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame); (5) Markedly diminished interest or participation in significant activities; (6) Feelings of detachment or estrangement from others and/or; (7) Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

  5. E.

    Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: (1) Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; (2) Reckless or self-destructive behavior; (3) Hypervigilance; (4) Exaggerated startle response; (5) Problems with concentration and/or; (6) Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

  6. F.

    Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

  7. G.

    The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  8. H.

    The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. (American Psychiatric Association, 2013, pp. 271–274)

First, and most importantly, is that criterion A is simply not met by comments and behavior of therapists typically targeted in cultural sensitivity training; perhaps such behavior is insensitive or unfortunate, but it does not constitute a trauma. That is, culturally insensitive comments or behavior simply doesn’t meet the definitional criteria of trauma. Next, given the strong wording of the diagnostic criteria (e.g., “persistent,” “recurrent,” “intense”), it is unlikely that one could validly claim culturally incompetent behavior solely caused the experience of diagnostically necessary negative psychological reactions (diagnostic criteria B–E), to the point of meeting all the diagnostic criteria of PTSD.

Acute stress disorder, which is a similar diagnosis to PTSD, is a psychological response to a traumatic event and lasts 3 days to 1 month (American Psychiatric Association, 2013). However, again, it encompasses the same strong, enduring psychological responses (e.g., persistent negative mood/lack of positive emotions, recurrent, distressing memories) and must cause significant impairment in functioning. These strong responses and impairment are not proportioned to the nature of the cultural incompetent behavior; thus a report of being traumatized due to cultural incompetence is an improper use of this construct.

Also, when a client states that a comment or a behavior of a professional “triggered” them, what does actually this mean? Exactly what psychological reactions resulted, and how does one evaluate the causal claim implicit in this assertion—i.e., that it was solely the behavior that caused the reaction? For example, it is a tenet of rational emotive behavior therapy (REBT) and other evidence-based cognitive behavioral approaches that events do not trigger emotions by themselves but that beliefs always mediate between environmental events and psychological reactions (it is not S- → R but rather S = →B-- → R). In this cognitive behavioral therapy (CBT) model, what sort of beliefs and contributions of the client’s psychological makeup or diatheses contributed to the alleged triggered reaction? Additionally, is the argument that a professional must comport oneself so that no level of uncomfortableness is ever evoked in any of their clients? Or is a certain level of discomfort acceptable—even around “cultural” issues?

With these allegations of experiencing adverse psychological reactions, it is also difficult to demonstrate causality, as there may be other variables contributing to the person’s uncomfortableness or other negative psychological reactions. If someone with generalized anxiety disorder or social anxiety is in session, it is likely that their symptoms of anxiety (e.g., sweating, fear of saying something wrong) will be causing uncomfortableness, so the likelihood of a therapist saying something that makes the client feel uncomfortable is substantially increased. It could instead be that the person feels discomfort because of their disorder and not due to the alleged culturally insensitive behavior of the therapist. Additionally, if a client is having a substantially stressful day or in the middle of a crisis, it is difficult to distinguish between what is a result of the accumulation of stressors and what is a result of the clinician’s actions. Also, suppose an African American therapist is working with a client who has biases against African Americans. It seems likely that the client would be seeking opportunities to see the therapist in a negative light (i.e., confirmation bias), when in actuality the client is being hypersensitive.

An additional problem with assuming causality is that, to our knowledge, there has been no research conducted that explicitly addresses the type and frequency of culturally “incompetent” behavior that produces negative psychological reactions, such as uncomfortableness or trauma in an individual. Does being told once that some of one’s values are maladaptive cause the average minority member to feel uncomfortable? Do only egregious behaviors, such as hate speech or racial slurs, create negative psychological reactions? Or can more covert, latent forms (e.g., “benevolent racism”) cause such distress? This also raises the question as to whether cultural competence is dependent upon the disorder the person has (see Frisby chapter in this volume on individual differences, this text). Would working with a client with a personality disorder cause different negative psychological reactions than a client with obsessive-compulsive disorder? Would people with these kinds of disorders have different (perhaps lower) thresholds? Given that individuals with personality disorders are more likely to make invalid or fabricated claims (see below), is it difficult to determine what kind of behavior a clinician could exhibit to avoid being deemed incompetent? Besides disorders, are there differences found between clients from different ethnicities or ages? There are too many unanswered questions and dimensions to understand or predict causality.

