*Minimum 400 words total*

Imagine that you are a high school counselor in a school with a culturally diverse student body.

1. A teacher refers a male student from a poor immigrant working class family to your office. The teacher is convinced that this student is highly intelligent and wants you to encourage him to continue his studies and go on to college. But he tells you that he is under family pressure to drop out and get a job to support his family. You suspect that his family is undocumented and entered the US illegally. What problems might you encounter in counseling this young man? What would you do?

2. A young female immigrant student from rural Pakistan confides to you that she is under great pressure from her family to return to their home country for an arranged marriage to a much older man for the family’s financial success. However, she is very upset and wishes to remain in school here in the US. What problems might you encounter in counseling this young woman?

Reference:

Module 4: Cross-Cultural Health: Counseling, Stress, and Healing Practices

Problems: Real, Complex, Rooted in Culture

Problems Presented by Those Who Seek Counseling

Some concerns presented by clients that require our attention to the cultural significance of a problem often set personal identity against external pressures. The following are two sample groupings of the most common issues. Categorization is arbitrary as most problems overlap the personal with the social.

First let’s look at problems concerning rejection and discrimination by family, friends, and/ or community. The types of problems that might fall into this category include the following:

conflict due to ethnic differences in one’s intimate relationship
adoption of racially different children
differening expectations for biracial and multicultural children
not knowing if one is accepted for tasks because of personal accomplishments or because of cultural affiliation
stress due to rearranging one’s life to accommodate ethnic and culturally different associates and friends
frustration with situations that seem to lack justice
dealing with misplaced rage resulting from someone else’s experience of discrimination

Some explanation of this last point might help show the complexity of problems related to culture. Part of the problem is how we tend to group people. For example, have you ever said or done something that seemed minor to you, but that elicited a much greater response from someone than you expected? You may, for example, have become the recipient of anger about racial discrimination in the past, even though you had nothing to do with the original situation. The other person’s angry reaction could have been the result of a long-collected rage rather than the actual situation that occurred in the present.

Other problems involve personal crises. Although this area overlaps with the above, personal crises include situations such as the following:

confusion about one’s ethnic or cultural identity
confrontation of stereotypes about one’s heritage including religion, ethnic roots, and cultural practices
depression from coping with overt and covert oppression
inability to de-escalate anger or fear
lack of the skill required to reality-test culturally ambiguous situations
severe guilt resulting from instigation and perpetration of racial discrimination or oppression
trauma from suicide ideation resulting from hostility related to race, ethnicity, and culture

For example, imagine a client who seeks counseling because of symptoms of depression and thoughts of suicide. Behind the depression are multiple experiences of feeling hated because of the client’s ethnic or cultural affiliation. On the other end of the spectrum is the client who becomes aware that he or she has racially discriminated and now realizes the enormity of suffering caused. This client may feel defensive and need help sorting through the guilt and sources of negative feelings.

Becoming Cross-Culturally Competent

Cross-cultural psychology calls for a more culturally conscious approach to psychotherapy with culturally different clients. What do we mean when we say culturally conscious? Paul Pederson, Ph.D. (1976,1977), a pioneer in techniques for more cultural inclusivity in counseling, suggests psychologists take a three-fold approach with their clients. A brief description of those three components follows.

Cultural Awareness

Developing cultural awareness requires that those in the helping professions examine their own assumptions, values, biases, and attitudes about ethnic differences. This principle requires counselors to look at their cultural roots to grasp some of the historical positions their ancestors held in regards to cultural others. In addition, it asks clinicians to examine the injunctions about race, ethnicity, and culture presented by their childhood family system as well as by their current beliefs.

Cultural Sensitivity

The task to develop cultural sensitivity partly derives from increased awareness of self and other cultures. Development of cultural sensitivity takes awareness one step further. This principle encourages those consulting and counseling culturally different clients to research social, historical, cultural, and familial dimensions of those populations. For example, therapists might read about identity development in the client group, ascertain whether traditional healing practices are still incorporated by the family, learn about special language and nonverbal cues important in the group, look into the relationship historically held between the therapist’s and the client’s racial/ethnic/cultural group which could provide insight into how the client sees the role of the therapist, and ask about the view of emotional distress held by the client’s ethnic group including significant myths and rituals.

