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Cultivating Cultural Competence

Understanding and Integrating Cultural Diversity in Psychotherapy

From a systemic-constructivist perspective, culture is intrinsic to every individual’s core meaning making processes. Both psychotherapist and client are immersed within their culturally shaped meaning systems. The culturally sensitive psychotherapist’s job is to develop an appreciation of his or her own culturally circumscribed constructs and learn to engage the client in a therapeutic discourse that allows the client’s culturally nuanced ways of construing to be drawn out and be the focus of psychotherapy.

We demonstrate by presenting preliminary results of our research with South Asian Canadian couples receiving a culturally grounded application of Systemic-Constructivist Couple Therapy (SCCT; Reid, Dalton, Laderoute, Doell, & Nguyen, 2006; Reid, Doell, Dalton, & Ahmad, 2008).

A Systemic-Constructivist Understanding of Culture

Systemic-constructivist theory is a postmodern epistemology that integrates classical systems theory of interpersonal dynamics with more recent social constructivist ideas about how individuals make meaning (Fergus & Reid, 2001, 2002; Mahoney, 1991). This view proposes that individuals actively construct their knowledge -- what they know and experience as their ‘reality’ – as they interact with their environment.

An objective and true account of reality as it exists is considered impossible. The knower and what is known are indistinguishable. Individuals are engaged in a process of reflexively making sense of their ongoing flow of experience in order to adapt (Wittezaele, 2004). What a person knows is derived and maintained to the extent that it is ‘functional’ for one’s existence, rather than a ‘verifiable’ universal given (Fergus & Reid, 2002; Neimeyer & Winter, 2006). In other words, constructs give order and meaning to the otherwise chaos of human experience and allow one to navigate their internal and external experiences and coexist with others in predictable and intelligible ways.

Each individual’s ways of construing are highly idiosyncratic and complex yet they are not randomly determined. People’s ways of knowing are a product of a consensual validation process within the various social systems they engage in such as their family, community, and country. This is not just an interpersonal validation process, but also an interpersonal process with internalized symbolic others. Such collective systems provide members with a view of morality and purpose, and these views are reflected in, as well as perpetuated by, the ways in which people think, feel, behave, interact, experience, etc.

The mutually validated construing systems of social groups represent equally legitimate ‘realities’ to that of other groups (Christopher, 2001; Markus, 2008).  It is important to note that every person within a specific community does not necessarily maintain the same construct system. People engage in many different collectives, and this is particularly salient for ethnic minorities such as South Asians who simultaneously participate in their heritage culture as well as their host culture.

An implicit and insidious assumption pervading the clinical literature and discussion of cultural sensitivity in psychotherapy is that culture is a thing people ‘have’; culture is an attribute or trait added on to a client’s authentic individual experience. Furthermore, culture is viewed as something ethnic minorities from traditional and Eastern societies have that people of a more individualistic and Western society have progressed beyond.

The tendency to view culture as another layer on top of presumed universal core psychological processes is reflective of a Western individualistic way of thinking -- which itself is cultural — that sees people as self-contained autonomous entities (Christopher, 2001; Markus, 2008; Wittezaele, 2004). This cultural bias explains the field’s inherent interest in studying and attempting to understand the phenomena of culture as distinct ‘groups of people’ differing on bipolar categories, where people belong to an Eastern or Western society; tend to be more individualistic or collectivist; are either high on independence or interdependence. This desire to analyze people in reductionist ways in order to identify internal basic, essential characteristics stripped of their social context is reflective of a Western idealistic view of people as self-reliant, behaving independent of their social milieu.

In order to develop cultural competence in clinical work, it is important to be conscious of such assumptions and start to cultivate an appreciation that culture is not a ‘thing’ that a person has, nor a type or category they fall into, but an integral part of every person’s ways of processing. In fact, culture is better understood as something people ‘do’ rather than ‘have’ (Markus, 2008). Individuals reify culture by their socially patterned ways of behaving, thinking, feeling, sensing themselves, etc.

A therapist’s sensitivity to their client’s culture involves sensitivity to their clients’ construct systems, while at the same time being astutely aware of their own construing processes.

Therapists’ Attunement to Cultural Construing Processes

In attempting to be more ‘culturally sensitive’ in psychotherapy, psychotherapists’ face the paradox of trying to understand their clients’ worlds using the clients’ constructs when inevitably psychotherapists use their own constructs. It helps greatly for psychotherapists to cultivate an awareness of how engulfed they are in their own cultural assumptions.

A good example of making one’s cultural self awareness conscious is to visit another culture. Consider, for example, what happens to an American upon starting to live in India. One’s sense of self, preferences, priorities, habits, food tastes, social norms, ways of understanding and so forth become very apparent because of the contrast of one’s own culture with that of others. Similarly, the client from a different cultural background is likely to sense the self in ways that reflect the cultural diversity and this sensitivity is highly dialectical in the relationship with the psychotherapist.

