What is interesting is that although Freud believed that he had found a universal theory o f man, therapists (by their action o f not taking on certain cultural groups) emphasise that, in fact, the practice o f psychodynamic psychotherapy (at least) is not a “universal” therapy.
The insistence o f some therapists in keeping the therapeutic orthodoxy, by keeping certain parts o f the setting consistent and interpreting with a western understanding, leads to the notion that psychodynamic therapy has only one frame o f reference. Intercultural therapy addresses the practicalities o f the therapy (several sessions per week, payment o f fees etc) and queries the application o f the theory .
Cultural specificity o f the treatment incorporates at least four aspects o f the encounter. Firstly there is the setting. How emic or etic is the setting. Does the patient understand the context? In the case o f individual therapy is the patient able to speak about self, perhaps family, emotions and experiences with a stranger. Is he or she “allowed” a conversation with a single therapist without a chaperone? Is the room layout comfortable and appropriate e.g. are the positioning o f the chairs too close or too distant. Is the room culturally comfortable, in terms o f pictures or ornaments.
Working interculturally, the therapist, as well as listening to the information being brought to the session and their understanding o f the mental distress, will also be considering whether there are anxieties about the setting for the patient. This may be by verbal or non-verbal means. The therapist then needs to consider whether action needs to be taken to remedy these problems. Perhaps alterations in the therapy may be needed. For example, for those from rural, traditional cultures, a group may be more appropriate for exchange o f thoughts, feelings and emotions, particularly single gender, single language groups. For others there might be thoughts about leaving a door to the therapy room ajar (of course arranging this at a time where others cannot overhear the conversation), arranging for patients to be seen by another therapist o f the same gender or culture as the patient and discussing the issues with the patient.
Secondly, the patient has a culture and this is brought to the encounter. Some o f their cultural experiences may be consonant with psychotherapy as many cultures have “talking therapies”. However, such talking therapies are rarely with people who are unknown to the person, and adding the extra dimensions o f the therapist potentially being o f a different gender, culture and younger (age is associated with wiseness in many cultures), this may add complications to the encounter. Other cultural experiences may be dissonant with psychotherapy such as expectations o f medicine or herbal remedies, or perhaps o f advice rather than counselling. There may also be differences in the patients understanding o f mental distress, its causes and its cure.
Thirdly, the therapist is brought up in a culture and thus brings their own culture to the encounter. Their own interpretations o f psychotherapy theory and practice affect the
encounter, as does their understanding o f racism or o f being a minority in Britain. They may also have a western view o f mental illness which may be at odds with that o f their patient. Therapists should be aware that their understanding o f other cultures has an impact on the encounter. This may be productive or counterproductive.
Hence, through an intercultural gaze, it is clear that a silent therapist may be interpreted differently by a white European patient (who may be expecting this) compared to a refugee fleeing their own country, where the relationship between themselves and a silent “other” might have been one o f differential power relationships. For those whose experiences include torture, such an experience may exacerbate serious psychological problems. It is therefore o f great importance that the psychological interpretation o f such situations is recognized as different, as the intercultural aspect is explored and understood.
Finally it is the theory o f psychodynamic therapy that may impinge on the process. Can psychotherapy offer the same insights into the workings o f a family when confronted with the many and various different extended family frameworks? How does the theory adapt to the situation where individuals are considered not individually but as part o f a community? The aims o f therapy may not be to increase the individuality but work with the person to find their own solution to their difficulties within the community.
The question on the cultural specificity o f psychotherapy remains an interesting one. Some o f the skills and therapeutic practice have arguably universal significance, for example those o f boundaries, confidentiality and interpretation. However, from the
work carried out at Nafsiyat, it seems the most important factor is whether a rapport, an understanding, can be built up between the therapist and the patient. Therapists can use therapy tools within the cultural world o f the patient. This is achieved by discussion and understanding o f the potential for culturally dissonant therapy practice. Modifications may be helpful on the basis o f this “conversation”. However, the goal o f therapy is to make the therapy culturally relevant, so that the cultural significance o f the material brought by the patient can be understood and the therapy can be helpful.
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