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Gestalt therapy in working with culturally diverse populations

The publisher's final edited version of this article is available at J Clin Psychol See other articles in PMC that cite the published article. Abstract Achieving effectiveness of therapeutic interventions across a diversity of patients continues to be a foremost concern of clinicians and clinical researchers alike.

Further, across gestalt therapy in working with culturally diverse populations orientations and in all treatment modalities, therapy alliance remains a critical component to determine such favorable outcome from therapy. Yet, there remains a scarcity of empirical data testing specific features that most readily facilitate effective collaboration in a multi-cultural therapy relationship.

This is followed by a multi-cultural case study presenting with several co-morbid Axis I disorders, to exemplify the application of these guidelines over the course of therapy. The role of culture in psychotherapy has been gaining significant attention in the past few decades Wohl, 1989 ; Seiden, 1999 ; Draguns, 1997particularly as the populations seeking psychological services grow increasingly diverse. This distinct gap between stated intent of incorporating cultural differences into current evidence-based treatments, and actual clear guidelines for accomplishing this goal must be more directly addressed.

This article therefore aims to review the empirical literature on effective enhancement of collaboration in the multicultural therapy setting, to reveal the common and specific features across a range of treatment modalities. Key Terms Researchers have provided several relevant working definitions within cultural therapy that are noted here.

Age and generational influences, Developmental disabilities and Disabilities obtained in later lifeReligion and spiritual orientation, Ethnic and racial identity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender.

Such a term captures the complexity of cultural identity and the number of factors to consider when we discuss the impact of cross-cultural differences in therapy.

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In addition, cultural identity of an individual is tied into other key processes not noted in even this rather comprehensive acronym, such as discrimination and acculturative stress. Indeed, several empirical studies have found differences based on this construct in acceptability towards, and extent of, certain psychological symptoms, including social anxiety Heinrichs et al. Again, these are important considerations that inform our understanding of the cultural lens of patients engaging in something as personally revealing as psychological therapy.

One other concept that is of particular importance in the current discussion is that of cross-cultural competency, which provides an index of how skilled 1 a clinician feels about their abilities to manage cultural issues raised in therapy, and 2 a patient perceives the clinician to be in their ability to handle such topics in the therapeutic context Lee, 2011.

Further, the therapists most likely to discuss cultural differences with patients were those who were older, female, of non-minority racial status, those who felt they were less experienced with treating diverse clients, and those who felt training is an important feature of effective therapy delivery. Given this inconsistency in the literature on the impact of cultural competency on outcome, there needs to be a more systematic empirical study of this concept across a diversity of populations.

Empirical Data Identifying Specific Features While differential rates in report and diagnosis of certain disorders across race-ethnic groups in the United States have been noted in several large-scale epidemiological studies Grant et al. Further, results indicated that when mental health treatments were designed targeting one particular cultural group in mind, these treatments outperformed other treatments serving patients from a variety of cultural backgrounds. Such findings highlight two needs: While both of these needs are recognized by proponents of culturally-responsive psychotherapy, there have been a reasonable number of smaller qualitative studies on specific aspects of multicultural therapy.

Such studies provide rich insight into the factors that clinicians are advised to consider when engaging in therapy with clients of varying cultural backgrounds, and preliminary directions for most gestalt therapy in working with culturally diverse populations, experimental study designs. Complex coding procedures from a narrative research perspective were supplemented by the information provided on various process and symptom measures which were both subjective and objective in nature.

Another qualitative study investigated the impact of how practitioners from a dynamic or relational treatment perspective addressed cultural issues with clients on the strength of the treatment alliance Lee, 2009. The therapists in this study consisted of 4 white clinicians, and the content of their therapy sessions with 6 minority patients were analyzed using Conversation Analysis and Structural Analysis of Social Behavior.

There was no significant association between these moment-by-moment interactions and the other two main subscales, i. Again, it appears that cultural congruence between client and therapist plays a role in enhancing the moment-to-moment collaboration and alliance of the therapeutic relationship. Such a finding further points to the need to incorporate cross-cultural features explicitly into treatment to facilitate the therapy relationship, regardless of treatment modality.

In addition, there are several other cross-cultural models examining the establishment of a strong working alliance, which are themselves grounded in existing evidence-based research findings e. The common features and themes as gleaned from these various sources are integrated to produce the following guidelines for practitioners.

All patients must still be regarded as unique individuals who lie on a more dynamic spectrum of cultural identification, and cultural groups must be seen as heterogeneous populations with some more or less likely dominant themes.

Related to this, before engaging in any adaptation of existing treatment techniques, gestalt therapy in working with culturally diverse populations must be adequate information gathered about how cultural beliefs are specifically shaping or maintaining problematic emotional symptoms.

A clinician should not make blanket assumptions about how a specific cultural belief introduced by patients informs their experience of distress. Engage in self-education about specific cultural norms and consult the literature for culture-specific treatment techniques As the meta-analytic findings by Smith and colleagues 2011 would indicate, patients might most benefit from treatments that have been specifically modified for a certain population rather than more generally culture-sensitive treatment techniques.

