The powerful thrust toward the development of comprehensive mental health services throughout the world has stimulated the search for a way to integrate the services already there, indigenous and available, with those of the imported variety.
Within the last few decades, a body of writing has come into being dealing with the delivery of mental health services beyond cultural frontiers (Higginbotham, 1976, 1979a, 1979b). The World Health Organization is currently engaged in a project in four developing countries around the world - Columbia, India, Sudan and Senegal - on the development of community-based mental health services (Diop, Collignon and Gueye, 1976). In these efforts, blending in of native psychotherapy is an important component.
Indigenous psychotherapy refers to the whole range of verbal and inter- personal techniques designed for the alleviation of personal distress and for the induction of change of behavior which have been developed independently of the Western tradition of scientifically based psychotherapy (Draguns, 1981). Both psychotherapy and counseling function to alleviate distress, to reintegrate the client or patient into the culture, and to enable him or her to respond to cultural roles and to meet cultural expectations (Draguns, 1981).
Briefly, it may be helpful at this point, to define what is meant in this paper by the terms counseling and psychotherapy. Counseling is an activity that facilitates and fosters personal problem solving. Psychotherapy is principally concerned with changing persons, their characteristic modes of subjective experience and overt behavior - that is, their personalities (Draguns, 1981).
A major share of the literature in this field is devoted to the maladaptation and stress of the culture contact situation. The problems of people removed from their cultural roots, through migration, sojourn, or involuntary displacement, occupy the efforts of a great many culturally-oriented mental health professionals (Alexander, Klein, Miller and Workneh, 198 ; Pedersen, Lonner and Draguns, 1976; Taft, 1977). This is also true about the phenomenon of culture shock. There is a considerable amount of information which has come into being on how to help people who are casualties of intercultural mobility. Examples include distraught college students, confused immigrants, traumatized expellees and refugees, discouraged and dissatisfied Peace Corps volunteers. There have been attempts to sketch a composite portrait of an individual who is least or most likely to succumb to this kind of stress (Pinter, 1969). Characteristice of host environments have also been scrutinized in attempts to identify those features which contribute to making such an environment particularly stressful or unusually stress-free for newcomers (Taft, 1977).
There is a sizeable amount of literature which deals with psychotherapy and counseling with individuals who have been transplanted to a new cultural setting (Szapocznik, Scopetta, Arondale and Kurtines, 1978; David, 1976). This body of writing provides practical relevant information for the professional involved in extending services to immigrants, sojourners or returnees from intensive cross-cultural encounters.
In highly controlled and over-regulated environments, psychotherapy may provide an avenue of release for feelings and emotions, a sort of safety valve (Tseng and Hsu, 1979). In contrast, in an under-regulated or even perhaps an anomic setting, psychotherapy would be likely to emphasize external and social control at the expense of self-expression. These two formulations open the possibility for testing differential hypotheses. This is a task which has not yet been attempted.
There have been statements made about the relationship of these impressionistic differences to the dominant values and the official ideologies of the countries in question (Wittkower and Warnes, 1974). The parallel between the prevalence of authoritarian-totalitarian political regimes and the de-emphasis of explorational, open-minded, insight-oriented therapy has repeatedly been noted in Germany, Japan and the Soviet Union (Draguns, 1981). Two of these countries have experienced an abrupt change in their political orientation, with a considerable cultural change in its wake. It has been suggested that in the United States, however, the goals and the ethos of psychotherapy have been transformed as the values in the larger society have changed.
In Japan, the two indigenously developed therapies, Naikan and Morita, are based on guilt induction and control and on suppression of communication respectively. In the Naikan system, the client is admonished to think of all the ways in which he has wronged his mother (Tanaka-Matsumi, 1979). In the course of Morita therapy, what the client may say and when and how is elaborately restricted and ritualized (Reynolds, 1976). The contrast between Western expectations and Japanese therapy is stark. Documentation on Morita therapy indicates that this therapy works in a substantial proportion of cases on its home grounds. As Sue (1977) has pointed out, therapy and counseling services geared to a culturally distinct group have to be appropriate in process and in goals to be acceptable and effective.
