|Good Communication: Key to Trans-Cultural Therapies|
A stranger came to the royal court. He was welcomed and soon became known for his erudition and wisdom. However, it was impossible to find out about his origins and his place of birth as he seemed to speak several languages fluently like a native of that country. The other courtiers asked him and the king was curious but too dignified to do so himself, but the stranger would not give a straight answer. Out of frustration, the king asked his clever jester to help out.
The jester was a very astute man. One night, he lay in wait for the stranger in a dark alley. As the poor man was walking by, immersed in his own thoughts, the jester suddenly came out and bumped into him. The stranger so surprised, burst out into invectives in a language which was unmistakable.
The jester apologised profusely, but he went back to the king with a joyful heart and told him the nationality of the newcomer. The language in which he had spoken when startled and in anger had to be his mother tongue!
The jester had correctly imagined that the stranger would betray himself and speak in his native tongue when his basic emotions of fear and anger were aroused.
Crisis theories tell us that after the initial shock, one tries to solve the problems surrounding the crisis following familiar, well-worn methods by which he had solved problems before. Only when those fail, other ways are explored or the person decompensates. Any crisis causes stress. Stress does not often produce mental illness but mental illness always creates stress.
Therefore, one may say that such illness or emotional conflict will similarly arouse responses often learnt in ones early development: a logical consequence of stress. A person who is losing a grasp of his emotional equilibrium will initially be prompted to look for familiar solutions. Hence the investigation of such events and possible therapeutic decisions to follow, necessitate an enquiry into the past of the person. This enquiry not only explores his past experiences, but also his environment and his general relationship with it, amongst other things. Depending on the type of therapy, this exploration may extend to the unconscious and thereby a consideration of the inner and outer worlds of the patient and their development.
The dynamic therapies thus emphasise the importance of early experience in creating later illnesses and problems. In fact, treatment based on such therapies consistently rely on a reconstruction of a persons developmental history and its impact on the present predicaments faced by the patient. Those therapies that use the relationship between the therapist and the patient continue to believe that in therapy, recognition of a pattern of repetition of important earlier experiences and associated conflicts are essential requisites in gaining insight leading to a resolution of pathology.
Freud showed that symptoms have meanings, if only the therapist can enter into the world of the patient and understand his communication. This is not just confined to what is considered to be neurotic illnesses but in psychosis too, the significance in the latter being the difficulty to recognise the complex metaphors used by someone who is not in touch often with the reality as everyone else sees it. Yet it is sometimes quite clear what a delusion or a hallucination means for the particular individual. When it is not immediately evident, it is perhaps that it is too intricate or that the therapist is unable to enter into the world of the patient because the communication between the two is occurring at disparate levels.
Culture, and language, which mostly enables one to learn about culture, equally become paramount when a person is under stress. Yet in a multilingual society where many cultures are present, the task of understanding each culture is difficult and to follow the nuances of the subcultures and their intricacies are almost too formidable to contemplate. No wonder, anyone working in that situation regularly faces an arduous barrier and mistakes are often made. When one is dealing with a person who is not well, specially in expressing his distress as in the case of someone who is mentally ill, the task is even harder. Many research shows how patients from a different culture end up having more compulsory admissions in mental hospitals.
Culture as we know is mostly transmitted through language. When we say, "John is drowning", a Hopi Indian might say, "The water is overwhelming John", denoting an inherent belief in the supremacy of natural elements over man. Here an important lesson of culture is being transmitted and can remain totally abstruse to an outsider.
I am reminded of an anecdote when one of my friends some thirty-five years ago came to England and wrote to his wife, "I find this country to be peculiar. Here when a woman crosses a street, she picks up her dog and pulls her child across on a leash and harness!" I wonder how many customs and behaviour are misunderstood and misinterpreted in this way.
The anthropologist, Weston LaBarre(1959) showed through the eyes of a
fictitious Professor Widjojo what he, the professor, might think of certain
western cultural activities. There was an hilarious description of a Koktel
party and mention of futbol games. Widjojo says about Koktel Parties, "At
all of them the natives receieve the ritualised drink called aignawg.
Everybody hates it and freely says so in private, but they must drink some
of it so as not to offend their hostess." About futbol, he goes on to say,
"The purpose of the Usan (people of the USA- author) colleges is to collect
young men by competitive subsidies to engage in these mock battles.... over
a sacred pigskin....."
C.S. Lewis(1954) in his Essays on Ethics and Theology describes an imaginary lost chapter from Herodotus regarding Exmas and Crissmas. In it, he says, "But during these fifty days, poorest and most miserable of the citizens put on false beards and red robes and walk about the market-place, being disguised(in my opinion) as Cronos."
To be politically correct, the local municipal authorities not so long ago were reported to have proposed to call the Christmas lights in town as "festive luminary embellishments"! Whether that becomes a bridge building exercise or a confusion is a moot point.
Whatever it is, one cannot deny the importance of culture. But one faces other variations in life whenever there is a transaction between people, culture being one of them; gender, race, age, social background, upbringing, life experiences are probably the most influential ones to name but a few. How can a therapist familiarise himself with all those variations so that those fundamental issues can be considered in treatment. It is a mammoth task, if it is even within the realms of possibility, let alone probability. One cannot have a specialist for each of these variations.
Much research has been done in investigating the importance of therapist-patient matching. Beutler and Bergan(1991) suggest matching at least in the dimensions of demography and a wish or need to fulfil an interpersonal relationships in terms of nurture, dependence and attachment to self-sufficiency, independence and autonomy at the other extreme. Patient-therapist congruency may in those circumstances promote a sense of trust and empathic resonance leading to growth.