The Complexities of Self-Reports of Internal States

An internal state may also be called a private event. Skinner (1984) defined private events as those stimuli and events uniquely perceived by an individual, in that these can only originate and be experienced within one’s own skin—no one beyond the individual can directly experience these private events, though the individual can attempt to describe or explain these to another. When people report that culturally insensitive behavior makes them experience some sort of negative psychological reaction or internal state (e.g., angry, uncomfortable, anxious), there may be problems regarding the reliability and validity of their self-report since, by definition, these can only be directly experienced by the person reporting it. Therefore, one is unable to independently observe these events to determine whether those self-reports are in fact accurate and true.

There is some relevant research that illustrates these complexities. Between 9% and 18% of people are unable to “tact” or label the emotions they experience (Franz et al., 2008; Kokkonen et al., 2001; Parker, Taylor, & Bagby, 1989; Salminen, Saarijarvi, Aarela, Toikka, & Kauhanen, 1999). Alexithymia is defined as “individuals who presented to therapy with an inability to experience or at least describe emotions” (Darrow & Follette, 2014, p. 1) and commonly occurs when someone has a limited verbal repertoire, as a result of a history of a lack of shaping of behavior by their verbal community. Therefore, someone with alexithymia would have difficulty correctly labeling their emotions they are experiencing, which casts doubt on whether we can rely on all people’s self-reports of their negative psychological reactions—even more if that emotion does not match their affect or behavior. Further, in social science research, there has been a problem with relying on self-reports, due to possible biases in responses, including acquiescence bias (tendency to agree with all questions, disregarding the content of the question), extreme response style (tendency to select responses on end points of a scale, e.g., strongly agree, 1 on a scale of 1–10), and social desirability bias, which are all posited to have a relation to the culture one belongs to (Johnson, Kulesa, Cho, & Shavitt, 2005).

Johnson and colleagues (2005) also found that individuals from cultures that emphasized masculinity and individualism had an inverse relationship with acquiescent response behavior. This raises an interesting conundrum: ought reports of adverse psychological reactions be seen as universal and a-cultural, or are these relative to culture themselves? Therefore, those from societies with low masculinity were more likely to agree with all questions even when they were in doubt about the answer. In the clinical setting, a person who responds acquiescently would endorse emotions and the severity of such emotions at higher rates than likely appropriate. For example, if a client with a minority background said they felt uncomfortable and the therapist asked them various examples of what “uncomfortableness” is sometimes described as (e.g., feeling distressed, sweating), the client would agree. Further, if they were asked if the level of impairment was severe, they could immediately respond yes without exploring the accuracy of whether they felt severely impaired or not. It is comparable to being pressured by peers, in that they are not making insightful decisions and rather agreeing with whomever they are interacting with. Somewhat similarly, someone who responds following a social desirability style would agree with what the listener says and make decisions independently of how they are feeling. Instead, they would adapt their responses to assimilate what they believe the other would want. Therefore, the accuracy of the self-report would be invalid, and the results would be entirely predicted by the question asked, instead of reflecting the actual psychological reaction of the client. Given that the cultural competence movement asserts that clients ought to feel even slightly uncomfortable or tense when discussing topics relevant to culture, it is possible that clients may inaccurately express/label these psychological reactions. Biases as such reflect the limitations in relying solely on one’s personal account of their negative psychological reactions and, in this context, its relation to treatment and culturally competent practices.

