Case Study 02 — Amara: The Water She Swam In

Chapter 38: Cultural Psychology — How Culture Shapes the Mind

Background

Amara's clinical training has been deepening her awareness of how social context shapes psychological distress. The cultural psychology chapter arrives as the culmination of the social forces section — and it gives her language for things she had been navigating without quite naming.

She grew up inside multiple cultural frameworks simultaneously: the culture of Grace's family (Southern Black working-class roots, transplanted north), the culture of the schools and programs she advanced through, the culture of a predominantly white academic environment, and the culture of clinical training. She had been doing acculturation work since she was seven years old.

She read the chapter in her apartment on a Friday evening, Yusuf on the phone during the first part (she called him after the first hour, needing to think out loud). She filled her journal with more than she had expected.

The Acculturation History Named

The acculturation concept gave Amara a framework for something she had not fully analyzed: the nature of her educational and professional mobility.

She was first-generation college, first-generation graduate school. The move from her family's world to the academic world had required adaptation at every level: communication register, relationship expectations, the implicit rules of academic culture, the cultural script for how to present yourself as capable without seeming arrogant, how to ask for help without seeming weak, what counted as professionalism and what didn't.

She had, largely, pursued the integration strategy: maintaining her connection to her family's cultural context and values while developing fluency in the new cultural context. But the integration had not always been conscious, and it had not always been clean. There had been periods of something closer to assimilation — performance of the dominant cultural style that had required suspension of parts of herself that didn't fit the professional frame. And there had been periods of something closer to separation — retreating into the familiar when the new cultural context felt too costly.

What the integration concept named was the trajectory: she was moving toward something that felt like genuine bicultural fluency. Both contexts were resources. Neither required the suspension of the other.

She thought about the Kemi conversations. Kemi knew the whole version. Yusuf was increasingly close to it. The clinical training relationship with Marcus had room for it. The peer group had built something genuinely inclusive — Sasha, Diana, Tomás, herself, all carrying different cultural histories, all finding the work meaningful, all building a professional community that had room for more than one cultural framework.

The Client from a High-Context Culture

Amara was seeing a client — she called him Francis in her clinical notes — a 31-year-old man from West Africa who had immigrated to the United States eight years earlier for graduate study and had decided to stay for work and, ultimately, a relationship. He had been referred for depression; the presenting picture was low mood, diminished interest, significant social withdrawal, and sleep disruption.

The first three sessions had been technically competent and clinically insufficient. Amara had conducted a thorough assessment, developed a CBT formulation around core beliefs and behavioral withdrawal, and proposed a graduated activation plan that followed the standard protocol for mild-to-moderate depression. Francis had engaged politely and not improved.

She brought the case to Marcus in supervision with specific questions: What was she missing?

Marcus asked his standard first question: "Tell me about the relationship."

Amara described it: formal, respectful, polite. Francis arrived on time, answered questions thoroughly, and left on time. "He's like a perfect client in terms of participation and nothing is moving."

Marcus: "What does he want from you?"

Amara realized she had been assuming the answer: symptom reduction, mood improvement, the standard CBT targets. She had not asked Francis directly what he wanted.

At the next session, she asked. Francis's answer was something she had not anticipated: "I want to understand whether what I'm feeling is a problem or whether I'm being asked to be a different kind of person."

She held that. She asked him to say more.

What emerged over the next thirty minutes was a cultural narrative she had been missing entirely: Francis came from a cultural context with strong collectivist values, significant family obligation structures, and a different relationship to individual emotional experience than the therapeutic framework she had been applying assumed. His "depression" was, in significant part, a grief about cultural dislocation — the distance from family, the difficulty of sustaining deep relationships in a cultural context that moved faster and valued different things than he had been shaped for, the sense that he was being asked to become a more individually autonomous person than he experienced himself as or wanted to be.

The CBT activation plan had been asking him to generate individual pleasurable activities. His source of meaning was relational and embedded in obligation structures that didn't exist here in the same form.

Amara returned to supervision with a revised formulation. Marcus: "Now you know who you're actually treating."

The Cultural Humility Shift

The Francis case produced a shift in Amara's clinical approach that the cultural humility framework made explicit.

She had been trained toward cultural competency: know what to expect from clients from different cultural backgrounds, apply that knowledge to assessment and treatment planning. The training was not wrong — background knowledge genuinely mattered. But the Francis case showed the limitation: she had known the broad contours of collectivist cultural psychology and had not applied it to the specific man in front of her.

