Cultural Safety & Countertransference: Working in Communities You Belong To
By Rahim Thawer, MSW
Introduction
If you’re racialized and have been in a therapeutic setting where you felt anxious talking about your cultural practices, and political beliefs, or were hesitant to delve into honest assessments about your family of origin, there’s a chance that `cultural safety’ was missing from the therapeutic relationship. If you’re a gay man and have been in a therapeutic setting where you weren’t sure if you should mention that you experience anxiety when you’re running low on poppers — firstly, that’s a bit funny, but secondly, there’s a chance cultural safety was missing. In each of these cases, your shame was activated and your nervous system guided you to a safer place. But the chicken-and-egg metaphor doesn’t apply here: first comes cultural safety and then we can expect to dismantle shame.
This is why so many people are now looking for therapists who share a similar identity or lived experience as they do. This paper focuses on the therapists on the receiving end of these requests. What I will argue is that when you work in a community to which you belong, it’s likely that one of your objectives is to cultivate cultural safety with clients. However, we need to take a closer look at how transference and countertransference operate following this initial presumption of similarity and sameness.
Cultural Safety
Cultural safety is a concept that I first learned about from Indigenous healthcare workers in Canada. According to Laurence J. Kirmayer (2013), the notion of cultural safety amounts to several key strategies that operate in direct practice settings (e.g. education, healthcare):
· recognizing the histories and current contexts that structure inequality;
· embodying and enacting difference;
· mutual respect;
· serious but playful engagement;
· an explicit emphasis on the therapist’s tolerance of not knowing as a bracketing of professional expertise; and
· a realistic appraisal of limitations and an ethical stance before the face of the other.
The concept of cultural safety is useful in psychotherapy settings as well. From my perspective, the goal is for clients to not be in a position where they must educate therapists about their marginalized community. Cultural safety enables therapists to explore nuances of culture, politics, and family dynamics. As such, seeking and cultivating cultural safety arises from:
- Clients looking for a practitioner who presumably has some shared life experience; often a similarity of non-privilege (a concept explored by Dr. Malin Fors in her book titled, The Grammar of Power in Psychotherapy, 2018).
- Practitioners being able to lean deeper into their own subjectivities, drawing from both personal experience and a political analysis of the present context (in effect, being less neutral than a traditionalist).
The normalization of seeking a therapist with similar lived experience has shaken some therapists, prompting them to wonder if they can even help someone who has a different social location than them. Of course, they can…but not always. And, reflecting on this limitation is important. To be effective, the therapist would need some degree of cultural knowledge so that the client doesn’t feel like they’re representative of an entire population. Cultural knowledge is about having a sense of issues faced by the larger community alongside an acute awareness that the individual experience will vary. Cultural knowledge also means being aware of some of the internal hierarchies of a community, and being curious about the ways some people in the community are more accepted than others.
My own history as a client in therapy has included a gay man, a straight man and a straight woman as therapists. The straight man and straight woman were great therapists. I didn’t have to go in-depth explaining how masculinity affects gay men, the normativity of open relationships, or why I might struggle with internalized racism. Without having to do that extra work, cultural and emotional safety was established. The transference was likely fairly easy for the therapists to interpret in relation to the paternal and maternal objects in my life. Paying attention to this is useful but we’re already widely trained in analyzing this kind of transference.
Thinking back, it was really nice to have a gay therapist. He was immediately more attuned to my world of hook-up apps, body consciousness, and racism within the gay community. However, the presumption of sameness and within-community signifiers were a big part of my transference in sessions. That is, I was constructing my own ideas about his social-sexual currency as a white gay man in our shared sub-culture and I had an ongoing curiosity about whether or not this therapist would be attracted to me if we met out in the world instead of in therapy. Undoubtedly, this transference expressed itself as unconscious pressure in the therapeutic relationship.
Again, my thesis: when you work in a community to which you belong, one of your objectives may be to cultivate cultural safety with clients. However, we need to take a closer look at how transference and counter-transference operate following this initial presumption of similarity and sameness.