The systemic constructivist approach attempts to address this paradox by developing a deeper understanding of the clients’ constructions that accompany their observable behaviours (Fergus & Reid, 2002; Reid, et al., 2006; 2008). The psychotherapist, through their own ways of talking and understanding, draw out their clients’ sense of their difference in a myriad of ways, some of which clients may not necessarily be open to or aware of until participating in the therapy. The psychotherapist guides clients to become more aware of their constructs; then this client awareness is combined with experimentation to make changes in clients’ ways of understanding and behaving that work for them interpersonally and intra-personally (examples of how this may be done is provided in the next section).

Theoretically, this is what we mean about working from within the client’s framework and reality; we spend a lot of time engaging the client to openly convey how they see, act and feel about their lives. The process of drawing out the client’s ways of seeing things is in itself therapeutic for the client who starts to have an increasing understanding of themselves which can be empowering.

Some of that increasing awareness of cultural difference may impede the therapy process not because of the client alone, but because culturally naïve therapists are not aware of their own difference in an interpersonally empathic way.  That naivety creates a glass wall that one cannot penetrate especially if the client and psychotherapist are not fluent in the nuances of the language used in the therapy sessions. This interpersonally dynamic cultural difference can become particularly poignant as the psychotherapist tries to instill a close and more intimate alliance commensurate with the therapist’s automatic goal to instill a therapeutic alliance that is itself, culturally defined.

Furthermore, the psychotherapist may be at risk of misinterpreting the client’s difficulties in the psychotherapy as being a form of therapeutic resistance on the part of the client rather than the psychotherapist’s culturally based difficulties in engaging the client in a therapeutic discourse. The antidote to such experiences is for psychotherapists to cultivate a deep awareness of the cultural diversity in meaning making that they and their clients have, respectively.

The psychotherapist develops a great deal of self sensitivity so as to not inadvertently impose culturally based ways of construing. To counter that risk, the psychotherapist normally takes an agnostic attitude that puts the client as the expert and constantly draws out the client’s ways of understanding so that the psychotherapist is learning from the client. The dialectical qualities of psychotherapist learning from the client helps greatly for the therapeutic alliance to move forward and in tune with the cultural nuances so critical to the client’s therapeutic progress.

The Systemic-Constructivist Approach to Working with South Asian Couples

To demonstrate what has been proposed in this paper thus far, we introduce our program of research which focuses on developing an empirically based approach to couple therapy that accommodates to the cultural nuances of the South Asian marriage (Ahmad, 2006; Ahmad & Reid, in process; Ahmad & Reid, 2008). This work is pioneering in that the psychotherapy combines both qualitative and quantitative methods in order to carefully assess the dynamics of each South Asian couple and subsequently provide interventions that are coherent with culturally based ways partner’s understand, experience and respond to each other. This program was designed so that the referred couples feel comfortable with the therapy model because it is consistent with their values and ideals.

This research is an extension of an empirically derived couple intervention called Systemic Constructivist Couple Therapy (SCCT; Reid, et.al, 2006: 2008). The SCCT itself was developed in a manner similar to the work with South Asians in that rather than using extant models of couple therapy that were themselves initially derived from a theory of therapy for the individual, Reid and his colleagues developed SCCT through experimental clinical interventions guided by systems and constructivist principles. This included careful qualitative analysis of in vivo change processes couple therapy sessions. Interventions were designed to draw out each partner’s ways of knowing, their intuitions, their experiencing, etc., to enhance their understanding of themselves, particularly of themselves in the context of their relationship.

The techniques were focused on working within each partner’s system of values, beliefs, experiences, etc. What emerged as a key component to the effectiveness of SCCT therapy was the enhancement of each partner’s couple identity or ‘we-ness’. We-ness is the degree to which partner’s identify themselves with their marital relationship. It is simultaneously an intra and intersubjective experience of partners who through the process of SCCT come to intuitively know their partner, as well as themselves in relation to their partner, in a deeper way. This identity was found to be central to how well the couple functions and the resulting satisfaction that partners have with their marriage at post therapy and gains made post therapy were significantly related to outcome at 2 year follow up (Reid et al., 2006). Details of the therapy and explanation of we-ness are published elsewhere (Reid et al, 2006; 2008).

The underlying principles of SCCT are accommodating of cultural differences, yet we continued to maintain an agnostic attitude towards South Asians and were rigorous in our calibration of SCCT to this population.

