Trapped between two worlds: An exploration of client perspectives in cross-cultural psychotherapy

by Lorena Sánchez Blanco

The real voyage of discovery consists not in seeking new landscapes,
but in having new eyes.

Marcel Proust

Introduction
Rising rates of immigration and the increasing cultural diversity of Irish society in the past twenty years have contributed to the expansion of cross-cultural psychotherapy in Ireland. Most of the literature in cross-cultural psychotherapy focuses on the psychotherapist’s perspective and research about the client’s perspective is still scarce. Thus, with the aim of enriching existing research, I carried out a research study as part of my MA in Psychotherapy in Dublin Business School.

The study’s goal was to explore and understand the experience in psychotherapy of culturally diverse clients, and to provide practitioners with ideas for working with those populations. The sample of this research study consisted of three clients of different ethnicities: Nicola from Asia, Angel from Africa and Diego from America; names have been changed to protect the identities of the participants in the study. Clients’ accounts were transcribed and analysed using a qualitative method: Interpretative Phenomenological Analysis (IPA).

One of the main themes that emerged from the interviews was the theme of cultural awareness. Therefore, this research stresses the need for psychotherapists to be culturally aware of their bias, using psychotherapeutic strategies that are consistent with the client’s values while also appreciating the client’s cultural identity. The findings of this study revealed a parallel process between the participants’ acceptance of their multicultural selves and their cultural awareness of the psychotherapeutic encounter.

Locating the researcher in the research
My interest in cross-cultural psychotherapy is seeded from my personal experiences as a foreigner living, working and studying in Ireland. My upbringing in a mono-cultural environment has shaped my viewpoints and experiences, which have been challenged later in my life as a result of my immersion in a new society. This is mainly due to my work in an intercultural context with individuals who have been discriminated against due to cultural reasons and, secondly, by my personal experience in psychotherapy with a psychotherapist from a different culture and with a different language than mine. These factors, along with the lack of clients’ voices in psychotherapeutic research, have strongly contributed to my interest in the role of culture in psychotherapy.

Therapeutic group with asylum seekers led by Lorena.

Cross-cultural psychotherapy and the Irish context
Cross-cultural psychotherapy entails encountering multiple cultures in the psychotherapy room (Chambers & Smith, 2006). This phenomenon can be regarded as the result of the emerging pluralism in western countries (Leong & Lee, 2006). In Ireland in particular, according to the Central Statistics Office (2011), the number of non-Irish nationals living in the country grew from 224,261 persons in 2002 to 544,357 in 2011, representing 199 different nations. With this growing diversity in the Irish context it is inevitable that psychotherapists will increasingly encounter clients with diverse cultural backgrounds.

Even though most psychotherapists are generally in agreement that issues of culture arise in the psychotherapy room, the lack of a comprehensive definition of the concept of culture produces much confusion and difficulty in the practice of psychotherapy (Sue, 2003). As a result, it seems that the notion of culture has been dismissed in therapy, and clients have been treated according to western beliefs and value systems (Helms & Richardson, 1997). This traditional notion of psychotherapy is described as “culturally encapsulated”, calling for more cultural diversity in the delivery of treatment (Sue, Arredondo, & McDavis, 1992). Palmer (2002) proposes that there is a need for expansion of knowledge and for more openness, tolerance, curiosity and acceptance of other cultural beliefs and practices, as well as for psychotherapists to increase their own levels of cultural awareness and competency in working with diverse clientele (Leong & Lee, 2006).

Additionally, the research that exists on culture and psychotherapy, and on cross-cultural or intercultural treatments, has rarely been informed by the views of foreign or ethnic psychotherapy clients. Instead, most of this research has been based fundamentally on psychotherapists’ perspectives (Seeley, 2006). Despite limited client viewpoints, the research studies available have shown that clients tend to prefer psychotherapists from the same ethnic group (Harrison, 1975).

Identity and culture
Identity denotes the sense of self and embraces elements that make a human being both unique and similar to others (Bhugra & Becker, 2005). The formation of identity is mediated by different factors: psychological, biological and cultural or social influences and is thus frequently influenced by life experiences (Mann, 2004). According to Markus and Kitayama (1991), as the source of values and personal beliefs, culture gives individuals and groups identity, just as it limits and controls individual choices. The inevitable presence of tensions and splits within any cultural system has significant implications for the development of the self and for the practice of psychotherapy, because it introduces into life the notion of multiplicity (McLeod, 2005).