Transference
In any therapeutic relationship, there’s going to be an experience of transference, though not all intervention modalities attend to it with the same importance as psychodynamic therapists. In his paper That Was Then, This Is Now (2006), Dr. Jonathan Shedler describes transference as,
[the] activation of pre-existing expectations, templates, scripts, fears, and desires in the context of the therapy relationship, with the patient viewing the therapist through the lenses of early important relationships. In psychoanalytic psychotherapy, our patients’ perceptions of us are not incidental to treatment and they are not interferences or distractions from the work. They are at the heart of therapy. It is specifically because old patterns, scripts, expectations, desires, schemas (call them what you will) become active and “alive” in the therapy sessions that we are able to help patients examine, understand, and rework them.
Transference is value-neutral and always present. As Dr. Shedler says, “there is no alternative other than to view this new relationship through the lens of past relationships; it’s not a matter of choice.”
Working with transference
How do we explore transference with our clients? For those of us who do, it’s done delicately and strategically. Here are three overarching questions I explore with supervisees and with my own clinical supervisors to first examine and then process the material. At times, I also use common themes (#4) as entry points into these conversations.
1. How does the client understand you as a person in the world and what pre-existing lens might they apply to you?
For example, do they idealize you? Do they see you as transient, impermanent, a competitive rival, a gatekeeping authority, adversarial, attractive, or successful? Perhaps they see you as the person they had to settle for because they couldn’t afford someone else’s fee or they imagine you have the best skills because you have the highest fee — both are important to consider because the unspoken will express itself in the therapeutic relationship.
I’ve had therapy clients look me up online and be really excited about some of the work I’ve done in the community — they’ll tell me as much in the first session. In these instances, I’ve had to consider the implications of idealization in the transference. There’s a chance that this client will want to impress me or make only a particular part of themselves visible to me; as a result, it might take me a little bit longer to see their vulnerability or for me to witness the parts of them that are guarded by shame avoidance strategies.
When you work in a non-profit agency, you often meet clients who have accessed many therapists (due to organizational turnover and chronic conditions in the client). This cycle calls us to consider whether they see the therapist as an impermanent object (or, at risk of leaving) and how that impacts the therapeutic relationship.
I’ve also had a few clients declare, “You know, I wish I could be in your chair. I always saw myself sitting on the other side of this kind of helping relationship.” Here I’m seeing envy and shame show up in the transference with a kind of comparison that is primed by a perception of sameness and similarity in social location. Being aware of this allows me to explore internalized expectations, understandings of achievement, and failure narratives.
2. Based on how you present as a therapist (and your practice setting), what assumptions might a client make about you and the power you have, e.g., income, culture, sexuality, gender, religion, age, ability, etc.?
If I had a therapist who was a white gay man and tall with broad shoulders, I’m going to have assumptions about how he moves through the world and why things might be easier for him than for me as a South Asian gay man. How would my feelings as the client show up in the transference? I might sexualize my therapist. I might be resentful of him. I might hold a belief that he cannot help me because he doesn’t experience racism. I may even feel some hostility. If the therapist can be attuned to the transference and tolerate the range of feelings I’m bringing into the space, only then can we process what it’s like for me to be a racialized gay man. By attending to these dynamics in the therapeutic space, we can explore both what I want from white people and what I hate about whiteness — the grief and despair of internalizing white supremacy.
3. When the client directs frustration or hostility toward you specifically, or they say you’re the only person who `gets them,’ who have you become to them? Which past relationship or interpersonal pattern might be getting re-enacted here?
I’ve treated a number of clients in long-term therapy with whom there was a rocky beginning characterized by some degree of hostility. It can be an incredibly confusing experience for the therapist. I’ve thought to myself, “This person kind of hates me and yet keeps coming back to therapy.” These instances remind me of Dr. Sarah Usher’s insistence that we take a proper family history during the assessment. In her book Introduction to Psychodynamic Psychotherapy Technique (2013), she explains how significant objects identified in the early stages of therapy can ignite therapist curiosities about possible familial and power-based transferences onto the therapist. This inquiry supports formulations about the client’s history with receiving help, power struggles in relationships, and their patterns in protective behaviour (e.g. continuing to keep people they dislike it their orbit).
