Psychotherapy and Cross-cultural Clients

by Mary de Courcy and Angela McCarthy


This paper intends to open discussion about the issues and concerns of
 psychotherapeutic work with multicultural clients. It proposes to invite 
comments and observations from Inside Out readers in relation to this subject.
 The terms appropriate for adequately describing the clients under discussion 
are inconclusive. Multicultural, cross-cultural, overseas clients, non-nationals,
 immigrants, New Irish – none seems entirely accurate or apt. The authors
 welcome suggestions for an all-embracing, inclusive, acceptable term.

Introduction

There has been a significant increase in the numbers of overseas clients
 presenting for counselling and psychotherapy in Ireland in the past 5-10
 years. While many non-nationals come here by choice as financially 
independent people, or as contract workers, others have had to flee from
 their country of origin and arrive as refugees and asylum seekers. Whatever
 their reason, most immigrants need and actively seek in Ireland a safe living
 environment, decent accommodation, further education or training, and
 greater employment opportunities. For a variety of reasons, a significant
 number of non-nationals are now presenting to counselling and 
psychotherapeutic services.

Some of these men and women may be 
suffering from depression, crises of identity and belonging, and sheer
 loneliness, while others may need to deal with the impact of harrowing
 experiences of rape, sexual abuse, torture and other trauma.
 Some of these clients are dependent on low-cost or state-funded 
psychotherapy, while others may seek privately funded psychotherapy. In
 each case, matters of the fee, the contract and the nature of the
 psychotherapeutic work will depend on the individual practitioner or
 service to which s/he belongs and the needs and circumstances of the
 individual client. It is essential however, that the psychotherapist who
 chooses to work with such clients has dealt with his or her own issues about 
race, religion, dress and difference, and is prepared to continue to work on 
personal challenges, which work with clients from culturally diverse 
backgrounds will necessitate.

Language, interpreters, and gender


Because the nature of therapeutic work is primarily about communication, 
reasonable verbal communication in the early stages of the work is
 important and needs particular attention and care. Many overseas clients 
speak poor English. Some may have learnt it as a foreign language and have
 been taught by a teacher with heavily accented pronunciation. It may have 
been learnt via the media- television and/or the Internet- and may have 
strong American intonation, with African or Middle Eastern overtones. So 
part of the building of the relationship may focus on both non-verbal and
 verbal understanding between the therapist and the client. Facial
 expressions and other body expressions are often very different to, for 
instance, those of white Irish clients. A veiled Muslim, wearing an all-covering coat, may move little and her facial expression may be difficult to 
read. Similarly a bearded Sikh wearing an elaborate turban may be cautious
 in his movements or facial expression. However, the eyes of these clients are
 visible and while often guarded, seldom lie.

With regard to verbal communication, it is important that phrases or 
explanations used by either the client or therapist are not assumed to be
 understood by the other. For instance some Far Eastern countries have no
 separate word for girl or boy, only ‘child’. In some Middle Eastern countries
 all older male relatives, for instance stepfathers, distant cousins, uncles-by-
marriage, are referred to as ‘uncle’. In other cultures, the words, ‘yes’ and
 ‘no’ do not exist. Similarly a phrase like ‘We’ll meet next Thursday’ may be
 interpreted by those educated through an American system as meaning that 
the session will take place two Thursdays hence. So careful clarification, 
being open to being questioned or, perhaps, to checking out a look of 
incomprehension is essential in the building of a therapeutic alliance with 
clients from other cultures.

