Investigating the Context

Investigating the Context: What Theory and Research can Contribute to Cross-cultural Therapeutic Practice

Güler Okman Fişek, Prof. Dr., Ph.D.


            The aim of this paper is to explore the enabling contributions of theoretical information to the provision of mental health services to diverse client populations.  As valuable and rewarding as it is, mental health practice is also often faced with frustrating setbacks, demands for urgent solutions and incomprehensible client behaviours.  While general  psychological theory and research can seem irrelevant to the harried practitioner, nevertheless informed utilisation of theory can also help render the sources of frustration understandable, even more amenable to intervention.

            This paper explores the issues involved in the interface of theory and practice by focusing on a specific domain of practice: the work of Western mental health professionals and immigrant clients from non-Western cultures.  The case of German therapists working with Turkish immigrant families is used as an example to demonstrate the issues.  Most mental health problems Western practitioners face in their work with immigrants tend to be family problems, indeed most health problems involve the family in many immigrant contexts.  Thus such a discussion may apply to other topics and other cultures as well.  This discussion considers first what the professional brings to the therapeutic encounter, second the problems posed by the culturally different client, and lastly the problem of intervention.


Case Example: The Professional and the Culturally Different Client.

            Human history has always involved immigration, but the recent emphasis on globalisation and multiculturalism is bringing the vicissitudes of intercultural encounter into primary focus.  Accordingly the mental health professions have to develop new approaches that are not based on the expectation of "assimilate or remain unserved".  The professional working with immigrant clients has to figure out how to view the therapy situation differently, what to do differently and what different reactions to expect.  The professional has to understand his/her contribution to the therapeutic relationship as well as the client's and fashion an approach on that basis.  Psychological theory has much to offer in this effort.


The Perspective of the Professional.

            The mental health professional approaches his/her work with certain expectations regarding the structure and process of the therapeutic relationship. The structuring of appointments, punctuality, exactly what kind of help is to be sought and offered, therapeutic compliance, the nature of the interpersonal relationship are all features of the "culture" of the professional.  The client who does not seem to hold the same sort of expectations presents a dilemma: the dilemma of difference, and the practitioner reacts as we all do, with a set of biases.  The professional may be unaware of these biases, yet feel constrained in trying to reach the client effectively.  Without an informed and systematic understanding of how biases operate, efforts to overcome constraints are oftentimes based on trial and error compounded by prejudice.  When something works, it will not be altogether clear why, nor will it be clear how to replicate the success.

            This is one point where theory on bias can help the practitioner.  Of the many theoretical approaches to the topic, Hare-Mustin and Marecek's (1988) discussion of the construction of gender differences is also particularly apt when applied to constructions of cultural differences (Fisek and Schepker, 1997).  They provide a systematic framework within which to understand distortions in construing difference and the resulting implications.

What the Practitioner Brings to the Relationship: Multiple Biases.

            The practitioner, like everybody else, is embedded in a particular social-structural, cultural and historical context, which influence and bias his/her approach to selfhood and relationships.  In addition however, as a member of a professional culture, he/she may be subject to one of two specific biases that influence how differences are construed and the consequent implications.

            "Alpha bias" (Hare-Mustin and Marecek, 1988) involves an exaggeration of the differences existing between two cultures.  The therapist of a host culture or an elite professional class dealing with a client from a different group sees the differences in behaviour, values, and mores between the two cultures as being too great to find a common ground.  The consequences of such an approach would be as follows:

            Emphasis on differences classifies people in such a way that variability within each group is obscured, especially those due to social class.  For example, an educated urban Turk will have more in common with an educated urban German than with a rural Turk in some ways, but this is obscured by classifying all Turks as being similar and different from all Germans.  Not only do these dichotomies obscure variation; they contain hidden hierarchies, so that the ways of one group are implicitly valued more highly than those of the other (Hare-Mustin and Marecek, 1988).  For example, the professional may see the prototypic Western norm of autonomy as inappropriate for the Turkish client whom s/he sees as being embedded in an interdependence culture.  The important thing here is to see whether this judgement also implies a devaluation of the norm of interdependence. Such devaluation may limit opportunities for meeting on common ground.  Where implicit hierarchies are absent, Alpha bias does have the potentially positive effect of highlighting the valuable aspects of the other culture.   However here lies the risk of cultural relativism, which can bring about double standards, where what is good for members of the dominant culture is different from what is good for members of the other group; separate but equal can easily become separate and unequal.  In extreme cases such bias can lead to outright rejection.  Unfortunately there are examples of professionals refusing to offer their services because of ostensible language problems, such as the case of an anorexic Turkish teenager in Germany who was shunted between services until she was referred to a therapist in Turkey (cf. Fisek and Kagitcibasi, 1999).

