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Psychotherapy or in a more historical way 'the talk therapy' is just a baby when compared with its other counterparts like the medicine. Freud and Breuer established this method in early 1900s, in the middle of Western Europe. Classical psychoanalysis has gone through many modifications, faced with many criticisms and today over two-hundreds of therapy techniques are used to 'cure' people's psychological problems. The foremost interest of psychotherapy is how the individual psychologically responds to certain situations and acts; as well as the disturbances they gone through in life. It would be impossible to isolate culture's effects from acts and disturbances; so it would be impossible to deny the culture's effects on psychotherapy process (Tseng, 2004).
For decades, culture has seen as a secondary and not so important factor in the psychotherapy literature and the practice. After 1960s as psychotherapy increasingly entered people's lives effects of different cultural backgrounds started to be discussed. With the effect of the human right movements, psychologists started to investigate the possible implications of culture, race and ethnic differences on therapies (Tseng, 2004).
This paper will briefly discuss the culture and psychotherapy with the help of the previous literature about it. After a short introduction to the concept of culture; the different mechanisms that cultural factors can affect the therapeutic processes will be discussed. In this section will include the findings about how culture can challenge our understanding of human psyche and a briefly the transference reactions in the therapy, self-object relationships and interpretations of symbols and dreams will be discussed. The following section will underlie how culture affects different psychopathological processes. At last, the recent literature about being a 'culturally-competent' therapist will be addressed. In all these sections the situation in Turkey and relevant examples will be presented. Discussion will be made about the applications and possible implications of these findings in Turkey's multi-cultural context.
What is Culture?
Tseng and Streltzer (2004) defined culture as the collection of unique behavioral patterns, values, ideas, ideals and living styles that are shared by a certain group of people. These patterns can also include different areas of daily functioning from eating habits to customs. Also the authors included that the culture and people are not static entities and their interaction is not one-sided but they interactively shape each other. Also La Roche & Maxie (2003) emphasized the transgenerational pattern of the culture and its complicated and dynamic nature. Thus, it can be concluded that even though the culture is passed through one generation to another its dynamic nature makes it not a static entity and people can show differences in a specific culture and different generations can experience it not necessarily in the same way.
It is also important to define race and ethnicity since they can be used interchangeably with the culture (La Roche & Maxie, 2003; Tseng, 1997) even though they are not same. Race or as the contemporary anthropologists put it geographical race represents a group of people who share biologically similar physical characteristics like shape of the eyes or color of the skin (Tseng, 1997). On the other hand, ethnicity represents a group of people who shared a mutual history and have a group identity in other words comes from a similar cultural background (Tseng, 1997). It is also argued that ethnicity is a more homogenous group of people, not as complex as culture and is subject to more stereotypical explanations (La Roche & Maxie, 2003).
Many things can constitute a culture from gender to spirituality and all these specific cultures can have several subcultures. This shows that it is not easy to comprehensively study everything about a particular culture. Even though this review paper will try to explain culture's effects on psychotherapeutic processes many cited paper used race and ethnicity interchangeable with the culture. A possible reason of this may be the previously stated abstract and complex nature of culture (Tseng, 1997). In the psychotherapy mainly three cultures are included; first the patient's culture, than the therapist's culture and at last the psychotherapy culture (Tseng & Streltzer, 2004). These three cultures interact with each other in a therapeutic setting. Since every little difference can be interpreted as a cultural one; from gender to occupations, therapy without any cultural discrepancy would not be possible (Tseng & Streltzer, 2004).
Therapeutic processes and culture: What changes?
Classical psychoanalysis deals solely with the individual's intra-psychic processes (Sayar, 2003) and how these processes represent themselves in the daily functioning. It should not be a coincidence that after 1960s not only the cultural influences on psychology has increased but also the criticisms and modifications on the classical psychoanalytic theory increased. This situation also led the foundations of different therapeutic approaches. One explanation of this may be that as the psychology became a world-wide science people found the theories not enough to explain every individual in every context. In this section of the current paper, possible ways that culture influences the therapeutic processes will be addressed.
Publications before 1960s mostly stated that race creates a negative therapeutic environment in which prejudices play a role and people from minorities do not benefit from the therapy (Holmes, 1992). For instance Devereux (Devereux, 1953) mentioned that a minority can think that the analyst is asking questions about culture because of an interest in that particular culture, not the patient as a unique human being and this thought can create a resistance. Studies mostly include same race and different race therapist-patient dyads and examined the possible implications of transference reactions.