Countertransference
The concepts of transference and countertransference aren’t understood or taught in a singular way. What’s more, their meanings have evolved over time. In Introduction to Psychoanalysis — contemporary theory and practice, Bateman and Homes (2022) speak to this shift:
Broadly speaking, the term ‘counter-transference’ now applies to those thoughts and feelings experienced by the analyst which are relevant to the patient’s internal world and which may be used by the analyst to understand the meaning of his patient’s communication to help rather than hinder the treatment, i.e. “patient-derived Counter-transference”, in contrast to the earlier notion of “analyst-derived counter-transference.
Expanding on the contemporary understanding of the concept, Shedler (2006) describes countertransference as “the clinician’s transference (often unconscious) based on emotional needs and conflicts from the clinician’s own history and/or current emotional responses to the manifestation of the client’s transference.”
However, we don’t all operate from a psychodynamic frame and we don’t necessarily seek clinical supervisors who are steeped in these concepts. Nevertheless, many therapists agree that a psychodynamic space for reflection can be useful regardless of their preferred modality. For instance, I personally supervise clinicians trained in cognitive processing therapy, emotion-focused therapy and Gestalt, and we process transference and countertransference regularly.
Exploring countertransference
Identifying countertransference reactions or exploring how they express themselves in the therapeutic relationship can be challenging if you haven’t been practicing clinical reflection that includes the unconscious process. To start, here are common entry points to identifying and exploring your own countertransference:
1. Your Subjectivity. Do you feel like you understand the client’s experience deeply because it resonates with your own? If so, consider how your own subjectivity can be used to develop exploratory questions while being cautious not to impose your ideas or solutions. In addition, consider how your own experience and history of decision-making in that similar situation might be getting in the way of your work with the client.
2. Projective Identification. Do you experience feelings in the session (or more specifically) toward the client that feel unique or atypical? The first part of this reflection is whether or not you label these feelings as positive or negative. Examples could include being excited to see a client or having a mental argument with a client long after the session is over. Then, consider whether or not the feelings you experience are driven by you and/or have been elicited by the client. If you want to delve deeper into the theory behind this, look into Melanie Klein’s theory of projective identification.
3. Deviating from the frame. Reflect on how you normally operate in your practice with regard to your working hours, length of sessions, pace and tone of your work, the direction of clinical inquiry, negotiation and collection of fees, session openings and endings, your termination formula, or unexpected desires to problem solve and get involved in the client’s life. Establish what your norm is (this is trickier if you’re in a hybrid case management role) and then reflect on when or how your actions have deviated from the therapeutic frame with a particular client. Examples of these practices can include:
o being late to sessions or rescheduling frequently;
o extending sessions;
o offering extra appointments or additional forms of support;
o relying on a particular client to be the most understanding when you need to make scheduling changes;
o being on the receiving end of hostility or withdrawal after returning from a vacation that disrupted the treatment.
4. Thematic analysis. In their article Experiences of Countertransference: Reports of Clinical Psychology Students (Cartwright et al, 2014), the authors identified the following themes that emerged for student therapists (with an explanation of what each means). These are useful because they can easily be transformed into prompts in clinical supervision:
o Wanting to protect or take care of the client
o Empathising and identifying with the client
o Feeling controlled, intimidated, or criticized
o Feeling helpless or inadequate
o Feeling overwhelmed
o Feeling disengaged
o Feeling frustrated or angry
When using a theme as an entry point into processing your countertransference, one of the questions to ask yourself is this: what are you learning about how the client operates in the world or the impact they have on other people when you examine your own inner thoughts, wishes, desires and feelings for/about the client?
