Mark A. Fairfield, LCSW, BCD
Los Angeles, California
April 25, 2008

Background

At the end of the last millennium, the U.S. Surgeon General reported that culture is a concept not limited to patients; clinicians view symptoms, diagnoses, and treatments in ways that sometimes diverge from their clients’ views, especially when the cultural backgrounds of the consumer and provider are dissimilar. “This divergence of viewpoints can create barriers to effective care. Clinicians and service systems, naturally immersed in their own cultures, have been ill-equipped to meet the needs of patients from different backgrounds and, in some cases, have displayed bias in the delivery of care" (Surgeon General’s Report, 1999).  

The Final Report of the President’s New Freedom Commission for Mental Health (2003) urges mental health providers to increase diversity in the health professions, recommending the following reforms to our current mental healthcare system:  1) ensure that systems of care integrate the consumer’s culture in the treatment process; 2) ensure that mental health systems adapt to meet the needs of people of color; 3) make cultural competence education mandatory in clinical training programs and in continuing professional education in medicine, social work, and clinical psychology; and 4) create readily accessible financial assistance programs, scholarship programs, and loan-forgiveness programs for graduate mental health education for people of color to pursue a mental health profession at the graduate level.    

Despite efforts to increase sensitivity to issues of diversity and to develop a more diverse pool of health care providers in our country, the mental health industry continues to be led primarily by white clinicians who have not developed capacity to manage the complex issues related to working across various cultures.  According to the 2007 Current Population Survey conducted by the Department of Labor, of the approximately 1.5 million mental health care providers (including psychologists, social workers and counselors) employed in the U.S. in 2007, 19.6% identified as African-American or Black, 9.6% as Latino, and 3.3% as Asian.  

And it seems the situation for African-Americans is difficult to measure for various reasons. In 1998, among clinically trained mental health professionals only 2% of psychiatrists, 2% of psychologists, and 4% of social workers said they were African American.  African Americans seeking help who would prefer an African American provider will have difficulty finding such a provider in these prominent mental health specialties. The availability of mental health services also depends on where one lives. A relatively high proportion of African Americans live in the rural South. Evidence indicates that mental health professionals are concentrated in urban areas and are less likely to be found in the most rural counties of the U.S.

Moreover, according to the Commonwealth Fund 2001 Health Care Quality Survey, one in three Hispanics and one in four Asian Americans have problems communicating with their doctors, while 15% of African Americans, 13% of Hispanics, and 11% of Asian Americans said there had been a time when they felt they would have received better care if they had been of a different race or ethnicity. In case it may occur to the reader that these statistics are not so relevant given that each of these minority groups is, in fact, a minority of the population in the U.S., and therefore should perhaps comprise a corresponding minority of the total fleet of mental health providers in our country, let me also provide some additional context regarding future projections of the total make-up of the U.S. Population.  According to U.S. Census Bureau, African Americans, American Indians, Asian Americans, and Latinos will make up roughly 50% of the total U.S. population by 2050. These projections point to the issue of the relevance of our current mental health models in the years to come.

It seems aggressive efforts must be made to engage people of color to enter into the field of mental health services.  Having more mental health providers from communities of color will naturally influence service delivery models in ways that will expand culturally competent care for marginalized and underserved communities.  Increasing minority participation will require action in at least three areas: 1) recruiting representatives from minority communities into graduate and post-graduate mental health education; 2) advancing representatives from target communities to leadership positions in training organizations, including management and board positions; and 3) providing technical assistance to training and educational institutions to increase their capacity to accomplish the first two action plans.

But in addition to these action steps, work must be done to expand training and continuing education that ensures that white clinicians who are essentially providing cross-cultural services are equipped to respond to the needs and challenges of minority consumers as effectively and sensitively as possible.  It can be argued that cross-cultural work is only effective when it is grounded in an understanding of the influences of context on the nature of human experience.  More specifically, mere exposure to different cultures--a strategy often employed by diversity sensitivity trainers--does not guarantee cultural competence or sensitivity.  Beliefs, values and assumptions operating in large part out of one’s awareness will shape and limit what one is even capable of noticing, let alone have the ability to change.  Cultural competence education must employ methods that help to identify underlying assumptions and contextual influences before any legitimate learning can happen.

The overarching theme that weaves through the implications of all these statistics and the various ensuing recommendations is that the mental health industry has been charged with the responsibility to recruit more minorities and develop leadership that is more highly representative of minority perspectives.  But perhaps the broader theme--the one this paper is specifically concerned with addressing--relates to the way cultural competence in general calls into our awareness our underlying assumptions about culture.  Perhaps what we will discover in our attempts to broaden our sensitivity to minority issues and concerns is that what these efforts will require is not all that dissimilar from what psychotherapists should be doing all the time.  It may become apparent that all mental health work is essentially cross-cultural to the degree that it presents us constantly with challenges to our capacity to engage with difference (contact) and to manage the feelings and reactions stirred by difference (emotional skills).  Whether or not we are successful in recruiting minorities and building a more diverse fleet of mental health providers, we will still be left with our prevailing theories and approaches and faced with the daunting task of evaluating their adequacy to address the problems most relevant to the underserved, especially as we move toward an increasingly diverse demographic in the U.S.

There is a growing compendium of literature on the subject of multicultural mental health services (e.g., Liu, 2005). Practitioners and researchers interested in this issue are working together to reshape the boundaries of psychological theories and methods to take minority issues more into account. My humble contribution to this ongoing project has to do with the models of training we employ in the field of mental health. Essentially, my way of getting at the question of how to develop minority leadership has been by focusing on including minority perspectives at the ground level--in mental health clinics and counseling centers where programs are being designed essentially as implementations of the prevalent paradigms for psychosocial intervention. Psychotherapists in training will find their first point of entry into the field at centers and clinics such as these because settings of this kind tend to be where mental health students find opportunities to fulfill their practicum and field work requirements to qualify for their graduate degrees.

