At one point my website included things like TBRI trained, Certified Brainspotting Therapist, Infant Adoption Specialist certificate, and Daring-Way informed… What is the difference between trained, certified, and informed? Do any of those make me competent in those things? Do they make me a specialist or an expert? I would say none of those make me an expert. Expertise about about always growing, always learning, always listening. It requires training and seeking mentorship and reading and researching and a commitment to ongoing growth in this specific field. An expert never arrives, but is always on the journey.
I am concerned about how we describe ourselves as professional counselors and therapists. I am concerned for what it means to clients who may or may not understand the differences and I am concerned for younger therapists and what they may be missing when trying to market themselves. Currently more and more young practitioners are jumping into independent private practice, creating their own peer consultation groups, and missing out on lessons learned in the trenches. By spending time with more experienced therapists, I am absorbing how they talk about theory, how they conceptualize clients, and their wisdom and experience from mistakes and years of trainings and CEs. I hope to write this blog to both potential clients seeking a therapist and to professional therapists, so we can all make more informed choices.
I have read probably every book by Harville Hendrix, but there is a big difference from being Imago Relationship Therapy informed and Imago Relationship Therapy trained. Certified simply means that an advanced practitioner is agreeing that I actually paid attention during the training and didn’t just pay my money. It means I am Imago Relationship Therapy competent. Competency is the goal for working in modalities. Our ethical standards state we can practice only within the boundaries of our competence; however, when talking about populations and cultures, competency requires more than just competency according to the research – and we may be failing our clients.
Gottlieb (2020) writes that culture “includes skin color, ethnicity, religion, citizenship, gender identity, sexual identity, ability, size, socioeconomic status, addiction history, trauma survivorship, family constellation, and more: a definition vast enough to contain any identity our clients describe as influential to their lives. This vast definition of culture, combined with notions of intersectionality, would thereby submit that every therapeutic relationship is cross-cultural in some manner.”
Unfortunately therapists may not be nearly as culturally competent as they believe they are. Hook et al. (2016) found that “81% of clients experienced at least one racial microaggression in counseling, including slights such as bias, denial/lack of awareness of stereotypes, and avoiding the discussion of cultural issues.” Owen et al. (2018) found that approximately 50% of therapists were able to identify only one of three microaggressions. If every therapeutic relationship is cross-cultural in some manner, we all have a lot of work to do.
It’s important to me to give credit where credit is due. The concepts of humility and comfort were introduced to me by Cherish Asha Bolton, LSW. I will be quoting our conversation and her paper on the topic is included in the references.
“Friendly”
This is a term used for advertising that just means someone is open and hopefully affirming of a population. A therapist could by kink friendly, meaning they are open to discussing kink, but have no training or experience. They may have blind spots and bias they do not realize they they have. They could also be an excellent therapist who regularly seeks consultation and researches and is simply missing the training and experience to be truly competent.
For clients seeking a therapist, this may not be the right therapist for you if kink is the, or part of the, primary reason for seeking services. If kink is an important part of who you are, but your primary reason for seeking counseling is OCD, for example, then finding a therapist that specializes in OCD and is kink friendly may be a perfect fit.
While telehealth has opened up whole states to people seeking a licensed therapist, there are still many groups who may not have great options for specialists where they live. (State by state licensing laws prevent therapists from legally working across state lines with few exceptions. It is important to find out if a therapist is licensed in the state where you will be during your appointments). People regularly reach out to me for referrals for adoption specialists, and in some areas, I have to refer them to adoption friendly therapists who are willing to seek consultation because there may not be other options; however, whenever possible I refer them to therapists that are adoption informed or have had an introductory training if there are not adoption specialists who have cultural humility.
“Informed” or “Aware”
If a therapist uses the term informed or aware, it most likely means that they have read books on the topic or modality, but not attended official trainings. Perhaps they have attended shortened trainings or introductions. They may have read a single book or an entire library. It is vague, and clients seeking a therapist may want to ask more questions.