Across cultures, there is much of value to learn from indigenous therapies. As Torrey (1972b) has put it, we have something to learn from the witch doctors. What we as modern psychotherapists and counselors could learn from them is to separate the effective ingredients from the incidental trappings in our own implementation of therapeutic services. Probably, for as long as psychotherapy and counseling have been practiced, these services have been delivered. In some instances, at least, they have even been delivered across culture lines. An example is Freud's (1953) treatment of the "wolf-man". Erikson (1950) drew upon therapeutic and quasi-therapeutic situations beyond the mainstream of American culture. Seward (1956) illustrated her work on culture and personality with case studies of psychotherapy with Americans from a variety of cultural backgrounds. Abel (1956) addressed herself to the problem of the role of cultural factors among American clients in psycho- therapy. Devereux (1951, 1953) ventured beyond the usual settings in which psychotherapy was conducted in order to undertake, and to report in detail, psychoanalytically oriented psychotherapy with a "Plains Indian". The person was not further identified in terms of nation or tribe in order to protect his privacy.
All of the above early contributions have extended verbal psychotherapy to new groups of clients, demonstrated its effectiveness on the case level with new populations, and illustrated the serendipitous "fallout" of psychotherapy as an avenue of learning about the personal experience of another culture. Currently, there are approaches which are even more venturesome that involve not only the extension but the adaptation of the therapy technique and experience as well.
All people respond to stimuli and situations by either changing themselves or the environment and by combining these two operations in various proportions. Particularly, psychotherapy with international students was characterized in the past by facilitating the process of accommodation to, and acceptance of, the host's culture norms. The possibility of extending the individual's scope of choices in the service of actively changing the environment was neglected and underemphasized. Historically, the implicit goal of counseling and psychotherapy has been to bring about a greater degree of conformity to the norms of the dominant majority group. In the case of members of minority groups, the contemporary counselor or therapist faces a choice. The therapist can prepare the client for changing obstacles in the environment, or he can equip him or her for a greater degree of accommodation to the social structure in its current state. In a pluralistic society like the United States, the increase in the individual's options also involves choices on the extent and nature of one's relationships, reference groups, and identity, especially in relation to one's ethnic or cultural group.
Wrenn (1962) sensitized counselors to the problem of cultural encapsulation and warned against the imposition of culturally alien goals, values and practices upon clients across cultural lines. Pedersen (1976) has taken the position that, at least in the multicultural setting of the United States, crossing the cultural gulf in the mental health field is the rule rather than the exception. Extending the concept of culture, he has maintained that the cultures of the counselor and of the counselee may be expected to differ, slightly yet perceptibly, in most counseling encounters.
Developments such as those mentioned resulted in recommendations made at the Vail Conference on Clinical Psychology which was sponsored by the American Psychological Association (Korman, 1974). The knowledge of the cultures of one's clients has been elevated to an ethical imperative. As a result, doing therapy or counseling without cultural sensitivity, knowledge or awareness is not just problematic. It has been declared unethical. The implication of these recommendations is that the knowledge on therapy and culture has ceased being an esoteric field. It has, instead, become a matter of direct and practical concern for the vast majority of clinical and counseling psychologists in the pluralistic culture of the United States.
The problems of doing research across cultural lines can be overwhelming. Much has been said about variations in psychotherapy around the world constituting a laboratory of nature. What research on cultural variations of psychotherapy exists pertains, with a few exceptions, to cultural variations in the United States. Abramowitz and Dokecki's (1977) review, based on analogue studies, seems to corroborate the impression that, in the appraisal of individuals in the mental health setting at this time, in the United States, class lines exercise a greater effect upon the interviewer than do race and sex.
Draguns (1981) suggests that four kinds of information are needed in research across cultural lines:
1. Intracultural data on the effects and consequences of various indigenous therapy techniques.
2. Cross-cultural comparisons of effectiveness of various techniques of psychotherapy, varying and, in the ideal case, counterbalancing both culture and psychotherapeutic technique.
3. Comparing the effectiveness of indigenous and extraneous psycho- therapies in a given setting.
4. Since native components of psychotherapy are increasingly being utilized, from Lambo's (1962; Erinosho, 1976) village model to the use of traditional healers within the Hispanic populations of North American cities (Ruiz and Longrod, 1976), the effect of using these indigenous mental health specialists upon outcome should be investigated.
Does the addition of healers of one's own cultural tradition result in the enhancement of effectiveness of mental health services? A start has been made in investigating the efficacy of Morita Therapy (Miura and Usa, 1970; Reynolds, 1976) and Naikan Therapy (Tanaka-Matsumi, 1979) in Japan. These are two procedures indigenous to their culture, yet developed and practiced by modern mental health professionals.
Jilek-Aal (1978) has noted the effectiveness of the Salish Indian spirit dance in promoting therapeutic change in alcoholics and other patients of that cultural group. It induces regression through an altered state of consciousness, promotes the experience of death and rebirth, and provides the participant with a new identity reoriented toward the ideal of the Salish culture. The rationale and the procedure appear to be reminiscent of the fixed-role therapy of George Kelly (1955), except for the greater reliance on affective and regressive processes, and on altered states of consciousness.