Working in the Communities You Belong To
Now that we’ve established the concepts of cultural safety, transference and countertransference, let’s talk about the nuances of working in communities to which you belong. Let’s say both the therapist and client are gay men. If transference results from a pre-existing lens being applied by the client and countertransference encompasses reactions and inner thoughts of the therapist toward the client, what emerges in the therapy is an intense microcosm of gay men’s cultural norms, internal hierarchies, and subcultural knowledge.
Before and during the therapeutic work, there will be an unconscious (or subconscious) assessment of how they each fit into the subculture, how their physical bodies measure up against the idealized mould and how they fit in their respective tribes (i.e. bear, circuit, twink, daddy, poz, drag, etc.). Each person will, without a doubt, consider what the other’s sexual currency is in the community. What can emerge very early in the therapeutic relationship, which remains faintly in the background, are shame and envy. Therefore, the gay therapist working in a community he belongs to will be able to provide his client with some cultural safety but could also experience a therapeutic impasse in the treatment if he’s not attuned to the transference and countertransference.
Below I present five brief vignettes of therapists working in communities in which they belong, followed by brief notes on countertransference and clinical supervision questions that could be explored with each therapist.
Vignette 1, Germany
The White Lesbian Therapist
Malin is working with a young woman who is really struggling with her sexuality. The client reports regularly trying to pray in hopes that she will wake up one day and desire a man so that she can just “be normal” and feel more aligned with her Creator. Malin has spent three sessions exploring the client’s relationship with her church and family. She wants to challenge the client but is hesitant to move too quickly. The client stopped attending sessions after the third session. What the therapist later wondered was if it would have made a difference if the client knew she was also a lesbian with a wife and a child. (Note: case scenario adapted from Fors, M., 2018).
Brief Notes on Countertransference
· Struggling with neutrality as a queer person, meaning there’s perhaps a fear of being seen as pushing a political agenda;
· Apprehension about which disclosures to make, e.g., that she’s also an atheist;
· Discomfort with her own vulnerability and thus avoiding a situation where she might feel defensive following her disclosure.
Supervision Questions
· How much do you think the client knew about you before beginning their work with you?
· Is there a chance they were subtly recruiting you to recreate two sides of their internal struggle? Perhaps they left when you didn’t participate in the way they anticipated.
· When you notice yourself overemphasizing neutrality with a client, what fears of your own have been activated?
· What part of yourself did you see in the client? Are you still grieving that part of you?
Vignette 2, Canada
The Intimate Partner Violence Therapist
Izumi is a therapist who specializes in supporting survivors of intimate partner violence. On her website, she states specifically that she is trained as a psychologist and also has lived experience as a survivor. She is working with a new mother whose husband’s anger has gotten more out-of-control than she’s ever seen before. She states while he didn’t hit her, she was still quite shaken up. He got upset about the baby being unable to be soothed at dinner and he suddenly threw a plate of food at the wall, causing it to shatter and make a mess everywhere. The client says she’s not sure if she wants to leave the home at this point. She has finances and stability to consider, especially because her mother-in-law helps with childcare. Izumi goes into ‘lecture mode’ during their session and says, “You have to leave your husband now. I can tell you from experience that it doesn’t get better. Staying with your husband will harm your child and would ultimately be selfish.” The client goes silent and feels ashamed.
Brief Notes on Countertransference
· Practitioner is undoubtedly experienced in this work but is perhaps over-identifying with the client;
· Feels personally triggered because of her own history;
· Uncertainty about self-determination and its parameters;
· Deviates from her usual way of operating by being directive, even though she knows on average, women often attempt to leave and then return to an abusive relationship multiple times;
· In addition, probably knows that attempts to leave can also lead to more serious abuse (this is part of the cycle of abuse).
Supervision Questions
· What is your biggest fear for your client and her situation?
· Can you describe the kind of urgency you experienced in the session? Did it match the client’s affect?
· How do you suspect your ‘lecture mode’ response will affect the therapeutic relationship, if at all? Would you want to reflect on the interaction when you see the client next?
