Cultural issues in
Psychotherapy
 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)
 “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)
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
 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.
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.
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?
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.
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.
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
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
3. Somatization and psychologization
(24-27)
4. The use of catharsis ( 28,29)
5. Transference and countertransference
6. Working with interpreters in
psychotherapy ( 30,31)
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.
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 .