Edward F. Foulks
Tulane University School of Medicine
I. Description of Cultural Issues and the Cultural
Formulation II. Theoretical Bases of Ethnic Identity III. Theoretical Bases of Racial Identity
IV Applications of Culturally Sensitive Psychotherapy
V Empirical Studies of Psychodynamics and Culture VI. Psychotherapy Specific to Cultural Groups
VII. Psychotherapy Technique and Culture VIII. Transference—Countertransference and Culture IX. Case Illustration X. Summary
countertransference An emotional reaction of the therapist toward the patient, usually meant to include two elements, which are the irrational feelings based on the therapist's unconscious mental organization, and the feelings and responses of the therapist in reaction to the patient's unconscious transference feelings toward the therapist. culture The concept encompassing the collective knowledge, shared beliefs, values, language, institutions, symbols, images, and artistic works of a group that represent, signify or allude to these values, beliefs, and ideas and result in a shared world view. cultural competency The awareness on the part of the psychotherapist of the various cultural factors influencing the behavior of the patient. These factors include the cultural identity of the individual, the cultural explanation of the individual's illness, cultural factors related to the psychosocial environment and functioning of the patient, and cultural elements in the relationship between the individual and the clinician. The idea of competency includes the ability to use this information in treatment planning and crafting effective psychotherapuetic interventions. cultural formulation The process whereby the ethnic/cultural identity of the patient is used in the process of diagnosis. transference The emotional reaction of the patient towards the therapist, in which thoughts or feelings related to earlier stages of development are transferred to the therapist.
I. DESCRIPTION OF CULTURAL ISSUES AND THE CULTURAL FORMULATION
There has recently been an increasing awareness of ethnic diversity within almost every country of the world.This awareness and the advocacy of various ethnic groups for equality in multicultural environments have resulted in an emphasis on cultural competencies in medical education and practice.
Cultural competency in psychotherapy has become an explicit goal in all mental health disciplines in the United States and provides a benchmark of quality in the public mental health systems in California, New York, and many other localities serving large minority populations. Cultural competency in psychotherapy requires that the therapist develop Knowledge and skills predicated on an attitude of receptiveness to "foreign" theories of illness and alternative pathways of healing such as is exemplified in the following case of Carlos:
Carlos is a 26-year-old Puerto Rican born man who was referred by a local spiritual healer in New York for medical and psychiatric workup. He had a skin rash that worried him to the point of despondency Over the course of six months he had become more and more depressed and feared that he might be suffering a fatal illness.
Carlos was treated with psychotherapy, at first twice a week for two months and later weekly for eight months. He was also prescribed imipramine hydrochloride, orally, which was increased during a two-Week period to 150 mg at bedtime. His symptoms improved. Several weeks later, Carlos said that he was going to have a religious intervention at a session in his spiritual healer's church. His psychiatrist was invited to attend and observe the session. There were about 25 to 30 persons in attendance at the healing center. In the churchlike room, there was an altar with many statues of "Saints" from the Catholic religion. In front of the altar there was a table with numerous religious paraphernalia, such as collars, prayer books, bottles of incense, and a cup with water. After some consultation with others in attendance in accordance to the norms and rituals of the center, Carlos was called in for his spiritual/religious intervention. The spiritual healer told him that he had to pray regularly in order to be protected from bad spiritual influences. He was also told about the woman in the neighborhood who put the "root" on him, with the intention of separating him and his wife. His wife acknowledged that she had actually considered that possibility all along. Later on, the spiritual healer put a cream on his abdomen, and massaged the area supposedly affected by the "root." Then he applied a lotion in order to make his digestive system, especially his stomach, less vulnerable to "rooting." Additionally, the spiritual healer gave him and his family advice as to how to protect their home from bad spiritual influences using water and special herbs. At the end of the religious session, everyone prayed together on behalf of Carlos. Carlos' daughters were present in the session, as were also many other children who came with members of their families. He subsequently became a devout follower of this healing center religion. His religious conversion made his wife very happy, since she had always gone to the center alone or with her two daughters.
Cultural competencies have been addressed in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, DSM-IV), published in 1994. A special Task Force on Cultural Psychiatry was created by the American Psychiatric Association to identify "specific culture, age, and gender features" for each diagnosis in the DSM-IV The Task Force emphasized that:
• Cultural pluralism has become a worldwide reality.