My focus is a pragmatic one. I want to explore the ways we can influence our theories and strategies by including the concerns and issues of minority mental health students in the planning, implementation and evaluation of mental health programs in community based organizations, the points of entry for most minority mental health students and for most minority mental health clients. But this objective will require a considerable degree of forethought because it is very likely that a mere recruitment campaign with incentives and additional concrete supports will not necessarily lead to an influx of mental health students who are invested in challenging the traditional thinking in the field of mental health. No, I believe something far more radical would be required, a shift in our approach to training based on an honest and rigorous reevaluation of the kind of “culture” that is perpetuated in educational institutions and training sites. I believe when there is a struggle to embrace diversity in any context, the primary issue to be considered is culture. If it is culture--and more specifically, different culture--that struggles to find its way into the ideas, action practices, rituals and language of any system, then it is culture that must be altered to address this problem.

So I want to spend the bulk of this paper exploring the culture of mental health training, intermittently examining how each cultural factor being discussed may be contributing to the reduced accessibility of minorities to the mental health field.  Each cultural factor will also be framed in terms of a dilemma. This literary device is intended to help the reader focus on what could be at stake in either maintaining or revamping the various features of the landscape of mental health education. Sensitivity to what we stand to gain and what we stand to lose as a consequence of making significant cultural shifts in our familiar worlds will help us make realistic decisions about how to proceed if there is to be any changing at all. Finally, I will offer some recommendations based on how I have chosen to deal with these dilemmas through the use of alternative structures and innovative programming in mental health training.

Leadership Development

Leadership equals ownership. When people see themselves as stakeholders in a collaborative endeavor, they take ownership of what has been created, they feel responsible for making it happen, and they hold themselves accountable for the outcome, whether success or failure. Conflict is inevitable, at times even leading to schisms and divorces; but ruptures are certainly more likely to happen wherever there is a tendency for people to blame each other. Blame is a symptom of a lack of support for shared ownership. Blaming is disowning responsibility, whereas shared ownership is an essential feature of any mutually beneficial relationship.

For every member of a community to feel a sense of ownership, everyone must have the opportunity to participate in creating the conditions that shape the possibilities in that community. In a learning institution, one example would be to give students opportunities to participate in designing course curricula, organizing the learning environment, choosing the trainers and instructors, and evaluating their own growth outcomes. A sustainable learning community is one that addresses the developmental needs and strivings of the most inclusive sample of students and one that increases access to greater participation in planning and implementation at every level of community life.

One way to get at the question of how to cultivate conditions that lead to greater inclusion and participation for minorities is through an organizational structure and culture that prioritizes maximal participation through the principles of parity, inclusion and representation.  Parity is, simply stated, the condition of people being on par with each other, including in areas of access to information, skill and technology. Inclusion is the condition of being taken into account, particularly in areas of allocation of resources and in decision-making. Representation is the condition of assuring points of view and issues of concern for people who are not present get incorporated into the planning and implementation of community action. As all these conditions increase, more minority perspectives are considered. These conditions correct for the natural discrimination and marginalization of minority perspectives in the larger context.

There is an uncanny similarity between these conditions of participation and the conditions of dialogue as described in the Gestalt model, particularly when considering the implications for dialogue at the community level (Fairfield, In Press). Gestalt practitioners with an interest in group work and organizational development tend to favor projects that look more closely at the ways Gestalt theory can more actively support health and well-being in groups and communities.  One such project specific to the question of the healthy learning community has been described by John Frew (2003) who favors the evolution of intimate enclaves characterized by mutuality, parity and innovation. Others in the Gestalt community have advocated similarly (e.g., Harris, 1999). Whereas academic models of scholarship are primarily strategic and competitive, a community model of education and training marries the pursuit of excellence with intimacy and inclusion of underprivileged perspectives.

When the range of endorsed perspectives narrows, the pool of potentially enriching resources also becomes limited, choking off new growth. Without diverse perspectives represented in a community’s leadership body, the possibility for a highly participatory community is greatly reduced.  I have argued that the absence of minority perspectives interferes with a learning community’s ability to adapt to shifting conditions in the larger context, a handicap that could limit the relevance and accessibility of what is being taught. Conversely, a learning community that promotes minorities to leadership positions increases participation in general and builds a greater sense of shared ownership among all its members.  This reduces blaming and promotes constructive problem-solving in the face of conflict and crisis.

But it is not a simple task to take on board the challenge of correcting for the barriers to participation that are potentially related to how leadership evolves in the current mental health training system. Confronting these barriers is at times confronting structures that do a good job of streamlining, economizing and maximizing processes and resources necessary to academic pursuits. Taking these apart risks losing essential structural supports in education. Leaving them intact risks perpetuating the participation barriers. It is a dilemma. In fact, there is a whole series of dilemmas that I can identify in my own experience as a trainer and an educator, a description of which now follows:

1. the promotion of a standard of good health that serves as a criterion for evaluating what is good therapy but simultaneously ignores important issues of context;
2. a system-wide endorsement of that ideal through the privileging of experts who safeguard the quality of psychotherapy practice but also unwittingly discourage innovation;
3. a power hierarchy that assures efficiency and clarity of purpose that is nevertheless organized around privilege;
4. the important celebration of honored leaders that also inadvertently fosters a culture of celebrity;
5. a pressing concern for evaluation of the quality of students’ work that sometimes yields premature performance appraisals without sufficient self-directed learning objectives; and
6. a privatized training market that guarantees trainers a high degree of freedom but also reduces access to the economically disadvantaged.

Universally Defined Criteria

One of the first conditions that may reduce the access of a more diverse range of candidates to the mental health field has to do with the way the mental health industry tends to define what is considered healthy or sane. Most theoretical systems put forward a notion of some hypergood (i.e., some superlative value that serves as a criterion for how to judge what is a life worth living). Every psychological theory does this, whether the hypergood is social adjustment, freedom from psychological symptoms, rational thinking, self-actualization, reduction in suffering, etc. Every system proposes a method for evaluating the quality of life.

In Gestalt therapy we subscribe to an idea we call the ‘autonomous criterion of health’, which essentially refers to quality of contact. The phrase ‘good contact’ has been used copiously in the seminal Gestalt therapy text written by Perls, Hefferline and Goodman 1951. (Perls et al., 1994/1951). The first instance occurs within the very first two paragraphs. I will quote, “…[w]here there is good contact, one can always show the cooperation of sense and movement (and also feeling)” (p. 4, italics mine). We get the picture quite early in the text that Gestalt therapy theory puts forward an idea of contact that can have good qualities (and therefore bad ones as well). In the above reference, what is good contact involves harmony of sense, movement and feeling. Where movement is impaired or sensation is cut off, contact is poor. Here health is related to coordination and integration.