As the cultural competency movement has expanded and more professionals are expected to implement practices to avoid being deemed “incompetent,” there has consequently been an increase in a client’s potential to either exaggerate or completely falsify claims of being distressed by a professionals’ competency, perhaps even for the client’s own gain. By making allegations of a professional’s cultural incompetence or insensitivity, the accuser may be reinforced or benefitted (e.g., being granted monetary damages, having their grade in class changed, seeking revenge for being rejected). Essentially, the movement has increased professionals’ liability when it has not yet been demonstrated that (1) these behaviors make clients experience negative psychological reactions;(2) a professional should have known ahead of time that their behavior would have such an effect; (3) making a client experience negative emotions such as “uncomfortable” or “invalidated” reaches some threshold where it is actionable and; (4) instead it may entice clients, especially certain clients suffering from certain problems (see below), to make false claims for their own personal benefit.

For example, suppose a therapist refers to an African American client, as a “colored person,” the client could (justifiably) become upset and report feeling distressed by being called a historically oppressive term (although the situation is a bit complex given the acceptance of the name of the NAACP). The therapist could then be sanctioned for culturally incompetent behavior that adversely affected the client’s psychological well-being. In this case, while calling someone a “colored person” is not politically correct given the historical usage of the term, it is unlikely the client would be significantly harmed.

This issue is further exacerbated with providing services to individuals with personality disorders. There are various symptoms of personality disorders that would make the accuracy of such self-reports of negative psychological reactions questionable. For example, individuals with antisocial personality disorder repeatedly lie and/or con others for their own personal profit or pleasure (American Psychiatric Association, 2013). Additionally, individuals with histrionic personality disorder expect others to approach them with excessive admiration and feel entitled to be treated on how they expect (American Psychiatric Association, 2013). Therefore, individuals presenting with this disorder may feel displeased if a therapist does not treat them with the level of respect and kindness they desire and may exploit the therapist for their own gain. Therefore, individuals with either diagnosis could be more likely to make false allegations of negative psychological reactions experienced because of the nature of their personality disorder.

Additionally, various other personality disorders consist of emotional lability, which may increase the likelihood of a client reporting an experience of negative psychological reactions at some point in treatment. For example, individuals with borderline personality disorder demonstrate “affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)” and “inappropriate, intense anger or difficulty controlling anger” (American Psychiatric Association, 2013, p. 663). Individuals with histrionic personality disorder also demonstrate emotional lability and show “self-dramatization, theatricality, and exaggerated expression of emotion” (American Psychological Association, 2013, p. 667). Individuals with either disorders experience negative emotions at higher rates than the general population; thus if they experience anger, discomfort, or some other negative emotions in therapy, it is likely not solely caused by the therapist but instead the nature of how the disorder manifests.

Lastly, paranoid and avoidant personality disorders include symptoms of feeling persecuted without sufficient evidence (American Psychiatric Association, 2013) and feelings of being criticized during social interactions (American Psychiatric Association, 2013); thus the highly sensitive manifestation of such paranoia (i.e., lower standard required to cause negative psychological reactions) may contribute to inaccurate or unwarranted allegations of incompetence. It is for these reasons that clients with borderline personality disorder, narcissistic personality disorder, and other personality disorders file higher rates of malpractice lawsuits because these populations are more likely to find faults in their therapists—either because of their own beliefs of persecution or victimization by all or because of their generally poor interpersonal skills (Hoffman & Steiner-Grossman, 2012). Despite these potential obstacles one may face while providing services for an individual with a personality disorder or overly sensitive individuals, this fear should not guide professional practice, nor do they warrant developing additional professional standards and required trainings.

In cases as such, where it has to be determined whether a therapist demonstrated culturally competent practices or not, the client’s accuracy and truthfulness about their report of adverse psychological reactions are a key factor. The only sources of information within these disputes are often the client’s own reports of their negative psychological reactions and perception of the events versus the clinician’s observations/inferences of the client and the events. This reliance on self-report of clients is problematic, as there is no current formal assessment of negative psychological reactions that is free of possible biases (e.g., social desirability, halo effect; Mazaheri, 2014). Some individuals may either intentionally falsify these claims or possibly even believe the therapist is cultural incompetent, when this may not always be the case. Given the various factors to consider, the validity and reliability of the causal effect assumed to exist between culturally incompetent practices and negative psychological reactions remain unknown.