            It should be stressed that bias can exist within the same society in the context of class differences.  A child from a low SES neighbourhood was brought to a clinic accompanied by his mother, grandmother, uncle and sister. The reaction of the therapists who saw them coming in was "what an enmeshed family!" In fact, the uncle had driven them in and the rest had come to see a part of the city they had never seen before!

            In "Beta bias" (Hare-Mustin and Marecek, 1988) cultural differences tend to be ignored, reflecting an assumption that "we are all part of the human family".  While at some level this is true, it is also true that we belong to different branches of the same human family. The underlying assumption of similarity rarely takes into account the qualities of the other, and the family resemblance tends to be based on "my branch of the family", thus obscuring that which is unique about the other.

            The most problematic outcome of Beta bias lies in ignoring the differential impact of the social context, that is differences in cultural expectations, power, and resources, on individuals. Members of the dominant or host culture and members of the "other" cultures do not benefit similarly from "neutral" procedures, and equal treatment is not always equitable.    For example the neutral therapeutic contract regarding the regulation of appointments and punctuality with respect to appointments can seem a punishing and alienating procedure to someone of lower social class. Similarly, the confidentiality rule can be alien to people with an Eastern familial self-construction (Roland, 1988). Thus, differences of culture and class can lead the lower class immigrant to be unaware of or to mistrust the social contracts implicit in professional relationships, which are "obvious" and "fair" to the practitioner.

            In summary, the point here is for the practitioner to be cognisant of relevant research and theory in the social sciences, especially social psychology and sociology, to counterbalance the potentially biased focus on the individual person or family.  Awareness of basic structural and contextual parameters is especially important in trying to understand one's own blind spots, thus one's share in intercultural impasses (Falicov, 1995).  Only then can one hope to achieve a fuller understanding of the client's frame of reference.


The Context of the Client.

            The client is neither so similar to the professional as to warrant the assumption of an easy match, nor so different as to preclude all workability.  In fact the client system is different in some theoretically and empirically specifiable ways, which once understood, can help generate some practical approaches to reaching the client.

            This issue points to another entry point for theory in conceptualising differences, based on the findings and formulations of cross-cultural psychology, sociology and anthropology (Kagitcibasi and Berry, 1989).  The approach used in the Multilevel Contextual Systems Perspective (Fisek and Schepker, 1997) describes cultural differences by the use of some key dimensions that are seen as underlying differences in interpersonal relations and personal experience in human collectivities.  The relevant theoretical and empirical literature tends to agree that two such important dimensions can be subsumed under the two wide ranging categories of "structure" referring to social organisation, role relationships and power orders, and "relationship" referring to the degree of social and emotional interconnectedness.  These two dimensions can be used to describe human experience at various levels of collectivity, going from the societal, to the familial to the individual.  The basic assumption is that cultural organisation provides the matrix for the development of family organisation, which in turn provides the matrix for the development of self  organisation (Hsu, 1985; Howard; 1991; Roland, 1988).

            At the cultural level, structure describes societies in terms of a bipolar dimension or continuum, ranging from a hierarchical/authoritarian structure to a horizontal/egalitarian one (Hsu, 1985; Kagitcibasi, 1990; Roland, 1988). Relationship at this level ranges from individualism/separateness to collectivism/ relatedness (Kagitcibasi, 1985; Triandis et al., 1988) in reflecting the preferred mode and extent of interconnectedness.  At the family level, structure is seen in the dimension of gender and generational hierarchy which varies in strength and identifies the power and role boundaries differentiating individuals and subsystems within the family system, while proximity varying in degree, reflects the interconnectedness and the emotional reactivity of the relationship network within the family (Fisek, 1991, 1995; Minuchin, 1976; Wood, 1985).  At the level of the self, the very definition of selfhood can differ across cultures (Landrine, 1992; Kagitcibasi, 1990; Markus and Kitayama, 1991; Roland, 1988; Shweder & Bourne, 1984).  At one pole of self structure is the "familial self", an intrapsychic organisation that allows the individual to find a niche for selfhood "within the hierarchical intimacy relations of the family", while the other pole contains the "individualised self", an intrapsychic organisation which permits autonomous existence and development within a network of "contractual egalitarian relations" (Roland, 1988, p. 7-8).  Relationship for the familial self involves "closeness through connections", an interpersonal relatedness that is assumed as a given; while for the individualised self it involves "closeness through autonomy", an interpersonal relatedness that is achieved through negotiated disclosure (Fisek and Schepker, 1997).