Kurt Goldstein, another hugely influential thinker in the origins of Gestalt therapy, defined the good Gestalt as ‘a special expression of the general tendency to realize optimal performances with a minimum expenditure of energy as measured in terms of the whole’ (1995, p. 292). Goldstein referred to ‘the preferred situation’ as that in which ‘the sensory thresholds are the most constant and the lowest. The movements that are demanded by the situation take place in the most adequate and most definite way, and distribution of “attention” occurs that guarantees the best apprehension of the world in accordance with the situation. From all this it follows that preferred behavior, good Gestalt, or whatever one chooses to call it, represents a very definite form of coming to terms of the organism with the world, that form in which the organism actualizes itself, according to its nature, in the best way’ (pp. 286-7).

But what makes contact good? Economy, flexibility, balance. And if these qualities of contact are absent? How do we map what we experience as contact to these qualities? And once we have, what do we do about that? For example, if we could agree that inflexibility is always an indicator of poor health, then we should be able to make some clear statements about what can be done when a client’s mobility has been interrupted. For some time, Gestalt therapists tended to do this, to spot signs of poor quality of contact and offer experiments that expand a client’s capacity to modulate the quality.  In the case of immobility, a client might be asked to try exaggerating his or her stagnation and then exaggerate fluid movement and then take stock of the contrast between those two conditions. This would create more awareness of how the inflexibility is maintained and what options there might be to adjust that.

But these days Gestalt therapists are thinking somewhat differently about good contact. We do not necessarily agree that interruptions of movement are always a sign of poor health--e.g., when an environmental threat makes it dangerous to make a move, so paralysis or playing dead is a preferred creative adjustment. In other words, what a specific motor interruption might mean actually depends on the context in which it is happening.

Goldstein qualifies his use of the term good Gestalt, saying ‘that the best Gestalt means the best for a coming to terms of organism and world, of adjustment in a definite situation, that is to say, during a definite task’ (p. 292). The task may be momentary and very basic or monumental and very complex. Basic tasks may lead most economically to a simple, linear progression of experience; what is most economic in the context of epic tasks may require a lifetime of energy and struggle. In evaluating the quality of a Gestalt (i.e., a unified, structured whole of experience), we are considering specific situations as they are organized around definite tasks, taking for granted that the organism is already engaged in finding the best possible way to come to terms with the world.

Let us say, for the purposes of argument, that we all subscribe to the Gestalt criterion of health--good form. If we agree further that whatever we determine to be healthy is also contextually dependent--i.e., understood in relation to specific problems and tasks--then we would have to trust the therapist/client system with the task of defining when the criterion for health has been met, given each specific situation. So in the case of the Gestalt criterion of good form as measured by simplicity, flexibility and economy, rather than attempt to modify the situation to fit with these qualities as generic ideals, we would instead take into consideration the nature of each person in relation to his or her specific environment, what Goldstein referred to as the ‘prerequisite for proper evaluation of what is a good Gestalt’ (p. 287). Moreover, we would probably take a similar approach to evaluating the qualities of good therapy as a whole.

Now here is the point toward which I have been building with my discussion of hypergoods and more specifically the autonomous criterion in Gestalt therapy. There is a parallel between the striving of an individual to engage with his or her world in the best possible way and the striving of a student of psychotherapy to develop in relation to his or her industry in the best possible way. The prerogative of each therapist/client system to identify when the criterion of good health has been met in some way is mirrored by the prerogative of each trainer/student system to work out when the standard of good therapy has been defined.

So what is the significance of this parallel to the question of what might be preventing minorities from more frequent entry into the field of mental health? The significance lies in the shift away from essentialist notions of health and sanity (literally, hygiene!) to more contextually sensitive understandings of what is worthwhile to people. Minorities are especially sensitive to these distinctions because most essentialist arguments put forward qualities that appear obvious and uncontested value criteria from the vantage point of those with privileged perspectives--the dominant culture. Generally, people who are socially located in the dominant position are not even aware they are taking a position. So all judgments are made without understanding them as judgments. They appear instead as self-evident truths. So social adjustment, freedom from suffering, absence of psychological symptoms, rational thinking, good contact--all these criteria for measuring health and sanity are simply self-evident: they do not require any further substantiation.

Meanwhile, people who live in more marginalized positions may well have a different understanding of what makes life worth living. Their judgments will likely be different from those in the dominant perspective. But more than this, they will always know that they are making these judgments because their ideas about quality of life will always be compared to what is generally accepted as normative by the dominant culture. Hence, those with a minority perspective will be burdened with the task of having to ‘prove’ that their hypergoods are valid. An example of this inequity can be found among gay, lesbian, bisexual and transgendered persons who have suffered with the burden of proving their sanity and their very dignity in the face of a decidedly heterosexist context.

Context, it turns out, is critical to building a model of mental health that takes into account the experiential worlds of those who hold a minority perspective. So to the extent that our mental health theories and methods do not address contextual issues explicitly, we are likely to continue seeing a predominantly white, middle class, heterosexual fleet of mental health providers. Having some criterion for measuring health will be indispensable to our practice, but it must also take into consideration issues of context if it will be useful and relevant to a more multicultural mental health practice.

Deference to Expertise

Psychotherapy teachers and supervisors have permission and often an inclination to set the standard of good therapy through teaching, demonstrating and critiquing. Certainly an effective means of transmitting the ‘good form’ we have been discussing is by modeling that form. If people are taught what ‘good’ therapy is, they can strive to practice in a way that approximates the model. Over time, perhaps they will adapt the model to their own unique personalities, interests, needs--assuming the model is relevant to their contexts. Putting forward a model is a clear and effective strategy for defining and upholding a paradigm around which others should be able to orient. Of course, there are other strategies which can be used to teach and train, and these may also be effective in eliciting outcomes besides the emulation of good form. But I think it is important to examine the impact of expert modeling on the experiences of minorities in mental health education.