One of the things that therapists of diverse orientations and cultures share is the ability to generate perceptions of competence and concern in their clients (Torrey, 1972b). The therapist's role, regardless of technique, is catalytic. He enables the client to make use of his or her existing assets and strengths (Prince, 1976, 1980). Non-western cultures have tended to rely to a greater extent than the west upon the induction of altered states of consciousness to bring about these catalytic effects. The range of such techniques is wide. What is lacking at this point is a more explicit, systematic and specific understanding of what techniques fulfill what expectations on the basis of what kinds of culturally-mediated learning.
On the negative side, psychotherapy fosters dependency, disorganization, passivity and nonspontaneity (Mendel, 1972). In terms of concrete operations, the universals in psychotherapy include confrontation, exploration of the past, exploring new alternative behaviors, and trying them out in practice. While Torrey (1972a, 1972b) and Prince (1976, 1980) address themselves to the issue of what matters in psychotherapy, Mendel (1972) is principally concerned with the problem of what happens in psychotherapy.
What features of a culture are reflected in its therapeutic services? What kinds of models are implicitly emulated in the conduct of psychotherapy? Once again, one can only point to statements placing psychotherapy in its respective cultural context (Draguns, 1975; Neki, 1973; Wittkower and Warnes, 1974) and relating it to the needs, expectations, models and opportunities experienced in that culture.
Collomb (1973) has attempted to answer the question: What impels a mental health professional to offer services outside his or her usual geographic and cultural milieu, and how may these motives interfere with his or her optimal functioning as a therapist? He has presented a provisional typology of what might be called the cultural distortions of countertransference. On the basis of his observations, he has distinguished three attitudes that could be described as those of universalism, cultural uniqueness and rejection of one's own culture of origin.
One prerequisite with which it is difficult to disagree is that the therapist, as part of his expertise and competence, should know the culture within which he operates. Deveraux (1969), for example, applied himself to a thorough study of the "Plains Indians", preparatory and concurrent to conducting psychotherapy with one of them.
In reference to a great many American ethnic groups, Giordano and Giordano (1976) have provided valuable and specific information that the counselor or therapist should keep in mind in initiating and main- taining contacts with members of these groups. It would be a grave mistake to do psychotherapy in the same way with all the people designated Black, Mexican or American Indian. Yet, the knowledge of the culture of one's clients provides the therapist with an entree and/or point of departure. The therapist's experience with a cultural group or the information on it in the relevant professional literature serve as sources of hypotheses, to be verified, discarded and modified on the basis of information acquired in the course of psychotherapy.
Therapists undertaking to treat members of minority groups should approach this task with a maximum of self-awareness and be prepared to deal with their own distortions of the therapy experience and relationship. An important theme that pervades the literature is the importance of client- therapist compatibility. The most concrete, but perhaps the most crucial, form that this compatibility takes is for both the therapist and the client to be members of the same minority group.
What emerges as a common thread in the writings of therapy with Blacks, Mexican Americans, American Indians and Asian Americans is the independent emphasis that writers of various persuasions and orientations place on activity, as opposed to reflection and passivity, as the recommended mode of intervention with these several groups (Abad, Ramos and Boyce, 1974; Atkinson, Maruyama and Matsui, 1978; Banks, Berenson and Carkhuff, 1967; Peoples and Dell, 1975; Ruiz and Padilla, 1977; Smith, 1977; Sue and Sue, 1972; Sue and McKinney, 1975; Vontress, 1969, 1970).
Weidman (1975), in her work with members of other cultures in Miami, Florida, pioneered the concept of culture-broker, a well-informed intermediary whose inputs are brought to bear upon the therapy process. Least formally and most ubiquitously, the client remains the major source of information about those features of his or her cultural experience which might otherwise baffle the therapist. The limit of this mode of inquiry is that the individual, not the culture, is the focus of all therapy (Draguns, 1981). Sessions should not deteriorate into ethnographic data-gathering in its own right and for its own purpose nor to satisfy the therapist's curiosity. Rather, the referent should be: Is this information needed for therapy, and, if so, how?
The client remains the major source of information about those features of his or her cultural experience which might otherwise baffle the therapist. The limit of this mode of inquiry is that the individual, not the culture, is the focus of all therapy. In cross-cultural counseling and psychotherapy an attempt is made to deal with the individual within the context of his or her cultural milieu and to adapt and adjust to it effectively. When they live in an alien or new culture, the problems of adjusting to two cultures complicates the task.
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