Cultural Humility: Curiosity Failure Critique Respect Growth

Proem

Something is missing. I’m not yet ready to conclude this series on emerging adults with mental illness. In the next and last episode, I’ll dive for pearls in the fifteen episodes published over the past ten months. What’s nagging at me? Each guest spoke from the culture they knew and the cultures in which they received or offered treatment and service. I need an episode about how people can approach, be curious about, and be open to the cultures they experience. Is this cultural competence or sensitivity or what?

I sought experts working with a kaleidoscope of cultures—first, Jamila Xible, a previous guest and community health worker with Cambridge Health Alliance. Jamila blows my socks off whenever I speak with her.

Next, my friend and previous guest, Kiame Mahaniah , referred me to Catherine Smail, Ph.D., a psychologist at the Lynn Community Health Center. Cat is a clinician therapist and the Associate Director of Training for Behavioral Health. Erika Malik at the Innovation and Value Initiative referred me to Theresa Nguyen, Ph.D., who has a social work background at Mental Health America . Theresa primarily does research and runs their screening program of youth coming onto the internet to solve problems for the first time. Hang on. Here we go. I learned a ton.

Podcast intro

Welcome to Health Hats, the Podcast. I’m Danny van Leeuwen, a two-legged cisgender old white man of privilege who knows a little bit about a lot of healthcare and a lot about very little. We will listen and learn about what it takes to adjust to life’s realities in the awesome circus of healthcare. Let’s make some sense of all of this.

Cultural competence

Health Hats: Let’s discuss cultural competence, sensitivity, and humility. How do cultural humility, sensitivity, and competence come into the team sport of best health? We’ll dwell here briefly, hearing all three guests speak in depth.

Catherine Smail: Cultural competence came about in the eighties, a first attempt to start grappling in a new way with the disparate health outcomes that providers saw in their immigrant populations. They tried to understand why that was happening and how to improve care to address it. Cultural competence is becoming aware of your own, who you are, and where you fit within your culture. It’s also about fact-finding, knowing the history of a culture different from yours, and knowing essential customs. One of the challenges is that when you get into medicine or get to a doctoral level of education, society expects you to adopt this expert position. We don’t get to walk into the room and be the experts we are trained to be. And that can feel hard and challenging. That’s a lot of tension, but yeah. It’s a lot to hold.

And cultural humility calls for us to do the opposite and to approach people in a way that feels more squidgy.

Health Hats: I think that, so you’re not excluding, or cultural competence, what you’re saying is it’s not sufficient.

Catherine Smail: Cultural competence can cause harm if you take a bird’s eye view of a population and then apply that to all people.

Are in that promote stereotypes. And that’s the harm in it. Yeah. Okay. Okay. So it’s a starting place but not a place to rest.

Cultural sensitivity

Theresa Nguyen: I’ve trained to be a clinician. I have trained others to be clinicians. You have your books. You have what the theory says and what the book says. The book says cultural sensitivity is about learning about other cultures, being prepared to address your bias, and to be aware of those issues.

And I think that’s true. I don’t think it lends to, as a person, how I’m supposed to take these words and apply them to a relationship. But I think if you think about this in a different context, like we are all human beings, I could be your friend, Danny if I took the time to be your friend.

And it doesn’t matter that I’m Vietnamese and you’re Danny. When we come together, and we want to be genuine, and we want to be friends, each of us takes a position of curiosity, love, support, and kindness, right? And I think that’s probably the number one requirement for good cultural sensitivity.

It takes sensitivity because how I define my culture is one tiny piece of the pie of who makes up myself, like me, Theresa. I don’t even represent Vietnamese people; I represent a halfway-generation immigrant who grew up born in America, and maybe that’s all I can speak to. I can’t say I would want a Vietnamese therapist, per se, because they would somehow understand my culture. After all, they might not understand my family dynamics. Are there things that they would share that would be easier?