I do see how reasonable it is to expect teachers and supervisors will have to show students how experienced therapists think and behave in order to motivate them to consider that there is something toward which to strive in their learning. Clearly, they must start from a place in which they feel a hunger to assimilate something new or different. They must start with uncertainty or unknowing, and from here they can move toward greater understanding and a larger range of possibilities. If we do not show them what good therapy looks like, then it is unlikely the students will feel motivated to learn anything about it. In fact, if they do not demonstrate what they can do, nobody will trust they can teach it!

As a Gestalt therapy trainer, I myself will go so far as to demonstrate a snippet of work, which I will qualify with a reminder that I do not mean for students to imitate what I am doing, only to use their observation as a data point along with so many other data points in their education. And generally students seem to need this observation piece, particularly when all my eager attempts to bring the theory to life through discussion have failed to draw them out. Gestalt theory is difficult to read, difficult to discuss without reading, and difficult to make relevant without demonstrating. So I demonstrate. And the students watch, usually quite engaged and excited by the vividness of the work, the depth of emotional process, the immediate access to developmental themes. What they will probably experience as dense, frustrating, esoteric in the theory will simply come to life in the demonstration.

But our concern must also go to creating opportunities for students to have a direct experience of therapeutic work, both as clients of therapy and as therapists-in-training. This is where live-supervised practice can be so useful and supportive to students of mental health. Whether it is in the form of taped or filmed sessions, role-playing with other students, or actual personal work done in a classroom or training group, direct experience is a way students can learn how to integrate theory with practice by noticing how they are actually depending on what they have learned and tracking what they are doing with that in moment-to-moment experience.

Still, there is some risk for my students that they will compare their own direct experience of practicing psychotherapy in a supervised setting to what they have seen me demonstrate. That risk comes from their need to do a good job, but striving to do well can sometimes distract students from a thorough and critical digestion of what they are learning. This distraction interferes with the healthy spirit of adventure they need to try new things, make a mess, do it all wrong. If students have some hypothesis about what is going on with a client, they can test it out to get information that either supports or disconfirms the hypothesis. But if they are primarily concerned with how the work is looking to others, then they will not have the space to learn anything other than performing well.

To bring the point closer to the issue at hand, by describing, modeling and reinforcing an ideal of good therapy, supervisors and teachers are taking for granted that the standard of therapy is ‘essentially’ good--i.e., good across all contexts--much in the same way therapists make the assumption that there is a universally validated standard of health. This is where exerting our expertise (through describing, modeling and correcting) runs the risk of reinforcing the acontextual leanings, discussed in the previous section, that will tend to be off-putting for students from minority communities who are highly sensitive (and with good reason) to how hypergoods originate from the center of the dominant culture.

Interestingly, tradition has it that the forebears of Gestalt therapy advocated their theory in such a way to intentionally prevent its introjection (i.e., swallowing whole without chewing). The founders of Gestalt therapy wanted to teach their therapeutic system in such a way that would mirror what that system stood for. The message would have sounded something like this: “If you wait to be spoon fed, you are only participating in your own oppression; so we will give you something gristly to gnaw on while you get in touch with your own aggression, with your power to take the ideas and use them in your life and make of them something that is your own.” The theory was given as something to contact aggressively, while struggling and frustrated, passionately impatient, grinding and chewing, but swallowing only what is nourishing.

Perhaps learning all psychotherapy practice is itself meant as an experience of aggressive participation, of acting responsibly in the service of one’s own growth. In any case, this is the orientation to learning most likely to appeal to minorities, who are looking for signals that their perspectives and experiences are actually valuable to the point that their exclusion would be repugnant to the whole community. Students of psychotherapy are, after all, consumers of a product. That product is education. If we take the educational consumer model to its productive limits, we can see the parallel between advocating consumer-driven care as a strategy for increasing utilization by underserved communities and advocating contextualized, learner-driven education as a method of ensuring that what is taught is relevant and usable to a wider and more diverse spectrum of students. In a learner-driven educational system, both the central purpose and the greatest possibility of learning lie in the way students include themselves and are included in a creative and contextually sensitive endeavor.

But how does this focus on student development and contextualization of training hold up to the task of assuring quality of care? Psychotherapy’s focus on healing and growth compels us often to the point that we become predominantly concerned with the health and growth of clients, forgetting that as teachers and supervisors we are charged with the responsibility of helping our students evolve into the therapists they have the greatest potential to become. We often forget to trust students to self-repair and creatively develop. If we are preoccupied with protecting the sacred experience of clients, then we will no doubt feel a great pressure to manage the quality of our students’ work so as to ensure their clients receive the best possible care. Yet, if we trust in the paradoxical theory of change--that change is only possible when we accept what is already unfolding--then perhaps we can soften our agenda for what should be going on with our students in the consulting room. This is a delicate situation, because we cannot give up fully our agenda to ensure quality and safety for the patients who will be under the care of our students. Quality assurance is another reason for the ascendancy of a model.

As teachers and supervisors we expect students to gain confidence in theoretical supports and also to trust in their creative integration of theory with their own interests, their cultures, their industries, their talents and their various responsibilities as clinicians. Perhaps it goes without saying that that students learn and grow in ways similar to how clients learn and grow. We have the option to supervise and teach with a keen appreciation for how students are currently coping with becoming therapists in their specific contexts. They are already integrating their new problems and challenges as they search for resources and creative solutions. We can find in every clumsy attempt an organismically wise and important reach for what lies beyond their leading edge. But if we cannot meet our students in their appropriate developmental strivings no matter how miserably they fail to hit the mark of good form, then the best we can expect from them is to introject the model and emulate it in their work. And this will simply hold us in that dilemma of maintaining the threshold of access at a point that keeps more diverse perspectives at bay.

Hierarchical Structure

Now all this does not imply that the teacher/student relationship is strictly egalitarian. The relationship, as in the therapeutic context, is mutual but asymmetrical. The trainer, despite the fact that he or she needs trainees in order to be a trainer, is in a power position that cannot be overcome. Partly that power derives from the trainer’s consensually acknowledged talent and experience, partly from the fact that the trainer is in a position to teach, give advice, and evaluate progress, and partly from the political leverage that comes with the trainer’s stature in the context of the broader learning community. There are surely many other sources of disparity as well. A partnership does not have to be literally egalitarian in order to permit both parties to have a voice and to take the concerns and needs of both parties into account.  This is, of course, a polarizing perspective which does not account for the influences of the larger social context on our understanding of authority and the ways in which we load our experiences of being disciplined with deeply felt concerns about being shunned. In a more collectivist culture, the association would potentially be less obvious.

