a paradigm for culturally based care in ethnic minority populations

Journal of Community Psychology Volume 22. April 1994

A Paradigm for Culturally Based Care in Ethnic Minority Populations

Marjorie Kagawa-Singer National Research Center on

Asian American Mental Health University of California, Los Angeles

Rita Chi-Ying Chung National Research Center on

Asian American Mental Health University of California, Los Angeles

Health care practitioners are encouraged to “know the cultures” of the multicultural client population they are serving in the United States. The premise behind this injunction is that the use of culturally sensitive techniques that are tailored to the cultural background of the client would result in effective therapy and produce positive outcomes. However, as reflected in the plethora of terms used to describe the application of this knowledge, it is not made explicit why culture would make a difference in therapy nor how it makes a difference, ultimately, in the outcome. The intent of this paper is to highlight one of the fundamental sources of variation in cultural beliefs that affect individual mental health. We propose a model that penetrates to the core of why culture makes a difference in how problems are perceived and appropriate responses defined. Humans have three basic needs: safety and security, integrity, and a sense of belonging. Yet each culture uniquely frames each of these needs and prescribes the sanctioned means to achieve them. In our struggle to define culturally competent or culturally based care, this fundamental aspect is often overlooked. Instead, the Western worldview, structure, and definitions are used as the template to assess dysfunction, diagnose a disorder, and prescribe appropriate care. The theoretical underpinnings of indigenous concepts of self and symbolic interactionism are integrated to clarify these cultural misconceptions and to construct a new paradigm for providing effective and acceptable mental health care.

Therapists working with ethnic populations are exhorted to “know the client’s culture.” The premise behind this thought is that use of culturally sensitive, appropriate, congruent, or competent techniques tailored to the client’s cultural background would result in more effective therapy and outcomes. However, despite the plethora of literature citing how culture affects symptom expression and how it affects a therapeutic interaction, the ‘‘why’’ of this impact has not been made explicit. Major questions that still need to be answered regarding the therapeutic interaction are: What is it about culture that makes a difference in therapy? How do therapists acquire this essential knowledge and understanding? and How should this information be used to improve the ultimate outcome?

This project was supported by the National Research Center on Asian American Mental Health (NIMH # R 0 1 MH 44331). Correspondence on this paper should be sent to Marjorie Kagawa-Singer, NRCAAMH, Department of Psychology, University of California, Los Angeles, CA 90024-1 563.

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A PARADIGM FOR CULTURALLY BASED CARE 193

Various techniques have been examined that are purported to make therapy more culturally responsive, such as clientltherapist match on ethnicity, gender, and/or language (e.g., Flaskerud, 1990; Sue, Fujino, Hu, Takeuchi, & Zane, 1991). Some have tried to analyze the interaction from the therapists’ viewpoint to identify what behavioral styles appear more effective (e.g., authoritarian styles appear more effective with Asian clients than an egalitarian approach, Sue, 1990), whereas other researchers have described the necessary elements required in a culturally sensitive therapeutic interaction (Ho, 1989, 1991; Kim, 1985; McGoldrick, Pearce, & Giordano, 1982; Root, 1985).

More recently, training models to provide culturally responsive care have been proposed. For example, Sue (1990) proposed a 3- to 6-month training program that provided the necessary knowledge of cultural behavioral and conceptual variations. Sue and Zane (1987) and Zane and Sue (1991) proposed the Proximal-Distal Objectives Model for Asian or Pacific Island (API) clients in which the initial interaction is more congruent with the API client’s expectations of therapeutic interactions. They proposed that due to social expectations, API clients expect a gift from the person in authority. The therapist gives a gift to the client to reinforce the expected paternalistic/dependent relationship between the therapist and client. Through the act of gift giving, ascribed and achieved credibility is reinforced.

These recommendations, however, are mainly based upon anecdotal experiences viewed through the infrastructure of the Western psychotherapeutic paradigm. Cross- cultural research has demonstrated that each culture creates its own framework of reality within which its members function (Hammond, 1978). Thus cultures will differ due to environmental, social, and political constraints on its construction. What seems to be missing at this juncture in ethnic minority mental health is a paradigm that incorporates the potentially different culturally based objectives of therapy between the client/family and therapist.

Kleinman, Eisenberg, and Good (1978) developed the paradigm of Explanatory Models (EM) to explore concepts of health and illness. The model places an individual’s physical, psychological, and/or social dysfunction within his or her cultural worldview. Although the EM model explores cultural differences, neither the EM model nor the other models and concepts commonly used in ethnic minority mental health have made explicit why these differences exist, and therefore how cultural differences create variations in both process and outcomes between the therapist and client/family. We propose that each culture provides different objectives of therapy because of differing indigenous constructs of the “healthy” self (Heelas & Lock, 1982; Marella, DeVos, & Hsu, 1985) and different intrapsychic and interpersonal means to maintain an individual’s sense of integrity and self-worth. Therapy that does not take into account the equal validity of these varying cultural paradigms will be destined to fall short of its objectives both for the client and therapist.

The purpose of this paper is to introduce a theoretical model for culturally based care that is built upon variations in the social definition of the self or personhood. Our premise is that if personhood is culturally constructed and is defined by specific social parameters, then the objectives and techniques to resolve dysfunction would be defined by cultural and contextual circumstances. To present this model, we first explore the theoretical premises upon which current psychotherapy is based and compare it with indigenous constructions of the self. Second, we define culture and ethnicity in a manner that emphasizes its fundamental, unifying nature, and clarifies why cultural differences must be accounted for in therapy. We then describe the proposed model, which

194 KAGAWA-SINGER AND CHUNG

incorporates the cultural construction of personhood and its relationship to the objectives of psychotherapy and specifies those elements of culture that impact the process and outcome of the therapist-ethnic client interaction. Last, we suggest how the model could be incorporated into education and training programs for health care practitioners and researchers.