• Psychiatric diagnosis must be predicated on considerations of cultural factors.
• Cultural differences in the meaning of illness and of health put the clinician, who is unaware of nuances of the patients' behavioral-environment and belief system, in jeopardy of seriously misunderstanding.
• Misunderstanding can lead the clinician to judge variations in normal behavior, belief, and experience as psychopathology, when such is not the case.
The Cultural Formulation outlined in the DSM-IV focuses on the effects of culture on the expression of symptoms, definition of illness, and treatment considerations, and effectively enriches the traditional biopsychosocial model of treatment in psychiatry practice. The Cultural Formulation recommends that the clinician address the following factors involved in patient care:
A. Cultural identity of the individual. The clinician should specify the individual's cultural reference groups. Attend particularly to language abilities, use, and preferences (including multilingualism). For immigrants and ethnic minorities, note separately the degree of involvement with both the culture of origin and with the host or majority culture.
B. Cultural explanations of the individual's illness. Identify (1) the predominant idioms of distress through which symptoms are communicated (e.g., such as the case of Carlos—"nerves," possessing spirits, somatic complaints, inexplicable misfortune); (2) the meaning and perceived severity of the individual's symptoms in relation to norms of the cultural reference group; (3) any local illness category used by the individual's family and community to identify the condition . . ; (see Part II of this Appendix, "Glossary of Culture-Bound Syndromes and Idioms of Distress" in DSM-IV); (4) the perceived causes or explanatory models that the individual and the reference group employ to explain the illness; and (5) current preferences and past experience with professional and popular sources of care.
C. Cultural factors related to psychosocial environment and functioning. Note culturally relevant interpretations of social stressors, available social supports (such as the spiritual center available to Carlos), and levels of functioning and disability. Special attention should be given to stresses in the local social environment and to the role of religion and kin networks in providing emotional, instrumental and informational support.
D. Cultural elements of the relationship between the individual and the clinician. Indicate differences in culture and social status between the individual and the clinician and problems that these differences may cause in diagnosis and treatment (e.g., difficulty in communicating in the individual's first language, in eliciting symptoms or understanding their cultural significance, in negotiating an appropriate relationship or level of intimacy, in determining whether a behavior is normative or pathological, etc.).
E. Overall cultural assessment for diagnosis and care. The formulation would conclude with a discussion of how these cultural considerations specifically influence comprehensive diagnosis and care.
The Cultural Formulation recommends that the clinician assess the ethnic identity of the patient as the first step in the process of diagnosis. This recommendation might seem familiar to most physicians, for they have been traditionally taught to begin the patient evaluation with "Identifying Information and Chief Complaint." Most clinical presentations begin with the phrase, "the patient is a 42-year-old, black male, who...," or "...is a 12-year-old, white female, who...," or ".is a 73-year-old, Hispanic male, who." Such descriptors are taken for granted and by now have become almost universal in clinical conferences, ward rounds, and case reports. The ethnic/racial descriptor is most often ascribed by the examining physician rather than by the patient.
Eliciting the patient's self-perception of his or her own ethnic identity is, however, an important procedure in the diagnostic process and is also helpful in designing the treatment and management interactions that follow. How then does the physician validly describe the ethnic "identity" of the patient? The first step in this process is to ask the patient about cultural and religious backgrounds. Notice that the plural is used in "backgrounds," for the patient's mother and father may have different cultural origins. People who live in multicultural societies may have several ethnic traditions from which much of their identity is derived. In patients from minority cultural backgrounds, the identity acquired by the process of enculturating to mainstream American culture renders another layer of complexity Modern mobility has resulted in many people growing up in different neighborhoods and even in different countries. This can add further dimensions to ethnic identifications. The dynamics of cultural influences on identity are as complex as psychodynamics are in the formation of personality. Although patients may be able to articulate some cultural influences with full aware ness, others may be so automatic and taken for granted that they are only discoverable by studied self-reflection and inference. In nearly all such cases, terms that we commonly use to categorize ethnicity may be too simplistic.
Giving the patient the opportunity to reflect on personal cultural identifications may allow for expressions that affirm the self and inform the clinician. Several caveats, however, must be considered in the process of assigning labels pertaining to ethnic identity. Much of the terminology now in official and common use to designate ethnic identity is actually quite questionable from a scientific perspective. For example, the ethnic categorization of people as black, Hispanic, Asian, and American Indian lacks precision and comparability because they have different referents; that is, Black refers to skin color; Hispanic to a language; Asian to a continent; and Indian to a heterogeneous group of aboriginal inhabitants within the United States.