In the Dublin Rape Crisis Centre, therapists working with asylum-seekers 
or refugees may, in some cases, work through the medium of a foreign 
language (e.g. French) or may need to work with an interpreter present.
 Issues concerning the interpreter’s general suitability for this work and 
appropriateness for working with the particular client need careful
 consideration; these would include considerations of nationality, or gender,
 for example, and the ability to listen to and tolerate traumatic material.
 Working with an interpreter requires extra adaptability on the part of the
 therapist, and the guidelines concerning, for instance, boundaries and
 confidentiality, and for working as a trio, need to be carefully explained 
both to the client and to the interpreter. Having an interpreter present creates 
a different dynamic, of which the therapist needs to be highly conscious. 
The client potentially could over-focus on the interpreter, as she is the 
person who is speaking their native language. Without careful attention to
 seating arrangements and training for the interpreter, the therapeutic 
relationship could be jeopardized. The process needs careful monitoring and
 the interpreters may need extra supports in place to do this difficult work.

Clients applying to the Department of Justice for asylum status frequently 
express anxiety in therapy sessions about the official interview that is a vital 
part of this process, as their whole future hinges on it. A female client for 
example, may be doubly anxious because she knows she will be expected to 
give a detailed account of her experience of rape. Many asylum seekers are
 re-traumatised by this experience. If the interviewer or interpreter is male, 
her distress and anxiety may be even greater. Issues concerning the gender 
of interviewer and interpreter need sensitive and careful consideration. The 
therapist should explain to the client that she has the right to ask for a female
 interviewer or interpreter, and can encourage the client to raise this issue 
with her solicitor prior to the interview.

Confidentiality

Confidentiality remains the single most important aspect of the therapeutic 
relationship, when working with clients from other cultures. Unfortunately,
 many refugees and asylum-seekers are not aware that there are therapeutic
 services available to help them, and that these services are strictly 
confidential. A certain number eventually find their way to counselling 
services such as Rape Crisis Centres, Health Board counselling services for 
refugees and asylum-seekers or to Spirasi, (a support service for victims of
 torture) through referrals by professionals, such as doctors, solicitors, social 
workers, and voluntary workers in support services. However, because of
 the levels of fear connected to their internalised self-blame and shame,
 which are common to traumatised clients of both genders, it is often 
difficult for them to have faith in the adherence to confidentiality by any
 professionals, such as doctors or counsellors.

For this reason, confidentiality may need to be explained more than once to
 traumatised clients i.e. they may need repeated reassurances that the
 therapist will not be discussing their case with outsiders. The client’s anxiety
 on this point is understandable as, if their country is torn by internal strife, 
they may not trust many of their compatriots living in Ireland: the therapist 
should not assume they can count on the support of fellow-nationals. In the 
DRCC, conditions governing the writing of a report by the therapist for the
 appeal process, (which follows an unsuccessful application for asylum 
status), will be clearly explained, reassuring the client that no information is released without his or her written permission, even to their
 solicitor/barrister.

In private practice, clients repeatedly demonstrate their need that the 
therapist has no direct contact with, nor is answerable to any person with
 whom the client is working or studying. The predominant reason tor this
 anxiety about confidentiality appears to be related to non-Western attitudes to therapy and to the strong, often ‘gossiping’ links, which communities 
retain across continents. The notion of discussing personal worries with a
 Western therapist who is clearly not a family member nor in most cases, of 
the same religious background, is particularly difficult for most clients.
 Many of these clients retain strong communicative links with their families,
 but remain anxious that the therapy will stay boundaried and confidential.

Clients’ internalised attitudes from their culture of origin

In the experience of the Dublin Rape Crisis Centre, there are a number of 
factors, which prevent refugees or asylum seekers who has experienced rape 
from coming forward to look for medical help or counselling when they first 
come to Ireland. One major factor is that these men and women bring with 
them the internalised cultural attitudes of their country of origin. In her 
country of origin, a woman who experiences rape may be seen as
 dishonouring her family and therefore may be ostracised by her community
 or abandoned by her husband. She is often seen as the equivalent of a
 prostitute and, if single, as no longer marriageable. In some cultures, instead 
of saying that the woman has been raped, it may be said that she ‘made love 
to’ another man. Therefore, she is the culprit and it is she who must be
 punished. Similarly a male, who has for example experienced repeated rape 
while imprisoned by enemy forces in his country of origin, may, because of
 his internalised attitudes, perceive these experiences to be deeply shameful
 and blame himself. In his own country he could never dare to speak about 
his experience of rape, for fear of ridicule, contempt or ostracisation, so he
 tends to maintain the same secrecy on arrival in Ireland.