Due to space limitations, a comprehensive review of the literature in cross-cultural mental health techniques will not be given. (See Kim, 1985; Root, 1985; Dana, 1993.) Also, due to the diversity of the API population, examples will be drawn mainly from Japanese and Chinese cultures because the majority of studies have thus far been con- ducted on these two groups. Except for Japanese Americans, the majority of Asians in the United States are foreign born (e.g., Southeast Asians >85%, Filipinos >6O%, and Chinese >6O%; Kim, 1985); thus, these cultural groups hold fairly traditional values, which, for the heuristic purposes of this discussion, have common cultural themes that we will refer to in broad generalities. Caution must be exercised, however, in generaliz- ing from the information presented herein to all of the 60 or more API groups in the United States (U.S. Census, 1990). Issues of intergroup and intragroup differences must be delineated as well as individual differences in acculturation and personality.

Present Psychotherapy Structure and Indigenous Concepts of Self

In this section we will briefly present the key issues to be discussed in the current theoretical basis of psychotherapy in America and then compare it with a cross-cultural conceptualization of self. The issues are: What is the concept of self and ethnic identity? and What implications do these concepts hold in the process of cross-cultural psychotherapy?

The Western ideal of personhood is based in the concepts of individualism, autonomy, dignity, and a sense of control over one’s existence and environment through rational means (Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985). This perspective has evolved from thinking expressed by such writers as James, Hobbes, Locke, and Descartes. In the Cartesian duality, the body and mind are separate, and hierarchically, the rational mind holds sway over the body and the emotions. Moreover, the self is unique, singular and exclusive unto itself, as in Emerson’s concept of the self-reliant man (1841/1967). Assuring one’s dignity and individuality has become a justifying moral argument in Western concepts and the goal in Western psychotherapy. In this paradigm, individuals can transform themselves into a desired state of emotional, physical, and mental well-being through rational introspection (Dana, 1993). The individual, then, is the focus of therapy, and self-transformation to a self-determined objective of well- being is the goal.

In contrast, in crosscultural psychology, each culture defines the self differently, and the prescribed and appropriate modes of maintaining a positive self-image are also culturally framed (Heelas & Lock, 1982). Hsu (1971) developed a cross-culturally applicable model of Psychosocial Homeostasis that incorporates the culturally variant social construction of personhood or JEN.’ In this model there are seven concentric, amorphous layers of being within an individual. (See Figure 1.)2 The innermost layer

‘JEN = “person” or “individual” in Chinese and Japanese (pronounced JIN). ’Hsu’s model for Psychosocial Homeostasis highlights the cultural construct of the self. He states that

this model can explain differences in styles of adaptation to cultural changes. The individual’s personal world is depicted as seven concentric, amorphous layers. (See Figure 1.)


is 7 and the outermost layer is 1. The three inner layers of being are analogous to Freud’s unconscious and preconscious self. Hsu identified layers 3 and 4 as Jen, the human aspects of self that are interpersonally created. More distant concentric boundaries represent weakening spheres of influence on the individual in which he or she has minimal influence and usually minimal attachment (e.g., the mass media and then the state). This idea is further illustrated in the ChineseIJapanese pictograph of “person” (Figure 2a), which clearly expresses the conceptualization of “self” in these two cultures by showing two human figures leaning against one another (Figure 2b).

Thus, within the character for the individual person is the inherent concept of dependency and support. The Japanese character for “human being,” “Ningen,” is also a graphic expression of the interpersonal nature of human existence (Figure 3). “Ningen” literally translates “between man and man.” That is, human-ness is created in relationships, not isolation. Thus a very different sense of self is conveyed with these characters than in the American ethos in which the individual defends his or her individual boundaries against the intrusion of others (Kagawa-Singer, 1988). Asian culture formally recognizes the social construct of being and the necessity of it in order to maintain har- mony in interpersonal relationships and family stability. In contrast, much time and effort is spent in the Euro-American socialization process to nurture the ability to declare clear ego boundaries between self and others. Indeed, this is the goal of Euro-Western psychotherapy (C hang, 1985).

Freudian [ 7 6 5

4 JEN [ (personage) 3

2 1 0

unconscious pre-conscious inexpressible

conscious expressible

conscious intimate society

and culture operative society and culture wider society and culture outer world

Layers 6 and 7 are the different Freudian layers of the unconscious aspects of our psyche-perhaps that which comprises the psychic-unity of mankind. The content of these layers is individual and idiosyn- cratic. Therefore, interpretation of these layers is not as helpful when attempting to ascertain group differences.

Layer 5 contains the individual’s “inexpressible conscious” feelings and ideas- his or her secrets. These are usually not expressed for fear of ridicule, shame, or the feeling that its content is too private and would be misunderstood by others.

Layers 3 and 4 contain those ideas, materials, and feelings that can be expressed and those with whom we have initial contact in our lives- our intimate family and extended family. These people, ideas, beliefs, and behaviors are associated with strong feelings of attachment. They provide our initial sources of intimacy and security. Our humanness or our JEN or personage is formed in these sectors.