· In your work, how often do find yourself trying to defy the statistics and disrupt the behavioural patterns you’ve come to know so well? Is there an image or memory that comes to mind when you visualize yourself pushing against the odds?
· In your own experience of domestic violence, were you the partner or the child? If the child, what do you wish you could say to your younger self? If the partner, is there a kind of shame you carry for the times you stayed? How do these feelings show up when you’re in session?
· Can you analyze your own subjectivity and create questions for the client that can increase her agency and contain her fear?
Vignette 3, United Kingdom
The Muslim School Social Worker
Zainab is a school social worker and provides one-on-one support to students when a need has been identified by a teacher. Zainab wanted to work in a school setting because she grew up in a home with many siblings and busy parents. School was her sanctuary and she performed well, allowing her to gain a full scholarship to a university program of her choice. She’s been assigned a student who is a young Muslim girl who is having trouble academically, defying her parents by removing her hijab when she’s at school, and feeling ambivalent about future studies. Zainab provides a safe space for this student, but also comes down hard on her by saying things like, “I’ve been in your position and rebelling against your parents is energy wasted”; “There are certain things that women have to do”; “You should feel lucky to have access to education”; or, “As a Muslim woman, it is your duty to represent our community well.”
Brief Notes on Countertransference
· Practitioner is trapped in her own subjectivity (she is urgently in need of processing what it means to work in a community she belongs to);
· Self-reflexivity is needed around the experience of being a Muslim woman navigating a patriarchal world while also experiencing gendered Islamophobia;
· Queen Bee Syndrome (Fors, 2018): coming down hard on someone who experiences a similar kind of subordinated position in the world;
· The role of intergenerational envy: the client may have more options than the therapist did;
· Logical fallacy: “I did it, so you should be able to”;
· Anxiety around cultural/racial group representation is a condition of oppression likely shared by both parties.
Supervision Questions
· What part of yourself can you see in the client?
· In what ways was school an emotionally safe place for you and why might it not feel the same for this client?
· What part of you has difficulty empathizing with the young girl? For example, the part of you that was reprimanded for questioning authority, the part that survived by conforming, or the part that’s concerned about cultural preservation?
· Tell me about how the client’s social context differs from your own. Are there options she has that were never a possibility for you? And does this incite fear in you?
· Is there a chance you’re `harder’ on this client compared to others? If we imagine this student to be from a white family, how would that shift your conceptualization of the issues at play?
· What has the client shared about her experience of being told what to do in the past? If that parent-teen dynamic is being replicated in your therapeutic relationship, how do you suspect the client sees you?
· What feels hard about seeing other Muslim women perform their Muslim-ness and woman-ness in different ways?
Vignette 4, South Africa
The Black Queer Male Therapist
Mandla (they/them) was specifically seeking a therapist who is Black and queer — someone like them. They’ve been working with Kgosi (he/him) for four months talking about grief after losing their grandmother, with whom they were very close, and talking about gender identity. Mandla has been a gender-fluid person since they were a child and only recently felt comfortable claiming a non-binary identity. When Kgosi explores what has made it difficult for the client to articulate their gender identity, Mandla explains that at age 12, they were taken to the mountains for a circumcision rite of passage which felt humiliating and traumatizing. It was supposed to “teach them how to be a man,” but these lessons felt ill-fitting for them and exposing their genitals brought up an immense amount of shame. Kgosi listened empathetically while feeling absolutely deflated. What Kgosi couldn’t share was his positive experience of a similar rite of passage in his community.
Brief Notes on Countertransference
· Practitioner grieves when they realize their own cisgender privilege;
· Self-reflection on their own participation in a system that can cause harm;
· Deep sense of shame and desire to conceal their own experience with circumcision;
· Presumption of sameness allowed for the client to disclose and share, but has left practitioner feeling deflated;
· Both belong to a subordinated position in society as Black queer people, yet they’re both positioned to engage in the nuances of the cultural constructions of masculinity and a kind of double colonization.