I’ve had some therapists who come off pretty strong off the bat by saying things like it sounds like you are X, Y, or Z, and to my brain, I’m like, that may be true, but it sounds especially harsh in the context of my family dynamic. I can’t abandon my family, just set boundaries and say screw you all. You’ve hurt me, so I’m going to cut you off. I don’t think I’d be in therapy if it were that easy. And it’s not just my culture that I come from; it’s a communal culture, and I come from an immigrant culture. So, my family only had each other. They didn’t have anybody else. So many things go into understanding those dynamics that if a therapist is curious and explores, that sets the relationship up on a good footing to help people understand how my culture and family dynamics influence my decisions. And then you, as a clinician and curious guide, can help me build insight and then develop boundaries. Does that make sense?

Healthcare, a product not delivered alone

Jamila Xible: Dr. Jann Murray-Garcia and Dr. Melanie Tervalon developed the concept of cultural humility in the early nineties when there were many racial tensions. Thirty years later, we still have the same issues. I was privileged to be trained by Dr. Tervalon, inspired by what she said. Healthcare is the only product that cannot be delivered alone by a healthcare professional. It needs the involvement of the person receiving it.

Let’s say you go to your doctor and say, I have this horrible headache. I can’t get out of bed most days. And the doctor says, oh, here, take this pill, gives you the prescription, and you go home. Perhaps you didn’t dare say, what is that for? What is it going to do for me? And the doctor didn’t give you that space either. I’m talking about a doctor, but it could be a nurse, a primary physician assistant, or another provider. If that person does not understand the plan and does not buy into it, the appointment will be lost. Do you have any questions, and what do I need to know to treat you well? You need to know that if you tell me I’m depressed, I might look for my religious leader or take herbal tea. I wouldn’t say I like pills.

So, when you talk about cultural humility, it is that humility to understand the other person in front of you. From what they tell you to what they need. You can be the all-powerful provider and tell you what’s good for you and what you know, what you can do to treat yourself, or you can say, let’s do this together. What do I need to know about you to treat you?

Not the same person forever

Jamila Xible: Cultural humility differs from a previous concept of cultural competence. And there was a time when everybody was trying to learn everything about you, Danny, and all your characteristics so that once I knew it, I could help you.

But you are not one person that will be the same forever. Maybe I can understand one part of you, but you are multi-dimensional. Look at me. I was born in Brazil. I am a white Latina cisgender with roots in many different countries. I’m Middle Eastern and Mexican. You might come to me and say, oh, you’re Brazilian. You might like Feijoada, you might like to go to the beach because that’s what Brazilians like. But Brazilians can be from the north, south, or center. They can be people of color. They can be straight or gay. They can be several things. And every aspect of that person, every dimension, will make that person unique. So cultural humility is the humility to listen, understand, and try to see what you are for regardless of that list of traits. Okay. Chance, I know this about you. I know that about you, so I feel like when you stop and listen to people in the health field, like in my role, I’m a health educator. Without having that discussion, I cannot go out there and tell people what good or what kind of lifestyle will be good for their health. Is this something that you are interested in discussing with me?

Curiosity in not knowing

Catherine Smail: And it’s different from cultural competence because it occupies more of a stance. So, it goes beyond education about the nuts and bolts and is about occupying the stance of not knowing. So when you have an individual presenting with illness, it’s essential not just to see them as somebody occupying a particular cultural space. But it’s essential to see them within their many contexts, right? That’s where intersectionality comes in, that we’re at this intersection, where our ability to be able-bodied or our race, age or gender expression, like all those things, come together to create an individual.

And so the idea of cultural humility is that you stand in that place of not knowing, and you can present yourself and treatment and ask questions so that the patient can inform you about who you are or who they are. Then, you can better the treatment plan with them and offer them services in a more individualistic way that will be more successful for them.

Health Hats: So, it sounds like curiosity. Are you curious?

Humility and getting it wrong are inexorably linked. I have so many stories about getting it wrong. My embarrassment, mortification, and if, I’m lucky, humor.? I’ve made some kind, warm, lasting friends getting it wrong.