I have read many books about Internal Family Systems therapy (IFS) from a variety of authors and several by a Dick Schwartz. I also attended a year long learning cell with an IFS Certified therapist which was very much like a training, but it is not an official IFS training. I utilize what I have learned frequently and would consider myself very IFS informed. I have also read books about Autism, listened to podcasts, had discussions with other therapists and Autistic individuals, and even know some Autistic individuals very well. I could be consider Autism informed, but I think I have a long way to go before I would ever advertise that. Unfortunately therapists who want to build up their caseload may be less discerning about what they advertise, particularly if they have a desire to work with a specific population.
“Trained”
Trained may be the most confusing term. Trained can refer to specific modalities, but it is not for populations. For example I am a Trained Star Behavioral Health Provider, but that is a specific training about working with military families, it does not mean I am competent yet in working with military families. It simply means that I have attended a training.
For some modalities there is no certification, so significant experience is needed after training to be truly competent in that modality. Trust-Based Relational Interventions (TBRI) training is intensive but there is no certification, yet I have certifications in things that I understand and use a lot less. I could be TBRI trained, but never use the information, or I could be TBRI trained and use the information daily. There are TBRI trained therapists who do not use the core principles. Without a certification process, all trained really says is that someone attended a training. Additional questions will need to be asked to determine how much the information from that training impacts their approach.
“Competent” and/or “Certified”
When a modality has a certification process, that can be a way of designating competence. Certification is generally a process where an advanced practitioner certifies the therapist’s knowledge and skills, indicating that they didn’t just sit through a training, but also understood the training. Modalities each have their own standards for certification, and some are easier to obtain than others. However, as mentioned above, some modalities do not offer certification, knowing that many therapists can understand material but fail to use it or use it as intended when working with clients. (While working behind closed doors is helpful for client confidentiality, it does create a situation where therapists can avoid oversight and much can go unnoticed for years if it is not brought to someone’s attention.)
“Cultural Competence”
Cultural competence is more complicated because there is not an agreed upon definition, and some of the definitions point towards cultural humility as a necessary component of competence. This is important to note for clinicians because our ethical codes state that we only work within and advertise working in areas in which we have competence. In fact when Tervalon & Murray-Garcia (1998) quoted L. Brown “cultural competence in clinical practice is best defined not by a discrete endpoint but as a commitment and active engagement in a lifelong process that individuals enter into on an ongoing basis with patients, communities, colleagues, and with themselves” they described that as Cultural Humility.
The National Association of Social Workers’ (NASW) “Standards and Indicators for Cultural Competence in Social Work Practice” states, “Cultural competence requires self-awareness, cultural humility, and the commitment to understanding and embracing culture as central to effective practice” (2015).
Perhaps the difference is most easily understood from Bolton’s definition that to be culturally competent “requires extensive training and experience with the population. But…there can still be lingering biases, and certainly there can be issues with authority and hierarchy.” I believe that training young clinicians to be ‘the expert’ creates an unhealthy power dynamic and leads to bad therapy. We are taught that we have to be careful not to abuse our power over a client as a therapist. While there are many concerning ways that therapists could abuse or take advantage of a client, perhaps the biggest abuse is not utilizing the client’s own wisdom and discouraging them to lead the process of their own growth and healing.
“Cultural Humility”
When Bolton defined humility for me, she said it “requires the clinician to recognize that they don’t and can’t know everything even with lived experience, and it places the client as the expert in their own lives…” As a Brainspotting Trainer, I hope this idea resonates with Brainspotting trained therapists. In Brainspotting terms, it is going beyond certification, and continuing to seek specialty trainings and consultation from a variety of trainers. However, the focus of humility is to be culturally humble in working with specific populations, not with any modality. 
Cultural humility recognizes both that the client is an individual, a part of but not fully defined by their culture, and that no matter what you’ve learned or experienced with a culture, including lived experience, there will always be more to learn.