In our first phase of this research program we recruited South Asian couples in distress that were looking to enhance their relationship. There were 30 partners comprising 15 couples. Couples were referred for couple therapy at an urban university clinic in Toronto, Canada. Partners identified themselves of South Asian ancestry that included 19 Asian Indians, 8 Pakistanis, and 2 Bengalis. The average length of marriage was 5.19 years (SD = 5.93) and ranged from 5 months to 19 years. Average age of wives was 30.27 years (SD = 5.44) and husbands was 33.06 yrs (SD = 6.42). There were 5 couples whose marriage was arranged by parents, 9 couples who indicated having personally selected each other and 1 common-law couple. Couples received seven weekly sessions of 2-hr SCCT couple therapy. They were self-referred, hearing about us from various sources that included physician, community services, the media, internet, and family/friends. Couples were not screened and were seen as long as both partners were interested in improving the relationship. Examples of presenting complaints: constant arguing, verbal/physical violence, problems with sexual intimacy, affair, extended family interference, unfulfilled expectations, etc.

Within the session the psychotherapist takes a participant-observer role (Fergus & Reid, 2001; 2002) of empathic sensitivity to the partners’ constructions, and of stepping back and observing the therapist-couple system. The psychotherapist takes an agnostic position with respect to the partners, being aware that they are not neutral observers, and exploring with the client the meaning of their words and descriptions of presenting issues.

For example, a common presenting complaint for South Asian partners has been ‘in-law interference’. One spouse feels their partner’s loyalties are towards their parents rather than the spouse. An initial reaction of the Western therapist may be that the partner has not successfully individuated from their family of origin. Other therapists who are becoming increasingly aware of the great degree of value placed on connectedness with extended family for South Asians may be sympathetic to this dilemma and attempt to help the couple negotiate a healthy balance between their parents and spouse. Both positions could be true, yet there still remains a need to draw out a richer understanding of how each partner in the relationship idiosyncratically construes this issue.

When partners express this issue of extended family interference to the therapist, open ended questions that facilitate emergence of the partners ways of knowing and feeling can draw out the partner’s constructs and the therapist may realize their initial formulation was based on their own constructs.

For instance, asking the couple to draw on examples from how their parents may have dealt with in-law conflict can explicate each partner’s values and ways thinking. While on the one hand it may appear that they are merely describing how their parents did things, there is a lot of meaning in their choice of words and reasoning that can be further explored with the clients to draw out the nuances of their understanding of family relationships, values and beliefs which they themselves had never fully thought through. It is not necessary that the psychotherapist be silent and not provide any suggestions for fear of tainting the therapy with their own cultural constructions. Indeed, the psychotherapist can provide a construction of the issue which is close to the client’s way of seeing things after immersing themselves in the client’s ways of thinking. Reid and colleagues (2006, 2008) have described other more focused interventions available in the approach. The overall spirit of the 7 session intervention is to drawing out partners’ deepened understanding of themselves and of the spouse that leads to a mutual discovery of their couple system and collaboratively identify alternative ways they may do things in their relationship that fit within their internal values and ideals.

A preliminary analysis of the 15 couples that completed the 7-session therapy found significant improvement on the main outcome variables at post therapy. On the widely used Dyadic Adjustment Survey (DAS; Spanier, 1976), which measures relationship satisfaction, at pre-therapy (session 1) 70% of the partners were in the clinically significant range and at post therapy (session 7) 43% of partners were in clinically significant range. On the Revised ENRICH Relationship Adjustment Survey (Fowlers & Olson, 1993) which in our program includes an additional 10 culturally relevant items (e.g. issues regarding extended family, social status, religion) validated on a large sample (n = 114) of South Asian Canadians (Ahmad & Reid, in press), couples demonstrated significant pre-post therapy change (p < .001).

The results were comparable to our previous sample of non-South Asian couples (Reid et al., 2006). Several process variables are currently being explored and a 2-year follow up will be done to ascertain the long-term maintenance of post-therapy gains and how these are connected with therapeutically induced changes in the therapy 2 years earlier.

Concluding Remarks

Research to date on developing evidence-based therapy for cross-cultural clients is lacking. Cultural competence in clinical work requires ongoing disciplined awareness of one’s own ways of knowing in order to cultivate an appreciation of clients’ culturally based constructs. Our program of research demonstrates a viable attempt to develop an intervention with South Asian couples that is grounded in an understanding of psychological processes that are indigenous to this group.

While our work is focused specifically on one cultural group, the systematic observation of psychological processes with this community we believe can broaden the basis of systemic-constructivist theory of psychotherapy and the science underlying clinical intervention in general.

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Cite This Article

Ahmad, S., & Reid, D. (2009, October). Cultivating cultural competence: Understanding and integrating cultural diversity in psychotherapy. [Web article]. Retrieved from http://societyforpsychotherapy.org/cultivating-cultural-competence-understanding-and-integrating-cultural-diversity-in-psychotherapy

References

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Ahmad, S. & Reid, D.(in process). Relationship Satisfaction among South Asian Canadians: The Role of ‘Complementary-Equality’ and Listening to Understand. Interpersona.

Ahmad, S. & Reid, D. (2008, September) Cultural Adaptation of Systemic-Constructivist Couples Therapy for South Asians: Exploring the Mechanisms of Change. Poster session presented at the 2008 North American Society for Psychotherapy Research (NASPR) conference, New Haven, Connecticut, United States.

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