By Carrie McDonnell, LICSW, LCSW-C
May 4, 2022

U.S. Army Photo by Master Sgt. Alexandra Hays

The Department of Defense is proud that today's U.S. military is more diverse than ever. For example, the Chairman of the Joint Chiefs of Staff, Army Gen. Mark Milley, stated in a Sept. 2020 global town hall that "[d]iversity builds a better team and readiness."¹ Bishop Garrison, senior advisor to the Secretary of Defense for human capital and diversity, equity, and inclusion, echoed this sentiment during a discussion at Arizona State University earlier this year saying, "What I want people to understand is that diversity makes for a stronger fighting force, it makes for a more capable force, it makes for a force multiplier across the board."²

It's true. Diversity, in all forms (religion, culture, age, sexual orientation, gender identity, ability status, and more), is one of the military's greatest assets. For providers working with service members, this means that often our patients will be different from ourselves in nearly every aspect.

So, how do we effectively provide services to individuals who may have vastly different experiences and world views than ours?

The answer is "cultural competence." But what is cultural competence and, more importantly, is "competent" the finish line, or should we be aiming for more?

There have been many definitions of cultural competence over the years, but the general idea stems from two papers written by Dr. Derald Wing Sue, Mr. Terry Cross and their colleagues. In his 1982 position paper, Dr. Sue countered the popular narrative at the time that the mental health practice strategies and research used were adequate for various minority groups. The paper instead recommended specific cross-cultural competencies for the therapeutic setting that are still used today.³

In 1989, Mr. Cross and colleagues expanded on the foundation laid out by Sue and shaped the definition of "cultural competence" as we understand it today.

Defined as involving "systems, agencies, and practitioners with the capacity to respond to the unique needs of populations whose cultures are different than that which might be called 'dominant' or 'mainstream' American," Cross went on to explain the phrase.⁴ He stated that he chose the term "culture" because it includes customs, beliefs, values, institutions, thoughts, and communications associated with a group, whether it be racial, ethnic, social, or religious. He chose "competence" because it implies "the capacity to function within the context of culturally integrated patterns of human behavior as defined by the group."⁴ Over the years, the phrase "cultural competence" has been refined. From a provider's perspective, cultural competence is an awareness of our own limitations, a recognition of our inability to know it all, and a willingness to learn about cultural differences, resources, and individual client perspectives.

On the surface, the concept seems far from controversial. Yet, there have been numerous publications challenging the idea of cultural competence and its prevalence in training, policy guidelines, and professional mandates. These criticisms come in many forms, but the following are most recognized:

Definition and operationalization

The biggest criticism of cultural competence is that there isn't a collectively agreed-upon definition of the phrase and the individual terms used. Perhaps because of that, it has been difficult to operationalize the concept.⁵ The common understanding of culture is that it encompasses beliefs, customs, and values, but many have theorized that "culture" in this context seems to be a surrogate for either strictly racial identity or prioritizing racial identity as the primary driver of "culture."^6—8 Were that to be the case, other aspects of identity and their potential disparities are unaccounted for, as is the intersectionality of those aspects.⁶

Less comfort, more self-reflection

Fisher-Borne, Cain, and Martin⁶ argue that many cultural competency models focus on the provider creating an environment where they are "comfortable" working with others. Instead of critically reflecting on our own biases, prejudices, assumptions, stereotypes, and the inherent power differentials between the provider and the client, the model's focus is more on all providers simply being aware of and exposed to non-familiar groups.⁹ Thus, current frameworks lack valuable exploration of how a client's culture and identity within "other" groups shape values, perspectives, experiences, available opportunities, choices, and overall worldview. These frameworks don't deal with how the provider's approach to providing care is affected by those same factors.^6,8,9

Is competency possible?

What does it mean to be "competent" in a subject? Generally, it means to be knowledgeable, proficient, or capable. However, given all the possible traits and the infinite number of intersections of those traits, how could a provider ever be genuinely competent on the subject? Possessing a broad knowledge of various group identities does not translate into understanding an individual client's life experiences and how that shapes their unique perceptions of the world around them.⁶ On the contrary, using broad knowledge to generalize about a particular group may lead to stereotypes that could further disrupt the therapeutic relationship.⁷

Cultural humility vs. cultural competence

Rather than viewing cultural competence as a finish line, Tervalon and Murray-Garcia⁹ encouraged providers to consider the process a lifelong endeavor, committing to and actively engaging in constant self-reflection and developing partnerships. They called this concept "cultural humility."⁹ Recognizing that a provider's knowledge about a client cannot be all-encompassing—as each client is an individual, multicultural, multifaceted being—allows for a certain freedom, a humility that gives way to flexibility, vulnerability, and openness.^9,10 Instead, cultural humility views the client as an expert in their unique experiences and the provider as a collaborator. This "power-cognizant, relationship-centered approach" differentiates cultural humility from cultural competence.¹⁰

Applications

While there continues to be discussion around the validity of the cultural competence and cultural humility constructs, they aren't necessarily mutually exclusive. For example, Mosher et al.¹¹ view the two as working together. Cultural competence would work as the how (knowledge, skills, etc.), while cultural humility functions as part of the therapist's orientation toward the client and their work together in a way that "prioritize(s) and value(s) diverse cultural identities."¹¹ Similarly, community leader Ella Greene-Moton offered my favorite view of the two concepts working together when she said, "I believe cultural humility is a spiritual attribute, drawing from the ability to be humble and couched in a state of selflessness, while cultural competence hinges on a deliberate engagement in cultural knowledge transfer."¹²

How do we provide services to our clients in a culturally competent and humble way?