While there is very little agreement among cultural theorists about the meaning of culture (Halton, 1992), there is, however, a general acceptance that culture is a process that is not  static but constantly changing in time and space within a given society (Eleftheriadou, 2010). Alternatively, culture may also be described as simply what is meaningful to a group. For example, cultural songs and rhythms can bring people together, providing the cultural group with a profoundly emotional experience (Storr, 1992). Moodley and Palmer (2006) point out that the concept of culture should not be treated as a global entity but as far as possible be disaggregated into a number of discrete variables or ‘constructs’, such as values, ideologies, beliefs or preferences. Similarly, Ahmad (1996) states:

Stripped of its dynamic social, economic, gender and historical context, culture becomes a rigid and constraining concept which is seen somehow to mechanistically determine people ́s behavior and actions rather than provide a flexible resource for living, for according meaning to what one feels, experiences and acts to change.

(Ahmad, 1996: 190)

Responses to cultural diversity
Despite different types of psychotherapy, such as psychoanalysis, person-centred or cognitive- behavioural therapy, being based on differing theoretical standpoints, they are all based on models of treatment which arise from the developed western world’s perspective about the mind, emotional distress and healing (Bhugra & Bhui, 2006). These different types of psychotherapy were ‘monoculture’ in nature, meaning that they were designed and applied in the context of western industrial society, and had little to say about cultural diversity (McLeod, 2009).

A psychotherapeutic model which develops in a particular country, a specific historical era and during a concrete and scientific period inevitably promotes these influences in its mental representation of the world and the self (Marsella & White, 1982). Additionally, within each society and its broad culture, there are sub-cultures which also shape definitions of normal from abnormal, healthy from ill, in need of help or not. Hence, culturally determined states of distress give rise to models or treatments which are in accord with that culture’s understanding of distress (Marsella & White, 1982). For example, in India it is accepted that a ‘possessed person’ can be cured by involving the local community in the healing process, thus possession becomes a means of seeking help in that specific cultural context. Knowledge that spirits of the ancestors and gods are present on earth and can possess an individual’s body is a prerequisite in a society which offers the possessed person culturally compatible healing, leading to relief from distress (Perera, Bhui, & Dein 1995). Sue and Zane (1987) suggest that in order for psychotherapists to be culturally credible, it is necessary to conceptualise problems in a manner that is consistent with the client’s belief system (Bhugra & Bhui, 2006).

All psychotherapies are grounded in a specific culturally determined ‘model of mind’ and its accompanying formulations about interventions and treatments (Bhugra & Bhui, 2006). However, nowadays psychotherapy has responded to the trend towards multiculturalism in different ways. While some approaches try to ‘assimilate’ or adjust the client’s culture within the therapy field, other approaches consider ‘culture’ at the core of a person’s identity (McLeod, 2009).

Cultural awareness
In this research study, Nicola from Asia, Angel from Africa and Diego from America were interviewed in order to understand how they made sense of their experiences as clients in  cross-cultural psychotherapy (Smith, Flowers, & Larkin, 2009). Following the interviews, I analysed the data to illuminate their experiences in cross-cultural psychotherapy. Their responses revealed a rich diversity regarding their experiences and their meanings of culture. This can be mediated by participants’ differences in relation to country of origin, gender, age or number of years attending psychotherapy. Despite the variability in the participants’ answers, several themes were generated. One of the most relevant was the theme of cultural awareness.

Nicola, Angel and Diego showed different levels of recognition of their own culture in the psychotherapeutic encounter. In the case of Diego, after more than 15 years in analysis, he points out that recently culture has acquired a central role in his therapy. According to him, this is due to the interest of his therapist and his invitation to explore and reconnect with his traditions, rituals and values. This indicates the need for a therapist to be culturally aware and to explore issues around culture. In relation to his cultural values, Diego states that now he feels that those are understood by his therapist. Talking about his therapist he says: ‘He actually makes me think about my culture, it’s interesting for me, he is interested in symbols, cultural issues as well, and he always brings me back’. In comparison to his previous analysis, in which he was not given the opportunity to reflect on his authentic self and his culture, Diego explains that currently he questions his identity and the grief he suffers because of the loss of his culture. During the interview, it seems that a parallel process took place where Diego relates to the researcher as an equal, calling her by her first name – perhaps in the transference the interviewee sees himself reflected.

Diego: That’s an interesting question, Lorena, because I never thought about that … the others treat me the same in a way, the current one makes me think about the theme of identity, the things that I am sacrificing … and never had it before. I think he sees me in connection with my culture, and he has a deep knowledge of Irish culture as well. I’m living in a limbo zone and being aware of those things that I am sacrificing because there is a mourning … I never had that before.

Conversely, Nicola briefly expresses her ideas about the impact of culture in psychotherapy, pointing out that cultural knowledge is not a significant condition in psychotherapy: ‘It will be helpful if we know each other’s culture but would not be necessarily, anything relevant would come out in the session … I don’t really consider the nationality in psychotherapy, I don’t mind’. This may suggest that Nicola relies on the psychodynamic process to avoid voicing cultural issues. Equally Diego, who has lived in Ireland for over two decades, acknowledges that for many years he repressed his own cultural identity in order to fit into the host country: ‘Maybe unconsciously in all those years here, in my process of adaptation I have to repress or suppress quite a lot of my cultural identity’. Perhaps Nicola, who has been residing in Ireland for five years, is also experiencing this process of repression. Consequently, to feel integrated in the current culture, she is forced to suppress a part of herself.

