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Monday, April 15, 2024

Therapists Should Build a New Cultural Competence: ‘Onlineness’

Many humanistic therapists aspire to practice “unconditional positive regard,” an unwavering acceptance and support of the client popularized by American psychological titan Carl Rogers. Like all ideals, unconditional positive regard is difficult (or impossible) to fully achieve. It takes skill, practice, and maturity to quiet and disregard the constant chattering of mental judgment—even for experts whose job it is to do this.

Some forms of reflexive, negative judgment are well-known and increasingly discussed: racism, sexism, homophobia, transphobia, and classism, for example. Anecdotes abound regarding therapists’ failures to maintain and display appropriate sensitivity to their clients, even very recently (the time when it might have been excusably ignorant has long passed).

As a result, therapists call for a renewed emphasis on “cultural competency”: a deliberately cultivated, expanded ability to understand and relate to clients from different personal and philosophical backgrounds. Though the term was used as early as 1989, awareness of the importance of cultural competence seems to have picked up in the past decade. The core, motivating idea is that without well-developed cultural competency, a therapist runs the risk not merely of failing to help clients but of actively harming them with damaging off-handed remarks or obtuse non-assistance.

But another critical element of cultural competency has gone underappreciated by the psychological field: “onlineness,” if you will. Being “extremely online” is a kind of self-deprecating joke that just won’t die, because it actually gestures towards an important dimension of contemporary human existence: the breadth, depth, and particular flavor of one’s life on the internet.

We now are at least one full generation into the rise of “digital natives,” people who grew up using computers and interacting online rather than having to adopt these practices as adults. In a brief slice of technological history, “going online” was a discrete, occasional event limited to periods spent sitting in front of a large, slow, dialup computer. Now, and for the foreseeable future, online and offline life are hardly separable at all, interacting at every turn. Even prior to Covid-19, ordinary American life was quickly moving online, by day and by night. Between pre-pandemic 2019 and the lockdowns of 2020, the percentage of employed Americans working purely from home rose 10-fold, from a trivial 4 percent to 43 percent. Online dating is no longer a cringeworthy admission by those with niche interests: Today, over one third of heterosexual couples report having met online. Online life affects which events you hear about and attend, how you perceive and interact with legacy institutions like government and school, which doctors you choose and what you expect from them, even where you decide to live and how your city changes under your nose.

As a life coach who works primarily with twenty- and thirtysomething clients who find me on Twitter, I’ve seen time and time again how online cultural issues impact individuals’ goals, desires, standards for themselves, and even core personal identities. (For better or worse, coaches tend to operate more freely from institutional and traditional constraints than therapists, and we do seem to be more clearly attuned to the needs of the extremely online.) Problems like repeated romantic failures, work frictions, and social anxiety are not themselves new, but they show up in very particular (and sometimes very complicated) ways online. Think: being unmatched on dating platforms, getting muted on Twitter, text message read receipts combined with the ambiguous radio silence of either notification fatigue or genuine indifference.

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It’s hard enough to walk into these conversations as strangers, let alone when it might be necessary first to explain the entire background, emergent norms, and inner workings of your friend group’s Discord server (perhaps none of whom who you’ve ever met IRL). Or, to someone who’s never seen dogpiling or sealioning in action, how could an already emotionally distraught person really explain it with full vividness?

Developing cultural competence is intrinsically valuable as an expression of respect for clients and a way to take responsibility for seeing them always as individuals and not interchangeable tokens of prejudicial types. But there is also a simple utilitarian need for cultural competence: Therapy can’t work to achieve its aims without understanding and rapport. Studies on therapy’s efficacy reveal that the most important predictor of therapeutic outcomes is not necessarily the use of any particular modality, but simply the “therapeutic alliance” between the provider and the client. Rapport always takes time and energy to develop, but if the basic fit is promising, then the initial investment in rapport-building becomes highly worth it.

From where I’m standing, it seems that pessimism about many therapists’ online cultural competence—and the seemingly inevitable lack of rapport stemming from that divide—can drive extremely online people to coaches, rather than therapists. It’s great for my business, and I am honored to help where I can. But when my extremely online coaching clients and I run up against something that seems more clearly therapy-apt, for many, I often cannot in good conscience recommend that trying therapy next will be worth their while.

Without an understanding of online life, the implied burden of explanation and proof would fall accidentally but onerously on the client, at least taking up more (expensive) session time than it should have, and quite possibly even causing an irreparable therapeutic rupture right out of the gate and arresting their desired progress. For any trait, onlineness included, some people will necessarily occupy the less relatable tail ends of the distribution, but they deserve sensitive care all the same.