More recent studies reported that race can also be used as a positive therapeutic tool when the transference reactions and the defenses they are standing for are evaluated well by the therapist (Holmes, 1992). The important thing in these situations is the therapist ability to understand why that particular transference reaction occurred at that instance of the therapy and the possible implications of it (Tang & Gardner, 1999). Holmes (Holmes, 1992) stated that the therapists needs to be gone through their own analysis and received supervision so that they could be aware of their own countertransference reactions in different race dyads. Also if the therapists are aware of their own attitudes and feelings for different cultures, they would also know whether they can work with specific populations or not (La Roche & Maxie, 2003); which would decrease the drop-out rates and be beneficial for the both parts.
Self and Self-object Relations
Kohut laid the ground for self psychology in 1970s in the mid-western United States, a highly individualistic part of the world, in which there is a strong emphasis on self-reliance, self-compliance and becoming an independent individual (Roland, 1996; Sayar, 2003). In Kohut's formulation of the human psyche, after the necessary self-object experiences one needs to be failed little by little and learn to soothe himself/herself to create a self-compliant, cohesive being (Mitchell & Black, 1995). Kohut's cohesive self stresses individuality (Mitchell & Black, 1995) which is an easily applicable thing for American culture.
Cross-cultural studies show that Asian cultures emphasize more collectivistic values than the European or Anglo-Saxon cultures. Thus in Asian cultures, people put more emphasis on the significant others' self-esteem than their own, they value hierarchical relationships and interdependence; in other words their self-object representations are far different than the ones in Kohut's theory. In collectivist cultures individuals' own independent self-regard is not that salient since they give much more importance to the familial regard and relational ties (Roland, 1996). These values and child rearing practices does not only affect self-objects also the perfectionist maternal care-giving and the lack of emotional talking in the households create differences in terms of the ego-ideal (Roland, 1996). Today we know that the caregiver's ability to talk the emotions affects the development of mentalization process of the children. So it can be suggested that there may be differences between people from two cultures in terms of understanding others' thoughts, behaviors and emotions. When we think about Turkey and where it stands in these cultural differences the common viewpoint is it is just in the middle. Kagitcibasi (1996) proposed a new model of relatedness for Turkey. This model evaluated the people in Turkey neither as individualistic nor collectivistic. It is argued that people in countries like Turkey have more "autonomous-relational self" which is a synthesis of the other two styles (Kagitcibasi, 1996).
How these differences are represented in the therapeutic relationships then? In the therapy transferences would partly depend on the self-object representations of the individual (Mitchell & Black, 1995). Since different socialization would affect the early self-object representations it is necessary to empathetically approach these differences in the therapy. Ronald (1996) emphasized the importance of identifying these differences and talking them with the analysand first, then deal with the person's immediate problems.
As a finalizing thought, it should be noted that it does not mean that all people in a specific culture share the same ideas, same values and similar self-object representations. The border between the things that are included in the self and excluded from the self is the real indicator of the cultural differences in terms of the self (Sayar, 2003).
Symbolic Meanings and Dreams
Psychoanalytic work relies on the individual's unconscious material which shows itself in the symbolic meaning of acts, words and the dreams. When working with psychoanalytic oriented therapy the therapist should understand what these symbolisms represents for the patient; these do not always have to match to a definition of a book or a common acceptance in a dominant culture (Tseng, 2004).
Being familiar with the patient's culture or to learn more about it would help the therapist to see the underlying meanings. For instance Devereux (Devereux, 1953) alluded an instance, in which he used his own knowledge about the Indian culture, added it up to the whole analyses material of that specific person and understood the real interpretation of a dream for the analysand. Familiarity with culture is important because sometimes a specific item can mean different things across cultures. As an example Tseng (2004) mentioned how a dragon symbol can stand for an authoritative figure whereas in the West it is more of an evil figure. With a similar idea a "mosque" figure which frequently appears in a patient's free associations or dreams in Turkey that has nearly 90% of Muslim population would be relevant to that culture and may represent the pressure of superego. But the same figure may represents fear or aggression for an American individual considering the popular "Muslim terrorist" threat in their culture.
As it is stated previously the therapist need to be aware of the real interpretation of the patient's symbolic meanings. This meaning does not have to always match the patient's culture; it can mean a totally different thing in that specific time. Dealing too much with the culture and missing the real meaning for that specific person may create a rupture in the therapy. In situations like this it may be helpful to keep in mind Freud's famous pop quote; "Sometimes a cigar is just a cigar".
Culture and psychopathology: Do we hear the same voices?
