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Culturally Competent Psychotherapy
Specific Cultural Competence Axis and Cultural Analysis
Specific cultural competence empowers therapists to use specific cultural knowledge effectively. Conceptually, the “specific” axis intersects with the “generic” axis to map out a 2-dimensional plane for the practice of culturally competent psychotherapy. In practice, culturally specific knowledge begins to be useful in the engagement phase and is often most fully used from the assessment phase onward (36).
The DSM-IV proposes the use of cultural formulation to systematically assess cultural influences on diagnosis and treatment (37). This process consists of examining 1) an individual’s cultural identity, 2) cultural explanations for individual illnesses, 3) cultural factors related to the psychosocial environment and levels of functioning, 4) cultural elements of the therapist–patient relationship, and 5) overall cultural assessment for diagnosis and care. Although the DSM covers several important and broad cultural issues, we propose a more elaborate scheme to examine specific effects of culture: we extend the commonly used biopsychosocial model of formulation and use a more detailed framework, which we call “Cultural Analysis (CA),” to guide the exploration of patients’ psychological worlds.
Culturally specific knowledge should inform biological, psychological, social, and spiritual components of the clinical assessment. (Biological difference is a less significant issue in psychotherapy, but it can be an important consideration in pharmacotherapy [38]). Psychologically, culture may considerably affect the patient’s world view. CA is used to help clinicians arrive at a culturally specific understanding of the patient’s world view; it informs and interacts with all phases of psychotherapy. In evaluating social factors, therapists can examine many relevant facets, including the sociopolitical history of the patient’s country of origin and culture; current forces in the host society, such as discrimination; and the particular dynamics and resources in the patient’s local ethnic community. Knowledge of specific spiritual beliefs and practices is useful in both assessment and treatment.
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Table 2 Cultural analysis: self, relations, and treatment
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Self
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Relations
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Treatment
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Affect
Behaviours
Cognition
Aims, goals, motivation
Body
Self-concept
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Environment, nature, universe
Family
Groups, others, society
Materials
Spirituality
Time
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Communications
Problem-solution models
Relationship (therapist–patient)
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Cultural Analysis
In all schools of psychotherapy, the therapeutic process is guided by theory, principles, and models of understanding regarding patients and their problems. CA is a framework designed to facilitate a systematic approach to integrating specific cultural knowledge derived from various disciplines, including cross-cultural psychology, psychiatry, anthropology, and sociology. Its goal is to achieve a more complete and culturally informed psychological understanding of the patient. However, this model should be flexibly revised during psychotherapy. While CA can inform and expand clinicians’ thinking, we emphasize that it should be treated as a hypothesis-generating strategy: it highlights potential areas to be explored, but it is not a shorthand device to stereotype and label patients. Hypotheses unsupported by clinical data should be discarded.
Various approaches are used to capture the diverse world views of different cultures (23). We propose that clinicians begin to understand patients’ world views by using a structure based on an object-relation treatment model, with an emphasis on the importance of self and its relationships with others and with the world (39). In addition, clinicians need to consider each patient’s culturally specific understanding of the treatment process. CA is therefore conceived as a framework with 3 broad domains: self, relations, and treatment. Within these domains, we identify basic elements, illustrated in a grid format (Table 2). Culture may affect the way in which each element is conceptualized, including its nature, relative importance, and ideal or desired state.
The self domain captures cultural influences on the psychological aspects of the self that may be relevant in psychotherapy. Culture may affect the very building blocks of internal psychological experiences and observable actions, including affect, cognition, and behaviour. Individual aims, goals, and motivating forces in life also depend on culture. For example, Freud’s emphasis on the importance of repressed sexual desires as basic, dominating motivational forces may have been considerably influenced by the culture of his time. Similarly, his conception of the death instinct was influenced by the wars of his era (40). Culture also influences the conceptualization of the body, which has given rise to the study of different presentations of somatic and psychological symptoms across cultures. To give another example, Cartesian dualism has influenced Western thought and culture and contrasts with the more blurred conceptualizations of body and mind espoused by traditional Chinese beliefs and reflected in such classical medical texts as the Huangdi Neijing (41). One’s overall self-concept is intrinsically tied to one’s culture. One of the most often cited broad cultural variations is the distinction between independent and interdependent self-construals, reflecting individualistic and collectivist cultures, respectively (42).
