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Psychoanalytic Psychology ©2014 American Psychological Association
2015, Vol. 32, No. 2, 275–292 0736-9735/15/$12.00 DOI:10.1037/a0034041
CULTURALCOMPETENCEASACORE
EMPHASIS OF PSYCHOANALYTIC
PSYCHOTHERAPY
broadly. Pratyusha Tummala-Narra, PhD
publishers. Boston College
allieddisseminated
its be Psychoanalytic theory has been criticized for decontextualizing individual de-
of to
one not velopment. While recognizing the historical neglect of sociocultural context in
or is psychoanalytic theory, this article raises attention to psychoanalytic contribu-
and tions to the exploration of sociocultural issues in psychotherapy and calls for a
user systematic inclusion of cultural competence as a core area of emphasis of
Association psychoanalytic psychotherapy. The article includes a brief review of cultural
competence in professional psychology, and both a critique of psychoanalysis
individual regarding the neglect of sociocultural context in psychotherapy and a discussion
the of psychoanalytic contributions to a complex understanding of sociocultural
Psychologicalof issues in psychotherapy. Specific approaches to cultural competence that extend
use existing psychoanalytic theory concerning sociocultural context are presented.
American These include the recognition of historical trauma and neglect of sociocultural
the personal issues, indigenous cultural narratives, role of context in the use of language and
by the expression of affect, influence of experiences of social oppression and stereo-
for types on therapeutic process and outcome, and the dynamic nature of cultural
identifications.
solely
copyrighted Keywords: psychoanalytic theory, psychoanalysis, psychotherapy, cultural
is
intended competence
is
document Psychoanalytic theory has been criticized for neglecting issues of social context and
Thisarticle identity and for privileging internal life over external realities of clients in psychotherapy
This (Brown, 2010; Wachtel, 2009). However, many psychoanalytic scholars over the two
decades in particular have examined various aspects of social context as it relates to
intrapsychic and interpersonal processes (Akhtar, 2011; Altman, 2010; Leary, 2006). The
present article aims to extend psychoanalytic contributions to the understanding of
diversity to a more systematic inclusion of cultural competence as a core, essential
component of psychoanalytic psychotherapy. In the following sections, I discuss how
This article was published Online First May 5, 2014.
Correspondence concerning this article should be addressed to Pratyusha Tummala-Narra,
PhD, Boston College, 319 Campion Hall, 140 Commonwealth Avenue, Chestnut Hill, MA 02467.
E-mail: tummalan@bc.edu
275
276 TUMMALA-NARRA
cultural competence has been defined in professional psychology, a critique of psycho-
analytic approaches to social context, recent psychoanalytic scholarship that addresses
issues of social identity, and the ways in which psychoanalytic theory can both be
transformed by and transform existing understandings of cultural competence in profes-
sional psychology.
Cultural Competence in Professional Psychology
Multiculturalism, identified as the “fourth force” in psychology (Pedersen, 1991), aims to
broadly.“encourage inclusion and enhances our ability to recognize ourselves in others” (Comas-
publishers.Díaz, 2011). The multicultural counseling movement in mental health paralleled the Civil
Rights movement of the 1950s and 1960s (Arredondo & Perez, 2003; Hurley & Gerstein,
allieddisseminated2013). Psychologists began to challenge the universal applications of psychotherapy
itsbe approaches rooted in Euro American cultural values and norms. Further, the multicultural
ofto movement in psychology, along with feminist psychology, has challenged traditional
onenot approaches to psychotherapy for rarely addressing issues of power, privilege, and more
oris broadly social context. From this view, Western-based psychotherapies, such as psycho-
and analytic, cognitive-behavioral, and humanistic therapies have historically decontextual-
user ized, ahistoricized, and depoliticized individual development. It is worth noting that
Associationscholars such as Abram Kardiner and Georges Devereaux, using a psychoanalytic-
anthropological framework, challenged the cross-cultural application of psychoanalytic
individualideas, and a number of psychoanalysts in the middle of the 20th century, such as Eric
the Fromm, Karen Horney, Harry Stack Sullivan, and Erik Erikson, argued that development
Psychologicalofis shaped by contextual issues that vary across cultures and time periods. In the 1970s,
use 1980s, and 1990s, American psychiatrists and psychologists who took an anthropological
perspective, such as Kleinman (1995), focused on culturally distinct explanatory models
Americanof distress. However, as Comas-Díaz (2011) has noted, psychiatric and psychological
thepersonalanthropology, and the cultural school of psychoanalysis did not develop specific methods
bythe to translate the theoretical understandings of culture and context to clinical practice.