Students require guidance and support, as well as some challenge or motivation to learn. Someone must act as an authority on the subject to be learned, otherwise there would be no way to measure whether the associated knowledge and skills have been competently acquired. So teachers, supervisors and trainers are given the responsibility to act as figures of authority, while also possessing the various supports and resources needed to carry out that responsibility. Ultimately, a trainer has to be held significantly more responsible than a student. The function of each role is determined by its level of responsibility in the execution of proscribed duties, while the roles themselves shape the overall organizational structure of the educational system. Remember that the system to which I am referring includes academic schools, training institutes, and the clinics and counseling centers in which students are placed for their practicum and field work experience. This is a complex system, a broadly defined learning community. Its structure dictates how we all act in the service of fulfilling our respective responsibilities. And of course action is monitored and shaped through agreed upon policies and procedures. Hierarchy is simply unavoidable in such a large, complex situation, with the need for definite divisions of labor and distributions of resources.

Of course, there is a lot we could say about the potential abuses of power in a hierarchical system. We could point out that among the primary building blocks of hierarchy we will find a tendency toward shame. Hierarchy requires a system for ranking people by status. Pulling rank sometimes evokes in others a sense of inferiority that has the potential to trigger shame and may even be designed to do so. On one level, shame inhibits expansiveness and creativity in ways that can be detrimental to the individual and to the organization as a whole. On the other hand, understanding shame as a regulator of social belonging, there will always be some benefit to having an affective signal of ‘incompetence’ in a situation primarily defined by a focus on building competency. The question to be explored is to what degree the benefits of shame will outweigh its deleterious effects, a question which can only be answered in the context of the specific scenarios in which the shame occurs and by taking into account the role of shame in the specific cultures represented within the learning community.

We could warn that power in hierarchy is inherently corrupt. The higher up you go, the more access to resources and supports you are given and the more influence you have in how decisions are made and whether they can be modified. If there are any changes to be made, you will have the authority to make them, but will probably be motivated to keep things the same if the current structure adequately supports your own needs.

Whether it seems ugly or not, all these points about hierarchy are valid. None of us needs to be reminded of the potential abuses of authority. I assume that an authoritarian system is not what we intend to create in a learning community. If power abuses occur, they are hopefully the exception, not the rule. Yes, the power is unevenly distributed; but it serves a good purpose. If you have too many cooks in the kitchen, you end up with too many recipes that do not add up to a satisfying meal. The disparity has a rationale: some of us have more responsibility and more privilege than others and this is based mostly on having more experience, more education, or more skill. The power disparity is obvious, felt by everyone, but also necessary and helpful to the efficient operation of organizations.

Some aspects of hierarchy are meant to be more visible than others. The least powerful person at the lowest level of hierarchy plainly sees what levels have more power and more access. This is essential to the hierarchy working the way it is intended to work. The visibility of exclusivity is a critical factor in holding the structure in place. This is because seeing how you are being excluded will either motivate you to fit in better by moving up to higher levels and demonstrating loyalty to the system or it will evoke the shame you must feel in order to maintain your silence, only further removing you from participation in decision-making. If you did not feel shame at the idea of questioning the designated leaders, you would probably confront them. But they would then have the option to discipline you or further exclude you from access and power and ultimately eliminate you from the structure.

We could also draw comparisons with capitalism. Hierarchy is indispensable to a market-based economy. It motivates individuals to work, to aspire, to reach for more. It guarantees competition among people with similar capabilities and skills. The competition in turn intensifies hierarchy by drawing attention to a series of ascending levels of success to be attained, but with increasing degrees of difficulty and restriction the higher you go. The most exclusive levels offer the most access to resources and influence for those who are granted entry.

But what about power abuses? How do we know when hierarchy is tyrannizing a community? Are we correct in assuming that if our students are oppressed by their teachers and supervisors they are free to speak up about it? Are our assumptions taking into account differences in skill and access depending upon each student’s culture and socioeconomic status? These are questions we must ask in order to evaluate the effects of hierarchy on the accessibility of mental health training for minorities.

In any case, whether a learning community’s structure is flexible or not, it is not likely that it can do away with hierarchy altogether. While it is true that hierarchy is indispensable to authoritarianism, it is also inevitable in any educational institution that makes use of various levels of expertise and knowledge while distributing information selectively and judiciously. By consenting to be ‘educated’, students necessarily enter into a contract with their teachers, putting trust in their expertise and wisdom, and inviting feedback and criticism. The more I move away from privileging my own perspective as ‘expert’, the less I distinguish myself as a trustworthy model of good psychotherapy. But the more I encourage students to hold me up as a model, the more I risk distracting them from an awareness of their own unique self-regulating processes, an awareness I believe to be crucial to their professional development. It is a delicate balance.

Frew (2003) has characterized learning as optimal ‘when relationships drive content, when both intellectual and affective dimensions are involved, when those whom we call students co-create the process and product, and when individual needs are recognized and valued but give way to collective aspirations’ (p. 19). This description of optimal learning matches my vision of a learning community that integrates hierarchy with increased participation among students, particularly students from marginalized cultures.

Celebrity as Celebration

Competent teachers and supervisors tend to gain a certain stature in any learning community. They are regarded as masters of their craft. As word of their mastery spreads, they gain a kind of following. Some are celebrated more than others. Some wear their celebrity well, with grace, modesty and poise; others not so well, perhaps unintentionally encouraging an unhealthy idealization. I have chosen not to focus on that form of celebrity, because nobody needs to be reminded that it does not serve our purposes very well. So I will focus instead on the kind of celebrity that is a legitimate celebration of a leader’s bountiful contributions, longstanding devotion to the community and undeniable excellence in supervising, teaching, training and writing. I would not want to belong to a community that did not find ways to honor its well-loved leaders. But we must also remember how easily students with minority perspectives can become further marginalized when they notice that figures being celebrated bear little resemblance to people from their own communities. Celebration of important figures should include celebration of diversity whenever possible.