Reading the room, getting it wrong

Catherine Smail: What you’re talking about is an important skill. I would say at least 50% of this work and cultural humility is being able to be wrong and to mess up with a little bit of grace. And humor, and you build that. Yeah. Yeah. You build that thicker skin over time. And realizing that, wow, like you’ve said, I’ve been wrong half the time. But that doesn’t necessarily mean that I’m a terrible person. It just means that I’m trying. And I can incorporate that new information and do better next time. Interesting. So you have to be able to hold both that I need to make progress, but also. I’m going to mess it up along the way.

Health Hats: I’m trying to get at this issue of having enough self-confidence to listen. And then, I have enough self-confidence to accept, oh, I read that wrong.

Self-reflection and self-critique

Jamila Xible: What you are talking about is one of the fundamental principles of cultural humility: a lifelong process of critical self-reflection and self-critique. That means you’re always thinking about what you bring. What am I bringing into this relationship with my client, patient, friend, or family? And in your case, you brought your bias there, right? That person would be him, he, she, her, right? So that self-reflection, so you, we all have biases, right? And it’s okay. That’s how we are brought up. We learn certain things and see life and the world through those lenses. The problem is when we are unaware of those biases and allow them to impact our work with our patients and clients negatively. So, that’s one of the principles; in that principle, you are looking at how dynamic you are as a human being. And with the changes in experiences, like you had that experience, right? Next time, that will impact how you treat that person who opened the door. So, you changed. You’re changing daily. And the person in front of you is also changing daily.

Not interacting with a statue

Health Hats: You’re not interacting with a statue.

Jamila Xible: You are not interacting with somebody who has certain traits because of where they were born, because of their sexual orientation, or because of their social standing. It’s a person that is constantly changing with experiences.

Redress the power imbalance

Jamila Xible: The second fundamental principle of cultural humility, Danny, redresses the powering balance in this patient-provider dynamic. When I tell you as a provider of services, a provider of health services, or, like in my case, in a community setting, when I tell you that I know what’s good for you, and here you go and take it. I’m the all-powerful here. I’m not doing anything to redress that powering imbalance, so you must involve the person in decisions they must follow up on. The third principle is developing mutually beneficial partnerships with communities on behalf of individuals and defined populations. And that’s something that I do all the time. Yeah. And we often attempted to say, oh my gosh, I read all of this and know everything about community processes. I know everything about the way people live. You have this frame of reference that you bring with you.

And I see that happening all the time with wonderfully intentioned individuals. I’m here, and I want to help. And a lot of the folks that are concerned about equity, they come in with all these theories and incredible knowledge that they develop when the most important thing is when they look at, in my case, I look at communities that are, that have been historically broken, disadvantaged, and lacking resources.

Many of the networks don’t function. Many institutions that could be helping them are pressed for resources, and they’re not working. So, when you look at them, you see chaos. And you try to apply all your book smarts on that instead of developing a partnership to say, okay, so what’s going on here, and how can we together figure out what the solutions are?

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What about emerging adults?

Health Hats: I wanted to return the discussions to emerging adults with mental illness. Each guest had a nuanced perspective.

Emerging Adults go through this process of rejecting everything, adopting what’s theirs, and then moving forward as themselves in an ideal situation. It seems like this cultural sensitivity or cultural humility is a moving target. It’s not static, it’s dynamic. We’re both changing over that time. And when somebody’s an emerging adult, that changing might be even more accelerated. So they are not only dealing with their culture, preferences, and situation, but they are also going through a transition.

