An episode of “Changing the Conversation” podcast
Chia Hsuan Sabrina Chang and host Lola Nedic discuss culturally responsive care and strategies for clinicians. This episode is sponsored by the New England Mental Health Technology Transfer Center Network (MHTTC).
December 4, 2023
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Lola Nedic, Host (00:05): Hello and welcome to Changing the Conversation. I’m your host, Lola Nedic. I am a clinical research coordinator at Beth Israel Deaconess Medical Center and the Harvard Site Coordinator of the New England Mental Health Technology Transfer Center. This episode is sponsored by the New England Mental Health Technologies Transfer Center.
(00:24): Our topic today is culturally responsive care in early psychosis, and our guest is Chia Hsuan Sabrina Chang, a psychologist in the Boston area working with individuals with serious mental illness who don’t often have the means to seek treatment in the private sector. Chia Hsuan also teaches and supervises at Harvard Medical School and Boston University’s Center for Multicultural Training in Psychology. Chia Hsuan, thank you so much for joining us today.
Chia Hsuan Sabrina Chang, Guest (00:50): Thank you for having me. I am so excited to be here.
Lola (00:53): Awesome. So let’s get into it. What are some key things that you think providers should know about culturally responsive care?
Chia Hsuan (01:01): We probably hear a lot about what’s cultural competence, what’s cultural humility, having awareness, skills, experience, all of that, and I think that’s great. What I hope to contribute to the conversation is my own approach to thinking about culturally responsive care. And I think about being a culturally responsive psychologist as a lifelong process. And so instead of hitting points, I often guide my own learning experience through a series of questions.
(01:34): So I often think about how do I be a helper or a healer to folks who don’t — not only not have the same experiences as me, but experience a profound different level of privilege than me. How do I become a healer to those whose very oppression I benefit from? That’s a very complicated question I often ask myself. Another question I ask is, what tools do I actually have to offer as a psychologist?
(02:08): I am currently offering tools who are made by people who share my levels of privilege often, tools that are designed for people who probably look like them with similar experiences as those creators, but I’m offering those tools to people who don’t actually have that level of privilege and who probably weren’t the audience or the patients that these creators of tools had in mind. The last question I think a lot about is the therapeutic space.
(02:44): How can I create a space when I come into the office sitting across from my client that is fundamentally different than the one that’s outside? The one that’s outside is violent, oppressive, silencing, filled with microaggressions, so on and so forth. How can I create a space that is fundamentally opposite of that? So I think helping myself answer those questions on a regular basis allows me to work to towards being a culturally responsive psychologist.
Lola (03:19): You did say that culturally responsive care is sort of a lifelong process. What would you say is something that you’ve learned or improved at since first starting?
Chia Hsuan (03:30): So many things. I think the first thing I learned was how little I actually learned in graduate school. [Laughter] Not to be a downer. [Laughter] I learned a lot in graduate school, and I also made a lot of space for what I didn’t learn and what I didn’t know. And I think once I allowed myself to have that space and process feelings related to having so much space filled with things I don’t know, I think that actually allowed me to step into actively becoming a culturally responsive psychologist.
(04:11): So in addition to that, I think having to unlearn some of the things I had to learn as a psychologist in graduate school, but just also as a human being, as a woman, as a woman of color. Lots of things I had to learn about myself I had to unlearn in order for me to be more responsive.
Lola (04:30): How do you begin to establish a therapeutic relationship with a client who has just came into your clinic?
Chia Hsuan (04:37): I think I think about not only what differences we have in terms of our backgrounds or our experiences, but it really comes back to the question of privilege, what I have had access to in my life, what type of power and resources I was simply given that folks don’t. And from that point, how can I actually understand what my client might be going through right now?
(05:09): There is so much that our clients can teach us about how to have a good relationship with them, and oftentimes we have to just take a step back from what we think is a good therapeutic relationship and really ask our clients about what do they think is a good therapeutic relationship and follow their lead, because ultimately the relationship is there to serve them.
