Since its origins, roughly 125 years ago, the field of psychotherapy has been primarily focused on individual clients, applying theories and practice that grew from Western European and American individualistic philosophies, religions and values. Since the 1970s and continuing into the 21st Century, a focus on couple therapy and a dramatic increase in clients with diverse backgrounds have emerged.

Many of these clients bring with them collectivist values, orientations, and religions, particularly around relationships, marriage and family values. How do our models of Euro-American psychotherapy work with couples from collectivistic cultures where values of harmony, fitting in, family ties and avoidance of shame take precedence over self-actualization? This is no small question.

To answer that question, we explored in depth four Asian cultures from East to West: The Philippines, China, India and Israel. Because my four colleagues themselves came from four such cultures, we were able to interview clients and therapists and read scholarly articles in their primary languages (Tagalog, Hindi, Tamil, Mandarin, Hebrew).

In our recent book, Couple Therapy through the Lens of Four Asian Cultures: Working with Clients from Collectivistic Cultures Living in North America, by Shapiro, Wei, Sethu, Gazit and Scott, we offer numerous case vignettes to illustrate the conceptual and intervention differences.

Barriers

We had to deal with client barriers as we worked on integrating multicultural understanding into therapy, including cultural stigma surrounding mental health, language proficiency issues, lack of access, culturally-informed professionals, unique nature of counseling relationships and unfamiliarity with the therapeutic process.

There are also barriers presented by therapists, including biases regarding gender roles and relationship equity, a lack of knowledge of clients’ home culture and expectations favoring Western forms of adaptation, especially around individuation and boundary-setting, lack of understanding and respect for arranged marriages, gender roles and traditional, indigenous forms of healing, and discomfort in introducing culturally-oriented topics in the therapy process.

What do therapists need to know about working with clients from Asian cultures?

The most dominant skill is the therapists use of themselves as persons in interaction, co-creating the therapy with the client couple. A therapist’s presence, empathy, curiosity, humility, and capacity to meet clients in their own cultural frame of reference is essential. The therapeutic process is as much about “being with” clients as it is about guiding them. Cultural humility, process orientation, and attunement to non-verbal cues are indispensable.

In these contexts, trust and safety are built more slowly. A cultural assessment including level of acculturation and clients’ values precede any solution-focused work. Empathy and listening were more important than specific cultural knowledge. As one client opined, “(the therapist) didn’t know anything about China and Chinese people, but she was always interested in learning how our background was important in the present. She was a good listener.”

Non-linear approaches, such as the use of symbols, stories, metaphors and language served to be effective without direct confrontation. We found it effective for clients to speak to one another in the language they use at home, even when the therapist does not understand that language.

It is essential to honor and incorporate clients’ beliefs in non-western systems, such as fortune telling, palmistry, astrology, indigenous healing practices, spirituality or religion.

Ultimately, therapy succeeds less because of the therapists’ expertise in Western-oriented solutions, but because they blended universal skills with cultural attunement.

For example, because interpersonal boundaries are different, therapists must be aware of the significance of family, community and social harmony. In a case example described in the book, one First-Generation Chinese-American man seeking a special accommodation at work, refrained from asking his direct boss for help. Instead, with therapeutic encouragement and some story-telling, he successfully arranged for a mutual friend as a go-between to avoid any hint of shame to either party.

An active but non-directive role

Because of cultural sensitivities, it is often important for therapists to introduce topics such as cultural identity, acculturation stress, religion, spirituality, and important cultural myths and stories with a multi-generational perspective for discussion. Thus, therapy goes beyond what clients are saying or avoiding saying, but includes the clients’ living contexts.

In the case of an Indian-American mother’s sense that her mother-in-law was being intrusive with regard to parenting, a Western approach might involve helping her set clear boundaries on what goes on within the household in a direct conversation. Yet in some cultures, issues of family harmony, shame and avoidance of confrontation may render that solution impossible. Instead, the therapist helped her identify specific areas of discomfort and then helped her involve her husband and father-in-law to indirectly intervene to “benefit the family as a whole.”

Awareness of therapist biases: Judgments that will interfere with cultural sensitivity.

In particular, a belief that arranged marriages are inferior can be detrimental. Similarly, a therapist’s deeply held values of equity between the sexes may be challenged in cultures where the woman’s role seems more constrained and anathema to modern Western beliefs of gender-role equality.

Final Reflection

• For couple therapists, the essential challenge lies in embracing complexity. By staying curious, attuned, and self-aware, we can help couples find strength in drawing sources of healing from their culture.
  • Techniques are secondary to the relationship and must serve the couple in their context.
  • Recognizing shame and harmony as central values is vital in collectivist contexts.
• The therapist’s self-awareness is the best safeguard against bias (especially around Western notions of love, marriage and relationships.
• Healing emerges primarily from co-creating meaning within the clients’ cultural world, rather than from theoretically-based “correct answers.”
• Indirect approaches such as stories, metaphors, and language shifts (decoding) can unlock cultural resonance and enhance alliances.
• Recognizing the non-verbal messaging may be particularly valuable especially in cultures in which verbal confrontation is unacceptable. Therapy in these contexts is more about walking alongside clients — in their languages, metaphors, and values, honoring their humanity and their cultural heritage.

Meeting this challenge requires that we as therapists lean less heavily on our traditional individualistic training, recognizing that only some of that knowledge of couple therapy will apply.