Theresa Nguyen: I would argue too that something’s interesting about mental health or maybe human beings in general is that sometimes I don’t even know the answer so when you say that we’re rejecting something, I don’t even know what I’m rejecting. Am I rejecting myself? Am I rejecting what my parents told me? An exciting thing about the adolescent phase is the identity formation period it can be fun and painful. And that’s why it moves. It’s because you don’t have the solid footing of knowing thyself. And when I do know myself, then I may be less inclined to change. But when I’m young, I rejected it because I was trying to make sense of what will stick. Does this feel right? Or does it not feel right? And I don’t have the muscle memory for how to make it even stick and feel right. Because once I adopt an identity, I have to go test it out. I’m going to go play and be this person and see if it causes me more suffering and more bullying, and that all happens during adolescence. I think that it’s important to consider the cultural framework, that’s, the dynamic. When you see shifts and as a therapist, if you’re not assigning this to rejection per se, this is part of that journey. And then the question is, what matters to you? Because if I say, okay, I’m forming myself. That might tell us where that young person is in that formation process because a young person might say, Oh, my culture is important to me. My family is important to me, but they also might say I don’t know; being young is important. Your basketball is important to me. You’re eating two cheeseburgers a day. Who knows, right? I love ice cream. So I think that if you think about culture and the formation of culture in too strict of a format, you end up missing some of the stuff that helps young people identify who they are and where they land to become who they are.

Person-centered approach to cultural identity

Theresa Nguyen: And that’s where a person-centered approach to cultural identity or even identity as a whole uncouples ourselves from the required labels. My mom was so mad for a long time because she was like, you’re a Vietnamese. And I grew up in Los Angeles, and I would literally say to her, I’m Mexican. I had to understand this growing up in the context of my mother being a Vietnamese immigrant and me being Asian in a predominantly Mexican community and feeling afraid to accept my Vietnamese identity because I wanted to fit in. I wanted to belong in anything.

Teenagers and cultural humility: Listen

Jamila Xible: So I have three kids. Yeah. And I’ve used cultural humility with them forever. Don’t tell them that.

Health Hats: Okay.

Jamila Xible: But one of the things about cultural humility is listening. The listening to learn. The listening without judging. The giving the space. I’m telling you not as a professional but as a parent, and I’ve had the best of experiences. It may have to do with my kids’ genes and their being so lovely, and perhaps the fact that they feel and verbalize this to me, that they can talk to me without being judged.

During their teenage years, it isn’t easy, and they go through several phases, but, for me, I educated myself to be that non-judgmental, good listener because sometimes that’s all that people need from you, that you sit in front of them. And especially if you are that parent with the power in your favor, right? When you are there and providing that space,

Health Hats: Wow. That’s very helpful. Alright

Jamila Xible: I don’t know. People will go through crises, and some crises will be worse than others. Some will require immediate medical intervention, and some will require a lot of love and dedication and being on that person’s side.

Relationship dyads and triads

Catherine Smail: Regarding approaching patients with cultural humility, who has challenging relationships with parents? I think probably one of the most important things I do as a therapist is normalizing the conflict of young adulthood. And that I mean that we are designed biologically to move away from our families in adolescence, continuing into young adulthood. I often tell people that your adolescence is where you figure out who you’re not, and your twenties are about figuring out who you are.

Which is an equally challenging task. We talk about a lot less than adolescents, and none of those things do not have to do as much with your family, right? The idea is to break away and figure out who you are separately. And then, as you get older, you start including more and more of what you learned.

Either intentionally or not into your relationships and your adulthood. But I think often it reminds both the young person and their parents that conflict has to happen during this stage of life, right? That it is normal and natural. Often, families can readjust to the new power dynamics to have a new adult in the family who can make their own decisions, keep going forward, and find a healthy balance.

So yeah, I think normalizing it is essential. I also think it’s a new level of decision-making for young people because they have more power to decide who they engage with and who they don’t. And so, they must reevaluate their relationships and decide who they will include going forward. And I think that can be hard for families in conflict because of the young person.

Cultural humility for the clinician

Health Hats: The contours that that takes differs individually and differs culturally. I’m just saying I guess I’m making a statement. I’m not sure I know what I’m talking about. But again, I’m trying to bring this conversation about cultural humility and what that means for me, say, as a clinician, when I’m adding a whole different dynamic into the equation.

