Cultural issues in Psychotherapy

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Cultural issues in Psychotherapy
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• Cultural considerations in the teaching and
  evaluation of psychotherapy
• Major studies assessing efficacy of psychotherapy
  have generally not considered cultural variables
  ( 1-13)
• gtgt one recent U.S review concluded
  empirically supported therapies are culturally
  sensitive therapies for one ethnic minority
  group European Americans ( Hall, 2001)
• Evaluative studies that exist are almost entirely
  descriptive (14-16)

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• many British psychotherapists privately suggest
  that therapy is not appropriate for minority
  groups because of their supposed lack of verbal
  facility or the ability to understand and work
  through their problems in a way that accords
  with the psychological model Roland Littlewood
  (2000)
• Psychotherapy is less often offered to minority
  group patients ( Littlewood and Lipsedge (1997)

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adapting psychotherapy to non-western clients
(or when there is a large cultural distance
between clinician and client).

• Preliminary assumptions
• all psychotherapy is intercultural
• There are some general characteristics of all
  psychotherapies
• The therapist needs to be self-reflexive and
  able to question his or her assumptions about the
  patient as well as the patients assumptions
  about the therapist and the therapy ( Bhugra and
  Bhui (2001).
• Modification of technique will be necessary when
  working with clients for whom psychotherapeutic
  approaches are culturally alien

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• A case study.
• A 46 year old married Vietnamese( ethnic
  Chinese) - Australian woman, came to Australia in
  early 1980s as part of the refugee resettlement
  program. Two adolescent children. Reported
  decreased activity, energy, and ability to work
  in factory employment. Says that she is
  uncharacteristically irritable with children.

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adapting psychotherapy to non-western clients (or
when there is a large cultural distance between
clinician and client).Cont..

• Areas of particular clinical attention
• 1.Expectation of a prescriptive approach and
  assistance with practical problems
• - eg settlement issues special problems of
  asylum seekers and refugees
• 2. Presumptions regarding the relationships
  between thought, affect, behaviour and personal
  history have to be questioned.
• 3. Somatization and psychologization
• 4. The use of catharsis.
• 5. Transference and countertransference
• 6. Working with interpreters in psychotherapy
• 7. family inclusive individual therapy
• 8.The concept of self sources of esteem,
  disappointment and shame
• 9. Over and under-attribution to culture by the
  clinician and client.

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1.Expectation of a prescriptive approach and
assistance with practical problems

• - the refugee may expect to be cured quickly.
  The idea that his complaints will disappear if
  he learns more about himself through a long
  series of talks is both strange and difficult to
  comprehend ( Guus van der Veer, 1998 p76)
• - practical issues re settlement special
  problems of asylum seekers and refugees ( 23)
• - resistance to addressing psychological
  issues?

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2. Presumptions regarding the relationships
between thought, affect, behaviour and personal
history

• Identifying cognitive distortions assumes
  cultural knowledge.
• - According to CBT common cognitive errors in
  depression include arbitrary inference,
  personalization, selective abstraction ( and
  confirmation bias), over-generalization,
  magnification and minimization. Occur
  particularly in relation to judgements re the
  self, the future and the persons circumstances.

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2. (cont). Presumptions regarding the
relationships between thought, affect, behaviour
and personal history

• I feel inadequate because I cannot provide for
  my parents in my country.
• I am dishonoured by the disrespect my children
  show me.
• I must avoid my compatriots because my life would
  be impossible if they found out I left my husband
  for someone else.
• When Im alone I hear a child crying, and I know
  my daughter is suffering
• What I have suffered ( rape by enemy soldiers)
  means I have been robbed of self-respect for ever
  and I will never again experience true happiness.

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2.(cont). Presumptions regarding the
relationships between thought, affect, behaviour
and personal history

• The most powerful and organizing defense used by
  depressive people is introjectionIn working with
  depressive patients, one can practically hear the
  internalized object speaking. When a client says
  something like, it must be because Im selfish,
  a therapist can ask, whos saying that?..the
  kind of introjection that characterizes
  depressive people is the unconscious
  internalization of the more hateful qualities of
  an old love object. His or her positive
  attributes are generally remembered fondly,
  while negative ones are felt as part of the self
  
• - Nancy McWilliams (1994) Psychoanalytic
  Diagnosis p232

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2. (cont). Presumptions regarding the
relationships between thought, affect, behaviour
and personal history

• History taking and historical interpretation
• - developmental models, the relevance of prior
  experience ( the child is father of man )
• vs fate, preordination

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• 3. Somatization and psychologization
• (24-27)
• 4. The use of catharsis ( 28,29)

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• 5. Transference and countertransference
• 6. Working with interpreters in psychotherapy (
  30,31)
• 7. family inclusive individual therapy

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• 8.The concept of self sources of esteem,
  disappointment and shame
• 9. Over and under-attribution to culture by the
  clinician and client.

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summary

• All psychotherapy is cross-cultural, but with
  increased cultural distance, more explicit
  attention needs to be paid to cultural variables
• Some of the significant cultural dimensions have
  been identified. The clinician consciously
  invokes these dimensions in undertaking the
  anthropological exercise of understanding the
  culturally diverse client.
• gtgt the constituents of psychotherapy
  interpreting affect, empathic understanding etc
  require ongoing critical appraisal .