Layer 2 contains role relationships outside of Layer 3, which the individual finds useful, but the performance of these roles does not imply or demand intimacy of affect. For example, in Layer 3 a teacher must have students, an employee must have an employer. The contents of layers 2 and 3 will differ from culture to culture. For many Americans, religion is a part of Layer 3. For many Japanese and Chinese, it would be a part of Layer 2. Religious preference might be a barrier to marriage for an American, but for Japanese and Chinese, it would be of minor consequence.

Layers 1 and 0 contain human beings, cultural rules, knowledge, and artifacts that are present in the larger society, but may or may not have any connection with the individual and progressively are of less and less consequence in his or her life.

196 KAGAWA-SINGER AND CHUNO

7 unconscious 6 pre-conscious) Freudian 5 unexoressible conscious 4 expressible conscious

3 intimate society and culture 2 operative society and culture 1 wider society and culture 0 outerwodd

} jen (personage)

FIG. 1 . Hsu’s Psychosocial Homeostasis Model (Reprinted with permission of Travistock Publications.)

“Face” is an important concept in Asian cultures. This concept enables the individual to maintain harmonious and reciprocal social relationships without losing one’s innermost


A A FIG. 2. (a) JIN or JEN (PERSON) (b) Inherent Dependency

FIO. 3. NINGEN (Human Being)

self. Doi (1985) describes this construct through honnehtemae. H o m e is the true, inner essence of one’s being.3 Tatemae is “face,” the public image or expression of one’s social being. “Face” is the integrity of one’s social reputation as a representative of some essential group, such as one’s family, and individuals are acutely conscious of the differentiation between the two and the primacy of public face. The unity of honne/tatemae defines a person’s sense of self. This concept is related to the American school of social interaction theory, where the public self is mutable and defined by role (Mead, 1934).

Socialization objectives become apparent in discipline styles as well. An Asian family would punish their children by excluding them from membership in the family or putting them outside the house. In contrast, Euro-Western middle-class American children are sent to their rooms and told not to come out. For both cultures, the ultimate punishment is de- signed to block the desired objective of socialization to the adult role (i.e,, Asians wish to remain “inside” the natal boundaries whereas Euro-Americans wish to leave home and become separate, self-sufficient individuals rather than see their identity as a family member; Bellah et al., 1985). The objectives of psychotherapy in the two cultures are analogous to the objectives of socialization in each culture-independence and ego definition for the Euro- American and interdependence and ego-diffusion for the Asian.

Therefore, the actual defense mechanisms or behavioral techniques or skills used to pro- tect one’s self-esteem are used for different objectives, because what is being protected,

’Home may also be analogous to Hsu’s level


the construct of the self, differs significantly. The behavioral and emotional cues must be read accordingly, and the crux for the therapeutic interaction lies in the fact that the objective of therapy may differ between that of the client and that of the therapist; the therapist must be astute and skilled to read the behavioral and emotional cues within the proper cultural context. In practice, cross-cultural interaction between a Western- trained psychotherapist and an Asian client requires that objectives must be clarified from the outset or the client/family and therapist may be on two disparate paths.

Defining Culture As noted earlier, it is crucial for the therapist to understand the impact and com-

plexity of culture and how it influences perceptions and behavior of both the therapist and client/family. In order to understand and appreciate the nature of cultural differences and how it affects the therapeutic alliance, this section will define culture in a way that will make it clinically usable.

Culture is a tool that defines reality for its members. Within this reality or worldview, the individual’s purpose in life is defined and proper, sanctioned behavior within the social group is prescribed. These beliefs, values, and behaviors of a culture provide its members with some degree of personal and social meaning for human existence, learned through tradition and transmitted from generation to gene ra t i~n .~

Culture, then, serves two functions: (1) Integrative- the beliefs and values that provide individuals a sense of identity and (2) Functional- the rules for behavior that enable the group to survive physically and provide for its welfare, and that also support an individual’s sense of self-worth and belonging. These patterns of belief and rules for behavior enable its members to maintain some behavioral consistency. They are then recognizable to each other and social interaction and integration is facilitated.

These two functions are analogous to the warp and woof of a tapestry. The technique of weaving a warp and woof is universal, but the patterns that emerge from each group are culturally identifiable. That is, the concepts of beauty, for example, color, balance, symmetry, and the subjects chosen to display in the tapestries express the ethos of the culture. The significance of this analogy is that specific beliefs and behaviors are like the threads in the tapestry. A thread can be taken out and compared across cultural groups for its inherent structure, but its function and integrity are not comprehensible unless seen within the pattern of the entire cultural fabric from which it came.

Taken in isolation and out of context, the belief or behavior may be misinterpreted or even disregarded as unnecessary or maladaptive. Difficulties in communication between therapist and client occur when the therapist disassembles the tapestry of the client and analyzes it according to the template of the therapist’s culture. The essence of the original pattern is lost, and if interventions are instituted with this one-sided perspective, the client/family, at best, feels misunderstood.

Ethnicity An ethnic group is a self-perceived cultural group that resides within another society

and permits appropriate interactive behavior (DeVos & Romanucci-Ross, 1982). This concept of ethnicity is much more fundamental to an individual’s identity than the more common use of ethnicity, which tends to be a more superficial glossing of the term as

4Seven domains of culture contain the symbolic emblems of one’s identity: Environment, Economy, Technology, Social Organization, Political Organization, Ideology (including beliefs and values), Arts (sym- bolism), and Language (see Hammond, 1978, for a more detailed explanation).


characteristic beliefs and values and/or the practice of identifiable cultural traditions (e.g., Zane & Sue, 1991). This latter use of the concept overlooks its vital nature to an individual’s sense of identity. Ethnicity, then, is an individual’s self-identification as well as identification by others outside the group, and most important, one’s ethnic group provides a sense of social belonging and ultimate loyalty (Berreman, 1982).