Most people familiar with the anti-psychiatry literature knows Rosenhan's (1973) famous study in which eight normally functioning people acted as "pseudo-patients" and entered into the psychiatric residences. After some time they were diagnosed as the relevant disorder, they started to act as 'normal' people but still treated as mental patients. This study did not aim to deny the psychological deviance or suffering that people go through (Rosenhan, 1974) but it made people to think about the diagnostic labels and their questionability.
Culture's effects on psychological problems have been increasingly studied. Symptom characteristics can change across the cultures (Tseng, 1997). For instance a more common delusion in a Christian population may believe that the individual's own actions are controlled by the Satan; whereas in a Muslim population delusions can include "the-three-lettered" powers (cins) controlling people's behaviors. As Tseng (Tseng, 1997) reported general categories of disorders can have variations affected by the culture, like people in Honk Kong with anorexia nervosa who do not care about being overweight. Like these differences culture can also affect the prevalence of the certain disorders and it can also create unique disorders in specific cultures (Tseng, 1998). These findings should add up to the question marks about diagnostic labels in our heads and approach cautiously to these issues. Dismissing the influence of culture to the presenting problems may result in a misleading diagnosis and wrong intervention. Trying to make a person to fit a specific diagnostic category would create misunderstandings of the real thing that person is going through.
Tseng (1998) identified the clinical diagnosis as a two-person job; first the patient's experiences, identifications and presentation of the problem appear then they are understood and diagnosed by the clinician. The two present cultures; the patient's and the therapist's, are effective in the diagnostic process. Therapist should be aware of the culture's effect on the patient's symptoms, do not rush to find a matching diagnostic label and also be aware of his/her own possible bias. In other words the therapist needs to be culturally competent to be able to make the patient benefit most from the therapy (Brown, 2009).
Cultural competency as a therapist skill
After it was discovered that cultural differences appear in most of the therapeutic relationships theorists started to formulize ways to approach these differences. Different authors have approached these cultural dissimilarities from different viewpoints. Three common approaches can be listed as universalist, particularist and transcendist approach (La Roche & Maxie, 2003). People using a universalist approach underline the importance of similarities rather than stressing the differences between people for the sake of a warmer therapeutic relationship. On the contrary a particularist approach argues that important cultural differences would create a negative therapeutic alliance since people from different backgrounds would not understand each other well. The third on is the transcendist approach which is a middle way between these two viewpoints (La Roche & Maxie, 2003). This approach accepts that there are important cultural differences but by using some techniques the therapist and the patient can go beyond these differences. Sue (1998, as cited in La Roche and Maxie, 2003) stated that by therapists' cultural competency abilities many more people from coming from different cultural backgrounds can be benefited from the therapy.
Being culturally competent means being aware of what values, thoughts and biases the one hold as a human; how much accumulated knowledge and acceptance he/she has for cultural differences and how he/she can identify and work on these cultural issues as a therapist (Brown, 2009). Tseng and Streltzer (2004) also listed being sensitive to different cultures, having knowledge about them, reaching empathically to people from different cultures, forming the relevant associations and offering for cultural guidance if necessary under the characteristics of cultural competence. So it can be said that cultural competency is a therapist skill and like all other skills its usefulness is not definite (Cardemil, 2008).
It is important to realize that there can be many differences between the therapist and the patient, including gender, socioeconomic status, or education. All these differences can be considered in terms of cultural competency but it is important to put more emphasis on the more outstanding one (La Roche & Maxie, 2003). For instance if a Kurdish woman with a history of sexual abuse came as a patient to a male Turkish therapist, the first difference to be attended should be the salient gender difference and if that patient feels comfortable with the male therapist or not. But it is also important to keep in mind that these importance levels of differences which can be frequently encountered are not static things and change throughout the therapy process (La Roche & Maxie, 2003). Thinking about the same example, after the gender difference problems are resolved, the ethnic background differences may become a problem. A culturally competent therapist needs to be aware of this ongoing interactions and changes in the therapeutic relationship and question the possible implications of these arising problems (La Roche & Maxie, 2003).
In the psychotherapy process, patients first arrive with the presenting problems and according to the approach of the therapist the underlying mechanisms of these problems can be identified. But before that a formulation of that specific person is constructed and a relevant diagnosis would be applied if necessary. In a culturally competent therapy, the therapist do not rush to make any clear-cut diagnosis but try to form the diagnostic explanation taking into the account of that person's cultural background, values and own narrative (Brown, 2009).
As previously stated, the salient cultural differences should be addressed in the therapy process. But it is also important to state the similarities between the two parties to attain the warm and close therapeutic relationship (La Roche & Maxie, 2003). We know that every individual is unique but they also share many similarities. Focusing too much on the differences would carry a threat of creating two "strangers". Brown (2009) stated that a therapy which is sensitive to the cultural differences automatically identifies one part of the dyad as "other" since it stresses the best ways to deal with the different one. From this perspective it is important stay on that transcendist line; being not too universalist or particularist.