These are deeply entrenched attitudes held within families and communities 
in many countries, which silence women and men. With these internalised
 attitudes, it is not difficult to see the obstacles these clients face in talking
 about their experiences of rape at their initial interview with the Department
 of Justice on arrival here – many initially fail to report these traumatic
 experiences. In working with clients from cultures which often have no
 counselling or psychotherapy services, it is very important that the therapist 
explains in a clear way what counselling is and what the ethos and approach
 of the service is. Clients who are refugees or asylum seekers need us to
 explain very clearly our attitudes towards them i.e. that, as therapists, we are 
there to support them and not to judge them.

A female client may fear that the counsellor will be critical of her or may 
regard her as a ‘raped woman’ or an outcast. A male client who has been
 raped may be fearful of revealing to the therapist experiences he believes
 reveal a shameful inadequacy on his part in ‘allowing’ the undermining of his 
manhood and honour – he may dread a response of contempt, ridicule or pity. In working with these clients the therapist has to try to gain an understanding 
of and empathise with the clients’ particular difficulties in speaking of and
 making sense of their experiences. Due to their internalised attitudes and
 beliefs from cultures that are deeply condemnatory of the victims of sexual 
violence, their traumatic experiences are framed within a context of high
 levels of cultural blaming, shaming and punishing.

In private practice, the impact on clients’ lives of the internalised attitudes
 from the culture of origin is frequently in evidence. An example would be 
the issue of homosexuality: the struggle with internalised attitudes is 
particularly apparent where clients come from cultures where marriage is 
seen as the norm and is expected in order to maintain family tradition, and
 where homosexuality is seen as abhorrent. There can be particular
 difficulties for clients who will be returning home to arranged marriages. 
Homophobia in the culture of origin can lead to social and professional
 ostracisation of the family, and can be a source of huge internal conflict for 
the client. They are also aware of the strong and immediate likelihood of 
other people from their country living in Ireland reporting back to their
 families, so they tend to be cautious and moderate in their behaviour here.
 The safety and confidentiality of the therapeutic space, combined with the
 acceptance and non-judgmental attitude of the therapist, offers the first 
valuable opportunity to explore these internalised cultural attitudes.

Therapists’ internalised attitudes from their culture of origin

And what about the therapist’s own internalised attitudes to clients from 
different cultures? One of the major difficulties facing overseas people
 living here is that Irish people can too readily stereotype or classify them.
 As therapists working in different settings, we need to develop our
 awareness of the risk of over-simplistic judgements and to work on our 
unconscious prejudices and biases. The reality is that there are enormous
 contrasts in the situations and circumstances of clients from other cultures, 
as well as the full range of individual differences. It is vital that we get 
beyond the stereotype of a particular culture to the individual sitting in front 
of us. We may not always like or agree with the cultural attitudes or value-
systems of some of our clients – e.g. the attitudes of males of certain cultures 
to females, hut we do have to make an effort to understand their frame of 
reference, while retaining, (and explaining, if appropriate) without 
imposing our own beliefs and value-systems. Whatever their cultural 
background, all our overseas clients come to psychotherapy needing to be 
heard, respected and met by us non-judgmentallv in revealing their internal
 burdens.

Issues

The issues which overseas clients bring to therapy, whether in private 
practice, or state-funded, voluntary or low-cost agencies, are varied. 
Anxiety, depression and trauma are among the most common, but many 
issues also arise from the struggles of daily life. Clients traumatised by rape 
carry physical, emotional and psychological effects; they are often dealing
 with the effects of PTSD: shock, withdrawal and confusion; flashbacks, 
traumatic memories and nightmares. However, in addition, clients who are 
refugees or asylum-seekers have been traumatically uprooted from their
 own countries of origin, often following multiple family losses, and are
 struggling to adapt to a new, strange and sometimes hostile environment, 
contending with many issues of daily survival.