As mentioned earlier, it is imperative that as we embark on cross-cultural therapy that we stay as close to the empirical data to guide us about effective treatments with different populations.

Therapists should therefore first refer to the literature about whether specific cultural adaptations of existing treatments have already been tested and validated e. Borrego, 2010 ; Native Americans: Ensure adequate and effective training of therapists in cross-cultural competency While the literature is mixed e. Also, it is clear that cross-cultural therapy is a complex and multi-layered process, and therefore ensuring cultural competency in mental health work is not simple for trainees to undergo.

Rather, others have suggested that therapists need to have a keen awareness of their own cultural and racial identity, and how this may impact their relationship with clients Plummer, 1997.

Such a reflection is indicative of an appreciation for the bidirectional influence of culture in a therapy interaction, to facilitate a healthy dialogue about sensitive cross-cultural topics that might arise during treatment. A related matter is being aware of the preference for a preconceived ideal of an appropriate relationship between the client and clinician. Specifically, most treatment perspectives in the West emphasize a collaborative therapeutic relationship Taber et al.

In fact, individuals identifying with cultures which are hierarchy-based e. On the other hand, certain treatment perspectives e. CBT involve a considerable amount of direct questioning, which might be construed as disrespectful in other cultures such as Native Americans, and older European Americans; Hays, 2009. Be aware of the importance of respect in the cross-cultural therapy setting Clinicians engaging in multi-cultural therapy must set an overarching tone of respect in order to meet the goals of therapy collaboratively with the client.

Furthermore, establishing trust in the therapy relationship is intricately interconnected to the level of respect shared between the client and therapist. Patients want to feel believed and therefore clinicians are advised to assume the reported incident occurred just as it was described by the patient, gestalt therapy in working with culturally diverse populations provide support around such an experience, and then to later examine how much that experience has influenced the current symptoms of interest Kelly, 2006.

Aligning oneself with patients by demonstrating full support for the difficult race- or culture-related stressors they may be facing will mitigate hesitation in discussing such sensitive issues with the therapist Vasquez, 2007.

For instance, the identified culture itself can be a major resource and provide an extensive support network for the client Cross, 2003. Also, culture itself influences a range of culture-specific skills e. Thus, it is important to bring these culture-influenced strengths of the individual to the therapy discussion, particularly if these positive attributes may be incorporated into treatment techniques and practice.

Hays 2009 astutely notes, however, that certain cultures e. Gestalt therapy in working with culturally diverse populations is therefore suggested that individuals from this more interdependent cultural set-up be asked to think what other significant individuals in their lives might say the strengths of the patient are, in order to access this information and incorporate it into the therapeutic relationship more readily. Therefore, while it is reasonable to utilize treatment techniques that have been seen to be efficacious, we must be ready to modify these techniques in a culturally-sensitive fashion.

Again, it is ideal to make cultural modifications that have been validated in the population of interest, but in the absence of definitive empirical evidence for all possible modifications, we must use our cross-cultural knowledge to make reasonable changes to effective techniques.

The therapist might choose instead to take a more culturally responsive approach Beck, 2005 and ask clients to question the utility or helpfulness of the thought, encouraging them to weigh out the pros and cons of holding on to this belief.

Similarly, CBT often leads to an eventual challenging of core negative beliefs that a patient holds about themselves or the world. With these guidelines in mind, the next section describes a case treated by one of the authors AA and highlights the practical use of these techniques throughout the treatment episode. The influence of these culturally-responsive directives are demonstrated in the progressive development of a strong working alliance in the following clinical case study.

Application of Alliance-Building Techniques: The Case of Karen 1 Karen was a 37-year-old Jamaican-American female and a single mother of 3 teenage-age children, who had recently lost her job due to a change in ownership at her medical insurance firm.

Karen presented to our cognitive-behavioral treatment CBT clinic with a primary diagnosis of panic disorder with significant agoraphobia, and additional diagnoses of obsessive-compulsive disorder and generalized anxiety disorder.

The Impact of History and Counseling Theories on Culturally Diverse Populations

She had also had a past history of major depression and post-traumatic stress disorder from chronic and multiple traumatic experiences. Karen had pursued significant prior treatment, but with little relief in her ongoing anxiety symptoms. She had decided to pursue treatment at our clinic because she had read about the efficacy of CBT for treatment of various anxiety symptoms.

She also hoped that the more structured and short-term nature of this type of treatment might help her develop a more healthy attachment to her provider, which had been difficult in the past. It therefore became apparent from early on in treatment that one therapy goal would have to be to effectively develop a strong working alliance while balancing reasonable boundaries to keep the purpose of the therapeutic relationship clear.