The diversity within the more than 60 API groups in the United States adds to the complexity of the effect of ethnicity on the therapeutic relationship. Intracultural differences within each of these groups must also be noted (e.g., foreign versus American born; country of origin, e.g., Chinese from Vietnam, Hong Kong, Taiwan or mainland China; refugee or immigrant; generational differences; educational levels; socioeconomic status; religion; and gender issues as well). Variations in the acculturation levels of ethnic members also play a significant role in modifying cultural beliefs and behaviors, as well as modifying a member’s sense of identification .with the group and by the group itself (Olmedo, 1979). Individuals need to have a sense of identity with a group; to be without a sense of continuity is to be faced with one’s own death (DeVos & Romanucci-Ross, 1982). Ishi, the last Yaqui Indian of California, stated this reality when he sadly com- mented on the death of his culture: “[Ethnic] identity is found in the ‘cup of custom’ passed on by one’s parents from which one drinks the meaning of existence. Once the cup is broken one can no longer taste of life” (DeVos & Romanucci-Ross, 1982, p. 388).

An erroneous assumption that has permeated much of education and psychotherapy in the United States is that the objective of the acculturation process is assimilation (Berry, & Kim, 1988) rather than biculturalism. Most immigrants and refugees in the United States have become at least bicultural. That is, they have learned the dominant set of beliefs, values, and behaviors well enough to function, but they have maintained their traditional beliefs and values. They have become adept at switching from one set of values and behaviors to another according to the demands of the social situation. An individual’s identity may well be a synthesis of two or more cultures. However, if the behaviors prescribed by the different cultural groups are not kept separate, use of behaviors sanctioned by one group in another may result in misunderstandings and miscommunication.

For example, in symbolic interaction theory, the creation of reality occurs within the interaction. Although the objective of social interaction for both Asian and U.S. cultures is communication, the rules of communication differ. The Euro-American is expected to present his or her “honne” (true inner self) in most encounters and not use “tatemae” (public presentation of self), for the use of “tatemae” is considered deception or insincere communication (Doi, 1985). The Asian individual would be expected to conceal his or her “honne” out of respect for the “other.” Open, “honne” communication only occurs once the “other” or outsider becomes part of the inner circle of “family.” The therapist must recognize this style as a rule of communication and not as an inability to communicate directly.

Ethnicity and Therapy Various elements of therapy, such as ethnic and language match between therapist

and client, have been positively correlated with length and number of sessions of therapy (see Yeh, Eastman, & Cheung, 1994). We propose that these elements are actually proxies for the cognitive map or worldview provided by one’s cultural background. If language and/or ethnicity are matched, then positive outcomes of therapy are more likely because the chances are greater that the worldviews of the fundamental cultural/ethnic definition of the self, the styles of verbal and nonverbal communication, and the therapeutic objectives will be congruent between the therapist and client (Hymes, 1972; Whorf, 1956).

200 KAGAWA-SINGER A N D CHUNG

When a therapist fails to comprehend differences in cultural patterns, the result is a recurrent incongruity between the therapist and client. The therapist uses the parameters of “normality” and therapy objectives derived from Western concepts of mental health and interpersonal relationships (Trimble, Manson, Dinges, & Medicine, 1984). This process ostensibly uses corresponding threads from another cultural tapestry without validating its equivalent structure and function in the client’s conceptualization (Kleinman et al., 1978; Liang, Bennett, Whitelaow, & Maeda, 1991; Sue & Sue, 1987).

Definition of Culturally Based and Competent Care The multitude of terms now used to try to describe the delivery of care that takes into

account the cultural background of the client indicates the still evolving process of this effort. In view of the definition of culture and of the brief overview of the psychotherapy models already presented, we propose the following model for “culturally based care” (Leininger, 1988) that emphasizes the foundation of an assessment that is built upon the fundamental nature of both the client’s and the therapist’s cultural background. Culturally competent care is achieved when the therapist can effectively use the knowledge of his or her own culture and the client’s to negotiate mutually acceptable goals of therapy with the client/family. Thus we define culturally based and competent care as:

A system, agency, and/or professional who assists individuals (sick or well) in the performance of those activities contributing to health or to its recovery (or to a peaceful death) that they would perform unaided if they had the necessary strength, will, or knowledge, (and to) help individuals to be independent of such assistance as soon as possible in a manner which is culturally comprehensible and acceptable to the individuals and their families. (Henderson, 1955, p.4; italics and underlined section added for definition of cultural competence)

In this definition of culturally based care, health is defined as the ability to achieve one’s life objectives within the beliefs and values of one’s culture (Kagawa-Singer, 1993). This definition of health emphasizes its subjective nature over physiologic or biomedical parameters. The therapist’s responsibility is to facilitate the attainment of health by assisting the client/family to attain, maintain, or obtain the skills necessary to achieve those ends without undue psychic or physical detriment. To provide culturally based care, the structure of the system, agency, and departments should enable its professionals and staff, through its policy making, administration, and practice, to obtain and use the culturally appropriate and acceptable knowledge, attitudes, and behaviors necessary to provide services that are effective and mutually satisfactory to both clients and therapists (Isaacs & Benjamin, 1991).

