The Psychotherapy of Hope: The Legacy of Persuasion and Healing

14 Cultural Dynamics in Psychotherapy and Cultural Psychotherapies: Ingredients, Processes, and Outcomes

CHAPTER 14 Cultural Dynamics in Psychotherapy and Cultural Psychotherapies Ingredients, Processes, and Outcomes Renato D. Alarcón, M.D., M.P.H., Julia B. Frank, M.D., and Mark Williams, M.D. . . . the psychotherapist, as a socially sanctioned expert and healer and a symbolic member of the patient’s reference groups, may be able to mobilize forces that are sufficiently powerful to combat demoralization and produce beneficial changes in the patient’s assumptive world, thereby improving the patient’s adaptation and bringing about a concomitant reduction in symptoms. —persuasion and healing, 1991, p. 51 Jerome Frank’s definition of psychotherapy captures its essential sociocultural nature: “a healing relationship . . . [in which] the healer tries to bring about relief of symptoms . . . typically accompanied by changes in emotional state, attitudes, and behavior . . . The healing influence is exercised primarily by words, acts and rituals in which sufferer, healer, and sometimes a group participate jointly” (Frank and Frank 1991, p. 2). It follows that the practice of psychotherapy requires both training and expertise and a solid cultural competence . Cultural competence is the individual clinician’s demonstration of respect for and interest in the cultural factors that shape a given patient’s context and behavior (Tseng 2004; Lu 2006). While exercising the ability to translate and integrate cultural information into a comprehensive therapeutic approach, clinicians must remain aware of their own perspectives or biases. At the same time, the cultural norms of the society in which the psychotherapeutic encounter takes How funny it’ll seem to come out among the people that walk with their heads downward! The Antipathies, I think, . . . but I shall have to ask them what the name of the country is, you know. Please, Ma’am, is this New Zealand or Australia? . . . And what an ignorant little girl she’ll think me for asking! No, it’ll never do to ask: perhaps I shall see it written up somewhere. —Alice’s Adventures in Wonderland 282 Alarcón, Frank, and Williams place dictate the roles of therapist and patient. The therapist’s methods and skills, the nature of the transactions, and even the outcomes of treatment reflect expectations nurtured by culture. Thus, culture itself becomes a therapeutic tool, a different lens through which to evaluate human transactions. Culture and psychotherapy mutually or reciprocally influence one another. Some psychotherapeutic schools have, on occasion, changed the cultural climate of their time; the best example is the “liberating” effect of psychoanalysis on the rigid Victorian codes of late nineteenth-century Europe. Psychoanalysis provided seemingly rational and logical (“scientific,” as Freud claimed) explanations for mysterious or profoundly troubling inner feelings or emotions and the behaviors that expressed them (Assoun 1981). Freud and his followers precipitated a dramatic shift in the surrounding culture, placing the effort to understand human subjective life in scientific terms, on an equal footing with religion and moral philosophy. Against culture as a conceptual frame, as outlined in a chapter 5, patient and therapist interact in ways that express culturally derived knowledge, beliefs, and the very notion of who they are and what made them the way they are. Participation in therapy exposes these qualities to scrutiny by another person, as each expresses views and emotions in an effort to understand the other. This dynamic, then, follows two converging routes: one that defines the patient and his or her problems and the therapist’s perceptions and skills (we call them “cultural endowments”), and another that delineates the psychotherapeutic encounter and its outcomes as a thoroughly cultural occurrence. In this chapter we explore the influence of culture on the participants in the psychotherapeutic encounter and discuss how culture structures the encounter and its outcome in light of the thoughts and perspectives expressed by Jerome Frank in Persuasion and Healing. Cultural Endowments of Patient and Therapist The cultural qualities of therapists and patients range from the “assumptive world” of each protagonist to the manifestations of the “culture-bound syndromes ” (Paniagua 2000; Baer et al. 2003). These syndromes, and the corresponding notion of culture-bound psychotherapy, create a loose network linking culture, symptoms, and the dynamics of psychotherapeutic transactions . The threads of this network, the active influence of meaning and identity as individual ingredients and of stigma as a more group-based and group- Cultural Dynamics in Psychotherapy 283 oriented occurrence, at once broaden and constrain the interaction of patient and therapist. Assumptive World Jerome Frank enriched the conceptual catalogue of psychiatry in elaborating Cantril...