Culture-Inclusive Skill Development

For many individuals regardless of cultural group, the credibility of the therapist is very much tied to the counselor’s style of intervention and much less tied to the specific psychological theory or techniques a counselor may use with clients. The word style here means a collection of nonverbal and verbal responses that resonate with the culture of the client but are not inauthentic on the part of the counselor. The responsibility to obtain such culture–inclusive skills rests with the counselor or consultant. Initially, professionals develop the skills in mediation, counseling, or consulting from their graduate program; however, the skills necessary to address diverse cultures, especially those different from the counselors’ culture, must be obtained through culture-specific training. This skill development would be in addition to graduate courses in diversity or multiculturalism.

For example, if the therapist does not have the awareness and skills to deal with clients who rely on a language that is not the primary language of the therapist (if, say, the therapist relies on English and English is the second or third language of the client), the client may feel rushed, misunderstood, or even embarrassed when the clinician misinterprets the client’s use of language. If the therapist is unaware and not sensitive to the client’s experience, the counselor may misinterpret or confuse the language issue with the psychological issue and possibly attach the emotional reaction to the wrong problem.

For Pederson, all counselors must become aware of their own background and study the different populations they work with. It is essential that clinicians learn to be culturally sensitive by being informed and adopting new clinical skills. Pederson’s conceptualization for clinicians opens the door to effectively working with a multicultural practice.

Multicultural Counseling: Understanding Behavior

Derald Wing Sue, Ph.D. (1998), a psychologist specializing in cross-cultural counseling, tells us that if we maintain a strictly universal view of human problems, we will miss valuable culturally unique effects on human behavior. For Wing Sue, we should examine individual, universal, and culture-specific components of a problem. In addition, the focus should be on nonverbal communication as carrying the most powerful message between counselor/consultant and the client. Wing Sue cautions that many nonverbal behaviors represent social and political attitudes and that these must be clarified to reduce misunderstanding. One of the greatest threats to authentic and clear communication across cultures is that the counselor or consultant may be unaware of the covert ethnocentric attitude of his or her responses, further confounding the communication.

Some of the influences that shape cross-cultural communication are the use and intensity of facial expressions, closeness of contact while talking, tone and loudness of voice, language clues specific to the culture, length and directness of eye contact, arrangement of hair (e.g., covering the face), pauses in speech, position of the body including arrangement of legs, the use of clothing, hand expressions, and even the arrangement of furniture and where people sit in the interview room, to name a few.

All nonverbal behavior is open for interpretation. Take for example the terms sneaky, shy, avoidance, depression, hostility, anger, disrespect, or even admiration and respect—all are possible, and contradictory, interpretations of not maintaining eye contact. Cultures will have their own understanding of what a behavior means. Two sites that discuss examples of culturally related nonverbal behaviors are Angel Wienecke’s article on detriments to nonverbal communication and the Mid-Atlantic Equity Consortium’s table showing cultural contracts in nonverbal communication. When you read the information posted on these two sites think about the implications for counselor/client communication. Misinterpreting nonverbal behavior can lead to incorrect diagnosis by the therapist and misunderstanding by the client. Both mistakes are dangerous precedents.

Healing Practices Across Cultures

Cross-cultural psychologists conducting research or counseling clients should also consider the traditional belief systems of diverse ethnic people. Culture-specific treatments may include spiritual beliefs, rites of passage, participation of family and community in public rituals, herbs and chants, and understanding sophisticated ancestral and environmental relationships.

Healing practices across cultures consider biological, behavioral, experiential, and metaphysical aspects of the problem. Shamans, medicine men and women, and native healers all over the globe exemplify numerous culture and tribal-specific healing practices.

Traditional Healing

Consider non-Western worldviews. Chinese practitioners may apply Taoist philosophy to return the patient to harmony. An examination of the relationship between Yin and Yangshows how elements relevant to the problem are out of balance with the whole—wholeness encompassing all elements in the universe. Yin and Yang provide a conceptual way to understand disruptions to balance. In India, ayurvedic and tantric approaches combine yoga, meditation, breathing exercises, herbs, cleansing, and pulse-reading as part of their approach to healing.

In North America, a Navajo traditional healer may apply herbs and sandpaintings to assist the patient with healing. A South American medicine man or woman may combine herbs with chanting. Many indigenous healers enter altered states of consciousness as well as induce altered states in the participants. Around the globe, traditional practices use special geographic sites maintained especially because of their power or historical significance for healing. Quite often, traditional healing practices draw on culture-specific religious ideologies.

A Comparison of Healing Approaches

There are some similarities between Western psychotherapy as a healing art and traditional healing ceremonies. For example, if the patient has symptoms of stress, a local traditional healer would diagnose the problem in order to name the illness, suggest culturally relevant cosmological or environmental influences, and act with culturally appropriate treatments. The power of healing resides in the strong beliefs of the patient and healer.