But there is something perhaps more subtle that creates conditions hostile to diversity in a learning community, something transmitted through the experience of ‘envy’. While students are drawn to celebrated teachers and supervisors, they are also in part responsible for perpetuating that celebrity. By emulating a trainer, students elevate him or her to the position of an example. I myself have relied upon my students’ emulation to the degree that it establishes a modicum of trust and grants me the benefit of the doubt. If students are antagonistic to my authority from the start, then our interactions will be more preoccupied with power struggles than with healthy debate. I do want students to attack the material, question ideas, examine their experience rigorously, but not to antagonize me to the point that my credibility comes into question. That will only put me in a place of wanting to fortify against attacks, and I do not do my best teaching when I am on the defense.

Furthermore, it is obvious to every student that trainers are protected from antagonism by virtue of their status as leaders. Particularly students pay a fee for their training and education, they have essentially endorsed the authority of the teachers. It would be an utter waste of time and money to undergo learning with a trainer you hold in high suspicion, or to attack a trainer’s credibility, thereby attacking the worthiness of the training you have already paid to receive. So there is a motivation to accept as given that the trainers know what they are doing and have something valuable to offer.

But I can imagine that it would be hard for students not to envy trainers their protected status. In addition to providing teachers and supervisors with supports for asserting their ideas and methods with authority, the reinforcement of their celebrity must appear to be a kind of reward for doing what they do as well as they do it. From the student’s standpoint, the celebrity enjoyed by trainers can look like first prize for consistently hitting the target, the model of good form. And we pull out the prize so all can see it and feel envy. I find it hard to believe we do not envy it. And wherever there is envy, there is also its counterpart--disavowal. What is disowned in the reaching for what is envied could well be the envy of others who are less privileged. So the whole process of nurturing celebrity in a community has the potential to set up levels of discrimination based on who is envying whom. Envy fosters classification; classification can lead to oppressive class distinctions.

Perpetuating celebrity in this way will lead to exclusive relationships between teachers and individual students, alliances that work against a collaborative spirit. I appreciate Jon Frew’s notion of learning as ‘embedded in the quality of contact between the individual and key aspects of the environment… [that] involves inspiring interpersonal relationships among all the members of a learning community. That contact is promoted and “held” by a culture that values at its core empowering each student to take responsibility for learning as a collective objective’ (2003, p. 24).

Another pitfall of the celebrity system is that it reduces the opportunities for minority perspectives to influence the dominant culture of the celebrated few. It goes beyond merely creating a competitive marketplace for high quality training. It is more of a monopoly that casts its shadow over the whole market, limiting the viability of smaller competitors. The leaders set the standard for what is considered good in the community. The acceptability of any new or expanded leadership hinges almost exclusively on getting an endorsement from the established leadership body. We may have succeeded in defining and upholding standards of practice in our communities by assigning that function to the most celebrated leaders; yet if this is true, the evaluation criteria have not been made explicit but are tied up in the opinions and preferences of only a few. The process is not transparent enough, making it very difficult for others to participate in influencing the standard, particularly others who hold an unorthodox perspective.

Remember that since we are talking about a complex learning community that includes educational institutions with their own hierarchical systems of tenure and field education sites that incorporate a hierarchical business model, I think it is important to underscore how pervasive and inflexible this power structure is. I do not believe an individual teacher or supervisor has enough influence to interrupt this dynamic; it is co-constituted by many conditions that lie outside any one person’s control. Moreover, I will say that I do not believe it is ultimately what anyone actually wants in the long run. Still, as long as it continues without at least some modifications, we are probably restricting our options and limiting minorities from accessing the system and influencing our thinking.

Performance Appraisal

Now what I have to say about critical evaluation of student practice is not meant to debunk the whole notion of evaluation. I think it is critical to establish some criteria and methods for determining when students have achieved an acceptable level of competency in mental health practice. I would be very interested in participating in a discussion about quality management in training. So I do not wish to be misunderstood when I draw our attention to the dilemmas I have encountered in an effort to cultivate a more diverse fleet of mental health providers. My objective is to make criticism something sound and useful, a support to learning, rather than an incentive to compliance.

Having clarified my intentions, I do still want to underscore the pitfalls of that kind of evaluation that comes too early and too copiously in the training situation. What I am about to describe are only the most extreme examples of what I would like to highlight. I have also seen very skillful supervision and teaching that supports students in all the ways they need it. So I am not describing all of what I have seen, but only the bits that worry me.

In the typical scenario where students bring into their training or practicum settings video or audio tapes of their sessions with clients, or volunteer to role-play or do a live piece of work with their fellow students, there is usually an expectation for ‘feedback’ from fellow students and from the supervisor. What I would like to highlight as a concern is the kind of feedback that seems to be trying to say how ‘well’ a student did. The remarks are usually in the range of: ‘I liked when you did such and such’ or ‘It was beautiful when such and such happened’ or ‘I was troubled by this and that’ or ‘You weren’t very attuned’ or ‘You got off track’. The students are essentially getting their ‘marks’ so that they can later adjust their work based on what the critics have said. But this may be one way students learn to self-monitor rather than develop an organic and integrated capacity to respond genuinely to what each situation calls for.

As I said before, I am sure that in addition to these qualitative evaluations other kinds of feedback are forthcoming. I am sure, for example, that supervisors are showing their interest in learning more about what was happening for the student during the work, what new experience the student became of aware of, what new idea came to mind at various choice points, etc. And we all hope that these kinds of questions are steering the student toward integrating theory and actualizing capabilities in the most creative way. But I suspect, given our quite competitive socioeconomic context, that comments about how well or poorly the student did will resonate at least as much, if not more, than specific feedback about what competencies they are struggling to integrate.

When the feedback is less obviously critical, it takes a different form. The old standards are: ‘I was so moved when you did this or that’ or ‘It really impacted me to see such and such’ or ‘I got bored during that part when you were a, b and c’. The focus on how the work impacted others, despite an overt attempt to withhold an analysis of the content, persists in activating the insidious conditions that require students to be vigilant to the reactions of an audience. It still creates a performance culture. Whether that audience has been sanctioned to act as judges in a competition or as admiring spectators whose applause is a measure of approval, the culture of performance is reinforced.