Another issue that needs to be explored is whether allegations of cultural incompetence may cause reciprocal negative psychological reactions for the accused behavioral health professional. For example, if clinician is African American and is treating a LGBTQ client who says “You made me feel uncomfortable. All of you blacks are homophobic,” such an accusation may cause a negative psychological reaction in the clinician. What if this therapist is a practicing Catholic and, after much deliberation, views that the Church’s teachings are that homosexual behavior is sinful? Is this homophobic and does the clinician deserve this label? What if the clinician respected the views of others and did nothing to force his or her views on the client? The negative psychological reaction of the clinician is usually completely disregarded in these analyses, and instead the clinician is expected to ignore any negative comments about cultural insensitivity aimed at them, even if these might be prejudicial in nature. Cultural competence training usually does not address this potential prejudice exhibited by the client.

This problem is also found when the clinician and client are affiliated with the same cultural groups. For example, if an African American client becomes upset with their African American therapist and states that the therapist is “not black enough” and “does not understand the struggle of being black” because they are now in upper-middle-class socioeconomic strata, this may cause an even larger reciprocal negative psychological reaction in the therapist. However, scenarios as such are overlooked in current cultural competence trainings, and there is a sort of an inherent invalidation of a therapist’s psychological reactions (with the exception of psychodynamic therapies, where transference and countertransference are acknowledged and tackled). Therefore, if cultural competence training is deemed to be necessary, there needs to be an aspect that acknowledges that reciprocal negative psychological reactions may occur within the therapeutic setting.

This sort of asymmetry is also found when a majority culture clinician is working with a minority culture client (or vice versa). Only the negative psychological reactions of the minority culture member are considered of concern—not that of the majority culture member. It is even more problematic when the clinician and client are from separate minority groups. Race and sexual orientation are typically prioritized over other minority groups (e.g., based on religion, physical disability). Therefore, we would also see an asymmetry in the consideration of negative psychological reactions racial or sexual minorities experience, in comparison to that of religious minorities, for example.

Level of Impairment

In assessing the negative psychological reactions that are presumed to be caused by culturally incompetent clinicians, an important step to consider is whether these psychological reactions are causing any actual impairment and, if so, how and to what extent. Similar to diagnosing mental disorders, it might be suggested that there are three different levels of impairment. To distinguish between the three, it is important to consider the frequency and duration of the psychological reactions or symptoms, as with the diagnosis of psychological disorders (see American Psychiatric Association, 2013 for further detail about differentiation between levels of impairment).

First, there are acceptable levels of adverse psychological reactions such as stress, distress, disappointment, and interpersonal strife that occur in day-to-day life and the normal interactions with others, all of which in the usual case do not cause any sort of abnormal amount of impairment. For example, a teen may become nervous when a clinician asks them about their romantic relationships. While the teen may feel awkward or nervous for the moment, these negative psychological reactions disappear when the discussion moves onto a different topic or the teen habituates to the discussion of romantic relationships. Another example would be the improper usage of pronouns to address an individual. Since the expansion of possible gender pronouns an individual may identify with, a therapist may incorrectly address an individual as “she” when the individual prefers being referred to as “they.” In the context of race, an example would be improperly addressing someone as Mexican when they instead identify as El Salvadorian. While all of these examples may cause minor discomfort within an individual who is improperly addressed, it does not reach the magnitude assumed to be caused by culturally incompetent behaviors, and these are very easily addressed by having the client educate the therapist of what they identify as—no formal training is necessary. This sort of behavior is not warranted to be considered culturally incompetent, but very rarely is this level of impairment considered.