Cultural humility required a different orientation: lead with curiosity about this specific person's experience, treat background knowledge as a source of hypotheses not conclusions, and make the cultural dimension explicit when relevant.

With Francis, she began doing something she now called "cultural inquiry" — directly asking about the cultural dimensions of his experience. Not as demographic data collection but as genuine clinical curiosity: How do people in your family understand what you're going through? What would "getting better" look like in the context of your original community? What do you miss most about that context? What are you carrying here that has no one to receive it?

The sessions changed. Francis began talking about his mother's death, which had occurred six months before the referral and which had been described in the initial intake as "a family bereavement" but had not been the central focus of treatment. He was carrying grief in a cultural context that had no ceremony, no community, no shared time for mourning it. He had not had the cultural rituals that the grief chapter had described as part of what makes grief processable.

Amara applied what she knew. She helped Francis create a space for the grief that the migration context had not provided. She acknowledged the cultural dislocation not as pathology but as real loss. She helped him identify what aspects of his interdependent self he could sustain here — the relationships he had, the ways of engaging the community that were available — rather than treating individual autonomy as the default treatment target.

Francis began improving. Slowly, with real engagement.

Marcus's end-of-supervision comment: "Good clinical work is culturally humble clinical work. The two aren't separable."

The Personal Thread

Amara's personal reflection from the chapter centered on something she named in her journal but had not yet brought to Dr. Liang: the WEIRD critique and its application to the therapeutic frameworks she was absorbing in training.

She had noticed, over the past year, a subtle tension between the therapeutic frameworks she was learning and the cultural values of her own family background. The emphasis on individual autonomy, personal goals, self-expression, and self-actualization that ran through so much of the training literature was a cultural preference as much as a universal psychological truth. In her family's framework — and in many of the communities she cared most about — the relevant questions were often different: What are your obligations? Who do you belong to? How do you serve?

She was not rejecting the Western therapeutic framework. It had given her real tools, and the self-knowledge it cultivated was genuinely valuable. But the WEIRD critique helped her hold it more lightly — as a framework, not a universal truth — and to bring that lighter hold into her clinical work.

In her journal, she wrote: I grew up in a world that asked "who do you belong to?" I'm being trained in a world that asks "who are you?" Neither question is complete without the other. The best version of what I'm building holds both.

What Amara Understood

The cultural psychology chapter gave Amara two things that arrived at the same time and proved inseparable.

Clinically, the Francis case and the cultural humility reframe replaced a cultural competency orientation with something more responsive: genuine curiosity about each individual's cultural experience as the starting point, background knowledge as hypothesis, cultural inquiry as a direct clinical tool. The improvement in the work was immediate and significant.

Personally, the acculturation framework named a trajectory she had been on for most of her life: first-generation mobility as a form of ongoing cultural navigation, integration as the strategy she was building toward, bicultural knowledge as a specific resource rather than primarily a cost. The tension she had been carrying between her family's cultural framework and the therapeutic world she was entering was not a problem to be solved. It was a source of the dual fluency that made her potentially better at serving people who were themselves navigating between cultural worlds.

She brought this to Dr. Liang. Dr. Liang's response was characteristically direct: "The best therapists I've known all had something they were working to integrate — some tension between where they came from and where they were going. Not resolved, not avoided. Held."

Amara let that land without managing it.

Discussion Questions

1. Francis's description of his experience — "I want to understand whether what I'm feeling is a problem or whether I'm being asked to be a different kind of person" — is a profound framing of the cultural mismatch between collectivist values and individually-oriented therapeutic frameworks. How should a clinician respond to this as a clinical question?

2. Amara's initial CBT formulation and activation plan were technically correct within their framework but clinically insufficient. What specific information was missing, and at what point in the assessment process should cultural context be explicitly explored?

3. The chapter distinguishes cultural competency from cultural humility. Is cultural knowledge valueless in this framework, or is the distinction about how knowledge is held? What is the difference between using cultural knowledge as a hypothesis generator versus using it as a conclusion?

4. Amara writes in her journal: "I grew up in a world that asked 'who do you belong to?' I'm being trained in a world that asks 'who are you?' Neither question is complete without the other." What therapeutic framework would hold both questions simultaneously, and what would treatment look like that honored both?

5. Francis's grief about cultural dislocation had been described as "a family bereavement" in the intake but had not been the focus of treatment. What does this miss, and how does the cultural context of grief (the ceremonies, community, and shared mourning that migration disrupted) affect what treatment for grief should look like?