But how can we ultimately avoid a pull toward performance. Evaluations are often referred to as ‘performance appraisals’ in work settings. Some kind of appraisal of competency is important to give. We cannot avoid evaluation if we want to set standards of mental health practice. But that is one of my many questions. How do we want to set standards of practice? Do we want to be evaluating the quality of our students’ work? And if it is not the quality of their performance that we should be evaluating, then what is it? What are the criteria that indicate good quality psychotherapy? How do we define them? How do we account for cultural and socioeconomic differences in the way we define and enforce those standards? These are the questions about which I invite more dialogue.

The Training Market

If there is any doubt as to what factors limit the diversity of the mental health field (at least in North America), let me refer to the market conditions of our training system. Advanced, post-graduate clinical training is provided primarily through private enterprise and much of the mental health graduate education in the U.S. is as well. Mental health training is often quite expensive for those who do not enjoy a comfortable margin of disposable income. Many trainers depend financially on the revenues from their training organizations. This would seem to make it difficult to reduce training fees substantially. So the cycle continues in which trainers offer their services for a reasonable fee, attracting students who can afford to pay the fee, stabilizing the supply and demand arrangement that will sustain the market.

In American society it is unfortunately still the case that racial and ethnic minorities tend to be less advantaged economically. That places them on the outer edges of the ‘free’ market. A vast array of resources and supports thus become less accessible, including quality healthcare, real estate, adequate security, legal advice, sound financial planning, and education, to name only a few. So what many of us take for granted as a ground of support in our lives is still up in the air for lots of people. For lots of people, the focus on growth and human potential is eclipsed by a more pressing preoccupation with basic survival.

Gestalt therapy in particular has earned a reputation of serving the middle class, though this is gradually changing. The Gestalt model had a high profile during the human potential movement. Not surprisingly, it took root among communities whose needs were defined in the context of a surplus economy. Survival needs were already met. So their attention turned for them to making relationships more satisfying, looking for a more fulfilling vocation, actualizing their strivings and achieving spiritual enlightenment. These were Gestalt therapy’s consumers. Consequently, services were tailored to their interests and needs and theory was well articulated to support that tailoring. Meanwhile, those struggling to stay afloat at the outermost edges of the market were not accessing Gestalt therapy. They could not afford it. But then it would probably not have appealed to them, given their different priorities and needs.

Students will frequently confess that the kind of training and practice they get in their schools and institutes look substantially different from the way they must work in their actual jobs. Students who work in non-profit agencies that cater primarily to underprivileged communities have little incentive to become trained in psychotherapy systems such as Gestalt therapy as long those systems persist in offering training that does not address the needs of a more diverse range of consumers. If a theory does not appear to deal adequately with issues of social injustice, poverty, hunger, violence and polysubstance use, then it will probably not appeal to minority mental health providers who will be looking for answers to the social and economic problems that plague their own communities.

If we would like to develop education and training that articulate psychotherapy theory in ways that support work with underprivileged communities, then we will be one step closer to appealing to minority service providers. But there is still the question of money. They will not be able to afford advanced training as long as they have to pay for it. While most educational institutions are structured as non-for-profit organizations, unless they have significant endowments they depend almost exclusively on revenues from student tuition and fees. Most other non-profit entities have to secure funding from sources other than their consumers. For mental health centers, it sometimes comes from insurance companies (though now rarely), sometimes private foundations, and most of the time government agencies, complete with burdensome bureaucratic systems. But nevertheless the funding is available, just not from the consumers.

If psychotherapy training institutions would develop programs relevant to the mental health providers who are working in the non-profit sector—and therefore with disadvantaged communities and minorities—and if those organizations could secure funding to offer these programs at low- or no-cost to these students, then I believe we would begin to see a sharp increase in the diversity of our mental health provider fleet. I believe that in my own community of Gestalt therapists, by disrupting our longstanding pattern of catering to the middle class, we will be less insulated from the kinds of problems facing most clients presenting for care these days, problems that would inspire us, even require us, to develop our thinking in different ways and adapt our practice to agree with that new thinking.

Recommendations

How do we set standards for mental health practice? Is it a problem if psychotherapy favors aesthetic standards? How can standards of good therapy account for variations in culture, class, gender, sexual orientation, religion, etc.? Must we flatten out the hierarchy of teacher and student? Should we all pool our resources and live together in a commune?

These are questions that pertain to our moral intuitions and sensibilities and to which I would therefore not want to attempt an answer without the benefit of many face-to-face conversations among those with whom I share my concerns. Nevertheless, I do have some recommendations I can make based on my own experiences in healthcare administration and psychotherapy training and supervision. I began this paper by proposing that the viability of a diverse mental health provider fleet hinges on expanding representation in leadership. I then reviewed a number of dilemmas we face as we attempt to reach this objective. At this point I would like to show how we can navigate those dilemmas most successfully by building our capacity in three areas: 1) greater flexibility; 2) appreciation for diversity; and 3) cutting edge innovation.

Flexibility. Clearly the most obvious barrier to flexibility is rigidity. Related to rigidity is intolerance of novelty or difference. Flexibility allows movement between orienting principles and experimental adaptations. For example, if we could attempt greater flexibility in our training methods, perhaps we might develop a greater sensitivity to the effects of modeling—that while it effectively sets standards of practice, it also perpetuates a culture of performance. This sort of strategy is effective when there is a strong preference for holding to a kind of orthodoxy of perspective. It is a gatekeeper function, in that it assures consistency with a core value or an ideal aesthetic.

But we are also interested in engaging with other perspectives in the interest of learning which new directions would profit us most to follow in the pursuit of our own relevance to the current and future sociopolitical contexts. So in addition to gatekeepers we also need visionaries to blaze new trails for us. If our concern were solely about protecting an ‘orthodoxy’ of mental health practice, then we would lose the opportunities that arise through dialogue with neighboring viewpoints. It seems that, in any psychotherapy system, greater flexibility would allow us both to hold down the proverbial fort, as it were, and to make a foray into more experimental territory.

We all know that intolerance is bred from intolerance. If we demonstrate intolerance to our students, they will learn how to exclude other perspectives. They need to understand clearly the essential principles of the model they are learning, but also to be looking beyond those boundaries enough that they will eventually be positioned to adjust to make their approach more accessible and relevant to our world. So I am advocating a flexible movement between clear definitions of essential principles on the one hand and curiosity for what lies outside our boundaries on the other hand.