Using affect as a more extensive example, one can systematically consider empirical data and relevant theories about how the patient’s specific culture modifies each element’s nature, importance, and ideal state. First, culture may influence the nature of affect, from its internal experiences to its outward display. Some researchers believe that the internal experiences of affect are inseparable from sociocultural constructions of experiences (43,44). Other researchers suggest that certain emotions may be universal across cultures, with apparent variations deriving from socioculturally defined display rules (45). Recent research has studied universal as well as culturally specific aspects of emotions beyond cultural display rules. For example, it has examined the different interpretations and antecedents of specific emotions (46). In psychotherapy, patients’ subjective conceptualization of affect may be even more relevant, influencing both assessment and treatment. Cultural metaphors and beliefs—such as the belief that uncontrollable substances within the body cause anger or bodily illness—may uniquely influence patient beliefs regarding the origins and controllability of affect (41,47). Second, culture may modify the importance of affect by perceiving it as something to be either emphasized or ignored. For example, Western cultures have been influenced by Plato and Eastern cultures have been influenced by Confucius; cognitive faculties in the former and social hierarchy in the latter may be privileged above personal emotions. Finally, culture may modify the perception of the ideal state or the acceptability of specific types of emotions (for example, pride) (48). However, there may be a discrepancy between ideal values and actual practices. For example, it may be a particular cultural ideal not to feel or express pride, but pride may nevertheless be readily observable in the culture. Exploring internalized cultural ideals with patients may uncover internal conflict and guilt regarding certain disavowed emotions. Reframing emotions in a culturally acceptable way may at times relieve this conflict (for example, in a collectivist culture, pride may be reframed as relatively acceptable if expressed for family members) (49).
The relations domain captures cultural influence on patients’ world views regarding their relationships. Culture powerfully influences patient relationships with immediate family members, friends, and the community at large. These relationships are guided by socioculturally defined roles, expected deportment, value systems, and the power hierarchy. Apart from human relationships, culture may influence patient relations with “others”: culture influences patients’ conceptions of nature and their attitude toward it. They may regard nature and the environment as something to be subservient to, live in harmony with, or dominate (23). The importance of material possessions may vary, with some belief systems advocating that the ideal state is nonpossessive of material things and others affirming that material wealth is power. Even the exchange of specific material things may take on cultural meanings. To some Chinese, for example, it is a cultural faux pas and an insult to give clocks as gifts, because the phrase “giving a clock” in Chinese sounds like “seeing you off to your final end or death.” Time orientation—the relative importance allocated to the past, present, or future—has been shown to differ among cultures (23). This may affect psychological adjustment and therapy for those who suffer from depression about past trauma (50) or anxiety about future uncertainties. Spirituality is an often neglected yet important issue (13): in many cultures, spirituality may be inseparable from the culture itself. This often becomes particularly important when patients are confronting life-threatening events or existential crises.
The treatment domain highlights elements of therapy that may be especially influenced by culture. These elements have been discussed above, under general cultural competence, but are included as part of the CA framework because they are critically important. Communication patterns, both verbal and nonverbal, are the very basis of the therapeutic process, yet they are subject to cultural influences. Problem-solution models refer to how patients conceptualize their difficulties. This term is preferable to the notion of illness models because patients may not necessarily think of their symptoms or difficulties as being related to illnesses. The therapist–client relationship, including the specified roles and transferences discussed above, is affected by the patient’s specific culture.
Culture not only influences each element within the 3 domains individually but may also cause interactions both within and across domains. For example, the patient’s cultural conception of emotions (affect) in the self domain may influence the treatment domain if the theapist interprets the patient’s difficulties as emotional rather than physical.To illustrate some of the principles discussed, we present the following case.
