As you learned in the diagnosis part of this unit, culture can play a key role in the manifestation of symptoms.  It is important that psychologists consider an emic approach to diagnostic, rather than simply applying their own cultural standards for diagnosis. It then follows that if this is important in diagnosis, culture must also play a significant role in the success of therapy. Cultural beliefs in a society influence the therapy process because they form a part of both the therapist's and the patient's definitions and understandings of the problem trying to be solved.

A counselor who takes on an etic perspective believes that disorders such as depression and the behaviours that come along with them occur the same way in every society. They believe that mental disorders are universal and all clients should and can be treated and diagnosed in the same manner.

A counselor who takes on an emic perspective believes that many factors come into play when diagnosing and treating a client especially in regards to their culture. Some factors can include cultural values, morals, and lifestyle.

In reality, when working in a diverse, global society - it is important to remember that there are cultural differences, but there are also many similarities. Therapists must engage with the never-ending tension between differences and universalities in abnormal behaviour. It is not the case that therapists must use either an etic or an emic approach, but that they are able to distinguish between the aspects of a disorder that appear to be universal and those that appear to be more embedded in a local culture.

Indigenous psychotherapy

Indigenous therapies reflect the values and practices of a culture. The study of indigenous psychotherapy is difficult for several reasons. Often indigenous therapies require no formal training.  It is often practiced within families or communities and is not open to people outside of the community.  There is a lack of standardized procedures that could be evaluated for effectiveness.  As a result, there is a lack of reliable quantitative results of these practices that could be studied through meta-analysis.

There are, however, exceptions to this.  Morita therapy is a therapy that is rooted in fundamental beliefs and values in Japanese culture.  These include:

• Feelings are natural responses to our life circumstances and we need not try to “fix” or “change” them.
• Dogmatic thinking - that is, perfectionism and high demands on oneself - hinder recovery. Liberation from self-centeredness leads to healing.
• Isolation and rest, rather than verbal interaction, is essential to recovery.

The therapy usually begins with a period of rest before counseling begins.  Counseling focuses on changing one's perspective toward the larger community and away from oneself. It also asks the patient to practice mindfulness through meditation. The focus of the therapy is recovery, not the origins of the disorder.

Ando et al (2009) wanted to determine the effect of mindfulness-based meditation therapy on anxiety and depression in Japanese patients undergoing anti-cancer treatment. The 28 patients participated in two sessions of meditation therapy. They were instructed to practice at home between sessions. The study used a pre-test / post-test design. Patients completed questionnaires before and after the treatment. The results showed that anxiety and depression levels decreased significantly. The researchers argue that a sense of spiritual well being is what resulted in lower levels of both anxiety and depression.

Spirituality or religious practices are often an integral part of indigenous therapies. For example, in Malaysia, time for prayer and focusing on verses of the Koran that address “worry” are some techniques that have made psychotherapy culturally relevant.  Sometimes, in therapy with Chinese clients, verses from Taoist writings that highlight main principles, such as restricting selfish desires, learning how to be content, and learning to let go, are read and reflected on by the client. This approach is known as Chinese Taoist cognitive psychotherapy (CTCP). 

Multicultural approaches

Since it is not always possible to transfer the therapeutic techniques from one culture to another, clients of a different culture often have to use the therapy that is available in the dominant culture.  This can be problematic. For example, let's say that an Asian client goes to a therapist who provides CBT in order to deal with feelings that she is bringing shame on her family by dropping out of medical school. If the therapist tells her that she cannot live her life solely to meet the expectations of others, she may never go back for another session.  She may feel that she is not culturally understood and that therapy is pointless. 

When there is a large community of a cultural group, it is possible that they may seek out help from within their community. Dein and Sembhi (2001) carried out a case study of 25 South Asian psychiatric patients in London. They found that 28% of the sample went to a traditional healer as a supplement to the psychiatric care they received in the UK. This may be the result of one's level of acculturation. Older patients were much more likely to seek out a traditional healer compared to younger patients.

A meta-analysis of 76 studies of Western therapy that had been adapted to meet the cultural needs of clients was carried out by Griner and Smith (2006). The findings indicate a moderately strong benefit of culturally adapted interventions. They were four times more effective than non-adapted strategies applied to a range of clients from a variety of cultural backgrounds. They also found that interventions conducted in clients' native language were twice as effective as interventions conducted in English.

Access to care

On November 9, 2004, the Chinese-American community was shocked to learn that one of their leading historical writers, Iris Chang, had committed suicide as a result of her continued depression. Her body was found in her car in Los Gatos, California, with a self-inflicted gunshot wound to her head. At 36 years old, she was well known for her book The Rape of Nanking.

Chang's death led many in the Chinese American community to begin discussing their approach to US mental health services. A report by Leong and Kalibatseva (2011) outlines the key barriers for this community.

Cognitive barriers: The way people think about treatment is influenced by culture. Among several ethnic minorities - including Asian, Hispanic, and African Americans -  it is often believed that mental illness can be treated or overcome through willpower and endurance of hardship without complaint, rather than by seeking external, professional psychological help  Some research indicates that Asian Americans are more likely than Caucasian Americans to believe that mental health was enhanced by exercising self-control.

Affective barriers: Many collectivistic cultures, like Chinese-Americans, avoid seeking help in order to avoid the stigma and shame of mental illness. Since the family name and “face” are very important, Asian Americans may decide to protect the family’s reputation by not openly seeking help even though they may be having psychological difficulties.

Sociocultural barriers: The disclosure of personal problems or family dysfunctions to strangers - for example, a therapist - is highly discouraged in collectivistic cultures, especially in cultures that place a strong emphasis on maintaining group harmony and firm in-group versus out-group boundaries.

Some of the sociocultural barriers are less theoretical and more practical. Often immigrants lack knowledge or awareness of the available services. Even if they are aware of what is available, mental health services may be unaffordable for individuals with a low socioeconomic status. Clients with lower socioeconomic status may not be able to spend time receiving care because they need to work multiple jobs and/or take care of family members. Finally, low English proficiency of immigrants and the scarcity of bicultural and bilingual mental health professionals also act as a barrier to seeking help.

Checking for understanding