Cultural issues in Psychotherapy

1. Cultural issues in Psychotherapy

2. Cultural considerations in the teaching and evaluation of psychotherapy • Major studies assessing efficacy of psychotherapy have generally not considered cultural variables ( 1-13) >> 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)

3. “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)

4. 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 patient’s 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

5. 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.

6. 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.

7. 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?

8. 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 person’s circumstances.

9. 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 I’m 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.

10. 2.(cont). Presumptions regarding the relationships between thought, affect, behaviour and personal history… • “The most powerful and organizing defense used by depressive people is introjection…In working with depressive patients, one can practically hear the internalized object speaking. When a client says something like, “it must be because I’m selfish”, a therapist can ask, “who’s 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

11. 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

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

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

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

15. 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. >> the constituents of psychotherapy – interpreting affect, empathic understanding etc – require ongoing critical appraisal .