Distinctions based on skin color have been used for purposes of social discrimination, oppression, and segregation. During the Reconstruction era following the Civil War, many families in the southern states were divided arbitrarily using the criterion of tone of skin color. Those members who could "pass" were considered "white," and those of darker hue were called "colored," "Negro," or "black." This issue remains problematic to their descendants to this day. Skin color is in fact a poor marker of ethnic or genetic differentiation.
"Hispanic" is another ethnic designator that is used as a political banner for many disenfranchised Americans but, like skin color, has dubious validity. "Hispan-ics," "Hispanic-Americans," or "Latinos" tend to be labeled as such regardless of country of origin and cultural background, thereby leading to clinical and research categories that are imprecise. "Hispanic" can apply to people from Spain or South America who speak Spanish. Are Spanish-speaking Filipinos to be considered "Hispanic" or "Asian"? Are Brazilians who speak Portuguese also "Hispanics"? Consider the cultural and possible genetic variability between "Hispanic" Argentinians of Jewish-European descent; Puerto Ricans of Afro-Caribbean descent; and Mexicans of Mayan Indian descent. All speak Spanish and are from "Latin" America. From the perspective of a racial grid based on skin color, one "Hispanic" group could be considered "white"; another "black"; and the third, "red."
Designations based on geographical place of origin are also inadequate indicators of ethnic identity. "Caucasian," "American Indian," "Asian American,"
and "African American" are examples of general categories used for this purpose. Caucasian refers to "white" people of European ancestry but would probably exclude those populations with epicanthic skin folds of the eye lids who actually live in the region of the Caucasian Mountains of Central Asia. "American Indian," on the other hand, refers to a heterogeneous people from 260 different language groups, some descended from groups that migrated from North Asia during the last Ice Age and others, such as the Innuit (Eskimos), who have migrated more recently (witness recent arrivals of Eskimos from Siberia to Alaska). Ironically, these recent arrivals from Asian Siberia are not, however, considered Asian Americans.
The term Asian American commonly refers to people emanating from the Far Eastern countries such as Japan, China, and those of Southeast Asia, Vietnam, Cambodia, Laos, and Thailand. Asians from India, Pakistan, Iran, Iraq, Turkey, and so on, are usually not included in this category. Instead, they are often referred to as Muslims (a religious preference) or Middle Easterners, but as yet they have not been categorized as an official ethnic minority.
Without actively exploring these issues during the interviewing process, attributing racial and ethnic identities to the patient may be invalid and may even have pernicious results. For example, arbitrarily classifying patients according to perceived skin tones may not only identify but also reinforce historically derived categories of social discrimination and negative stereotyping. Therefore, clinicians need to be aware of and actively inquire about the patients' self-attributions regarding ethnicity, race, social class, and religion. By exploring each of these items, the clinician can develop mutual understanding with the patient in regards to cultural and social influences on the mental disorder and its treatment.
There is no ready consensus these days as to what is meant by race, nor is there agreement on what is actually meant by "black" or "white." The genetic heterogeneity of American society makes it impossible to define what is meant by race-linked terminology. In the southern United States it was census law that a drop of "black blood" made an individual black. However, it was commonly observed that a light-skinned woman living as a black in one community might have an equally light-skinned sibling living as a "white" in another community where few had knowledge of the family's relationships.
Despite such lack of precision and clarity with respect to racial classifications, race has taken on particular significance in the United States. The historical American experience with slavery has led to associating stereotyped concepts and stigma to dark skin. On the other hand, equally stereotypic notions of superiority and intellectual cleverness have come to be associated with light skin color.
The complexity of grouping people together on the basis of such arbitrary racial distinction is compounded by consensual identifications because of common cultural heritage. Hence, "blacks" can indeed look very different but still agree that they are African American in cultural outlook. Furthermore, only relatively recently has the notion of substantive variability in ethnic identity among blacks been examined. For example, one dark-skinned individual may be minimally Afrocentric and "mainstream" in political outlook, whereas another equally dark-skinned person may be resolutely Afrocentric. Some psychotherapists have observed that the same individual may change ethnic identity over the period of adult life with a Afro-centrism developing with maturity.