(05:35): I’ve also found that it has really provoked some really great conversations at the start of therapy to ask clients about what’s been their experience receiving care from the mental health system, and to really make enough space for them to talk about all the ways they’ve been harmed by the system, all the ways they have not been helped, all the ways they’ve been neglected.
(05:59): And for them to know that I know that I exist in that space and that I work for that system, and that when we come together, yes, we are part of the system, but we’re going to acknowledge the system so we can then actually try our best to parse out the effects of the system. That’s been some meaningful conversations from the jump.
Lola (06:22): Wow. So I want to talk a little bit about how you’re learning about your client’s experiences. So how do you step into that space with the intention of learning everything you can about a client, while also not placing any undue burden on them to explain every bit of their experience to you because that can also be a huge burden for clients?
Chia Hsuan (06:47): Yeah. We often talk about culturally responsive care as something that happens in the room. And I think what you’re alluding to is that there’s actually a lot of work that ought to happen outside of the room, and I completely agree with that. I think it would be really difficult to sit across from a client without actually knowing what’s going on in their community, for example. Coming back to your question about how to establish a good relationship with a client, I think even before that, what I like to do is establish a good relationship with the communities that my clients belong to.
(07:27): Just know what’s happening in those communities, what they’re experiencing, what they’re coming up against. And I try to cultivate a relationship with those communities that is meaningful, that is opposite to what is typical out there. That’s a lot of meaningful work that someone can do outside the therapeutic space. And I think second, there’s a lot of work that one can do with their own relationship with themself.
(07:58): With myself, I’ve had to really examine my own values, my assumptions, my reactions, my beliefs, and think about ways I can decolonize my own mindset, and think about ways that I can practice not just cultural humility and flexibility and competence when I’m sitting across from a client, but practicing those things within myself. How can I be culturally affirming to me to start with, to begin my own healing process? So yes, I think there’s a lot that can happen before you even start to ask the client, “So, tell me about yourself.”
Lola (08:39): Gotcha, yeah. So it sounds like clinicians have to do a lot of work internally to even get to that place. You talked a little bit about building a relationship with various communities that your clients are a part of. How does one begin to build a relationship with a community that’s very different from your own? What are some steps that you’re taking to do that?
Chia Hsuan (09:02): I do a lot of volunteer work. The way I started was to just spend more time in these neighborhoods, in these communities, attend events. And I know that probably what comes up for people when they think about stepping out of their own neighborhood and community is this feeling of discomfort, that I’m going to say something wrong or I’m going to do something that’s going to offend people. And I think, yes, you’re going to do that. You will, because all this is very new to you.
(09:36): You will make mistakes, and that’s part of the process. I’ve definitely made my fair share of mistakes. I’ve gotten really good apologizing. To quote Marsha Linehan, who authored Dialectical Behavior Therapy, “a good therapist is one who’s really good at apologizing.” I really firmly believe that. And so when I found myself spending more time at these communities, and especially at meaningful cultural events at these communities, I found very natural ways to connect with folks and organizations that are doing really great work.
(10:11): Just recently after the last round of the census, I was able to volunteer when it came to the redistricting process ahead of voting. And I did everything. I bought coffee for events. I set up chairs. I spoke at some of these community events, and I spoke to our senators in the Massachusetts Senate. I think just saying yes to things and not take yourself too seriously really helps. And yeah, actually I was able to earn a citation from the Massachusetts Senate for doing the volunteer work that I did.
Lola (10:52): Oh, wow. Congrats.
Chia Hsuan (10:54): It was really cool. I don’t think I earned it. I think I really share with the people that trust in me enough to be in that position to speak on their behalf. But I think another thing to think about too is really take a really hard, good, thorough look at your own social network. In order to be culturally responsive when you’re sitting across from a client who’s from a different background than you, you probably would be a psychologist that have meaningful relationships with people who have diverse backgrounds, different experiences than you.
(11:35): So if I look at my social network and all I see are people who are other psychologists who have the same skin color and sexual orientation and gender identity as me, I’m probably not going to be able to then go to work, sit across from a client 9:00 Monday morning and be culturally responsive. And so I’ve also had to learn to really value how to build friendships and relationships with people who I don’t naturally bump into on the street, get out of my comfort zone. And people are so generous.
