I have found that artful self-disclosure is a needed skill for cross-cultural work in psychotherapy. I am writing to assert and justify the use of self-disclosure particularly for people who experience “psychosis” in which complex cultural barriers appear to be present.

Historically, it has seemed that many in the psychotherapy establishment have tended to emphasize theories that are rooted in a history of blank slate transference. I have seen PhD and Psy.D. students get told that in their advanced studies they are going to need to study a complicated theory like psycho-dynamic or psychoanalytic. I am aware that some programs feature these schools of thought in their curriculum. When I ask licensed psychologists what they practice, I often hear they are trained in one of the above two disciplines. It’s true I am not studied in that way and may not understand multi-cultural aspects of those theories. Perhaps there is potential for sophisticated use of self-disclosure within.

However, I feel called to point out that the notion of a blank slate may get misused and fail to identify the therapist as a cultural player in the therapeutic reality that gets created. I tend to want to point out that many practitioners who hide their personal realities from the participant, also seem to say that I, the therapist, am not part of the problem or reason you are here. This may work for some people when harsh social and cultural barriers do not exist.

The Victims of Systemic Cultural Barriers: 

I write for a culture of people who are on disability or have lost sustaining social functioning, had to survive on the streets, or been treated forcefully in a psychiatric ER. I feel that often they have good reasons for resistance when it comes to psychotherapy. Moreover, additional cultural barriers like race, gender and class may involve historical oppression of slavery, confinement, or oppression through which the relationship needs to work. Additionally, it is arguable that many clinics stand to profit or sustain themselves when participants stay dependent.

The culture I am writing for appears to be expanding locally in homeless encampments, selective shelters, and unlicensed board and care homes as technology advances and local peoples get displaced.

The Danger of Wielding Ethnocentric Power:

As a privileged working white man educated in a Quaker private school and hired to work with people on public insurance in an urban California, one might think that I rarely work with people who share traditional cultural traits. I like most therapists who work with the underprivileged, am accustomed to crossing racial, gender, class, prestige, sexual and spiritual divides. However, I argue that as I have developed a practice that focuses on self-disclosure, that my ability to cross cultures in work with disadvantaged populations has deepened.

I regularly define elements of my own culture like my spiritual upbringing and the fact that I was raised on the East Coast. I openly reflect on my relevant experiences that define me, like moving into the ghetto to attend college and living and working in the community there. I also recount challenging the power structure that regulates section 8 housing and ending up incarcerated in a State Hospital, homeless, and vagrant. As I do this, I explain to my clients that this empowers them to understand my world view, so they can decide when to listen and when to teach.

I have come to feel that failure to do this enables me to wield ethnocentric power over the recipient that can result in misunderstanding, degradation or abuse. As therapists, it impossible to hide our skin colour, our gender, our way of speaking from marginalized individuals. We may be able to hide our own mental health struggles and class background to some extent but is that really fair? Acknowledging who we are even if it is not perfect (or too perfect) is respectful and authentic. I also think that therapists’ who work in such contexts need to have a reason for wanting to do so and acknowledge the potential that their education-influenced perceptions may do harm and mitigate the damage.

Ultimately, it’s hard to deny that psychotherapy work excavates a systemic reality for marginalized persons in which cultural elements play out. Ultimately, if our intention is to see the reality of the client as a cultural being, then, I argue the culture of the therapist or anthropologist is extremely important.

Artful Self-Disclosure in the Pursuit of Cultural Reality:

For the past ten years, I have been developing a transparent and experiential way of being a psychotherapist that artfully uses self-disclosure to explore and redefine what “psychosis” means. In doing this, I have used my own silenced stories to start reflection and discourse about what psychosis means and identify eight universal components. If I start to dominate the discussion in the group, I notice that and make amends.

In doing this, I readily reference my experiences as a patient in the mental health system and things I experienced during a two-year period of madness during which I struggled to establish a residence and employment. Sharing these experiences and lessons learned can help take away power dynamics in the helping relationship that can be a barrier for many vulnerable people in genuinely seeking and engaging in therapy at all.

I have worked hard during this time to define myself as a cultural being to the people I work with. This means I do my best to own and name my counter-transference instead of acting according to them. I act in ways that help the person work through their objections to create safety between us. I tend to do this by just being honest and interested to learn more.

When I think about what I have been doing, I go back to ideas that first emerged in my consciousness some twenty-five years ago, when I studied psychological anthropology.

The Value of Psychological Anthropology:

With a quick glance and Wikipedia, one can see that psychological anthropology is a sub-field that officially started in 1972 but has deeper roots. Founded by Francis Hsu, the psychological anthropology suggests that culture affects mental processes and the idea that belonging to a cultural group can shape processes of, “cognition, emotion, perception, motivation and mental health.”