The importance of race as a dynamic factor in American life is practically ubiquitous in its effects, and the potentially problematic interaction between different racial groups is a significant element in practically every facet of life. Clinicians have come to recognize that race has some importance in the context of psychiatric practice, especially pertaining to the patient/clinician dyad and the clinician/supervisor dyad, which may be substantively influenced by racial considerations. Race can impact on clinical understanding, with significant consequences for the diagnostic process and ultimately for treatment decisions.
IV. APPLICATIONS OF CULTURALLY SENSITIVE PSYCHOTHERAPY
Cultural explanations regarding the nature and experience of illnesses are related to the initiation, process, and termination of psychotherapy. Patients often have cultural explanations for their stress and symptoms that differ from those of their psychotherapist. Many people who suffer from psychiatric disorders do not seek psychotherapy for this reason. Studies have shown that patients who believe that their illness resulted from religious, magical, or other sources not considered valid by modern medicine were more likely to fail standard psychotherapy than those who shared a similar model of causation with their therapist. It is not uncommon in the cross-cultural treatment situation to hear patients state that religious problems contribute to their illness: that God is punishing them for past sins, that they are not in God's grace, or that their problems are God's will. Some patients believe that others have caused their sickness through voodoo or the "evil eye." Other examples of alternative nonmedical beliefs can be found in patients who follow modern popular health movements or who believe in traditional herbal practices that attribute psychological problems to imbal-anced diets or to the toxic effects of sugar, meat, food additives, or other edibles. In contrast, patients who endorse medical model explanations and reject folk explanations of their psychiatric symptoms will be more likely to follow a psychotherapist's treatment advice. Similarity or difference in the explanatory model of the psychiatric illness between the psychotherapist and the patient may have a profound influence on the course of treatment. The use of psychotherapy in treating mental disorders that occur in nonmajority patients has therefore been a subject of consideration in planning psychiatric services. Many clinicians working with ethnically diverse populations have questioned several basic assumptions of psychotherapy as developed in Western Europe and the United States and its applicability to people raised in different cultural environments. For example, psychoanalytic psychotherapy is a talk therapy aimed at bringing insight and transformation to a personal, often unconscious, aspect of the individual self. According to this theoretical approach, even interpersonal relationships are "psychologized" and brought back for self-reflection in a person-centric construct focused on the individual as a unitary, active agent.
Some scholars in cultural psychiatry view this form of psychotherapy as a uniquely Western ethnotherapy that is best applied to those of this tradition (i.e., white, educated, middle class), and not used with members of other ethnic groups. A few might even regard psychoanalytic psychotherapy as a pernicious, harmful practice meant to reinforce the values of the elite majority while damaging further the self-esteem derived from traditional identity.
Although some of these arguments may be inspired by recognizing that self-esteem and identity are enhanced by the solidarity of accepting and identifying with one's ethnic or racial heritage, they ironically lend support to the not-so-scholarly opinions of those psychotherapists who believe that, for a variety of reasons, minority or low socioeconomic status patients are not "good candidates" for insight-oriented psychotherapy. Such psychotherapists have observed that "minority" patients often express conflict by "acting out" rather than by verbalization and cognitive mastery, and that the early life traumas (common in lower socioeconomic status populations) preclude the more mature object-relational capabilities required for successful engagement in psychotherapy. Policymakers and agencies that are concerned with cost reduction in psychiatric services are also bolstered by these arguments to reduce basic psychiatric services to those who might most need them but cannot afford them.
Although psychotherapy has become an important treatment modality in general psychiatry, it has been for the most part reserved for the affluent members of society. Many surveys have revealed that minorities, particularly those of low socioeconomic status, receive less psychotherapy, for shorter periods of time, by less experienced staff.
A number of studies have indicated, however, that members of many major ethnic minority groups in the United States are as receptive to psychotherapy as members of the majority group. These studies find no differences between Mexican Americans and Anglo Americans in terms of referral, compliance, and resistance to psychotherapy, and they reveal that neither race nor ethnicity has any effect on the number of treatment sessions, treatment modality, or treatment environments. Some studies have also demonstrated the efficacy of culturally sensitive psychotherapy with Asian-American patients, refuting the cultural stereotype that Asians are unable to express themselves in emotional terms. It is well recognized by now that, even abroad in India and Japan, psychotherapy and psychoanalysis have obtained a valuable place as treatment modalities appropriately offered to many patients in these societies.