(12:13): People are so generous and loving. And if you’re willing to listen, I think you have an opportunity to learn a lot. That’s at least been my experience.
Lola (12:25): As someone who has to do a lot of work outside of the therapeutic space, how do you balance that with the burnout that so many clinicians feel? You have too many clients and you work such long hours. How do you and how should other people make space to make those improvements and to think about those things?
Chia Hsuan (12:44): One is to not be too proud, to seek help, and to know that you have your own limits. One thing that I’ve really enjoyed lately is this peer supervision group that I belong to. I share an hour a month with other women psychologists of color where we can talk about not only our clinical work, but about ourselves and how those two things intersect. I also want to say that I want to get away from the Eurocentric framework of me doing the work and then getting away from that and in order to say that every person in my life really helps with that.
(13:32): Every time I get up in the morning, my husband makes me breakfast. He takes the dogs for a walk. That’s helpful. Every conversation I have with my mom about her lived experiences as a first generation immigrant, that helps. I think when you feel not so alone in doing what you’re doing, yeah, it feels like it’s more sustainable. So whenever I’m sitting across from a client, I’m always really in a way, I’m always in there with my community of people.
Lola (14:01): How do your own personal values and conceptions of culture play into how you’re delivering care? How do you view culture?
Chia Hsuan (14:11): I see culture as something that is extremely hard to define, so I really appreciate the question, because how do we define something that is everywhere, everything all at once? [Laughter] I would say that culture are all the forces that make us who we are. There are so many different levels of culture, so many ways that cultures show up.
(14:39): And I think it’s really difficult to talk about anything without talking about culture. What is satisfaction with life? What is quality of life? What is joy? What is depression? What is psychosis? What is reality? I would say all concepts are culturally bound.
Lola (15:02): Yeah, I agree that it’s everything. I think the issue starts when people start trying to create a solid definition of culture and limit it to what we would think of. I think race and religion are probably the most common things that people think of when they think of culture, but it’s really so much more than that. And bouncing off of that, what are some misconceptions you think people have about practicing culturally responsive care, especially in early psychosis?
Chia Hsuan (15:31): I think folks tend to have a checklist mentality when it comes to culturally responsive care. I got to asked this question, I got to do this, I got to make sure I hit that point. And then they’re like, “Oh, cool. I did it. Congratulations to me.” [Laughter] And I’m speaking from my own experience. That’s how I used to think about culturally responsive care is I got to make sure I get to these places and open those doors, and then I can go ahead and shut them [Laughter] because we’ve done that. I think that’s a really common misconception.
(16:06): It’s just such a tantalizing one because it makes one feel like they accomplished something, when we can clearly delineate, okay, what is culturally responsive care? And just do those things. Then we get to, we as psychologists and clinicians, get to walk away from that clinical encounter and go, “Oh, I did it.” While that’s really comfortable and that probably feels really nice, I really try to invite myself to get away from that mindset and think about it as a journey.
(16:37): That’s probably a place that I will likely never reach ever with any of my clients, but I’m always constantly continually going to take steps towards there.
Lola (16:48): If culturally responsive care is not something with a finite start and end, how do you conceptualize your own improvements and personal development, and how do you think about that in terms of a therapeutic relationship if it’s not something that really has steps to it?
Chia Hsuan (17:05): The simple thing is is I ask my clients how they experience therapy, and I think that is the expert in the room, that’s the expert anywhere when it comes to my ability as psychologist to provide culturally responsive care are my clients. And I think one thing that I’ve tracked over time is how long clients are willing to have conversations with me about their culture. How open are they when we talk about culture? How safe do they feel? How much emotion can they express?
(17:47): How much anger are they permitting me to witness when we talk about culture and ways that white supremacist culture can be oppressive? So those are some landmarks I try to navigate my journey by. I have the privilege of working with some incredibly wonderful psychologists and trainees, and I feel so encouraged by how much the younger generations of psychologists are learning about culturally responsive care. And so they check me.