Catherine Smail: For example, talking to broad strokes culturally. It is widespread for an 18-year-old white person to move out of their house and to become independent, whether half independent if they’re going to college, right? That is the normative age for that to happen.

In Latino cultures, you usually stay in your parents’ house much longer. And that is culturally normative, healthy, and appropriate. So when thinking about what people should and shouldn’t be doing at a specific age, Young adults, particularly those norms, adapt and shift based on their cultures.

And, what deciding or helps to determine with the patient what’s appropriate and what’s not is influenced by culture. And then you have, on top of that, the individual’s experience with their family. So they have a high conflict relationship with their parents. Even if they’re Latinx, they may be disinclined to stay.

And so you have to view that as an additional lens through which you understand the young person. It’s also essential because of the developmental age of young people to understand more fully what aspects of their culture they’re either accepting and going with or rejecting.

Humility in the relationship, power dynamic

Health Hats: I also think this humility is a two-way street because sometimes people are forgiving and sometimes offended. Sometimes, people don’t say anything, and you have no idea that you stepped in it and they’ve shut down. You may get a sense that something has changed here. Oh my goodness, did I say something? Because the room temperature just dropped 20 degrees. Again, it’s two. There are two sides to it. And people who are, and so anyway, I’m grateful when the other person is confident to call me on it and straighten me out, but I don’t expect it because I’m with them. After all, they feel like crap. When you feel like crap, you’re not on top of your game, right? You’re not necessarily sensitive yourself.

Catherine Smail: It sounds like your question is whether humility is only incorporated within a provider stance or is held within a relationship’s context. Because of the power that you mentioned suitably, it is essential. The onus is on me because I am in a position of power, not only as a provider but also as a white person from middle, upper-class socioeconomic status. I have a lot of privilege, right? And it’s on me to recognize that and bring a humble stance. That said, the right culture or people’s intersectionality is brought by both sides, right? That informs my perspective, and it also informs my patient’s perspective.

For example, I often work with people from Central and South America because I speak Spanish. And so much of that culture is that providers require a differential attitude, right? That they will say yes, ma’am, to whatever I tell them. Even if it sounds completely bananas to them, but they will say yes because of my position as a doctor. It’s extra work on my part to help shift that attitude or that belief by providing them opportunities to share and asking them questions. And it’s true that when we’re talking about oppressed people, that causes an immeasurable amount of pain and people who are in pain, especially chronically pain, painful. They have more irritability. They tend to be more depressed. They tend to have much more chronic or challenging mental health symptoms. And all those things interact or influence how we receive challenges, right? Or the way that we rise to greet it or don’t. And yes, there are instances when you know you’ve made a mistake or an error, and it doesn’t seem like a repair is possible. I. You’ve stepped in it, and the reaction has gone poorly, and no matter what you do or say, that won’t be heard in the moment. And that’s just true.

But that doesn’t mean that our efforts were for nothing. And it doesn’t mean that in the future. We can’t go back and re-look at that. We can’t have this conversation again. But that makes sense. I hope that if we do the right thing, we’ll be rewarded for it. And that, unfortunately, isn’t the case, and I know we must keep going despite that.

Theresa Nguyen: Interesting because I’m a clinician, so much of our discussion has come from an approach of clinical care and as people who experience mental health challenges and have to go into it—therapy or clinical environments to process our stuff. And I think much of the advice has been about how to shape this.

How do I think about this framework and its influence on my life? And how do I approach how do I approach mental health? Thinking about cultural competency. But I think so much more attention has been paid to clinicians on how to be culturally sensitive because I think the system wants to make sure that clinicians don’t do more harm, and that’s where we have the control is to treat clinicians.

And so I think that I hope that some of my frameworks, which we think about being person-centered as clinicians. And, a positionality of curiosity that will be a protective asset for you as a clinician not to do more harm, right? And to build that therapeutic relationship.