Fundamental to this definition is the assumption that it is not the therapist alone who sets the outcome standards. If Western-trained therapists truly honor the autonomy of the client, then they must respect the client’s established objectives if they are not of harm to others- especially in a multicultural society. In working towards those ends, the therapist can continue to assess the accuracy of the client’s evaluation of the reported life situation and continually keep the client/family informed of viable alternatives should they desire to modify their decisions.

Model of Culturally Responsive Care This culturally based model of therapeutic interactions expands the present approach

to ethnic mental health by integrating two theoretical domains into a cross-culturally applicable framework for research and practice. These two elements explain why cultural

A PARADIGM FOR CULTURALLY BASED CARE 20 1

4 Negotiated objectives

for health

FIG. 4. Model for Culturally Based Care

knowledge is essential and what specific knowledge and skills are required by the therapist to provide effective care to ethnic minorities. The first domain is the clear recognition that each culture defines the self differently. If the client and therapist are from two different ethnic groups, each may hold two equally valid and potentially variant objectives of therapy. Therefore, if the objective of therapy is to reestablish a positive sense of self and an ability to function comfortably in the "real" world, it is crucial for the therapist to fully acknowledge and accept that culture plays a vital part in defining this objective. The second element is that therapy outcome is achieved through aprocess of negotiation between the therapist and client on expectations and objectives of therapy to attain mutually acceptable goals. This second element has been advocated by many cross- cultural researchers (e.g., Leininger, 1988; Tripp-Reimer, Brink, & Saunders, 1984; Klein- man, 1980; Dasen, Berry, & Sartorius, 1988). However, what has not been stressed clearly enough is the fact that the negotiation must occur between two equally valid cultural constructs of reality that are each created within social-historical contexts. This


perspective sharply contrasts with the unilateral perspective of the Euro-Western nosology of psychotherapy as the correct way of symptom perception, expression, and intervention. The proposed model makes these elements explicit and applicable to the therapeutic interaction.

In Figure 4, “A” represents the intersections of the therapist’s professional belief system with that of his or her ethnic background and concept of “health” (i.e., the objective of therapy). “B” represents the intersection of the client’s belief system with that of his or her ethnic background and concept of “health” (i.e., the inten- tion of therapy). A and B each exist within their own sociocultural context and the interaction between A and B occurs within a larger, encompassing sociocultural context. The first dyad, “1” represents the therapist-client interaction. “2” represents the efforts of the therapist to bring the client to the therapist’s concept of health, an “imposed etic” (Kleinman, 1980). “3” represents the position where the therapist might consider the client’s objectives equally or perhaps more valid and direct the process of therapy to the objectives envisioned in B without serious consideration of the present context in which the client/family now live. “4” represents negotiated outcome(s) of therapy between client and therapist. The cultural symbols in A and B, such as communication styles, verbal and nonverbal language and etiquette, family structure and cultural values, and their significance, must be made explicit so that the therapist and client can work out the desired objectives in light of emotional, social, and physical resources.

Application of the Model in Practice

Three basic pan-human needs for psychological well-being are: (1) a sense of safety, (2) a sense of self-worth, and (3) a sense of belonging (Kagawa-Singer, 1993). Most behavior is directed to maintain these three essentials of life (DeVos & Romanucci-Ross, 1982; Durkheim, 1947; Goldschmidt, 1959; Maslow, 1973). Safety is defined as a sense of physical security and well-being. A sense of self-worth is achieved by being a productive and integral member of one’s social group, and a sense of belonging is to be a desired and nurtured member of a group with which one wishes to identify. As described earlier, culture provides the definitions and means to fulfill these three basic needs, and as such, both the specific objectives and the means to achieve those ends will vary according to the pattern of each group’s cultural “tapestry.”

YOU

EYES

UNDIVIDED A ” T I 0 N

FIG. 5. The Chinese Character for Listen


The first step, then, in the therapeutic process is to demonstrate to the clients that they are seen as unique individuals and that the therapist is sincerely concerned and capable of helping (Sue & Zane, 1987). The Chinese character for “listen” encapsulates how this can be achieved. The character is composed of the concept of active listening with ear, eyes, and heart which is essential in the therapeutic encounter (Figure 5 ) .

Next, the therapist must demonstrate sincere respect and caring. The essential steps necessary in this process are captured in the acronym KOPF.’ This technique elicits the necessary knowledge to provide culturally based and competent care:

K - Knowledge 0 - Openness and Observation P - Patience F - Facilitation

Knowledge

It is crucial to learn about the values, beliefs, and behavioral practices of the client/family’s culture by (1) reading the literature in transcultural health care, anthropology, cross-cultural psychology, and sociology and (2) obtaining information from informants in the community. Although membership in an ethnic group does not mean that the members understand the “why” of their belief system or see its coherency, most members can tell you what should be done in various circumstances or what would make them feel uneasy.

Five questions need to be addressed to attain basic cultural knowledge:

1. What are the predominant beliefs, values, and norms of behavior of this group (e.g., religion, worldview, or life philosophy)?

2. What is the ideal serf in that culture; that is, what are the characteristics of such an individual and what are culturally prescribed means of achieving sense of integrity or integrated sense of wholeness? For example, is the ego bounded by individuality (Figure 6A), or is the ego boundary diffuse and integrated with a group identity (Figure 6B)?

3. What are the rules of social interaction? Knowledge of the rules and expectations of communication, such as social etiquette and amenities, is essential. The therapist must be aware of such elements as respect, timing, level of language fluency (dialects, English proficiency, desired language, and rules of linguistic and social hierarchy), nonverbal communication styles, and degree of self-disclosure by the therapist (Sue, 1990) including the symbolic meaning of body parts. Information should also be obtained regarding age-appropriate, social status, and gender rules of interaction.