These clients may raise issues in therapy such as difficulties in finding 
suitable accommodation, or living in unsuitable surroundings; struggling to 
survive on a very low income with related issues such as the cost of 
transport to therapy and other services; difficulties regarding childcare,
 given the absence of family and of a supportive community; problems in
 dealing with medical issues related to the trauma; dealing with the complex
 processes of applying for asylum status or appealing a negative decision,
 and possible re-traumatisation in the process; and dealing with the
 confusing and complicated procedures of applying for welfare assistance, 
without the necessary language skills. Racist attacks or threats and the ever-
present fear, for some, of being deported to their country of origin, to further
 unknown trauma, exacerbate the impact of rape, bereavement,
 displacement, culture shock and daily struggles.

These clients need help with the trauma of the now. In many instances, these 
issues of daily survival initially take precedence over the original trauma, as 
the clients have not yet the mental space, or sufficient internal or external 
resources to focus on the traumatic experiences, and would be re-
traumatised and overwhelmed, if this were prematurely attempted. The 
therapist may need, at times, as a foundation to any deeper work being done,
 to advocate on their behalf to assist their access to services, that allow their 
basic needs to be met. Therapists may feel unsure or uneasy with the 
different demands and challenges of their role with these clients, and these 
emerging issues need discussion in supervision and at agency level. In
 addition, supervision and additional support are required to help deal with
 the accompanying counter-transference issues, as therapists respond to very
 intense feelings of terror, helplessness, confusion, shame, frustration, anger
 and hopelessness.

Clients in private practice, in common with clients attending low-cost 
agencies, particularly those who are easily identified by clothing or
 appearance, carry high levels of anxiety and fear as they walk the streets of 
Dublin, or other Irish towns. The events of September 11th 2001, for
 example, had a considerable effect in the rise of anxiety among overseas 
clients about personal safety. In some cases these fears are based on actual
 experiences on our streets. In others, fear arising from threats and the
 negative experiences and stories of others can create, for these clients,
 considerable internal distress. These issues concerning basic safety
 significantly increase the stress levels of these private clients, whatever their 
presenting problems, and notwithstanding their financial resources.

The issue of money, a grounding subject in our culture, serves to illustrate 
the significant variation in the lives of cross-cultural clients. While most
 refugees and asylum seekers try to live for the week on the average cost of
 one hour of private therapy, many financially secure clients from other 
cultures will take a taxi to therapy, and request the cab driver to wait outside 
before being driven home. Glaring contrasts, yes, but yet these clients have
 much in common: the challenges of trying to find their place in a strange
 environment and a different value-system, the fear or actual experience of
 hostility because of being different, and the human need for help with their
 personal issues.

Conclusion

Psychotherapeutic practice can be greatly enriched by working with
 multicultural clients, though there are many challenges for the therapist in
 dealing with difference, often involving a steep learning curve. Despite the 
diversity of life styles, language and appearance, the authors are repeatedly 
struck by the fundamental similarities between people regardless of 
background. The need for belonging, hopes, dreams and desires suffering 
and trauma may be expressed in many and varied cultural ways, yet these 
fundamental aspects of being human are shared by all of us.

Therapy provides overseas clients with a safe space to explore their issues, an opportunity for personal growth and healing, but the therapist needs to bear in mind that it is also for many a new, unfamiliar and strange
 experience, for which there is often no precedent in their own culture.

Without question, the therapist’s understanding of the struggles of our 
common humanity and of the power of relationships is greatly enhanced by 
the work with these courageous clients: additionally courageous, because they have taken a step into unfamiliar territory and are willing to work across cultural barriers.

Mary de Courcy is a psychotherapist working in private practice with clients from every continent.

Angela McCarthy is a psychotherapist and Head of Training in Dublin Rape Crisis Centre, where she and her colleagues frequently work with asylum-seekers and refugees who have experienced rape or sexual violence.