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Culturally Competent Psychotherapy
Engagement
Engagement begins with actual clinical contact. In this initial phase, the therapeutic alliance starts to develop and solidify. In practice, this phase unfolds concurrently with the assessment phase. Research documenting that minority patients have high dropout rates from the mental health care system highlights the critical importance of therapeutic engagement (7).
During this phase, ethnic match is an important consideration. Although some evidence suggests that patient–therapist matching according to ethnicity, language, and value system leads to improved therapeutic outcomes (8), such arrangements are not always feasible. Further, some patients are concerned about confidentiality and stigma. These patients may prefer a therapist who is not a member of their ethnocultural community. Whether the engagement process involves an ethnic match or not, highlighting such commonalities as educational background can facilitate the engagement process (9).
Respective conceptualizations of the therapist and patient roles also affect the engagement process. Some patients may find psychotherapy within a health context incomprehensible and may cast the therapist as a “village elder.” This role can engender a sense of familiarity and kinship and is simultaneously imbued with healing authority, power, and wisdom. Patients in some cultures expect the therapist to be knowledgeable and not to ask too many questions. In such cases, patient expectations about therapist insight may be at odds with some authors’ admonitions about the value of therapists’ displaying curiosity and cultural naiveté (10). Therefore, to avoid making erroneous assumptions and indulging in unjustified stereotypes, therapists must learn to recognize and operate within the contrasting frameworks of therapeutic omniscience and naiveté. They should maintain a constantly open attitude, while making opportune and appropriately formulated enquiries about the patient’s culture.
In many ethnocultural communities, shame about seeking mental health services is an important issue for both the patient and the family (11). Reassuring patients and their families about confidentiality is important. Psychoeducation may also help to modify some prevalent cultural myths—for example, that mental illness is incurable or implacably heritable.
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Table 1 Generic cultural competence axis in psychotherapy
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Therapist
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Patient
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Family or Group
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Technique
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Preengagement
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Explanatory model
Help-seeking pathway
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Attitude of group
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Positive referral
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Engagement
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-
Therapist role
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Ethnic match
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Patient role
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Group agenda
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Cultural naiveté
Psychoeducation
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Assessment and Feedback
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Patient’s world view
Cultural identity
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Family dynamics
Community dynamics
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BPSS
Cultural analysis
Cultural consultant
Gift
Pretherapy preparation
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Treatment goal
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Individual goal
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Group goal
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Negotiation
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Treatment content
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Content defined by Therapist
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Content defined by patient
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Content defined by group
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Negotiation
Response to concrete
content
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Treatment process
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Therapist’s language and communication style
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Counter transference
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Patient’s language and communication style
Transference
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Involvement of family
Community healing practices
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Language independence
Cultural independence
Cultural reattribution
Social role prescription
Avoidance of inappropriate techniques
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Termination
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Need for ongoing support
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View of treatment
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“Door ajar”
Institutional transference
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BPSS = bio-psycho-social-spiritual
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Assessment and Feedback
During assessment, sensitivity is required to foster and maintain the therapeutic alliance. Therapists should approach such taboo subjects as sex cautiously. Attempts to understand patient problems should begin with what the patient deems important.
A comprehensive approach to assessment includes examining the problems from biological, psychological, and social perspectives (12). The spiritual perspective is another significant component in many cultures (13). For a thorough assessment, knowledge of the patient’s particular culture and world view is necessary, as described below. A cultural consultant is sometimes needed. This consultant may be (for example) a bicultural professional who can describe the home country sociopolitical situation, help interpret certain aspects of the patient’s mental state, or suggest community resources in the resettlement country.
Cultural identity is an important and multidimensional area of exploration. A given individual may have different cultural preferences for language, food, entertainment, and value system, and none of these dimensions can be inferred from another. For example, individuals may cling to the foods they ate in a parental home, while simultaneously abandoning parental values regarding sexual behaviour or filial obligation in favour of those prevalent in the larger Canadian society. It is also important to recognize that cultural identity is fluid and dynamic and may be differently invoked, depending on the context and situation (14,15). Further, the diverse acculturative strategies used by immigrants may have an impact on mental health and psychosocial adjustment (16,17). Immigrants may adopt the host culture with or without maintaining their heritage culture, employing, respectively, “integration” or “assimilation” strategies. It has been proposed that integration—a harmonious blend of both cultures—leads to good psychological adjustment. Conversely, immigrants may adhere to their heritage culture without acculturation. This “separation” strategy may not create problems if the ethnic community is sufficiently large and sufficiently developed to provide a viable ethnic enclave (18,19). Individuals who fail to fit within both their heritage culture and the host culture may become marginalized and are at particular risk of developing mental health problems (16–19). Clinicians should explore each patient’s particular type of acculturation strategy, paying particular attention to its rigidity and fit with the environment.
Family dynamics is another element to be assessed, especially in collectivist cultures. At times, this assessment has to be conducted in various subgroups, allowing for subsystem interventions (11). For example, a separate discussion with the father may help him avoid the loss face that would result from admitting errors in front of the family. Sometimes, a family member can be enlisted to act as the therapist’s auxiliary to effect certain interventions. Understanding the patient’s relations with the local communities, with the country of origin, and with the dominant society can alert the therapist to problems with acculturative stress and intercultural conflict (such as discrimination at the patient’s workplace).
After an initial assessment, therapist feedback may be particularly important for the culturally different patient. The idea of a “gift” to the patient, offered even in the first assessment session, is a useful technique that encourages the patient to continue with therapy (20). Engagement-enhancing gifts include explanations about problems, reassurances, or a prescription for medications.