On the other hand, some research has shown that a difference between therapist and client in their attitudes and personalities might be more beneficial. This dissimilarity has been studied in certain areas by Beutler and Clarkin(1990) and found to produce more therapeutic change. Empathic listening can overcome the differences and a contrast between therapist and patient may accelerate learning and change. Warmth and genuineness must play their parts as well.
It may be said that therapies generally are Eurocentric meaning that they have developed with observations and practice on white Caucasians. Guthrie(1976) described this phenomenon aptly as "even the rat was white". These therapies emphasise independence, individuation, responsibility and insight whereas the importance of such things may or may not be so relevant in other cultures. Some of these cultures lay stress on predetermination, divine interventions, evil possessions, karmic consequence and resignation to fate. Insight may be seen as secondary and extended families often apportion responsibility differently.
When the dimensions of culture and sub-cultures, ethnicity, race, minority issues, socio-economic background, life experiences and various other sub groupings are considered, the problems multiply. No one theory or practice can encompass so many variations. Ramirez(1991) advocated an eclectic approach in a multicultural model embracing many theories, i.e. dynamic, behavioural, cognitive and humanistic. He suggests that cultural uniqueness has to be accepted and worked with to promote acceptance of self and others and a flexibility to adapt and develop new coping strategies.
While it is vitally important to educate, make aware and develop new ideas to understand and help anyone working in a multi-cultural society, the enormity of the task is obvious. As social diffusion continues in second and third generation immigrants, an intergenerational cultural gap is fast becoming an issue. In the circumstances, one may need to look at some basic principles of therapy and determine ways in which the gaps between therapist and client can be closed.
Winnicott(1986) in his seminal book, "Playing and Reality", first published in 1971, says, "The place where cultural experience is located is in the potential space between the individual and the environment(originally the object)." This earliest interaction takes place through communication that occur between the mother and the baby. This language between them is the main transporter of culture as the infant grows up and becomes part of society.
I suggest, therefore that in talking therapies, the issue of culture and other diversities are similarly communicated between the therapist and the client, if only the two parties concerned operate at the same wave length. The development of a meaningful and healing relationship "can happen only if there is effective communication between them through the nurturing of a common language in its broadest sense, both verbal and non-verbal"(Bhattacharyya, 1997). That is in a way how the individual has learnt about culture and is able to disseminate that knowledge to the other if both can be in tune with each other.
If the communication is faulty, culture is misread and misinterpreted leading to further alienation and fear. An amusing yet deadly serious report (Butcher, 1997) appeared in the newspaper regarding Gurkha soldiers coming to Britain for the first time. The major had to have his horse put down because the animal had suffered a severe tendon injury. He later noticed a dramatic improvement amongst recruits who had sprains and strains in their ankles and knees!
To echo what du Plock(1995) says in relation to existential therapy, "that a crucial part of therapy involves tuning into the clients world by attending closely not only to what is said but to the way in which it is said, and, beyond this, to the clients demeanour as a whole...," and by taking that as a principle can one begin to find some light in dealing with transcultural issues.
The trend to provide help for various groups through setting up of specialist organisations and institutions have their value in creating awareness and knowledge, but a real impact can be made if communication skills of therapists can be improved. Cobb and Lieberman(1987) showed how easily and economically, trainee doctors could be helped to improve in those areas. There are many other methods which can be further developed in relation to cultural differences.
In my view, that will be the way forward so that people can function in diversity and use the richness inherent in a multi cultural society towards greater understanding and harmony. If one can identify the similarities, differences can be easily overcome.
Beutler, L.E., & Bergan, J.(1991) Value Change in Counselling and Psychotherapy: A Search for Scientific Credibility. Journal of Counselling Psychology. 38, 16-24
Beutler, L. E., & Clarkin, J (1990) Systematic Treatment Selection: Toward Targetted Therapeutic Interventions. New York: Brunner/Mazel
Bhattacharyya, A(1997) Culture and Psychotherapy. Changes, Journal of the Psychology and Psychotherapy Association Vol.15, No.3 Chichester: John Wiley
Butcher,T.(1997) The Daily Telegraph. Page 3, March 8, 1997
Cobb, J.P and Lieberman, S (1987) The Grammar of Psychotherapy. British Journal of Psychiatry, 151, pp 589-594
du Plock, S(1995) The Existential-Phenomenological Movement, 1836-1995,p.45 Developments in Psychotherapy, ed. W. Dryden. London, New Delhi: Sage
Guthrie, R.V(1976) Even the Rat was White: A Historical View of Psychology. New York: Harper and Row
LaBarre, W(1959) Professor Widjojo Goes to a Koktel Party, New York Times Magazine,December 9, 1959, pp 42-47
Lewis, C.S(1954) XMas and Christmas: Undeception. Essays on Theology and Ethics
Reprinted (1971) Lost Chapter from Herodotus. London: Geoffrey Bles
Ramirez,M.(1991) Psychotherapy and Counselling with Minorities: A Cognitive Approach to Individual and Cultural Differences. New York: Pergamon Press
Winnicott, D.W(1986) Playing and Reality. Harmondsworth: Pelican Books. First published 1971 by London: Tavistock
Authors address: Dept. of Psychotherapy, Northampton Community Healthcare Trust, Cheyne Walk Clinic, 3, Cheyne Walk, Northampton, NN1 5PT.
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Last Amended: 27/03/99