Bilingual ability alone is not sufficient. The therapist must be trained in cross-cultural theory and application in order to practice culturally based care. When bilingual/bicultural therapists are not available, translators can be employed, but it is critical that they be trained to prevent common mistakes as omission, editing, and interpretation without the knowledge of the therapist and client.

The therapist also needs to be aware that Asian Pacific Islander (API) clients are often more comfortable talking about symptoms in the style of reporting their life history

_____

’“KOPF” means “head” in German.


Self Group Self = Individual Interdependence Independent

A B

FIG. 6 . Ego Boundaries

rather than merely listing symptoms out of context. This process of eliciting a history is time intensive and appears circular, but API clients often seek problem solution by in- ductively relating what they think the etiology of the disorder may have been, whereas the Western approach is to report symptoms (i.e., incidence, duration, frequency, and in- tensity). The therapist then uses a deductive approach from a biomedical framework to determine the etiology (Eisenberg &Wright, 1985). For example, the API client might respond to the question “How long have you had these feelings of nervousness?” by saying “When my Auntie was a little girl, she heard that . . . ” and continue this life history narrative to tell you why he or she now feels vulnerable to these outer forces; for example, some vulnerability may be constitutional weaknesses (e.g., Lock, 1980), but the presentation is usually made of external contextual forces and not intrapsychic forces.

Lock (1983) describes the Western therapeutic approach as symptomatic treatment, whereas the Asian perspective is to realign the fundamental imbalance that has occurred and made the individual vulnerable to the precipitating pathology (Gould-Martin & Ngin, 198 l), thus the dissimilar objectives require distinct interventions. For example, the goal of Japanese psychotherapeutic treatment is to seek a balance between inevitably conflicting emotions of a social being. The Western ethos seeks to eliminate dysphoria and situational stressors. The objective of the former is to transcend the negative issues and learn to function in spite of them- to endure them- whereas the objective of the latter is to reaffirm the hierarchical structure of mind over body and change the situation to foster one’s identity (Ots, 1990).


4. What problem is the individual experiencing (etic or therapist’s [outsider’s] perspective) compared to what the individual identifies as the problem (emic or client’s [insider%] perspective) ( Weiss & Klein man, 1988)?

The therapist must understand the client’s construct of the disorder, perceived etiology, and expected modes of appropriate treatment in order to negotiate effective therapy (Good & Delvecchio Good, 1981). It is important also at this point to ascertain what other attempts or methods the client/family has made to overcome the problem.

5. Are the traditional means of achieving that sense of integrity (as defined in question # I above) adaptive in the present context?

Is it achievable, realistic, or desirable in the present economic and social context?

Observation and Openness Although knowledge is obtained through reading and listening, observation and

openness are often the key to unlocking perplexing or conflicting information with individual clients/families. Questions to be addressed in this area are: ( I ) How do the beliefs and behaviors of the client/family coincide or conflict with those of the therapist’s cultural beliefs and styles for meeting the three basic needs of seu-integrity, security, and sense of connection to others? (2) Are the client/family and therapist aware of these variations? (3) What does the therapist understand of the client’s expectations of therapy?

Two objectives in the therapeutic process are healing and curing. To cure is to eliminate the pathology according to the biomedical and Western psychotherapeutic models. To heal is to address the existential and spiritual distress that may exist with the disease. Eisenberg (Eisenberg & Wright, 1985) differentiates this as the illness/disease dichotomy. The disease is the objective, measurable pathology. The illness is the meaning of the disease experienced by the client/family. Treating the client holistically requires that both aspects must be addressed, and in order to do so, the therapist must fully understand and respect the symbols, message, and intent of the client’s communication.

Eliciting valid information requires informed, culturally based observations and a prepared openness to detect cultural generalities, culturally specific similarities, and individual variances. An openness to different traditions will be more productive than hav- ing superficial knowledge of a few cultural customs and not understanding the whole pattern of the culture.

A further question related to observation or information gathering is: (4) Are there also issues of assimilation, acculturation, and/or bicultural tensions? The client/family’s status regarding foreign versus American born, country of origin, refugee or immigrant, generational differences, acculturation levels, education, socioeconomic status, religion, and gender issues must be assessed. It is essential to evaluate these factors that modify individual responses.

Patience Clients and families who come for assistance want desperately to be understood. It is

essential that the therapist attempt to normalize the clients’ reaction to their perceived situation. They will usually superficially answer the therapist’s inquiries according to “face” value. However, before divulging or sharing their beliefs, clients/families will test the therapist’s credibility, trustworthiness, and capabilities. Rapport is not possible if the clients, families, and therapist do not feel mutually respected. Western-based psychotherapy can leave the client/family feeling as though they are just a list of symptoms and invalidated as whole individuals. Culturally competent care requires patience, respect, receptiveness, and awareness of important cultural norms and expectations of


behavior in order to demonstrate credibility, trustworthiness, and capabilities and elicit valid life histories.

Facilitation The therapist must then use the information he or she obtains to facilitate and

negotiate with the clients/families how best to meet their objectives by reducing the discrepancy between their abilities and those objectives. Culture specificity requires at- tention to the order in which therapy is to occur. For example, Ho (1989) decribes the use of the Fundamental Interpersonal Relations Orientation (FIRO) for therapy with API families in which three fundamental issues in human relations must be dealt with: In- clusion (i.e., boundary maintenance for the family); control, or issues of respect and responsibility between members; and affection, or intimacy between members. He shows that these issues must be dealt with in sequence or API families will drop out of therapy. It is noteworthy that this same model would be applied in reverse order in Western psychotherapy (e.g., beginning with intrapsychic, affective distress; then control issues; and finally family boundaries).