The reading list I laboured to learn was put together by the Sociology and Anthropology Department at Rutgers in Camden and featured books like Coming of Age in Samoa, by Margaret Mead; Never in Anger by Jean L Briggs; and Saints, Scholars and Schizophrenics, by Nancy Scheper-Hughes.

I remember being impressed that particularly with Never in Anger. I found that when the author was transparent it gave the reader more power with which to understand the culture they were studying. I came to feel this was an extremely important step to take before trying to describe another culture. Some of the other books, like Coming of Age in Samoa, were less fearless in their introspection and led to errors that were based on the author’s judgments and desire to be popular. I came to trust narrators who decreased the power of what they reported by honestly acknowledging their limits. I felt that even though Jean L Briggs issues annoyed me, that being able to judge the writer as much as I might judge the society leads to a deeper reality of what transpired and ultimately gives me a better understanding of the culture. And, so, the disenfranchised can better understand themselves when differences are articulated.

I find that working through this process with people has helped me better understand a divided and disbanded culture of “psychosis.” Reconstructing a culture that includes people does affect psychological processes in a positive way. And for each participant sharing and understanding who they are culturally is very important. It enables people to see what they have in common with each other.

Exploring an individual’s disadvantaged cultural reality with an unidentified blank slate mentality who maintains the reality they are exploring is sick and doesn’t deserve to exist just doesn’t seem humane? Would you trust someone who tried to do that with you? This was the very nature of all the imposed psychotherapy I endured.

The Anthropological Reconstruction of the Oppressed Culture:

I moved through my dumbass western counselling psychology program and practised therapy in social work jobs. In doing so, I learned to understand the marginalized world view of the most vulnerable in our society. And then I became one of those most vulnerable people. I have come to believe that distinctive world views and realities can only be understood through the lens of a person’s experiences or subjective perspective. I believe the role of the therapist needs to be study and understanding of those world views. I put that together with sets of a cultural group’s experience and it has helped me develop in my practice towards establishing treatment for psychosis significantly.

The idea of using phenomenology to deconstruct illness constructs into clearly articulated experiences is a powerful one that enables a person to recovery. That is what DBT does! However, to recover, many people who are different suffer and need cultural support. Oppressed cultures impacted by slavery, war, genocide, or institutional incarceration need a sense of identity to overcome and support ending the oppression. Hence, what is needed is not only a deconstruction but a reconstruction of the “problem” so that it can persist without being so misunderstood.

Thanks to the DSM, we call oppressed culture a sickness and when it comes to the phenomenon of “psychosis, this ensures ongoing diagnostic differentiation, oppression and incarceration. If the problems are reconstructed into solvable components, the problem does not have to dominate the individuals’ life. In the case of “psychosis” misunderstanding the experiences and viewing them as a problem can enhance the suffering and lead to more and more accurate oppressed realities.

In other words, artful cultural self-disclosure helps bridge cultural divides that are necessary not only to help people recover but also to help research the social problems we experience as psychotherapists, philosophers and theorists. I think it is time for artful self-disclosure for psychotherapy when it comes to working with those who are institutionally oppressed. Additionally, people who have been oppressed and subjected to these circumstances can be very good at using their stories to help others. They need to be included in the treatment of these situations.

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Early in my career as a social worker, I couldn’t even see the phenomenon of mental health warehousing let alone know how address the issue in a relationship. My college texts had promoted the mainstream eugenic presumptions associated with mental illness. I didn’t know what was needed to recover from things like psychosis, personality disorders, or addictions and live a fulfilling life other than to tell the client to take their medication.

Now, in my twenty-three years of experience working in the system, I have seen many other workers not really learn about the effects of mental health warehousing. It’s as if those of us who work in the field slept during social psychology lessons of Stanley Milligram and the Stanford Prison Experiments. And many of us who do understand the dehumanization process associated with warehousing may abandon the work for private practice. It’d nice it they left a little space in their practice for warehoused individuals. Perhaps some do.

Believe me, I never imagined that mental health warehousing would happen to a conscientious person who excelled in the mental health professional like myself. I used to think I was empathetic towards clients because that’s what always impressed others about me. Now I think I was just sympathetic and encapsulated! Indeed, though it could happen to most us, we rarely think that way. When I did land in warehousing, it was a real education.

I went to work in a section eight housing project and alerted the press and challenged the police. A resident warned me to stop bucking the system, or the same thing could happen to me. He was right.

Now, seventeen years later, most of my clients live in warehoused conditions and need help adjusting to them. Many have lost family support and lived this way decades. Of course, I do what I can do to help them be free; but learning to do so has taken some time. For clinicians new to working with warehoused individuals, I have just five suggestions to make.