When Angel explains about how she chose her psychotherapist, she acknowledges how important the language and her psychotherapist’s knowledge about Africa was for her. Angel’s laughter may indicate that she was uncomfortable recognising the need for a psychotherapist experienced in African culture, probably a difficult task for her due to the scarcity of psychotherapists with an African background in Ireland.

Angel: I wanted someone who at least speaks French or that has been in Africa somehow, I didn’t want to waste my time explaining everything … I wouldn’t have gone with someone who was trying to learn about the African culture, I wanted someone experienced (laughing).

Angel described what she considers a very beneficial intervention in therapy, she felt culturally connected with her current psychotherapist when in the first session she offered her a glass of water, therefore her psychotherapist’s identification with her own culture has enhanced the analysis.

Angel: That therapist (her first therapist) never offered me a glass of water, and then I had my other therapist that offered me in the first session a glass of water. In my own culture I would have done the same so in some way I culturally connected with that therapist. Any kind of active kindness is also cultural constructed, this is why the glass of water.

Finally, when interviewees were asked about further recommendations for psychotherapists in relation to the cross-cultural encounter, Nicola declined to give any recommendations. However, Angel and Diego agreed on the need to be culturally aware and informed. Diego highlights the importance of valuing the culture of origin and recognising the differences within oneself as a way to enrich the new culture. By using the phrase ‘you are almost Irish’, Diego may be recalling introjections about not being ‘good enough’ as a result of being a foreigner, at the same time as trying to integrate his identity as a person who is living in Ireland, but is not Irish.

Diego: Psychotherapists need to be very sensitive and appreciating a culture that is not even yours. That could be very affirming to the client, to look at things, good things there, acknowledge the good bits in yourself and appreciation … It is important to recognise the differences … it’s accepting the way you are, with differences … I wonder about this phrase ‘You are almost Irish’. It’s a very damaging thing to say to someone, you are good but not enough, very nasty phrase.

In the psychotherapeutic encounter, Diego and Angel were encouraged to explore and to value cultural issues at the same time as learning from others, in order to help individuals to integrate the good parts of the culture within the self (Eleftheriadou, 2010). Furthermore, it is also important to explore and embrace elements of commonality and sameness that link diverse communities and cultures. Eleftheriadou (2010) points out that this is the most important area, in order to prevent splits or pathologies due to cultural differences.

As was seen in the responses of the participants in the study, the awareness around culture can be represented in a continuum. While Nicola dismissed the impact of culture in psychotherapy, Diego and Angel highlighted the relevance of being culturally aware in the psychotherapeutic encounter.

Conclusion
The main aim of this research study was to acquire a better insight into clients’ experiences when attending cross-cultural psychotherapy. For that purpose, this research study explored the experiences of three individuals – Nicola, Angel and Diego – in cross-cultural psychotherapy, using IPA and from an intersubjective approach. The findings from the research study revealed a wide variety in the responses of the interviewees, in relation to their experiences as clients in the psychotherapeutic encounter.

Two of the participants in this study strongly emphasised the need for curiosity, openness, knowledge, understanding, sensitivity and appreciation of the culture of others in the psychotherapeutic relationship. In addition, they also emphasised the need for multicultural psychotherapy to be included as part of psychotherapists’ training in the future. Nicola and Diego reflected on their experiences in their training and they noted the lack of intercultural studies, calling attention to the need for greater cultural awareness and intercultural training.

In the light of these findings, it is important for psychotherapists to be aware that culture- bound barriers are presented in the psychotherapeutic encounter. Thus, it becomes clear that effective cross-cultural psychotherapy occurs when psychotherapists are informed, curious and appreciate clients’ culture from an open stance, valuing the differences of their clients. Likewise, it is important that psychotherapists are aware of their own beliefs and values.

Recommendations and considerations for future research
In conclusion, I would like to share some recommendations and considerations for future research, which have emerged from both the findings of this study and from the research reviewed:

• Further research with clients without a psychotherapeutic background is recommended.
• Due to the diversity in the responses of the participants in this study, it is suggested that further research, with a more homogenous sample, is undertaken, with individuals at a similar life stage and from analogous cultures.
• Further research could be carried out in relation to an apparent parallel process among culturally diverse clients who hide their differences in the psychotherapeutic encounter, and the obstacles in finding culturally diverse psychotherapists who, in an unconscious way, may hide themselves.
• Psychotherapists need to be open, curious and value their culturally diverse clients in order to effectively work with them.
• It is recommended that psychotherapists attempt to educate themselves about different cultures in order to be aware of their clients’ values and notions about identity and family, calling for more culturally diverse trainings and workshops.