New alternatives, beliefs, and/or behaviors may also be necessary if presently available cultural techniques for coping are insufficient. The therapist might ask: (Z) What do you expect therapy will do for you? (2) How would your life be dflerent ifyou were not feeling the discomfort you do now? (3) What kinds of things have you tried to reach your objectives? Do these activities dctfer from those your family wishes you to try?

By drawing upon the richness of the cultural support system and integrating Western psychotherapeutic techniques the therapist can negotiate mutually acceptable goals.

If clients choose to decline or discontinue therapy, and the therapist is assured that they are making informed choices, then their ability to exercise their autonomy must be honored. The option to return to therapy or perhaps more culturally congruent alternatives for assistance should be offered.

If the basic premises of this model are accepted and the steps outlined are followed, both the client’s and therapist’s explanatory models are made explicit. Negotiation of objectives is then possible, and culturally based and competent care will occur.

Summary

Therapies with ethnic minorities have primarily focused upon the assumption of their deficit of interpersonal communication skills and ability to be in touch with and articulate psychological insight according to the theoretical format taught in mainstream educational programs. The culturally based model presented in this paper integrates the theoretical bases of indigenous concepts of self and symbolic interactionism, and emphasizes the differential protection and strengths provided by various cultural intepreta- tions of stressful situations.

Thus we have operationalized the definition of culture to highlight its core function of contextualizing both the objectives of therapy and the means to achieve the desired outcome. A practice guide has also been presented to elicit the basic information necessary to begin cross-cultural psychotherapy.

The magnitude of changes in ethnic diversity in the United States mandates that we broaden the restrictive concepts of mental health classifications and styles of intervention that will accommodate and incorporate interpretations of reality afforded by various cultures for its members. Effective and economical care can only be provided when it is culturally and socially appropriate and acceptable. Paradoxically, “in order to be treated fairly and equally, individuals must be treated differently” (Konner, 1991, p. 405). Our


theoretical paradigms must be flexible enough to support this edict. This paper has presented an alternative paradigm for mental health interventions that could begin discussion of this reorganization and increase the likelihood of providing culturally based and responsive care.

References

Bellah, R., Madsen, R., Sullivan, W., Swidler, A., & Tipton, S . (1985). Habits of the heart: Individualism and commitment in American life. New York: Harper and Row.

Berreman, G. (1982). Bazar behavior; Social identity and social interaction in urban India. In G. DeVos & L. Romanucci-Ross (Eds.), Ethnic identity: Cultural continuities and change (pp. 71-150). Chicago & London: The University of Chicago Press.

Berry, J . W., &Kim, U. (1988). Acculturation and mental health. In P. R. Dasen, J. W. Berry, & N. Sar- torius (Eds.), Health and cross-culturalpsychology: Toward applications (pp. 207-238). Newbury Park, CA: Sage.

Chang, W. (1985). A cross-cultural study of depressive symptomatology. Culture, Medicine, and Psychiatry,

Dana, R. H. (1993). Multiculturalossessmentperspectives forprofessionalpsychology. Boston, MA: Allyn & Bacon.

Dasen. P. R., Berry, J . W., & Sartorius, N. (1988). Health and cross-culturalpsychology: Toward applications. Newbury Park, CA: Sage.

DeVos, G., & Romanucci-Ross, L. (Eds.). (1982). Ethnic identity: Cultural continuities and change. Chicago & London: The University of Chicago Press.

Doi, T. (1985). Durkheim, E. (1947). Elementary formsof the religious life (J. W. Swain, trans.). Glencoe, IL: Free Press. Eisenberg, D., &Wright, T. L. (1985). Encounter with Qi: Exploring Chinesemedicine. New York: Viking

Emerson, R. W. (1967). Self-reliance. White Plains, NY: Peter Pauper Press (Original work published 1841). Flaskerud, J. H. (1990). Matching client and therapist ethnicity, language and gender: A review of research.

Issues in Mental Health Nursing, 11, 321-336. Goldschmidt, W. (1959). Man’s way: Preface to the understanding of society. New York: Holt, Rinehart

& Winston. Good, B., & Delvecchio Good, M. J. (1981). The meaning of symptoms: A cultural hermeneutic model

for clinical practice. In L. Eisenberg & A. Kleinman (Eds.), The relevance of sociulscience for medicine (Vol. 1, pp. 165-196). Dordrecht: Holland/Boston: D. Reidel.

Gould-Martin, K., & Ngin, C. (1981). Chinese Americans. In A. Harwood (Ed.), Ethnicity and medical care (pp. 130-171). Cambridge, MA & London, England: Harvard University Press.

Hammond, P. (1978). Introduction to cultural and social anthropology. New York: Macmillan. Heelas, P., & Lock, A. (1982). Indigenous concepts of the sew London: Academic Press. Henderson, V. (1955). Textbook of principles and practice of nursing (5th ed). New York: Macmillan. Ho, M. K. (1989). Applying family therapy theories to AsianIPacific Americans. Contemporary Family

Therapy, 11(1), 61-70. Ho, M. K. (1991). Use of ethnic-sensitive inventory to enhance practitioner skills with minorities. Journal

of Multicultural Social Work, I ( ] ) , 57-67. Hsu, F. L. (1971). Psychosocial homeostasis and Jen: Conceptual tools for advancing psychological an-

thropology. American Anthropologist, 73, 23-44. Hymes, D. (1972). Models of the interaction of language and social life. In J . Gumperz & D. Hymes (Eds.),

Directions in sociolingusitics (pp. 35-71). New York: Holt, Rinehart and Winston. Isaacs, M. R., & Benjamin, M. P. (1991, December). Towards a culturally competent system of cure, Vol.