 One, don’t presume it is easy to leave these very real experiences behind:

Once subjected to warehouse conditions, people may have a need to honor their experience and have a hard time leaving the neglect behind. Many tolerate and honor things that don’t make sense to the observer. In fact, many observers might have a hard time believing that what warehoused individuals report is real.

How could it be, for example, that in the land of the free, that the only job that a privileged white man with a master’s degree and a beef with organized crime and the police could find was at an Italian Deli with a four-hour daily bike/train commute? It was not for lack of job applications or resumes, I assure you.

During a two-year period, I had to learn not to snitch. I had to accept that people were breaking into my apartment and stealing my things, just as they had done when I was warehoused three-months in the dilapidated Montana State Hospital. Maybe you can’t believe it possible until it’s happened to you!

For people like me, it can take years of revolving door hospitalizations to get to the place where they accept warehouse living to start with. Then, to move on can be a lot for the ego to manage. It is hard to say all the warped things they learned from their experiences in incarceration were unnecessary. It is hard to abandon the post because, often, warehoused people know first-hand that things could be worse.

Two, don’t presume that you could get out of the very real holes they are in:

In working with warehoused people, it is important to temper the amount of advice you give them about how to be empowered in their situation. Just because you have power, doesn’t mean that they do. Thinking that they don’t know how to assert themselves is a good way to diminish the amount of trust that develops.

I have seen clinicians burn out because their advice is never heeded. Maybe they leave behind their duties physically or emotionally because they don’t believe the oppression is real. Many clients have seen this happen repeatedly. Here comes another staff person they are responsible for training. Now, they start from scratch, just so they can get their weekly check.

No matter how seasoned you are, it is always wise to be thankful when your client teaches you something that deepens your understanding of the layers of oppression they face.

Many workers may not realize that they couldn’t manage themselves what they are presuming their clients ought to.

Many clients, like the section eight resident who tried to warn me, know better than to try to fight the system politically. They will see advice or action towards that end as simply being naïve and insulting. Really, they usually know what’s up! Respecting the power structure but talking about how oppressive it is may help.

Three, find ways to address the fact that you are financially exploiting them in the context of the relationship:

Many would say it is cynical to look at the mental health industry and say that there is a lot of money reinforcing the suppression of its subjects into mental house warehousing. Seeing the mental health industry from this vantage point makes it seem like it is a plantation industry with finely educated suits with six figure salaries making decisions about how to keep the peasants maintained.

Clearly, not all the people I work with see managing the trauma and strife in their lives from so cynical a perspective. Still, I believe a therapist who works with people who have been warehoused needs to be prepared to work through these realities and feelings as they get unpeeled in the relationship. At times, I have found that it is important to argue the cynical perspective to help people become sensitive to how being warehoused has impacted them. It may be necessary to help people see and remember the value that they really have. This may help reinforce social rehabilitation.

Many warehoused people will appreciate it when you acknowledge your buzzard role in nickel and diming them and picking through their bones. At least talking about it will help them know you will do what you can not to get caught up in that trajectory.

Although I was only warehoused for a short time, the therapy I got at 125$ an hour while I was making 9$ an hour at a Deli seemed ridiculous. Talk about financial exploitation—for years it was. My parents mandated it and paid for it from a nest egg, but would not give me money for a car.

 Four, know that therapy is still valuable and walk the line:

In retrospect, and knowing the business as I now do, I am just grateful that my therapist did not refer me back to the hospital so that I lost my job and my apartment. If I had seen an intern who wasn’t making top dollar, I likely would have overwhelmed them and their supervisor and been incarcerated back in the system where it would have taken me much longer to heal.

Having a therapist for warehoused individuals is important even if they don’t seem to like you. And good clinicians need to be tolerant, competent with what they are dealing with, and maintain unconditional positive regard.

Supporting your partners is ways that help them make well thought out slightly empowered improvements in their interpersonal situation is possible. In doing this, it is important not to act as if you know, but to collect a lot of information about the barriers in the situation with curiosity.

I think good therapy advances the mindset that it is possible to help warehoused individuals pursue healthy integrated activities that can mitigate the effects of warehousing. That is what I did maintaining a job. Many amazing people have taught me that a bed in a warehouse is just what it is. One can still do their hygiene up and go out and find healthy activities and connections. I now see and support people doing this every day.

Five, help!

And yet when I look at the workshops available to me as a licensed individual, there is little out there in my trade organization that encourages therapists to learn to work with these conditions and limitations.

I wish that more therapists would learn to specialize in helping warehoused individuals. For practitioners who care about social justice, there really is no better way to be of service in the community than to develop specialty practices that can reach out and include such individuals.

Currently we know this population growing exponentially in our local homeless encampments, our flooded shelters, our barrack-like board and care homes, our county jails and over-crowded prisons. Know people can recover and gain back their freedom! Help!

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