While I have traveled extensively and cultivated relationships with a wide variety of individuals and cultures, I was born and raised in Central Indiana, all of my homes being within a 90 minute drive. This week, I noticed two bumper stickers with a reference that I did not understand and had to google. This wasn’t some pop culture reference that I was “too old” to understand, but a phrase that is used commonly – and I then stumbled on in the fiction book Kindle First Reads gifted me this month. The people driving the vehicles looked like me in age and race, and their vehicles were not noticeably more expensive or less expensive than mine.
A phrase that was used in graduate school is there are always more within group differences than between group differences. Even being a part of a population does not expose us to the full variety of experiences and beliefs within that culture. Cultural humility requires that we are curious and trust the client’s experience more than our own knowing. It leads us to be open to feedback from clients.
Culturally humble therapists also seek to find and dismantle their own bias and to be open and teachable, demonstrated by seeking consultation and training from a variety of sources. This could include listening to those with lived experience, reading books and memoirs, and asking for feedback and critique. In working with the adoption constellation, I listen to and follow on social media adult adoptees, first mothers, and organizations run by adoptees and first mothers. I have developed relationships with adoptees and first mothers, seek their input, and actively ask for critique. I read books and memoirs by adoptees and first mothers regularly and recommend them to others. I out myself as an adoptive parent and answer questions about that (why did you adopt? being the most common; answer: I had the flexibility and resources to care for a child living outside of a family and knew the probable outcomes for older children in that situation) without sharing information about my boys’ story that they wouldn’t share themselves. While I believe strongly in listening to many different people with lived experience, culturally humble therapists also prioritize professional growth activities.
Dodd (2020) points out that to be culturally humble, a therapist needs to seek education from a variety of sources, consultations, and supervision, while also actively engaging in working with the culture. Even if this is your area of specialization, there is always more to learn and wisdom to glean from other practitioners. Iron sharpens iron, as they say. Trainings provide information, but supervision and consultation go deeper, help you apply what you have learned to specific cases, and create an opportunity for critique. If you want to dismantle your own bias and blind spots, consultation with advanced therapists is the best opportunity to do so.
“Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships” (Tervalon and Murray-Garcia, 1998). Cultural humility includes an anti-oppression lens which is essential when working with minoritized and oppressed populations, including adult adoptees. Gottlieb (2020) and Ross (2010) emphasize, that “we must be willing to ‘relinquish the role of expert’ and to have empathy and patience for the mistrust that is likely present within communities due to historical and institutional engagements with ‘helpers’” and also “acknowledge the colonializing roots of the ‘helping’ professions and the need to remedy this power imbalance”.
We can be personally humble, but professionally to have cultural humility also includes all of the competence training and experience. I am very humble about really only knowing the basics about eating disorders. It is one of those areas that I consult with other experts on when disordered eating comes up as a secondary concern to one of my clients. But it would be misleading to portray myself as having cultural humility for working with eating disorders because I have not had any specific trainings, and I am not competent to be working with eating disorders. To finish Bolton’s quote from above “humility requires training and experience, but it also includes that extra piece of self-work. But…you can be culturally humble and still be uncomfortable, and new research shows that even with all the things, discomfort can still alienate the client.
“Cultural Comfort”
“Comfort includes all the things AND comes after the therapist is truly at ease with clients and themselves on the topic. They view the client as expert in their own experience AND is comfortable about their privileged position AND is confident in their training AND recognizes that they are going to learn new things and that’s ok. The research shows that the more comfort the clinician has, even with some shortcomings, the more likely the therapeutic relationship will work.” (Bolton, personal communication, 2023)
Bartholomew et al. (2021) describes Cultural comfort as not just being open to feedback, but therapists being “more likely to initiate cultural conversations that in turn may signal to the client that they are safe and thus encourage the client to share more openly and authentically”. This will strengthen the therapeutic relationship which improves outcomes for the client.