Although Western approaches to counseling do not incorporate a specific spiritual element, philosophical ideas form the foundation of the particular school of psychology. The counselor, like the traditional healer, names the problem by giving a diagnosis and then helps the client frame his or her problem within a particular theoretical framework. Naming the psychological distress, facilitating insight, and prescribing tasks ground the resolution of problems in a psychological context. Unlike traditional cultural healing practices where the client is familiar with the healer and the practices, Western counseling and psychotherapy are a temporary “culture” the client enters, because of distress, and then leaves to return to his or her life situation.

Culture-specific practices and Western psychology are similar in goals and in their underlying processes. Both approaches include myths, rituals, and symbolic elements to help the patient. In Western psychology, myth may take the form of family stories passed from generation to generation as well as social beliefs. Ritual centers on the particular practice of the therapist and may include fees; time of the session; office structure; theoretical framework; health insurance requirements and referral strategies; therapeutic techniques such as hypnosis, medication, treatment plans; and the required presence of family members.

Although Western psychotherapeutic approaches are viewed as universal and applicable across cultures, culture-specific healing beliefs and practices make no such claim. Given the global increase of Western-trained psychotherapists, and as practitioners return to indigenous rural communities, both systems of healing will be increasingly applied together. This amalgam works best when the client, traditional healer, and therapist are all willing and able to contribute. The combination of traditional healing practices and Western strategies is a powerful and effective cross-cultural intervention. In addition, there is an advantage to the patient when healing systems merge. Where once the patient had little or no say in his or her treatment, the client now becomes a bridge between traditional and modern practices. In both traditional and Western healing disciplines, belief and trust are important elements for successful treatment. For effectiveness, exceptional cross-cultural communication and respect are essential.

Cross-Cultural Research into Mental Health

Three significant areas for study in cross-cultural mental health are: 1) psychological testing, such as intelligence tests and personality tests (psychologists continue to examine the validity of psychological tests for non-Western populations and develop culture-appropriate testing); 2) psychological disorders, such as depression and anxiety, as well as culturally different approaches to healing; and 3) counseling diverse ethnic populations.

Psychological Testing

In the Overview we asked a question about children’s test scores. Specifically, what if we misinterpret non-Western children’s tests scores and label the children as “slow” when comparing their scores to Western children’s test scores. Let’s take a look at this research in more detail. Questioning the universality of Piaget’s theory of child development, Dasen (1994) investigated concrete operational and spatial reasoning as a cross-cultural phenomenon. Explorations with Australian Aboriginal children, and later studies with Inuit Alaskan children and with children of the Ebri and Baoule’ of Cote d’Ivoire (West Africa), demonstrated how culture intervenes in cognitive development.

The Research: Concrete Operational Reasoning

Conservation: Two identical glasses of water are presented to the child. Water of one glass is poured into another container of different shape, “visually” changing the amount of water. The children who believe the amount of water has changed (not just the container) are in Piaget’s “pre-operational” stage. Children who say the amount of water does not change are using “concrete operational” reasoning.

Spatial reasoning: Children are presented with two landscapes; one turned 180 degrees. The task is to locate an object, such as a doll, on both landscapes.

Results:

Children
Skill
Age of Competence

Western (Geneva)
Concrete operational reasoning

5–7 years

Spatial reasoning is more difficult than weight and volume and develops more slowly.

Australian
Concrete operational reasoning

10–13 years

Spatial reasoning was easier and obtained more rapidly than in Western children.

Inuit
The Alaskan group achieved similar skills and stages as the Australian Aborigine.

Ebri and the Baoule’ of Cote d’Ivoire
Both groups of African children moved rapidly through quantitative stages and more slowly through spatial reasoning. Their test results were similar to the children of Geneva.

Piaget’s theory proved to be universal, but the actual age of reasoning proficiency differed with tasks as well as from culture to culture. Western children would be viewed as quite slow in spatial reasoning when compared to the Australian Aborigine or the Alaskan indigenous group if we did not consider culture as an important and powerful intervening factor. The findings confirm an eco-cultural perspective where learning is dependent on environment, including factors of language, cultural values, and parental and social expectations.

Mental Illness and Health

Looking at individual problems might include a study of difference in symptoms or the prevalence of a particular mental disorder. Consider the differences that might emerge for the following:

depression and other psychological disorders
cultural influences on mental disorders
culturally unique descriptions of mental illness
variations in the definition of normal and abnormal

the effects of language differences in counseling, culture shock, and cultural adjustment
culture-bound syndromes
racial bias in evaluation and treatment of minority populations

Community-focused approaches for cross-cultural psychologists interested in mental health and stress examine problems such as the effects of rapid population growth; differences in mental health services for minority or marginalized populations; culturally unique treatments; variations in psychotherapy; the training and practice of physicians, psychologists, and community workers; the effects of war and natural disaster on the mental health of the population; and ways to reach underserved populations around the world.