Supervision Questions
· When you learned this client was looking specifically for a Black queer therapist, what did you make of that request?
· Do you worry about the client asking you personal questions about your experience in the community?
· In what ways has your own understanding of rituals and culture been challenged by your client’s experience?
· How are you integrating the client’s experience — as an anomaly or a new realization about the system in which you also operate?
· How have cultural teachings around manliness and masculinity fit for you personally?
· What would your client have needed to feel equally supported in their community?
· Sometimes we feel guilt, shame and grief around our privilege. How do those feelings facilitate or hinder your emotional process with the client?
· From a treatment planning perspective, what do you need to explore next? How do you want to treat the trauma specifically?
Vignette 5, South Africa
The Tokenized Black Therapist in Group Practice
Poppy has decided to join a private practice of social justice-oriented psychotherapists. While she really appreciates her colleagues, it feels a bit isolating that she’s the only Black woman on the team. Since she joined three months ago, she’s found that 80% of her referrals have been Black clients while the other therapists have much more racial diversity on their caseloads. She still loves her work but finds that a lot of what she provides her clients is something the other clinicians cannot: an acute understanding of the internal hierarchies within Zulu culture when it comes to social class, education, gender roles, generational differences in thinking, and cultural practices. Poppy is also steeped in academia so she appreciates the ways culture evolves and doesn’t see it as static. This insight is something she can pass on to clients in an implicit way that’s empowering. What’s isolating about her work, however, is that she feels much more tired than her colleagues and cannot see as many clients as they do because of the weight of the work. That means she also earns less than they do.
Brief Notes on Countertransference
· Shared lived experience between practitioner and client carries a different `weight’;
· Increased likelihood of `taking work home’;
· Much of the therapist’s sessions involve examining the impact of white supremacy and patriarchal gender norms;
· Unique bi-cultural-bilingual experience in sessions but this is also exhausting;
· Guilt when practitioner can’t take on someone else who `really needs her’;
· Some resentment for being pigeonholed into practice focus.
Supervision Questions
· How does it feel when your clients know that you really understand them?
· Does the connection you have with your clients make you feel like you’re in a familial role with them (at times)?
· What would it be like for you (and them) if you had to halt or stop your practice?
· Tell me about the impact of working with people who, in many ways, could be you, if you didn’t grow up with that extra pinch of class access/privilege?
· What are your anxieties, professionally speaking, about working with one population?
· Are you concerned about your overall worth?
· How do you suppose your peers understand your work with clients?
· Do you think you’re perceived as having a specialization or as lacking the skills needed to work with a wider community?
· How do you imagine your peers see you in the picture of the larger clinic? Is this something you anticipated? What do you feel now that you could not have anticipated when you began?
· Would your peers be able to cultivate cultural safety with clients you see? If so, how might this translate into a conversation with your clinic about a shift in referral distribution?
Conclusion
You might wonder how I’ve compared the experience of working within and outside queer communities. There was one year when I worked in children’s mental health and that’s been the ultimate measure for comparison. In generalized settings where therapists work with just about everyone, the quality and weight of the therapeutic work are different (not easier, just different). For most of my career, I have worked in communities I belong to and my clinical supervision needs have been more specialized than what I might receive in a generalized practice. Between 2010 and 2020, I worked as a Counselling Student in a queer addiction program; Bathhouse Counsellor at an HIV service organization; HIV Tester/Counsellor at a sexual health clinic, and as a Therapist/Clinical Coordinator on an LGBT2SQ family health team. I’ve also had a private practice since 2014. Clients often seek me out as a result of one of my identity markers: South Asian, Muslim, gay, or queer. The opportunity to do this work and to hold space for my people is such an honour. However, it’s not easy work. What’s helped me immensely has been space to consider the unconscious processes that emerge in these particular therapist-client dyads. Regardless of modality orientation, I hope this paper has motivated you to similarly reflect on how cultural safety and countertransference operate when working with clients with whom you also experience some stripes of sameness.
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