Studies of the psychodynamics of people in Asian societies emphasize emotions as embedded in interpersonal relations, in which persons are rarely considered autonomous and separate from their society. Thoughts, feelings, ambitions, and desires are perceived to reside not in the individual, but in family and close social networks. Some psychiatrists have reported that Japanese have no clear-cut conceptual demarcation between self and others. There seems to be "blurred ego boundaries" between self and significant others, which creates a sense of group identity rather than individual identity. The goal of one type of psychotherapy practiced in Japan (Nai-Kan—look within oneself) is to bring awareness to the patient of how ungrateful and troublesome he or she has been to parents, teachers, and benefactors. The patient is appropriately counseled as to how to show gratitude and alliance. In this process, patients realize that they have no right to expect that their personal wishes and desires will be gratified by others. Instead, they realize that they exist for the sake of others. Egocentric traits such as "sticking to a personal opinion" are seen to be neurotic and selfish. Therefore, the patient must come into harmony with group goals that may be equally assertive and competitive but will collectively serve the family, class, or company's needs rather than personal needs.
Many Asian patients with such sociocentric orientations also have problems speaking to a psychotherapist about intrapsychic or interpersonal problems. They often have emotional and cognitive conflicts involving feelings of selfishness, ingratitude, and betrayal about considering such issues. Some psychiatrists have commented on the Asian patient's desire to protect his "inner self" from exposure. Others have speculated that, in sociocentric societies, the inner self is undefined, with minimal referential vocabulary, or is psychologically undeveloped to the extent that the patient has little or nothing to report regarding an awareness of an inner self. Such patients will distrust talk therapy and, when severely symptomatic, will express their distress somatically rather than in psychological terms. Such presentations of illness may not only be defensive in function but may also reflect a context-dependent perspective in which organs, body parts, individuals, and groups are considered holistically balanced or im-balanced in a unified-interactive system.
Because many patients in Asian countries complain of somatic symptoms in time of distress, it is assumed that they lack psychological mindedness. Some studies have observed that the use of proverbs may provide a vehicle for expressing interpersonal and intrapsychic conflict. Asian societies use proverbs to express empa-thetic understanding and often point out dysfunctional defenses in a manner acceptable to the listener. Traditionally educated Vietnamese are required to memorize volumes of such verses, which are considered to be classics.
Many Vietnamese proverbs express psychological awareness of, and concern for, intrapsychic and interpersonal conflict. Proverbs are used to interpret and instruct family members and close friends in regard to their defensive handling of affects. In psychotherapy, proverbs are used in a gentle, indirect, nonconfronting way when approaching psychological or sensitive interpersonal issues, particularly in such culturally specific therapies as Nai-Kan and Morita.
Specific forms of psychotherapy practiced within unique cultural groups range from the laying on of hands and prayers that commonly occur in many Christian denominations to spiritual centers (espiritismo centros), evil-eye curing centers (malocchio/mal de oio), sweat lodges (southwestern American Indians), and root work (rural African-American communities), among many others. The merit of many of these culturally specific therapies is currently an issue of much interest and study, as at the Center for Alternative/ Complementary Medicine at Columbia University. Culturally specific therapies often reaffirm traditional cultural values and reinforce group solidarity, providing support and identity to a patient in distress. In addition, many ethnic curing practices identify and explicate unique culturally related interpersonal conflicts that cause distress and provide mechanisms for appeasement or resolution.
As valuable as many of these specific cultural approaches may be for special and unique populations, their general applicability in multicultural environments seems limited. Some have suggested creating a broad array of culturally specific clinics or having each therapist or clinic achieve competence in administering the myriad culturally specific therapies required to bring an equal quality of mental health care to all diverse citizens. This would seem to be an organizational and quality assurance task of daunting proportions. In addition, sensitive civil rights issues may be encountered in triaging and assigning minority patients to culturally specific therapies, while majority patients are referred to standard treatments.
Integrating knowledge of the unique cultural values and beliefs into personal psychodynamics in the treatment of people from non-Western societies would seem to offer the most parsimonious and optimal approach to this dilemma. Familiarity with cultural traditions, val-
ues, and context as well as language ability are essential to such a cross-cultural psychotherapeutic enterprise. The following case study of a Japanese-American woman will illustrate these principles.
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