Within the first session itself, Karen expressed her strong religious belief and heavy involvement in church. This did not deter Karen from seeking treatment, but through therapist exploration, Karen admitted that this certainly fueled her own negative beliefs about being different from everyone around her and made her feel discouraged about ever becoming better.

With these larger cultural themes in mind, the therapy content started focusing on specific anxiety symptoms, and explored how culture infused her psychological symptoms in more detail. For instance, Karen reported that her obsessive thoughts about being poisoned by others which would result in avoidance of eating or drinking gestalt therapy in working with culturally diverse populations given to her by others at their homes, or in other settings outside her own home stemmed from a strong belief in black magic, and that others were trying to harm her out of jealousy and control by the devil.

Pathologizing such a common belief from that cultural system as disordered or undesirable was regarded as culturally insensitive and potentially isolating for the patient. Instead, the therapist focused more on increasing her motivation to target the avoidance and interference associated with this thought. Karen really started identifying with this perspective shift, and became much more receptive to the more traditional treatment techniques presented when they were framed with this religious lens.

Ensure adequate and effective training of therapists in cross-cultural competency An interesting feature regarding these two interrelated themes philosophical perspective and stigma was that Karen actually challenged the therapist to reflect at a very early stage in treatment about her own beliefs regarding these issues, and how that might affect the therapeutic relationship.

However, this was recognized as quite likely to be detrimental to the therapeutic alliance, and would run the risk of having Karen disengage from treatment because of a feeling of disconnection from the therapist. An excerpt from the session where the patient directly questioned the therapist about her own beliefs is given below: Do you think people who need therapy are weaker?

Do I think such individuals are weaker than who - those who do not seek a therapist, or those who do not experience emotional distress? And why is it important for you to know how I feel about it?

Do you think that I really should be able to deal with this on my own, and that generally your work is to help people who are weak? Is that partly why you were asking, to see if I feel the way they [her mother, children, and church community] do?

  1. In addition, cultural identity of an individual is tied into other key processes not noted in even this rather comprehensive acronym, such as discrimination and acculturative stress. Culturally responsive cognitive and behavioral practice with Latino families.
  2. As more and more counselors set out to become culturally competent and comply with the ACA Code of Ethics 2014, the future may produce a world where persons of all races, ethnicities, and cultures will be served by the mental health field, and where their issues will be addressed in a competent manner. Posttraumatic stress disorder among ethnoracial minorities in the United States.
  3. Since respect for elders is important in Asian cultures, it is unlikely the client will feel comfortable disclosing her feelings to her father. Indeed, several empirical studies have found differences based on this construct in acceptability towards, and extent of, certain psychological symptoms, including social anxiety Heinrichs et al.
  4. Why psychotherapeutic engagement fails in the treatment of Asian clients.
  5. Journal of Nervous and Mental Disease. The discussion in this article assumes primarily a traditional therapy set-up, and therefore the focus is on how to make more traditional modes of therapy more culturally responsive.

You know, Karen, when I told my family that I wanted to study Clinical Psychology, they were extremely resistant to it. Yet, I had to make a tough decision to stay true to my course of study despite their protest, because I felt that while willpower and spiritual pursuits can be extremely powerful, they are not always effective on their own, in the absence of other resources.

I think you and I are a lot alike in that way — both determined to do our best and get gestalt therapy in working with culturally diverse populations most out of our lives, even when our families or communities might not agree. I need this jumpstart in my life. This was presented after consultation with other clinicians, the literature, and reflection on her personal beliefs towards psychological dysfunction. Even with only this partial disclosure on the part of the therapist, Karen expressed feeling respected and more willing to continue with treatment with this provider.

She noted, however, that she had deeply enjoyed several of these therapy experiences, specifically because of the strong therapeutic relationship she shared with the providers during those experiences. That being said, in the first session she verbalized a concern that her close relationship with her past therapists eventually became a disadvantage, primarily because she found it difficult to terminate these relationships or to continue with skills independently once therapy ended.

Boundary setting in the therapy relationship therefore became a shared goal throughout the course of treatment. This had to be handled in a culturally-responsive way, because it was important not to make Karen feel isolated in her experiences so she would feel comfortable confiding in the therapist.


Specifically, she felt significant distress when interacting with her mother, and yet she worried constantly about her mother dying, and felt that she would be unable to function with her mother gone. Most of her inner conflict in this relationship stemmed from a strongly ingrained cultural pressure to maintain an active relationship with her mother, but this relationship posed significant barriers to her own ability to be productive and stress-free.

Instead, Karen was asked to reflect thoroughly on this relationship with various in-session exercises on the pros and cons of her relationship with her motherto help the patient become comfortable with finding her own balance of meeting her familial responsibility and yet, protecting her own mental health. Similarly, while Karen expressed many traditional cognitions associated with her agoraphobic concerns e. This experience was met with empathic validation and it was discussed at length how much her own perceptions of being negatively regarded by others due to her race tie into her fears around being helpless when experiencing panic outside from her own geographic community.