Another important factor in cultural competency is the timing. It would be an early time to confront the cultural differences and explore the possible meanings if the patient came with a high level of psychological distress (La Roche & Maxie, 2003). The most crucial and important ethical consideration of the psychotherapists is not to do any harm. An approach in which the immediate needs of the patient would be ignored for the sake of cultural differences may cause more harm than benefit.
All in all, cultural differences should be addressed by the culturally competent therapists when working with someone from a different culture. The therapist should increase his/her knowledge about that specific culture or even try to learn more from the patient when there are things that are important for the therapy. But it should be kept in mind that every culture has its own subculture (La Roche & Maxie, 2003) and important thing is to come at the unique individual level.
Culture is an accumulation of shared values, ideas and ideals which are transmitted throughout the generations by a certain group of people (La Roche & Maxie, 2003). Culture can include many things from customs to outfit styles. Since culture is something human beings are molded with, thinking a psychotherapeutic process free from culture's effects is not possible.
This paper aimed to present the recent literature about culture's influence on psychotherapy and ways to deal with the arising cultural differences in the therapy. After a brief description of culture, race and ethnicity; mechanisms through which the culture affects psychotherapy were discussed. One highly cited mechanism was the transference reactions with respect to the culture. Before the 1960s mostly authors approached cultural differences as something unpleasant in the psychotherapy because of the occurrence of negative transferences (Holmes, 1992). But with the recent literature, it is argued that these transferences can be used as a beneficial tool to understand the conflicts of being a different one in the culture (Holmes, 1992). Also boundaries of self and self-object relationship are affected by the culture. Differences are apparent between individualistic and more collectivistic cultures in terms of self-object representations (Roland, 1996) and there is a high probability that these differences would affect the therapeutic processes. And a discussion was made about how these differences would affect the symbolic meanings in people's lives and the importance of the therapist's ability to find out the real implication of certain cultural symbols in dreams or free-associations. In another section culture's affects on understanding the psychopathology were discussed. In the last part, the importance of being culturally competent as a therapist and recent literature about the degree to integrating culture into the psychotherapy process was addressed.
Cultural competency literature is a recently established one. Even thought it has many benefits to the area it also has some limitations. Cardemil (2009) stated that there are not many studies that show the effectiveness of culturally competent therapists and how people from diverse populations are benefited from this approach. Also in this approach, there are still some lack of attention to the individual differences and a tendency to evaluate cultures as homogenous entities (Cardemil, 2008).
Turkey is a multi-ethnic country, in which many subcultures lived throughout the decades. Not only ethnic differences, but also many differences in terms of customs or life sty are existent between the east and west part of the Turkey. As a psychotherapist working in Turkey, one should always be ready and prepared to work with people from different cultural backgrounds. Since Turkey is diverse country it is not possible to know everything in terms of different cultures but a general knowledge of different ethnic groups or life styles would be helpful. When working with a Jewish patient lack of knowledge about the 6th and 7th of September incidents would cause a missing link in understanding the possible transgenerational anxiety states of that person. Another important thing, in clinical psychology graduate training students should be aware of the possible differences of the literature coming from more individualistic cultures and evaluate them with caution since they may not be applied to all of the cases. But all theories may be applicable to one person and not to the other, so this caution is not specific to culture. It is undeniably important to attain the different dynamics of groups but individual dynamics should also effectively be dealt with (La Roche & Maxie, 2003).
Culture has its influence on people's daily functioning, from their eating habits to customs, idioms and everything. For these reason it is impossible to neglect its effect on the
therapeutic processes. But putting too much emphasis on culture and denying the individual's uniqueness will also have unwanted affects on the psychotherapy. Therapists should always keep in mind that in every therapeutic relationships patient and the therapist come from a different culture; in terms of education, family, etc. (Tseng & Streltzer, 2004). What needed is a middle way, in which the therapist sees, knows and empathically understands the differences between the two parties confront them to the patient at the right time and make these differences a beneficial tool in therapeutic relationship. Since knowing therapist's own biases or feelings about other cultures is important, a psychotherapist must go through his/her own therapy process and solved these conflicts if there are any. But all in all, every culture creates its own subcultures and what should be dealt in a therapy is an individual's own intrapsychic processes. Therapists should realize that they are working with the smallest unit of a cultural history but what really matters is the feelings, thoughts, desires and conflicts of that smallest unit, in other words the patient.