Figure 2 Conceptual diagram of the internal representations of self and relations in cultural analysis
Case Illustration
Clinical Presentation
Mr Lee, a 40-year-old, married Chinese, lived with his mother, wife, and 2 children in Toronto. He worked as a renovation worker until 2000, when he was involved in a severe motor vehicle accident. The van in which he was a passenger rolled over and crashed, killing 2 of the 4 occupants. He was dragged out of the vehicle by his friend Mr Chan, the other survivor. Mr Lee sustained no major physical injuries but complained of chronic headaches and neck pain. Several weeks after the accident, he began to experience depressed mood, irritability, anhedonia, middle insomnia, impaired short-term memory, decreased concentration, decreased energy, feelings of worthlessness, and passive thoughts of death. He also had occasional nightmares and increased vigilance when riding in a car. He was referred to one of us by his family doctor after a 6-month treatment of his headaches and neck pain with analgesics and physiotherapy failed to produce much benefit.
Mr Lee had a normal childhood development in a small town in China, with no history of abuse. His father was a carpenter, and his mother was a farmer. He could only describe his parents as “good.” He had a grade 10 education and immigrated to Canada in 1985. After various jobs, he worked as a renovation worker for the same company for 5 years before the accident. He met his first wife in Toronto and married in 1990. They had a child, but his wife died unexpectedly in 1995. He remarried in 1998 and had a second child.
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Table 3 Cultural analysis: some potential influences of Chinese culture
on Mr Lee
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Self
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Affect
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Indirectly expressed or suppressed? (41)
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Behaviour
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Decreased eye contact - cultural? (23)
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Cognition
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Field dependent? (52) Less "psychological mindedness"?
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Aims, goals, motivation
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Individual and collective (family) goals? (10)
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Body
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Less body–mind distinction? Somatization? (53)
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Concept (self-concept)
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Independent < interdependent self? Acculturated cultural identity? (55)
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Relations
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Environment
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Karma? External locus of control (for example, fate)? Virtue of forbearance
to outside forces? (23,56,57)
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Family
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Responsibility to children? Insiders vs outsiders? (11)
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Groups, others, society
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Confucian values of hierarchy: inferior social status leading to decreased
assertiveness?
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Materials
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Less materialistic due to communist upbringing?
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Spirituality
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Buddhist and Taoists? Folk beliefs and superstitions?
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Time
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Past- and present-oriented? (58)
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Treatment
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Communications
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Indirect and passive style? (58)
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Problem-solution models
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Multimodal therapy expected (including herbs and acupuncture)? (59) Concrete
plan, action vs talk therapy expected? (23)
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Relationship
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Authoritative healer–passive obedient patient relationship expected? A
"respectful" distance observed? (23)
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When examined, Mr Lee presented as sullen and irritable, with intermittent eye contact, often focusing on the ground. While deferential, he tended to answer questions briefly, without elaboration. His mood was “not good,” and his affect appeared depressed, with decreased range. He was preoccupied with physical pain and lack of energy. He had no active suicidal thoughts. Initially, his insight appeared limited and his judgment undisturbed.
Diagnosis and Treatment Course
Although Mr Lee presented with somatic complaints, specific questioning revealed a range of symptoms leading to a diagnosis of major depressive disorder. This sequence is consistent with with research on somatization (51,52). He also exhibited some subthreshold posttraumatic stress disorder symptoms. To develop a comprehensive understanding and treatment plan, his therapist used CA to take Mr Lee’s Chinese background into account. Table 3 lists some of the initial hypotheses generated.
The initial treatment plan included assistance with insurance matters, pharmacotherapy, and cognitive-behavioural psychotherapy. The therapeutic alliance solidified after Mr Lee felt that his physical symptoms were taken seriously and that he was supported in his efforts to seek physiotherapy and to use traditional herbal ointments for pain. In addition, through treatment goal process negotiation and psychoeducation, he began to acknowledge and accept his affective symptoms and started taking an antidepressant (sertraline), which significantly improved many of his symptoms. With an enhanced therapeutic alliance and explanation of therapy, he began to participate actively, despite his initial somatization and brief, concrete responses, which at first and perhaps erroneously suggested he lacked “psychological mindedness.”