(18:19): I feel very lucky that I have the type of supervisory experiences that I’ve had where my trainees are able to provide me feedback about how I can get better. So that’s been incredibly helpful.
Lola (18:34): What are some helpful feedback you’ve received from a trainee?
Chia Hsuan (18:38): This is probably very uncomfortable to do, but I encourage everyone to do it, which is to share your tapes with your trainees, to actually let your trainees into the room as much as you can. It feels really vulnerable because according to Eurocentric educational system, I’m supposed to be the knower and I’m supposed to impart knowledge and leave it at that. But again, trying to decolonize my own mindset, really trying to think about how I can learn from my students. I do show recordings to my trainees.
(19:09): And I think one thing that my trainees have really helped me with is pointing out when I feel uncomfortable in session, when clients bring up something that bristle up against my privilege or bristle up against something related to what I think about meritocracy and how it might exist out in this unfair world. Basically bristling up against my unconscious biases. My supervisees can point that out to me. I mean, that’s invaluable.
Lola (19:48): Yeah, sounds like a really valuable experience. Well, you touched a little bit at the beginning about the tools and resources that you as a clinician have on hand and how it’s obvious that those tools come from a place of privilege. In terms of thinking about the future of culturally responsive care, do you think we’re going to be continuing to use those tools or developing new tools, or perhaps even moving away from the idea of fidelity tools as a concept?
Chia Hsuan (20:20): I think the tools are probably here to stay, and there is a place for them, in my opinion. I think what we want to get really curious about is how these tools are used and how what we offer, these tools, and everything we offer as psychologists, it’s imperfect. But I really hope that there will be a time, and I get to witness it while I’m still practicing, that there will be more diverse psychologists and researchers who are thinking about therapy and thinking about creating novel new tools that we can add to our current toolkit.
(21:03): Because our current toolkit, it’s very White. It’s very upper middle class. It’s for people who are educated. I don’t know if you’ve heard of the acronym WEIRD?
Lola (21:16): Yes. For our listeners, what does WEIRD stand for?
Chia Hsuan (21:19): It’s White, Educated, Industrialized, Rich, Democratic.
Lola (21:26): Correct.
Chia Hsuan (21:29): [Laughter] So, these tools are very WEIRD. So I hope that we will be able to have diverse voices in the laboratory who are making tools that are not so WEIRD, and I think that’s going to have to come from a place of re-imagining what academia looks like, who deserves lab space, who deserves resources, who deserves a place at a university. We also need to reimagine funding and how funding is currently structured and how publication and meritocracy is currently set up in the academic system.
(22:08): Because if we continue with the system as it is today, we’re going to continue to reward folks who are within the system, who have the same stale voices as we’ve heard. In terms of fidelity tools, again, I think we absolutely need folks with different experiences at the table evaluating those tools. And more importantly, I would love to see us psychologists be much more innovative about how we can invite more people with lived experiences in creating those fidelity tools and including different therapeutic modalities.
(22:49): Right now there’s such a separation between psychologists or who are the healers and who are the people receiving help. And again, that’s a very artificial divide. It’s a very Eurocentric divide. It’s a very white concept. I like to think of us as existing, hopefully, one day as one community. And so if we’re part of the same community, how can it be that a huge chunk of our community is not actually able to have a voice at what is being offered to them? So maybe lots of exciting things to come.
Lola (23:27): Well, Chia Hsuan Sabrina Chang, thank you so, so much for being with us today.
Chia Hsuan (23:33): Thank you. It’s been so fun talking with you.
Lola (23:36): And to our listeners, join us next time on Changing the Conversation.
Erika Simon, Producer (23:41): Visit c4innovates.com and follow us on Twitter, Facebook, LinkedIn, and YouTube for more resources to grow your impact. Thank you for joining us. This episode is sponsored by New England Mental Health Technology Transfer Center, New England MHTTC, and was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Our hosts for this series are Joey Rodriguez and Lola Nedic. Join us next time on Changing the Conversation.
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