Cultures, families and individuals are seen as being situated differentially on these dimensions but they do not act alone.  Variables such as social class, degree of intercultural exposure, socio-economic change, and especially differences in the degree of structural/organisational differentiation among institutions of different cultures influence where individuals and families fall on these dimensions.

            Schematically, traditional Turkish culture is represented as being closer the hierarchical/relatedness end of the relevant dimensions, the family leans towards strong hierarchy and high proximity, and the self tends to be familial in structure and enjoys closeness through connection.  In contrast, German culture falls closer to the horizontal/separateness end of the dimensions, with the family showing weak to moderate hierarchy and low to moderate proximity, self experience tends to be individualised and closeness is achieved through autonomy (Fisek, 1982, 1991, 1993, 1995; Fisek and Schepker, 1997; Kagitcibasi, 1990).  German institutional structure is highly differentiated and involved in the lives of individual citizens, while Turkish institutional structure is less involved, leaving the individual very much in the hands of the family.  Even though contemporary Turkey is undergoing major social changes, the traditional underpinnings of the culture tend to be as stated.

Knowledge of such a multilevel contextual perspective, combined with an awareness of class differences, can help the practitioner "place the client system in context" so that previously incomprehensible or unacceptable behaviours can become meaningful.  For example, the issue of therapeutic noncompliance and the relative underrepresentation of low SES Turkish immigrant families in the German mental health system has been a frequent problem (Eberding and von Schlippe, 2000).  Assumptions about the somaticizing tendencies of this group or references to religious differences are frequent among practitioners, all examples of potential alpha bias.

Awareness of the above perspective would add another dimension; the issue would become one of searching for relationship building and interactive attunement, as follows. To the lower class family of rural origin, the urban mental health center or hospital is a complex elite institution high up and distant in the societal hierarchy.  This distance and a relative lack of an individualistic sense of civil rights as a consumer make approach difficult.  Back home these families solve their problem through the use of an intermediary familiar with the system, usually a relative or village mate, an expression of familial relatedness  (Gokce et al, 1993).  Once in the system, they tend to approach the professional with a discourse borrowed from familial hierarchy, referring to him/her as an older sibling, uncle or at least a teacher, again trying to build a familial bridge to cross the hierarchical gap (Duben, 1982).  Immigrant families frequently resort to intermediaries in the host culture also. However the prototypic Western therapeutic encounter does not easily allow a familial, relationship building discourse; especially if the professional is uninformed about cultural dimensions as specified above, leaving the family at risk of being cut off from contact.   The professional can "join" and build a relationship if s/he is able to place the client behaviours in context through an informed awareness of multilevel contextual influences on psychological experience.  Further the practitioner can then help the clients place their own problems in a cross-cultural context, thereby rendering them more open to intervention.


Problems of Intervention.

            Once the practitioner is aware of his/her own biases and has understood the client system's context, the next step has to do with intervention.  Here there are two concerns: the issue of what intervention will be useful and the issue of values, toward what kind of goal the practitioner should aim.  A typical problem encountered in the German context may help elucidate this point

            German therapists working with Turkish families frequently wonder "What do we do with the authoritarian father figure?"  The therapists' egalitarian democratic values lead them to rebel against intrafamilial hierarchy yet their efforts to get the father to change often lead to increased rigidity of the system, lack of compliance or even losing the family.  Looking at the family system through the lens of the multilevel contextual schema may clarify why focusing on hierarchy alone is likely to be counterproductive, in so far as it elicits protective negative feedback mechanisms and rigidity rather than transformation to a more democratic horizontal structure.  The above schema indicates that the normative family system balances strong hierarchy with high proximity.  Thus if traditional hierarchy dissolves too rapidly, existing as it does in conjunction with a relational style of high proximity, this imbalance is likely to lead to dedifferentiation, high emotional reactivity and overinvolvement, ie, pathological enmeshment, or to escalating conflict and the risk of system breakdown.  Needless to say therapists want to avoid such consequences.