for Multicultural psychology, on the other hand, involved a turn toward new models that
solelywould explain minority and majority group identities as rooted in the context of particular
copyrightedsocial (gendered and racialized) interactions. The new frameworks that emerged recog-
is nized that psychotherapy, which decontextualized, apoliticized, and ahistoricized devel-
intendedopment may actually contribute to internalized oppression and a compromised sense of
is agency (Atkinson, Morton, & Sue, 1998; Comas-Díaz, 2011; Helms, Nicolas, & Green,
document2010). The American Psychiatric Association (1994) published the cultural formulation
Thisarticleand culture-bound syndromes, in response to the increasing awareness of the role of
This culture in diagnosis. The American Psychological Association developed guidelines for
providers of services to ethnic, linguistic, and culturally diverse clients, and it was not
until 2003 that it approved its Guidelines on Multicultural Education, Training, Research,
Practice, and Organizational Change (American Psychological Association, 2003). These
guidelines support the place of context in a client’s life and call for culturally competent
practice, including using culturally appropriate assessment tools and psychological tests,
the inclusion of a broad range of psychological interventions, and the inclusion of
culture-specific healing interventions (Comas-Díaz, 2011). Cultural competence devel-
opedasaframeworkinmentalhealthinthe1970sand1980stoaddresstherapist’sneglect
of sociocultural context in the client’s life and its impact on psychotherapy process
(Kirmayer, 2012). Cultural competence refers to a process or an orientation that is not
CULTURAL COMPETENCE 277
weddedtoanyspecifictechnique, but rather involves “a way of construing the therapeutic
encounter” (S. Sue, 2003, p. 968).
Stanley Sue (1998) suggested that the essence of cultural competence involves
scientific mindedness, which encourages therapists to resist premature conclusions about
clients who are from a different sociocultural context than themselves, dynamic sizing,
whichinvolves the therapist’s ability to appropriately generalize and individualize client’s
experiences such that stereotyping is minimized, and culture-specific expertise, which
involves the therapist’s specific knowledge about his or her own sociocultural context and
that of the clients with whom he or she works. Derald Wing Sue (2001) further elaborated
on the need to address universal, group, and individual levels of personal identity,
broadly.emphasizing that therapists tend not to attend to the influence of individual’s connection
publishers.with groups, such as ethnic or religious groups, on their psychological well-being. In this
perspective, cultural competence is linked with social justice, providing access to appro-
allieddisseminatedpriate mental health services (D. W. Sue, 2001). Culturally competent therapists aim to
itsbe engage with several tasks: (a) develop (therapist’s) self-awareness; (b) develop general
ofto knowledge about multicultural issues and the impact of various cultural group member-
onenot ship on clients; (c) develop a sense of multicultural self-efficacy, or the therapist’s sense
oris of confidence in delivering culturally competent care; (d) understand unique cultural
and factors; (e) develop an effective counseling working alliance in which mutuality and
user collaboration are emphasized; and (f) develop intervention skills in working with cultur-
Associationally diverse clients (Constantine & Ladany, 2001; D. W. Sue, 2001). Several obstacles to
cultural competence have been outlined in the literature, such as the difficulty of address-
individualing one’s personal biases, the tendency to avoid unpleasant topics such as racism and
the homophobia and accompanying emotions, and the challenge of accepting responsibility
Psychologicaloffor actions that may directly or indirectly contribute to social injustice (D. W. Sue, 2001).
use Although the multicultural movement has been a major influence in research and
practice in psychology, approaches to cultural competence have been criticized by mental
Americanhealth professionals. For example, literature concerning cultural competence has been
thepersonalcriticized for reducing culture to ascribed or self-assigned membership to a specific group,
bythe contributing to a view of culture as characterized by fixed features that are disconnected
for fromtheindividual’s life history (Fowers & Richardson, 1996; Kirmayer, 2012). The term
solelycultural competence often evokes feelings of anger, helplessness, and frustration among
copyrightedacademics and clinicians. Interestingly, similar to the way that the word feminist is
is received in contemporary society, this term can even be experienced at times as oppressive
intendedandburdensome.Theuseofthetermcompetencehasbeencriticizedasimplyingtechnical
is expertise, drawing attention to the institutionalization of cultural competence as poten-
documenttially dangerous to the regulation and delivery of mental health services (Kirmayer, 2012).