One way this can be done is to arrange for supplemental trainings that engage therapists of other theories to co-lead training sessions and provide joint supervision, with each trainer highlighting similarities and differences, and using these as opportunities for extensive dialogue and teaching. Or periodically workshops could be organized that impanel teachers of various approaches to carry on a lively debate publicly, leading to ongoing discussions that might further enrich the learning process. Another way would be to offer cross-training programs that zero in on using the common ground among various theories while also underscoring where they diverge and why.

Diversity. How wide are we throwing our training nets? As I mentioned in my discussion of our training market, which kinds of students we appeal to determines which kinds of consumers we will reach. The current homogeneity of the mental health field is preventing us from reaching those communities in dire need of pragmatic and humanistic care but not as yet engaged by any model of psychotherapy. This in turn stands in the way of our capacity to demonstrate our own relevance to contemporary problems and issues. To access a more diverse training base, we will have to become more flexible in our training methods, the design of our programs, and perhaps especially the financial structure of our organizations. In the case of Gestalt therapy, we should also envision how our model can be adapted to working with less verbal, less organized and less privileged consumers. In all approaches, we must adjust our sensibilities and prejudices to a more multicultural spectrum. And we must develop resources through means other than out-of-pocket student fees.

To this end, I would recommend that we develop psychotherapy theories in ways that support our work with the multiply diagnosed, indigent, and culturally disenfranchised clients in most need of care in our current context. To do this, we will need the help of those in our community who are already working with these populations. We need their leadership and their expertise. I recommend that we design alternative programs to accommodate the needs and capabilities of the nonprofit social services industry. Such accommodation would include adaptations to the standard training paradigm that would allow for a series of frequent, time-limited training sessions to both professional and pre-professional care providers that can be delivered on-site at clinics or agencies. I recommend that training institutes develop funds to cover the costs associated with providing these programs, either through grant writing, donor solicitation or in-kind contributions. And I recommend more rigorous evaluation of all training programs, offering students more opportunities to provide feedback about the quality of training and more access to decision-making in program design.

Another barrier to diversity is the limitation to the utility of mental health interventions that comes with restricting mental health practice to professional counseling and psychotherapy. There is a potential for a much wider application of psychotherapy theories in the fields of social science and human development. Even our notion of what psychotherapy is can limit our sphere of influence. Harkening back to the question of our relevance to the problems and issues in today’s world, I think we are narrowing the possibilities by restricting mental practice to psychotherapy.

Psychotherapy has distinctly medical connotations in many cultures. People who make these associations to psychotherapists expect to be treated like medical patients with an illness that needs curing. They imagine that accepting a therapeutic intervention is an admission of insanity. But there are other figures to whom they might turn for support and expect more of a dialogical exchange. For example, African Americans, when faced with personal difficulties, have been shown to seek guidance more often from family and religious communities, rather than mental health professionals who are looked upon as less acceptable forms of support when dealing with emotional distress (Broman, 1996, Barnes, 2005).

Perhaps those figures are not working out of consulting offices, but rather accessible in the milieus in which people live their lives. Perhaps those figures are more mobile and offer less formal services and more spontaneous human contact. Perhaps they have their greatest impact through community work rather than interventions with individuals. All this should be taken into consideration when designing programs for communities with priorities that do not match a homogenized middle class ethics. But again, that would require us to rethink how our services are designed and structured.

Cutting Edge. It is critical for psychotherapists to be cognizant of those areas in the various practice disciplines where we are well positioned—perhaps even best positioned—to take the lead in developing new or improved services or innovative concepts. Leadership means taking the lead in meaningful endeavors. Often, if nobody takes the lead, the endeavors do not move forward. To more fully embody our leadership capabilities, we must recognize what expertise or orientations or skills we possess that others actually rely on to actualize their own growth. We should notice when a vision we might have has become visionary for others, especially for minorities. If we shy away from our leadership potential, psychotherapy could easily fade away. It would be wise for us to attend to the issue of our own relevance in the contemporary context.

In the Gestalt community, some have already begun to explore these possibilities. Carolyn Lukensmeyer has taken the lead in the political sphere in the founding of AmericaSpeaks, recognizing the unique support that the relational theory of Gestalt therapy can contribute to the democratic process to ensure increased participation in decision-making among more citizens and greater ownership of governance in our country (see www.americaspeaks.org). Others have stepped into the forefront of community and organizational development, as Ed and Sonia Nevis have done in the founding of the Gestalt International Study Center (see www.gisc.org). The Esalen Institute, under the visionary leadership of Gordon Wheeler, has also seized the opportunity to usher the human potential movement into its next developmental epoch in part by sponsoring educational workshops and conferences that bring psychotherapists from across the globe together to address sociopolitical and environmental challenges and crises (see www.esalen.org).

I mention only a few examples of what I consider to be emergent leadership that is responsive to relevant sociopolitical and environmental issues. There may be other areas of need, for example, in medicine, psychology, holistic health, social welfare or other allied professions. I am certain mental health providers are active and responding to those needs as they emerge. Yet it is crucial that we disseminate whatever wisdom we gain by addressing relevant challenges in our various industries and professions. To be at our own cutting edge is to know what that edge is and how we are experimenting with that knowledge. We need a form of scholarship in psychotherapy theory and practice that invites innovation in addition to gate keeping. The possibility of innovation will only be furthered by support for experimentation with emergent challenges and frank reporting on the findings.

Conclusion

I have argued that we are significantly limited in the field of mental health to the degree that our perspectives and theories are uninformed by the experiences of minorities. I have discussed some dilemmas with which I have struggled as a psychotherapy trainer, conditions I believe may be reinforcing a homogeneous provider fleet rather than expanding and diversifying our community of practitioners. I have offered recommendations that point to only a few ways we might incorporate a more diverse range of perspectives in our training cultures. I have also discussed the benefits of shifting to a fuller integration of our concerns about managing the quality and consistency of mental health practice on the one hand and an adventure into cutting edge innovation and fruitful diversification of perspectives on the other hand.

It would be putting these ideas into practice to invite readers to respond to my ideas. So if you take issue with any points I have made or conclusions I have drawn, I would like to hear your thinking and would be willing to enter into more conversation with you. I hope that as members of a global mental health community, we can engage with each other with an open mind and a robust spirit. It is in just such a community that I believe our greatest learning and teaching potentials lie.

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