But then what I don’t necessarily see is the other side where coming from MHA, and what’s important to us is how do I empower, how do I build power from clients, from people who are the receiving end to enter into therapy or treatment with more power instead of what many of us do when we’re passive. We’re receivers, and I think that when I, we, I’ve done more work thinking about that question, how, do we have more power in the context and a lot of the answers that come up is don’t go into treatment.

If you could prevent yourself from going into treatment Without knowing what you’re facing, that would help you. You have power. Go into treatment with some things in mind. What do you want to solve? Who are you? Do you have a therapist you feel comfortable confronting as much as you receive?

We’re often not even told that. I guess I’m supposed to pick a therapist in my network. I don’t know one that looks and sounds like somebody I resonate with. But what’s my role? Do I get to ask you questions? And increasingly, every time I go to therapy, I love that I do this. I interview my therapist as much as they interview me.

And when I have a therapist who says, I don’t feel comfortable sharing those things with you because they’ve been trained in this format where they’re supposed to always reflect something back to you, I’m like, this isn’t going to work. That’s not going to be what builds trust for me. I need a relationship in which I can push and ask questions and not feel like you’re a weird robot.

Providers, hang out on social media feeds where your patients hang out

Catherine Smail: So I’d like to discuss some steps providers could take to move along with cultural humility. Please. I don’t know. But I recommend that if you have a group of people you are interested in working more effectively with, you start filling your social media feeds with all different kinds of people who represent that group.

So, if you are interested in working with young people, start trying to fill your social media feed with all kinds of young people and see the different expressions of their youth that they bring to social media. It’s easy to start educating yourself about a much broader population by having a more diverse social media feed.

That extends to all media consumption. So if it’s, you’re going to start watching shows that young people are interested in or if you are going to start reading books by people with different perspectives who are in the population you’re interested in.

So, I’m just starting to try to get a broader perspective on your daily life. And then to really. Start seeing what comes up as you consume things different from your life and perspective.

Health Hats: What comes up? What do you mean?

Catherine Smail: Is this easy for you to accept? Do you understand this perspective? Do you accept it? If you have a young person expressing gender fluidity, that’s not something you have experience with. Does that make you squidgy? Is that you are interested? What are the points of acceptance and resistance you are finding in yourself? And then exploring those.

Reflection

The more you burrow into the culture, the more you find unexpected tunnels, encounter unforeseen adventures, and meet varied beings. There are no average tunnels, adventures, or beings, but perhaps a range. You can feel invigorated if you’re at the top of your game and scared and exhausted if you’re not.

Thankfully, we can’t predict the future. If we could, we might lose gifts of humility, humor, and renewing warmth from unforeseen relationships.

I appreciate the pearls of curiosity when not knowing, reimagining, embracing failure through self-reflection and self-critique, and spending time where your emerging partners congregate.

I offer heartfelt thanks to Cat, Jamila, and Theresa. I couldn’t use everything they offered. Editing can be wrenching.

Want an in-depth picture of the impact of culture and cultural misalignment? I recommend the book The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures , a 1997 book by?Anne Fadiman . A much-quoted section:

[Dwight] Conquergood considered his relationship with the Hmong to be a form of barter, “a productive and mutually invigorating dialog, with neither side dominating or winning out.” In his opinion, the physicians and nurses at Ban Vinai failed to win the cooperation of the camp inhabitants because they considered the relationship one-sided, with the Westerners holding all the knowledge. As long as they persisted in this view, Conquergood believed that what the medical establishment was offering would continue to be rejected since the Hmong would view it not as a gift but as a form of coercion.

May the force be with you.

Podcast Outro

I host, write, edit, engineer, and produce Health Hats, the Podcast, with assistance from Kayla Nelson and three van Leeuwens, Joey, Leon, and Oscar. I play Bari Sax on some episodes alone or with the Lechuga Fresca Latin Band. I buy my hats at Salmagundi Boston. I’m grateful to you, who have the most critical roles as listeners, readers, and watchers. See the show notes, previous podcasts, and other resources through my website, www.health-hats.com , and YouTube channel . Please subscribe and contribute. If you like it, share it. See you around the block.