Can you determine that you are comfortable with a population or should your clients be the ones assessing your comfort with their culture? Just like there is diversity within a culture, there will be some clients with whom a therapist is more comfortable than with others. Does comfort with some members of a population indicate cultural comfort though? The research is suggesting that clients are the ones that assess cultural comfort. Bartholomew et al. (2021) found that clients’ distress decreased as their perception of the therapist’s cultural comfort increased. Gundel et al. (2020) found that clients perceive clinical benefit when therapists are comfortable integrating cultural language and values into the clinical process.
Most importantly, Owen et al. (2015) stated that therapists’ racial/ethnic comfort may help explain disparities in unilateral termination. While academic programs may teach newer therapists that when clients drop out of counseling it is because they aren’t ready, I believe it is more often a failure on the part of the therapist, whether that is lack of competency, lack of humility, lack of relationship building, or a lack of meeting the client where they are.
Unfortunately, too often clients either say nothing or tell a therapist they will call back or they will take a break or give some other reason, rather telling the therapist that it doesn’t feel like a fit, which reinforces the hierarchical idea that the client simply is not ready for the work. The therapist can continue to hold on to the false idea of being the expert, rather than being given the opportunity to learn from their clients and discover their own blindspots and bias, which they could then work on in consultation and supervision to better help future clients.
This was such a great exercise to review the literature and put thoughts together in a hopefully cohort framework that I hope is easier to digest than research articles. (There is some great stuff in the research listed below if reading research is your thing.) It was great to really examine when I am comfortable and when I might not be. While cultural comfort is always the goal, I am leaving that up to my clients to determine about me, while I focus on all learning opportunities included in cultural humility as I am always growing, always learning, always reading, and always listening.
References
Bartholomew, T. T., Pérez-Rojas, A. E., Lockard, A. J., Joy, E. E., Robbins, K. A., Kang, E., & Maldonado-Aguiñiga, S. (2021). Therapists’ cultural comfort and clients’ distress: An initial exploration. Psychotherapy, 58(2), 275–281. https://doi.org/10.1037/pst0000331
Bolton, C.A. (2023). Social Worker Comfort with Taboo Conversations: Measuring the “Ick Factor” with Sex and Relationships Among Baccalaureate Social Work Students [Unpublished paper]. Department of Social Work, Indiana State University.
Gottlieb, M. (April 2020). The case for a cultural humility framework in social work practice. Journal of Ethnic & Cultural Diversity in Social Work 30(6): 463-481. https://www.researchgate.net/publication/340703935_The_Case_for_a_Cultural_Humility_Framework_in_Social_Work_Practice
Hook, J. N., Farrell, J. E., Davis, D. E., DeBlaere, C., Van Tongeren, D. R., & Utsey, S. O. (2016). Cultural humility and racial microaggressions in counseling. Journal of Counseling Psychology, 63, 269 –277.
Mosher, D.K., Hook, J.N., Captari, L.E., Davis, D.E., DeBlaere, C., Owen, J. (December 2017). Cultural humility: A therapeutic framework for engaging diverse clients. Practice Innovations 2(4): 221-233.
Owen, J., Drinane, J. M., Tao, K. W., DasGupta, D. R., Zhang, Y. S. D., & Adelson, J. (2018). An experimental test of microaggression detection in psychotherapy: Therapist multicultural orientation. Professional Psychology: Research and Practice, 49(1), 9–21. https://doi.org/10.1037/pro0000152
Owen, J., Drinane, J., Tao, K.W., Adelson, J.L., Hook, J.N., Davis, D., & Fookune, N. (2017) Racial/ethnic disparities in client unilateral termination: The role of therapists’ cultural comfort, Psychotherapy Research, 27:1, 102-111, DOI: 10.1080/10503307.2015.1078517
Ross, L. (2010) Notes From the Field: Learning Cultural Humility Through Critical Incidents and Central Challenges in Community-Based Participatory Research, Journal of Community Practice, 18:2-3, 315-335, DOI: 10.1080/10705422.2010.490161
Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. https://nhchc.org/wp-content/uploads/2020/01/Cultural-Humility-vs-Cultural-Compentence.pdf