11: Programs which utilize culturally competent principles. Washington DC: Child and Adolescent Ser- vice System Program (CASSP) Technical Assistance Center, Center for Child Health and Mental Health Policy, Georgetown University Child Development Center.

Kagawa-Singer, M. (1988). Bamboo and Oak: Differences in adaptation to cancer by Japanese-American and Anglo-American patients. Unpublished dissertation. University of Los Angeles.

Kagawa-Singer, M. (1993). Redefining health: Living with cancer. Social Science and Medicine, 37, 295-304. Kim, S . (1985). Family therapy for Asian Americans: A strategic-structural framework. Psychotherapy,

9(3), 295-317.

The anatomy of self. Tokyo: Kodansha International.

Penguin.

22(2), 342-348.


Kleinman, A. (1980). Patients and healers in the context of culture. Berkeley: University of California Press. Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care. Annals of Internal Medicine,

Konner, M. (1991). Leininger, M. (1988). Leininger’s theory of nursing: Cultural care diversity and universality. Nursing Science

Liang, J., Bennett, J., Whitelaow, N., & Maeda, D. (1991). The structure of self-reported physical health

Lock, M. (1980). Organization and practice of East Asian Medicine in Japan: Continuity and change. Social

Lock, M. (1983). Japanese responses to social change-making the strange familiar. Western Journal of

Marsella, A. J., DeVos, G., & Hsu, F.L.K. (Eds.). (1985). Culture and self: Asian and Western perspec-

Maslow, A. H. (1973). A theory of human motivation. In R. J. Lowry (Ed.), Dominance, selfesteem, self-

McGoldrick, M., Pearce, J . K., & Giordano, J . (1982). Ethnicityand family therapy. New York: The Guilford

Mead, G. H. (1934). Mind, self and society. Chicago: University of Chicago Press. Olmedo, E. L. (1979). Acculturation: A psychometric perspective. American fsychologist, 34(1 l), 1061-1070. Ots, T. (1990).

88, 251-258. Childhood. Boston: Little, Brown & Company.

Quarterly, 1(4), 152- 160.

among the aged in the United States and Japan. Medical Care, 29(12), 1161-1180.

Science and Medicine, 143, 245-253.

Medicine, I Z ( 139), 829-834.

tives. New York & London: Tavistock.

actualization: germinal papers of Abraham Harold Maslow. Monterey, CA: BrooksKole.

Press.

Angry liver, melancholy spleen. Culture, Medicine and Psychiatry, 14, 21-58. Root, M. (1985). Guidelines for facilitating therapy with Asian American clients. Psychotherapy, 22(2),

349-356. Sue, D. W. (1990). Culture-specific strategies in counseling: A conceptual framework. Educational Psychology:

Research and Practice, 21(6), 424-433. Sue, D., & Sue, S. (1987). Cultural factors in the clinical assessment of Asian Americans. Journal of Con-

sulting and Clinical Psychology, 55(4), 479-487. Sue, S., Fujino, D., Hu, L., Takeuchi, D., &Zane, N. (1991). Community mental health services for ethnic

minority groups: A test of the cultural responsiveness hypothesis. Journal of Consulting and Clinical

The role of culture and cultural techniques in psychotherapy. American Psychologist, 42(1), 37-45.

American Indian concepts of mental health: Reflections and directions. In P. B. Pederson, N. Sartorius, & A . J. Marsella (Eds.), Mental health services: The cross-cultural context (Vol. 7, pp. 199-220). Beverly Hills, CA: Sage.

Tripp-Reimer, T., Brink, P. J., & Saunders, J . M. (1984). Cultural assessment: Content and process. Nurs- ing Outlook, 32(2), 78-82.

US. Bureau of the Census. (1990). I990 Census: National and statepopulation counts on Asian or Pacific Islander Americans. Washington, DC: U.S. Department of Commerce, Bureau of the Census.

Weiss, M. G., & Kleinman, A. (1988). Depression in cross-cultural perspective: Developing a culturally informed model. In P. R. Dasen, J . W. Berry, & N. Sartorius (Eds.), Health andcross-culturalpsychology: Toward application (Vol. 10, pp. 179-206). Newbury Park, CA: Sage.

Whorf, B. L. (1956). Language, thought and reality: The selected writings of Benjamin Lee Whorf. Cam- bridge, MA: The M.I.T. Press.

Yeh, M., Eastman, K., & Cheung, M. K. (1994). Children and adolescents on community health centers: Does the ethnicity or the language of the therapist matter? Journal of Community Psychologv, 22,271-781.

Zane, N . , & Sue, S. (1991). Culturally-responsive mental health services for Asian Americans: Treatment and training issues. In H. Myers, P. Wohlford, P. Guzman, & R. Echemendia (Eds.), Ethnic minority perspectives on clinical training and services in psychology. (pp. 49-58). Washington, D.C.: American Psychological Association.

PSyChOlOgy, 59(4), 533-540. Sue, S., & Zane, N. (1987).

Trimble, J . E. , Manson, S. M, Dinges, N. G., &Medicine, B. (1984).

a paradigm for culturally based care in ethnic minority populations

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