Next, there is subclinical impairment of functioning. In this level, some impairment in functioning is present but not sufficient to be considered a disorder or “clinically significant.” In this sense, the source of stress or some other negative stimuli causes some negative effect on one’s life, but these negative effects are not present in many contexts of the person’s life (e.g., at home but not at work or school), do not last long, generally are of lower magnitude, or do not occur often. Benevolent sexism, defined as patronizing a woman in a way that appears to be flattering but simultaneously promotes male dominance (Becker & Wright, 2011), would likely fall under this category. For example, if during an assessment a female client states that she works at a law firm and the clinician states “oh secretaries are an important part of any organization,” this would be a form of benevolent sexism because the clinician assumes that the client’s profession is a secretary because she is a woman. This, along with microaggressions (i.e., subtle racial slights or insults; Torres, Driscoll, & Burrow, 2010), may make the client feel offended and become momentarily upset. They may hold onto that anger for longer than the session (maybe even for a day or two); however, it is unlikely that they would be able to identify any sort of significant impairment in their functioning at home, school, or work life. This would generally be considered subclinical because, while they exhibit some symptoms and negative psychological reactions, the client’s life is not being significantly impacted to the point that intensive intervention is required to improve. The negative psychological reactions will likely remit on their own without individual therapy—the same principle of the mind being able to naturally recover, void of intervention, applies as it does in other psychological symptoms (e.g., PTSD, social anxiety; Kolassa et al., 2010; Vriends, Bolt, & Kuns, 2014).

Lastly, there may be significant impairment of functioning that is considered in the disordered or clinical range. This would be when the “disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” (American Psychiatric Association, 2013, p. 21). In this regard, the negative psychological reactions would be longer-lasting, be apparent in various contexts, and occur more often than not. Given the extent of impairment, treatment would be necessary to extinguish such symptoms. More blatant forms of prejudice (e.g., hate speech, racial slurs) may cause impairment to this extent, especially if the therapist is constantly bullying the individual. However, more acute and minor forms likely would not reach this level, and it seems unlikely that a client would continue attending treatment if the behavior was so overt and hurtful. In addition, it seems unlikely that such a person (one who bullies individuals and uses hate speech in therapy) would be able to graduate from a program and gain a license, as there are no known cases of this. The cultural sensitivity movement can’t be validly predicated on the assertion (or strawman fallacy) that this type of behavior frequently occurs and needs to be remediated.

Despite these distinctions between levels of impairment, when one makes a claim about a professional exhibiting culturally incompetent practices, it is generally assumed that the negative psychological reactions are significantly impairing them and thus deserve the attention that these generally receive. However, that may not necessarily be the case—it is almost unlikely it could. This is an important distinction to make. Is it justifiable to have a professional be reprimanded for breaching the ethical standard of being culturally competent when the client has a brief moment of “uncomfortableness” within the session? Given that there are often standard topics that come up during treatment, especially during assessment, which commonly make people feel uncomfortable yet are not reported, why are only topics related to culture considered inappropriate and capable of significantly impairing an individual? Are such feelings idiosyncratic—some individuals react strongly to x (e.g., “being called a girl”), while others not at all. How is a therapist to predict this? Is very bland behavior always recommended?

Pseudo/Problematic Attempts at Relating to Culturally Diverse Clients

From the cultural competency perspective, when a clinician attempts to relate to diverse clients by perpetuating stereotypes of the client’s culture, the client may experience negative psychological reactions. This is purported to occur when a therapist treats a client as a token of the cultural group they belong to, instead of as the individual that they are. Could this in fact cause negative psychological reactions in the client similar to overt prejudices? For example, if a therapist says “I like burritos” to a Hispanic American or “Barrack Obama was my favorite president” to an African American, does this have the ability to engender feelings of “uncomfortableness ” or “trauma” or “being triggered” in the client? Exhibiting these behaviors may reinforce one’s distrust or disdain for majority culture, but it is unlikely the reactions could result in psychological reactions or disorders or any sort of significant distress. Further, is this truly considered culturally incompetent behavior? Nowhere in current professional standards are these attempts directly prohibited, and this may be beneficial to building rapport with an individual. With child clients, professionals try to not sound like an authoritative figure and instead try to seem “cool” and relatable, so why is it any different to make such attempts with clients belonging to other forms of culture, such as ethnicity or religion? Further, are children or individuals with low cognitive ability likely to understand and be aware of when they should be offended or uncomfortable?