• Listen and learn. Cultural humility is a lifelong process. Commit to being a life learner.⁹
• Engage in critical self-reflection and self-critique. Challenge your stereotypes and assumptions.⁹
• Get comfortable with the uncomfortable and be open about your lack of knowledge.⁹
• Address and attempt to mitigate power discrepancies in the patient-provider relationship.⁹
• View the client as an expert in their life experiences.⁹
• Advocate for institutional accountability. Organizations and individual providers should engage in critical self-reflection of policies, environments, and workplace culture.⁹
• Recognize and acknowledge the unique culture inherent in the military and how that may intersect with a member's other traits.¹³

Resources

• Community Providers Toolkit from Department of Veterans Affairs (VA) Mental Health
• Intersectionality and Cultural Competence: A Quick Introduction (Clinician's Corner)
• Provision of Mental Health Counseling Services Under TRICARE from the Institute of Medicine (IOM)

References

1. Vergun, D. (2020, Sept. 24). Top leaders discuss diversity, inclusion with military members, families. U.S. Department of Defense. https://www.defense.gov/News/News-Stories/Article/Article/2360075/top-leaders-discuss-diversity-inclusion-with-military-members-families/msclkid/top-leaders-discuss-diversity-inclusion-with-military-members-families/
2. Seckel, S. (2022, Feb. 17). Diversity in the military and why it matters. Arizona State University Office of Veteran and Military Academic Engagement. https://vetengagement.asu.edu/diversity-military-and-why-it-matters?msclkid=b7176f0eb1c211ecb85626dd9cd03581
3. Sue, D. W., Bernier, J. E., Durran, A., Feinberg, L., Pedersen, P., Smith, E. J., & Vasquez-Nuttall, E. (1982). Position Paper: Cross-Cultural Counseling Competencies. The Counseling Psychologist, 10(2), 45–52. https://doi.org/10.1177/0011000082102008
4. Cross, T. L., Bazron, B. J., Isaacs, M. R., & Dennis, K. W. (1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: Georgetown University Center Child Health and Mental Health Policy, CASSP Technical Assistance Center. https://eric.ed.gov/?id=ED330171
5. Ridley, C. R., Baker, D. M., & Hill, C. L. (2001). Critical issues concerning cultural competence. The Counseling Psychologist, 29, 822-832. https://doi.org/10.1177/0011000001296003
6. Fisher-Borne, M., Cain, J. M., & Martin, S. L. (2015). From mastery to accountability: Cultural humility as an alternative to cultural competence. Social Work Education, 34(2), 165–181. https://doi.org/10.1080/02615479.2014.977244
7. Dunn A. M. (2002). Culture competence and the primary care provider. Journal of pediatric health care: Official publication of National Association of Pediatric Nurse Associates & Practitioners, 16(3), 105–111. https://doi.org/10.1067/mph.2002.118245
8. Purnell, L. D. (2005). The Purnell model for cultural competence. Journal of Multicultural Nursing & Health, 11, 7-15. https://doi.org/10.1177/10459602013003006
9. 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://doi.org/10.1353/hpu.2010.0233
10. Tormala, T. T., Patel, S. G., Soukup, E. E., & Clarke, A. V. (2018). Developing measurable cultural competence and cultural humility: An application of the cultural formulation. Training and Education in Professional Psychology, 12(1), 54-61. https://doi.org/10.1037/tep0000183
11. Mosher, D. K., Hook, J. N., Captari, L. E., Davis, D. E., DeBlaere, C., & Owen, J. (2017). Cultural humility: A therapeutic framework for engaging diverse clients. Practice Innovations, 2(4), 221-233. https://doi.org/10.1037/pri0000055
12. Greene-Moton, E., & Minkler, M. (2020). Cultural Competence or Cultural Humility? Moving Beyond the Debate. Health Promotion Practice, 21(1), 142–145. https://doi.org/10.1177/1524839919884912
13. Lane, M. (2019). Understanding cultural humility through the lens of a military culture. Reflections: Narratives of Professional Helping, 25(1), 90–100. Retrieved from https://reflectionsnarrativesofprofessionalhelping.org/index.php/Reflections/article/view/1754

Ms. McDonnell is a contracted social work subject matter expert for clinical care at the Psychological Health Center of Excellence. She is a licensed clinical social worker with extensive experience in both direct service and administrative oversight of programs specializing in crisis intervention.