Moving beyond cultural competence
As an Aboriginal psychologist, who for some years has worked out of an Aboriginal Medical Service (AMS) in northwest New South Wales, I have often had people referred to me after they requested to see an Aboriginal psychologist. My first thought has often been, “How can I help this person?” and what is it that they want from me that is different from my non-Indigenous colleagues? I have also questioned my own cultural competence and what it means for me to be Aboriginal, especially since I grew up in the city, away from the Country of my ancestors, the son of a mother who was removed in the time of the Stolen Generations, with no tribal language and no strong cultural connections to people or Country.
A key to unlocking the questions in my head about my cultural identity came from living back on Country over the past 10 years and listening to the stories and the experiences of my people. Aboriginal and Torres Strait Islander people understand that we are of the Australian diaspora and there is an appreciation of the struggles that this brings. We all carry within us the stories and the memories of our people and our families. Even though every story is distinct, we share a common heritage that links us to this ancient land.
The AMS where I am located is, according to clients, a place of cultural safety. It is vivid with the black, red and gold colours of the Aboriginal flag, which sits proudly on the reception desk next to the flag of the saltwater people of the Torres Strait. Around the windows there is a frieze, which features Indigenous artwork that immediately identifies the building as being associated with Aboriginal people. On the door, the practice bears the name of the mission, some 30 kilometres out of town where local families were sequestered for generations. And although this might seem like a curious acknowledgement, it is the collective history and shared memory of our local people, and culture is also about history.
Reflecting again on the Aboriginal clients referred to me and listening to their stories, they were seeking a place of acceptance and safety, somewhere that they did not have to prove who they are or where they belong, and somewhere that for them is familiar and reassuring.
The meaning of cultural safety
Aboriginal and Torres Strait Islander people have frequently reported that they find health services (including mental health services) to be culturally unsafe, describing staff as being unfriendly and unwelcoming (Curtis et al., 2019; Kendall & Barnett, 2015) and they often only attend for services when they are in critical need (Fredericks, 2010). This presents a challenge to us all as psychologists and is a sobering reminder to ensure that our clients do not feel alienated and disrespected.
Cultural safety as a concept was first adopted by the Nursing Council of New Zealand in 1992. It proposed that health practitioners must necessarily engage in a process of self-reflection about the rights of their patients and the power that may exist in patient/practitioner relationships. But cultural safety requires more than this; it implies that practitioners understand how their own cultural values can impact on others and that they must therefore make necessary changes (Curtis et al., 2019). Cultural safety, in effect, asks that we as psychologists step out of our own cultural value system and into the cultural value system of the client.
It is an ongoing process for me as a psychologist to question not only my competence, but also what I do and how I go about my interventions. It means that as a researcher, I must question who benefits or who might be disadvantaged by my research. It means that as a teacher, I must be mindful of what I communicate to students and question ways that I may be able to help give voice to Aboriginal and Torres Strait Islander clients.
Cultural safety also places a decolonising lens on our practices. It is a process of critical analysis that is much more than just reflection on clinical practice. It acknowledges the impact of colonisation on the health and wellbeing of Indigenous clients and identifies where colonisation endures or may be emerging within systems and organisations (Ryder et al., 2017). It also asks us to look at who we are and what are some of our core values, as well as what we do in relation to our work with Aboriginal and Torres Strait Islander clients.
The Australian Concise Oxford Dictionary (2009) defines colonisation as the process of acquiring colonies by exploitation of people by a larger power. Cultural safety looks at how power and privilege are used and where power inequities lie. A feature of colonial societies has been the classification of differences which have marked a dividing line in the colonial dialectic (Chatterjee, 2014). Non-white/white, dominant/subservient, civilised/savage, self/other are just a few of the distinctions that have been enshrined in the language of power and continue to serve the dominant culture.
Why is cultural safety important?
Indigenous people have been observed, measured, assessed and evaluated for more than 200 years by the dominant society, so there remains much suspicion and fear, even when approaches are made with the best of intentions. I was reminded of this some years ago while working in an in-home therapy program for families, and a colleague telephoned a client to arrange an appointment for a home visit. My friend was asked by the client if she was Aboriginal, and when the answer was “No”, the response was that the forthcoming home visit would not be welcome.