Focus on Community and Ethnicity

In addition to types of problems and services, a great deal of literature describing specific approaches to treating different cultural groups can be found in professional journals in psychology and counseling as well as in chapters in textbooks. Most often those studies examine indigenous populations such as Native North Americans in Canada, Mexico, and the United States; and cultural groups within the United States such as African Americans, Alaskans, and South Pacific indigenous groups, Asian Americans (those who immigrated from China, Indonesia, Japan, Korea, and the Philippines), Mexican and Latinos, and small immigrant populations. The focus for these studies is to understand within their cultural community the unique array of attitudes about mental health within their group. Other studies compare culturally diverse groups that reside in close geographic proximity and in interrelating communities.

On occasion professional journals in psychology focus an entire issue on mental health across cultures. For example, the American Psychological Association’s journal Health Psychology, volume 14, number 7, December 1995, presented behavioral and sociocultural perspectives on ethnicity and health. Articles focused on the following topics:

epidemiology of minority health
macrosocial and environmental influences on minority health
behavioral risk factors related to chronic diseases in ethnic minorities
risk-taking and abusive behaviors among ethnic minorities
adaptive health behaviors among ethnic minorities
ethnic minorities, health care systems, and behavior

In the Journal of Community Psychology, volume 22, number 2, April 1994, this special issue focused on Asian-American mental health. A list of some of the topic titles gives you an idea of the range of topics for just one cultural group.

Ethnic-specific mental health services: Evaluation of the parallel approach for Asian American clients
Asian Americans’ differential patterns of utilization of inpatient and outpatient public mental health services in Hawaii
Mental health and Asian Indians: Relevant issues and community implications
Help-seeking behavior among Southeast Asian refugees
Differential responses to trauma: Migration-related discriminants of post-traumatic stress disorder among Southeast Asian refugees
After the Sa-I-gu (April 29) Los Angeles riots: Correlates of subjective well-being in the Korean-American community
Asian-American women in the mental health system: An examination of ethnic and gender match between therapists and client
Treatment outcomes of Asian and White-American clients’ outpatient therapy

The above list of articles from just two journals shows an array of topics for cross-cultural research into mental health. Psychologists’ research interests include environmental aspects of psychological well-being as well as cultural factors that shape our approaches in counseling-specific ethnic groups. If you go to the Web site for the World Health Organization and type in mental health in the search space, you will find links to examine the current research and findings for global mental health concerns. Another site on the Web to gather information on hundreds of studies comparing human behavior across cultures is the Human Relations Area Files also referred to in module 3.

Summary

In this module we surveyed different aspects of psychological health. We pointed out how some research focuses on comparative studies within the United States, whereas other research examines mental health practices across cultures. We sampled types of psychological problems that may be brought to a counseling session or that may affect relations in organizations. To more effectively deal with these issues, we presented guidelines for the development of competence in counseling and consulting.

Examples of healing systems from a few cultures showed the uniqueness of their approaches to healing. We also mentioned how culture-specific practices are attached to a culture’s philosophy, myths, and rituals. A rich possibility is suggested with the combination of culturally anchored healing practices with Western psychological techniques. We concluded with a list of research topics into health psychology. The World Health Organization, the Human Relations Area File, and two psychology journals outside the Journal of Cross-Cultural Psychology demonstrate resources dedicated to cross-cultural aspects of mental health.

References

Dasen, P & Heron, A. (1981). Cross-cultural tests of Piaget’s theory. In H.C. Triandis & A. Heron (Eds.), Handbook of cross-cultural psychology. Vol. 4: Developmental psychology (pp. 295–342). Boston: Allyn & Bacon.

Pedersen, P. B. (1977). The triad model of cross-cultural counselor training. Personnel and Guidance Journal, 55: 94–100.

Pedersen P. B., Lonner, W. J., and Draguns, J. G. (Eds.). (1976). Counseling across cultures. Honolulu: University of Hawaii Press.

Serpell, R. (1994). The cultural construction of intelligence. In W.J. Lonner & R. Malpass (Eds.), Psychology and culture. Needham Heights, MA: Allyn and Bacon.

Wing Sue, et al. (1998). Multicultural counseling competencies: Individual and organizational development. Thousand Oaks: Sage Publications.