In addition, there has been little concern to identify or address possible negative effects induced by cultural competence training itself. Does such training itself produce adverse psychological reactions? Does it rely on stereotypes such as Hispanic males are macho that can produce adverse psychological reactions? Does it avoid critical problems such as prejudice and oppression and instead deal with proxy and more minor issues which can produce negative psychological reactions? Does it produce psychological reactions in certain groups like Catholics, Jews, and Muslims because of their religious beliefs? Does it create a sense of fundamental incompetence in dealing with the vast arrays of minority groups and their intersectionality? Does it produce a false sense of competence that will inevitably lead to future adverse psychological reactions because it fails to do what it attempts to do—produce cultural competent behavior?

Cultural Competence and Positive Psychological Reactions

Given the promised benefits of the cultural competence movement, it is important to assess whether cultural competence results in positive psychological reactions. To our knowledge, no data exists that directly addresses the relationship between positive psychological reactions and cultural competence. Instead, research focuses on patient satisfaction and/or patient adherence to health care/treatment (e.g., Beach et al., 2005; Way, Stone, Schwager, Wagoner, & Bassman, 2002). While the data demonstrates overall moderate effect sizes, it does not provide any insight into the psychological reactions of the patients, and there may be confounding variables (e.g., less life stressors, recent job promotion, good rapport building). Therefore, the reported satisfaction does not necessarily mean the patients have positive psychological reactions solely as a result of culturally competent practices.

Additionally, it is unclear what dosage of culturally competent practices is necessary to yield positive psychological reactions, as well as what demographic variables serve as predictors—do culturally competent practices yield positive psychological reactions for Jewish individuals? Physically disabled individuals? Does it differ depending on how many distinct minority cultures one belongs to? It seems unlikely one would be able to parse through these various steps to decide upon how to be culturally competent enough to only create positive reactions, which could explain the lack of research directly addressing this. It is also possible that attempting to only cause positive reactions in a client could detract from the therapeutic process, as a clinician would be hypersensitive, out of fear of making a client uncomfortable, triggered, or traumatized.

Conclusions

The cultural competence movement has aimed at improving treatment for diverse individuals by equipping professionals with more culturally sensitive/appropriate tools to reduce commonly reported negative psychological reactions in clients. However, despite these attempts, there are various limitations that need to be acknowledged. The commonly reported negative psychological reactions are not well-defined, the primary data used in these allegations are self-reports which may be biased and invalid, the level of impairment often is not assessed, and there are no empirical data to support whether these culturally competent trainings even reduce negative psychological reactions or rule out iatrogenic effects. In addition, it is not clear that the psychological reactions of a person are even relevant in evaluating a claim in a scientific epistemology.

Further, can cultural competence even ensure this happens? It is unlikely one could be trained in how to be competent at working with all diverse individuals, as there are many subgroups of cultures (e.g., upper class vs. lower class, urban vs. rural, Mexican-American vs Cuban-American). Cultural identity is too complex and heterogeneous (Leung & Cohen, 2011). Psychological reactions vary between individuals from the same culture, and even popular opinions of cultural groups regularly fluctuate (e.g., during a time of political turmoil, individuals affected may be more sensitive). There is also no research that demonstrates what specific things related to culture will upset individuals or make an individual experience positive emotions. These shortcomings make cultural competence training unimportant, as it does not capture the perspectives of diverse individuals as well as it claims to.

Despite that these questions and limitations remain unresolved, a plethora of organizations continue to adapt their ethical standards and principles to include cultural competence considerations (e.g., the American Psychological Association, National Association of Social Workers). They continue to state all the detrimental effects that may result from culturally incompetent behavior, and while there may be some level of discomfort or anger within a session, it does not warrant such a comprehensive, new approach toward treatment. Thus far, instead of serving as a scientific or “best practices” movement, it has instead become a sociopolitical advocacy movement.