As a mental health practitioner, it was important for her to step back for a moment and reflect on the meaning of this response, and to consider that for reasons that may not have been clear, the client deemed the home visit to be culturally unsafe. Feelings of apprehension such as this are not uncommon within Aboriginal and Torres Strait Islander communities and families where transgenerational trauma runs deep, and the scrutiny of government and non-government authorities has been relentless.
Living in a rural community I am also reminded by clients that racism can lurk close to the surface in daily life. Attitudes formed from stereotypical thinking, common phrases in language and values of discrimination can be a vehicle for racist behaviour which serves to maintain the power of the dominant culture. As psychologists, our task is to find within ourselves the humility to pause and to consider the ways in which past negative events have impacted our clients.
Cultural humility
A term closely related to cultural safety is ‘cultural humility’, which means that I focus on another and not on myself, and I suspend any belief about cultural superiority towards another’s cultural background and experience (Hook et al., 2013). It is a necessary element for working with persons from other cultures and the genuinely humble practitioner becomes aware of deficits in knowledge and experience, and makes efforts to build on that knowledge in a manner that is attuned to the client. The culturally humble psychologist gives importance and centrality to Indigenous knowledge systems and healing practices (Dudgeon & Walker, 2015) and accepts Indigenous values such as the importance of collectivism and the role of family, community, Country and spirituality in therapy and wellbeing.
Indigenous people have been observed, measured, assessed and evaluated for more than 200 years by the dominant society, so there remains much suspicion and fear, even when approaches are made with the best of intentions
Cultural responsiveness
This ability to step out of one’s own cultural value system, while acknowledging the importance of cultural safety, brings the mental health practitioner into a space of cultural responsiveness, which is centred on personal reflexivity, and which is a dynamic process that facilitates an outward movement towards learning and discovery and back towards the reflexive self (Smith et al., 2020). As a system or a process, cultural responsiveness remains in perpetual motion or oscillation (Foucault, 2001) as the need to learn and to explore never subsides for the individual who has developed the genuine humility to step away from preconceived notions, values and opinions.
The events around my colleague’s phone call and the ‘not welcome’ response, presented her with a set of alternatives. She could have been dismissive or even critical of this client or could have just put her at the bottom of the to-do list, but instead she moved into her reflexive self and then as a way of seeking more knowledge, consulted an Aboriginal team advisor, who then helped her to once again engage with her client. The Aboriginal team advisor became a cultural mentor, was able to vouch for her in the local community, made the first face-to-face contact, and accompanied her on her first home visit. This is the dynamic of cultural responsiveness that moves back and forth between experience and reflexivity. It can sometimes be fraught with mistakes, but with reflexivity these are opportunities for learning.
As psychologists, our task is to find within ourselves the humility to pause and to consider the ways in which past negative events have impacted our clients
Where to from here?
Cultural safety, cultural humility and cultural responsiveness offer a challenge to us psychologists to re-evaluate how we go about our work with our clients. The Australian Psychology Accreditation Council (APAC) has directed that cultural responsiveness must become a core competency for all four levels of qualification for psychology students and for those aspiring to be practitioners (APAC, 2019). For those seeking registration as a psychologist the Psychology Board of Australia National Psychology Examination includes as one of the eight competencies for examination working in cross-cultural contexts, including Aboriginal and Torres Strait Islander issues (Psychology Board of Australia, 2020).
The Australian Indigenous Psychology Education Project (AIPEP) in its statement of pedagogical principles has noted that the psychology workforce must ensure that it builds effective clinical care for Aboriginal and Torres Strait Islander people, integrating Indigenous content and values into existing worldviews “in areas such as policy, management, program development, health promotion and education” (p. 15) because these all have the potential to impact on health and wellbeing (AIPEP, 2016).
The APAC directive means that we all have a responsibility to inform ourselves not only about cultural responsiveness, but in the process of becoming culturally responsive, to become more culturally safe and culturally humble. These are the ingredients that make us all stronger, decolonising organisations and workplaces, and as we move into the future, ensuring that within our mental health services no one feels excluded.
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1Member Australian Indigenous Psychologists Association