So what’s the extremely online—and the therapists who want to help them—to do?

The “cultural competency” devil is all in the details. There is no convenient consensus on either the fundamentals of cultural competency in theory nor convergence on how to teach or implement it in practice. Light systemic fixes like tacking “Cultural Competency 101” or “Understanding Social Media” onto the mainstream credentialing curriculum cannot be trusted to really do the job. Plus, in a truly intersectional fashion, onlineness cuts unpredictably across other more legible and discrete aspects of human categorization. People of all ethnicities use Twitter, of course, but “Black Twitter” in particular has different patterns and practices from what a new, egg-avatared user finds on her default home feed. Millennials, for instance, were commonly exposed to a kind of “follow your passion” and “hustle” culture online in a way that may seem anachronistic to Zoomers.

Different online spaces evolve different cultures quickly, as a function of who made it, who shows up, and what they’re trying to do. Attempting to chat with randos in YouTube comments is a whole different ball game than posting that same video on Facebook, where only your long-lost high school friends and distant familial relations would see it. Even an apparently single space can develop radically disparate cultures. Reddit “subs” are well known for featuring both explicitly stated rules and unstated norms. While it isn’t necessary that a therapist become familiar in advance with all of these subcultures (a Sisyphean task anyway), a general willingness to take client reports about them seriously, and envision that online climate as it really is, is needed to close the understanding gap.

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Researchers have had some success in investigating particular “cultural adaptations,” analogous to patches or updates for making existing therapy treatments more culturally sensitive and responsible. Instead of metaphorically reinventing the wheel, the cultural adaptations approach builds upon already evidence-based practices to (hopefully) make them more effective for more prospective client populations. These “adaptations” may shift the language employed in a therapy or broaden its context, without changing the core of what (apparently) makes it effective. For instance, psychologists have documented success in adapting cognitive behavioral therapy specifically for depressed Puerto Rican teens.

One particularly intriguing meta-analysis of culturally adapted psychological treatments indicates that therapists who speak to clients’ existing cultural myths regarding explanations for illness secure better outcomes than those who speak from the default (i.e., Western) perspective. Cultural myths are not “myths” in the sense of being false, but are more like socially maintained tenets or traditions. For instance, Eastern cultures are less likely to view the self individualistically than Western ones, so adapting therapy in recognition of this difference—perhaps inviting clients to preserve harmony more than to individualistically assert their “boundaries”—makes sense.

Attending to clients’ cultural background via adaptations makes an apparent difference in therapy effectiveness, whereas simply matching client and therapist background did not. This bodes well for the idea that practitioners are not inherently limited in their ability to reach across lines and expand cultural competency.

This also suggests that even therapists who lack first-hand experience in the “creator economy,” meme making, or online dating may be able to close the gap with enhanced factual knowledge on these topics. For instance, evidence suggests that online daters rely more heavily on certain markers of prospective date compatibility than is warranted by the (very unpredictable) profiles of ultimately happy couples. With this knowledge, even a therapist who has no personal experience of online dating and who doesn’t “get it” on that level can still be poised to help their client reframe past online dating failures and approach future online (and offline) dating experiences with a fresh, constructive perspective. In particular, cognitive-behavioral approaches seem amenable to empirically driven revision of this kind: a cognitive-behavioral therapist helps clients to challenge their own questionable, ineffective beliefs and behave in accordance with desired new beliefs instead.

We will probably have to wait quite a while for actual research to develop regarding cultural adaptations for the treatment of the extremely online. As usual, the future is here, but it’s unevenly distributed. The simple passage of time will partially address the issue as non-digital-natives age out of the psychological workforce, but a new bleeding edge in extreme onlineness is emerging all the time. For example, I have worked with a number of coaching clients who’ve experienced huge cryptocurrency windfalls and also losses, with all those attendant issues.

Still, therapists have always worked with clients who are different from them, yet the field persists and grows. Knowing may be half of the battle—though therapy consumers are not obligated to train their therapists in online cultural competence, being forward about the need for understanding in this domain can help individual therapists and the overall field take online cultural competence seriously.

In the meantime, must extremely online people fret in misunderstood isolation or tolerate obviously subpar therapy? Clients shouldn’t be afraid to screen a prospective therapist for basic familiarity with similar clients and situations. As one researcher expresses it, cultural competence may not consist in a particular, acquired body of knowledge so much as in a therapist’s basic attitude of curiosity and humility about clients’ potential differences. You don’t necessarily need to hire a TikTok therapist (they exist!), but do insist on finding someone with a demonstrated curiosity about, and openness to, clients whose lifestyles may at first seem off the IRL path.

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