ThisarticleAlternatively, theorists have proposed that the concept of competence be broadened such
This that culturally responsive and competent treatment be defined to be more inclusive of a
variety of different therapeutic approaches. In addition, mental health professionals have
recently advocated for an expansion of multicultural competencies to include an interna-
tional focus, drawing attention to increasing economic and cultural interconnectedness in
contemporary society (Hurley & Gerstein, 2013).
Onapractical level, clinicians struggle with the application of multicultural guidelines
as they typically have little support during and beyond their training years in the
translation of these guidelines to their interactions with clients in psychotherapy (Tum-
mala-Narra, Singer, Esposito, & Ash, 2012). Although many programs in counseling
psychology and clinical psychology now require a course in cultural diversity, with the
hope of implementing these principles of cultural competence, there is a great deal of
278 TUMMALA-NARRA
variation in definitions and implementation of cultural competence in training and beyond,
the receptivity to this framework, and the evaluation of cultural competence in practice.
Much of the criticism of existing approaches to cultural competence in professional
psychology center around the complexity of navigating across and within individual,
interpersonal, and systemic issues relevant to client, the therapist, and the therapeutic
process, and of addressing the dynamic nature of culture itself. A psychoanalytic per-
spective can facilitate an understanding of why the implementation of cultural competence
requires a deeper examination of social context and identity.
broadly. Critique of Psychoanalytic Approaches to Social Context
publishers.
McWilliams (2003) has pointed out that therapists are not neutral, and that therapists
allieddisseminatedreveal to clients their psychoanalytic values and attitudes. In her view, therapists socialize
itsbe clients in how to engage with the therapeutic relationship (e.g., frame), express emotion,
ofto and engage with issues of development, the effects of trauma and stress, sexuality, and
onenot self-esteem. Although there has been increasing recognition in psychoanalytic models that
oris
and the therapist is not a “blank screen,” and perhaps should not even try to assume this
position, few scholars have addressed what this particular type of socialization may feel
user like to clients depending on their particular social and cultural context. Among psycho-
Associationanalytic journal publications concerning overarching analytic principles or areas of
emphasis, there are no articles that mention attending to the client’s and the therapist’s
individualsocial and cultural contexts as a basic value of psychoanalytic approaches. This is also true
the for the papers that include reviews of empirical evidence for the efficacy of psychoanalytic
Psychologicalofpsychotherapy. There is no mention in these papers (Luborsky & Barrett, 2006; McWil-
use liams, 2003; Shedler, 2010) about the potential influence of social context in clients’ lives
Americanor in the efficacy of psychoanalytic or psychodynamic psychotherapy.
thepersonalWatkins (2012) examined reviews and meta-analyses of psychodynamic treatment
bythe over the past decade (a total of 104 studies, including over 9,000 participants), and found
for that approximately 75% of the studies did not provide any information about race or
ethnicity, and when this information was provided, 75%, 21%, and 4% of the participants,
solelyrespectively, were identified as being White, Black, or other (i.e., Asian, Hispanic,
copyrightedAmerican Indian, and unspecified). The exclusion of information about race and ethnicity
is
intendedis not particular to empirical studies. Such exclusion is also evident in discussions of case
is studies and case material in clinically oriented scholarship, when the social identity of the
documentclient and that of the therapist are either not mentioned at all or mentioned briefly without
Thisarticleconnecting social identity factors with clinical presentation or the therapeutic process.
This Testing instruments further exclude social identity. For example, the Shedler-Westen
Assessment Procedure (SWAP; Shedler & Westen, 2007), which aims to assess inner
capacities and more broadly healthy functioning, does not include any items correspond-
ing to cultural identity or adjustment. There is an assumption that operates when social
identity is neglected in these ways, that is the assumption of what composes a “healthy,
normative”client and a “healthy, normative” therapist. The neglect of cultural competence
as a core emphasis of psychoanalytic theory stands in contrast to recent efforts of theorists
from some other theoretical paradigms. For example, some cognitive-behavioral theorists
(Hays, 2009; Newman, 2010) have explicitly stated that cultural competency is a foun-
dational principle of CBT, on par with principles such as respecting and understanding
scientific underpinnings of treatment and an emphasis on the therapeutic relationship.
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