Therapists can also use feedback as an opportunity to introduce the concept of psychotherapy to patients, who may not share the therapists’ underlying assumptions (such as assumptions about the process and about the respective roles of therapist and patient). A pretherapy introduction to psychotherapy in the form of a brochure, a video, or a group discussion has been shown to reduce premature termination (21,22).
Treatment
We discuss this phase in terms of 3 interrelated components: goals, or the desired endpoints of therapy; content, or the specific area that is worked on; and process, or the way in which therapy is conducted. For example, in treating a patient with depression, the goal may be to elevate mood and restore functioning, the content may be grief over a mother’s death, and the process may be interpersonal psychotherapy. Sue has emphasized the importance of culturally appropriate goals and process in psychotherapy (23).
Goals. It is important for therapists and patients to establish goals collaboratively. Treatment goals set by the therapist alone may be incongruent with the patient’s cultural frame of reference. The patient’s primary group may have different goals from those of the patient, which adds to the complexity of goal setting (24). For example, an Asian adolescent’s desire for autonomy may conflict with the traditional values of his or her family. Ultimately, the primary principle in setting appropriate goals should be the patient’s subjective well-being, conducive to healthy functioning in the patient’s environment.
Content. The patient’s culture often influences the choice of content in psychotherapy. Cultural analysis (CA), as we will discuss later, helps direct the therapist’s attention to potential content areas. The explanatory model of the patient may differ from that of the therapist, and a process of negotiation may be necessary. For example, some patients may want to work on practical issues, such as somatic symptoms or relationships with neighbours, that may appear to be too concrete to therapists. Initially, therapists may need to respond to these issues to maintain the therapeutic alliance before embarking on other relevant issues. Empathizing with the patient, teaching problem-solving skills, supporting the patient in seeking Western or alternative solutions, and even giving direct advice may all be useful psychotherapeutic techniques. We further explore other specific process-related issues in the following section.
Process. Effective communication is the basis of any psychotherapeutic intervention. Therapists may need to accommodate their communication style, both verbal and nonverbal, to that of a culturally different patient because, for example, apparently linguistically equivalent words may evoke different psychological associations. This phenomenon is termed “language independence,” defined as the capacity to maintain 2 sets of languages with different lexical, syntactic, phonetic, and ideational components (25,26). A bilingual therapist familiar with the concept of language independence can help patients elucidate the various meanings of words like “love,” which in English can be used to cover many different emotional states. Some patients report different comfort levels when using different languages to discuss certain topics like sex: for example, bilingual Chinese patients may choose to speak about sexual matters in English rather than in Chinese (27).
Expanding on the concept of language independence, “cultural independence” has been proposed. Cultural icons such as temples may assume different meanings in different cultures. Maintaining cultural independence and actively exploring assumptions with the patient helps the patient to reexamine issues from a fresh perspective (27). Culture not only modifies meanings and associations, it can also guide the process and direction of psychotherapy. Depending on each individual case, therapists may find reinforcing cultural norms the most helpful route. Conversely, a countercultural direction may be required when patient adherence to certain aspects of culture is part of the problem. In the latter case, reframing problems in the context of culture is a useful technique to reattribute blame and help patients reduce personal shame and guilt. For example, if an Asian husband from a male-dominated society is told that his controlling way of relating to his wife may have stemmed from his culture, he may be encouraged to modify it.
The development, maintenance, and use of the therapeutic relationship in cross-cultural psychotherapy can present unique challenges. Patients’ culturally based expectations may challenge conventionally defined therapeutic boundaries, such as the convention that therapists refuse gifts. Problems may also arise from specific ethnocultural transference and countertransference (28). Patients may distrust a therapist from a culture that has oppressed them, or they may discount cultural issues, feeling that they are already quite assimilated. On the other hand, therapists may also minimize cultural differences, trying to appear less discriminating. Often, power dynamics are at the root of transference problems. Frank discussion of the discrepancy in power between therapist and patient may facilitate therapy (29,30). Conversely, problems can arise when the patient and therapist share the same cultural background, and cultural differences may in some cases actually have a positive transference effect that facilitates rather than impedes therapy (27). Asian patients, for example, may feel that a Western therapist is less judgmental than a culturally matched therapist about subjects taboo in their culture, such as homosexuality.
Beyond the traditional therapeutic dyad, it is often necessary to involve family members actively, although not necessarily in conventional family therapy. Therapists can invite family members to participate in part of the treatment, in a culturally appropriate manner. In some collectivist cultures, part of the self-identity and the interdependent self may be defined by the patient’s social role in relation to other family members. For example, eldest sons may need to follow their fathers’ footsteps, or the patients’ vocational status may determine how they will be treated in the community. To assist these patients, it may be necessary to use resources in either the ethnic or the mainstream community creatively to procure volunteer work or develop an alternative social role. Other community resources include indigenous healing ceremonies, such as sweat lodges among Aboriginal populations (31), and more recently developed interventions such as network therapy (32,33,34).
Some conventional techniques may not be culturally appropriate for some patients. For example, open confrontation is not acceptable in some Asian cultures, with their emphasis on preserving “face.” Other techniques, such as paradoxical intervention, role-play, and relaxation therapy, may be difficult for some patients to grasp or use (35).
Termination
Ethnic patients and their families may particularly need to maintain contact after termination, owing to limited support in the community and to their cultural understanding of relationships, which are rarely terminated artificially. Therapists may choose to leave the “door ajar” and maintain a link with patients and family members by defining appropriate circumstances in which they should reconsult. Sometimes, an institutional transference may be established, enabling patients to derive continued support from institutions such as hospitals or community agencies, should a particular therapist become unavailable.
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