            How does one approach hierarchy in a culturally sensitive manner, without a counterproductive confrontation of "traditional Middle Eastern patriarchy", or a postmodern noninterventionist "to each his own" relativism?  Here again theory and research can provide useful leads for the professional, from family systems theory (Hoffmann, 1981) and practice based research on work with immigrant groups focusing on a contextual approach that emphasises intercultural and intergenerational communication (eg. Szapoznick and Kurtines, 1993).

            Family systems theory talks about two kinds of change, first and second order (Hoffmann, 1981). First order change can involve a negative feedback sequence whereby the family turns in on itself in a protective homeostatic move to avoid demands for change or a positive feedback sequence where demands for change lead to escalation of intrafamily conflict and to the risk of system dissolution.  There is another possibility, second order change, in which the system reorganises at a new level of adaptation to external conditions (Hoffmann, 1981).  Second order change would involve escalation of conflict to the point at which family members would see the need to negotiate new rules for family life, thus opening the way to adaptation.  Of the three reactions this obviously is the preferred reaction to therapeutic interventions.

            Knowledge of the family's structure may indicate what conditions facilitate families' ability to transform themselves.  Systems cannot change in all respects at once; small partial changes need to occur in the process of overall transformation (Hoffmann, 1981).  Thus one subsystem can begin changing while others remain unmodified. Immigrant children, for example, develop new attitudes, while their parents remain wedded to old ideas.  This is possible if there are clear boundaries, which allow subsystems to function independently of each other to some degree.  In enmeshed systems that are "too richly cross-joined" (Hoffman, 1981, p. 71), change in one member immediately sets off a reaction in other members and can hinder partial modification.

Subsystem boundaries that allow partial change can exist along the hierarchy or proximity dimensions.  In the prototypic German family, moderate hierarchy, moderate to low proximity and resulting individual autonomy ensure boundary clarity and independence.  In the traditional Turkish family system boundary clarity is ensured by virtue of gender and generational hierarchy, since high proximity by itself would engender enmeshment.  Individuals in female subsystems can engage in activities that they are not expected to share with those in authority over them; hierarchical distance between father and child can allow the father not to have to confront some newfangled activities and interests of the child and so on.  An immigrant father stated "By pretending not to know about my daughter's boyfriend I don't have to confront her and can still keep my authority".  Thus seemingly oppressive boundaries can paradoxically serve to create subsystem autonomy, allow relative individuation and subsystem change and moderate the effects of otherwise too richly cross-joined proximity.  Roland (1988) refers to this way of coping as "contextualisation", the simultaneous maintenance of contradictory values and practices within the Eastern psyche. These seeming contradictions can be fruitfully utilised in therapy only if the therapist is aware of the role of these dimensions in the traditional Turkish context, and can make use of this awareness. 

Theoretical understanding of the role of hierarchy and proximity in family functioning can facilitate interventions whereby families are taught to see these dimensions at work (Szapoznick and Kurtines, 1993).  For example confrontation of hierarchy can be facilitated by normalising and legitimising a variety of voices in the family, individuation can be encouraged via separate sessions for members of different subsystems, acceptance of intrafamilial differences can be facilitated by a discussion of multiple needs, etc.  Finally awareness of culturally based intrafamilial constraints can help differentiate them from universally dysfunctional structural aberrations and open the way to proper intervention.  Needless to say many of these points are of value in individual therapy since much of the discussion will focus on the familial, within and without the psyche of the individual.


What Practice Can Offer Theory.

            Scientific theory has traditionally claimed to be pure and objective.  We know in this postmodern age that there is no absolute purity and objectivity yet science tends to cling to such claims.  In fact the biases described here exist in all of us including pure scientists and theoreticians.  In combating these biases I find one practice-based principle of paramount importance.  Truly effective and ethically sound cross-cultural psychotherapy practice has one dictum above all: know that you do not know and be curious (Falicov, 1995).  This means accepting that despite being experts we do not know our culturally different clients, are humbly curious about them and wait for them to teach us.  This is also the essence of good theorising.  If science can maintain this dictum in its ongoing practice, then not just a very effective bridge but a unity underlying science and practice can be achieved.




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