As Mr Lee became more open and his thoughts were explored using cognitive-behavioural techniques, it became evident that his firm belief in fate and hard luck was a persistent source of entrenched cognitive distortions, leading to amotivation and social isolation. This belief exacerbated his survivor guilt. He revealed that he stopped himself from visiting relatives during Chinese New Year, isolated himself from his children’s activities, and cut off his contacts with his friends. Based on the death of his first wife and coworkers, Mr Lee began to fixate on a superstitious folk belief that his hard luck would bring bad luck to those around him, even though he himself would not be harmed by bad events.
At this phase of treatment, various approaches were considered and used. A countercultural approach with standard cognitive-behavioral techniques was used to challenge his beliefs directly. He was helped to evaluate personal counter- examples. For example, he had many other relationships and had previously gone on other social outings, none of which were ever subjected to danger. He was also challenged as to whether survivors of floods in China should be thought of as having hard luck. These techniques produced limit effects: they raised some doubts in Mr Lee’s mind but failed to effect major shifts in his belief system. A cultural reinforcing approach was briefly explored, including such possible indigenous solutions as consulting with a fortuneteller or the temple. Unfortunately, Mr Lee quickly dismissed them because he did not believe in their power to shift hard luck. Several other approaches, framed to be culturally congruent, were then used successively. Tapping into his sense of an interdependent self and using techniques of interpersonal psychotherapy with a grief focus, his therapist helped him rebuild and strengthen his relationships, including those with his friend Mr Chan; with family members of his deceased friends; and most important, with his own family members. While respecting Mr Lee’s sense of fate, his therapist encouraged him to explore existential questions, such as finding new meaning in his survival that included his responsibilities to his family. Although family sessions might have helped address some of these issues, Ms Lee’s work schedule made this difficult, and before arrangements could be made, Mr Lee had improved so greatly that family sessions no longer seemed necessary. Finally, within the complex and diverse Chinese culture, it was possible to find contradictory cultural beliefs to challenge Mr Lee’s belief in hard luck. These included alternative folk beliefs based on ancient Chinese sayings that suggest “survivors of great catastrophe surely will have good luck later on,” and “good people are protected and helped by heaven.”
Mr Lee gradually improved and eventually returned to work after a year and a half of therapy. He and his family were reassured that they could contact the therapist again, if necessary.
This case illustrates the influence of culture on various aspects of therapy, including nonpsychotherapeutic interventions; the therapeutic alliance; and suitable psychotherapeutic goals, process, and content. When informed by culture, psychotherapeutic strategies can be approached from diverse treatment perspectives and strategies. The success of the therapy sometimes depends on combining different strategies across time. When a particular approach leads to an impasse, therapists should have the flexibility to shift therapeutic strategies while keeping in mind the influence of culture.
Conclusion
Insofar as therapists and patients have different reference groups, all encounters may be considered cross-cultural (60). If this perspective is endorsed, then one may indeed consider cultural competence to be essential to overall clinical competence. Therapists should strive for cultural competency by acquiring both generic and specific cultural knowledge and skill sets. Various generic cultural issues may arise at each phase of psychotherapy, and specific cultural knowledge guides their resolution. To guide clinicians, we conceptualize and propose 2 intersecting axes, each embedded within a matrix of relevant issues. Similar considerations may be useful in other cross-cultural clinical encounters apart from psychotherapy.
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Author(s)
Manuscript received and accepted February 2003.
1. Assistant Professor, Department of Psychiatry, University of Toronto; Consultant, Culture, Community, and Health Studies, Centre for Addiction and Mental Health, Toronto, Ontario.
2. Lecturer, Department of Psychiatry, University of Toronto; Clinical Director, Asian Initiative in Mental Health, University Health Network, Toronto, Ontario.
Address for correspondence: Dr K Fung, Toronto Western Hospital, Department of Psychiatry EC-3C, 399 Bathurst Street, Toronto ON M5T 2S8
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