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Part I
Intersections of culture and theories
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Unpacking and re-packing theories and meanings
Irene W. Chung
Introduction
What are clinical theories?
Clinical theories in the behavioral sciences are bodies of knowledge that attempt to make sense of the complexities of human nature and behavior. They inform the way we focus on the interplay of thoughts, emotions, and behavior in our assessment and intervention with clients. Over the years we have seen theories rise and fall, with new theories building on existing concepts and reflecting the social, political, and cultural ideologies of their times (Applegate, 2000; Berzoff et al., 2011). With the advent of post-modern practice approaches that examine the social construction of meanings and identities in shaping human emotions and behavior (Anderson, 2005; Neimeyer and Bridges, 2003), there has been much recognition that clinical theories, influenced by Euro-American values, need to be deconstructed and reconstructed to better reflect the diversity of client populations who may adhere to drastically different worldviews and behavioral norms (Bonner, 2002; Hodge and Nadir, 2008; Lokken and Twohey, 2004; Manning et al., 2004; Nye, 2005; Sue and Sue, 2003). For those of us who work with Asian immigrants in our clinical practice, the implication is that we need to be able to distill the inherent Western cultural values that are embedded in theories and redefine them in an Asiacentric context (Nagai, 2007).
How can we apply Eurocentric theories in clinical practice with Asian immigrants?
First of all, we need to understand the difference between clinical and cultural meanings. Ideally, clinical meanings provide us with a framework to examine and understand how human beings tend to think, act, and feel when they seek to fulfill their needs and desires, and how they cope with disappointments, losses, and traumas in their lives. However, clinical theories are generally infused with cultural meanings when theorists emphasize and de-emphasize certain foci in their theoretical elucidation. Maslow's (1954) hierarchy of human needs in characterizing human nature is a good case in point. Maslow postulated that our intrinsic human needs that seek and sustain survival, which include basic provisions, physical and psychological safety, social support and connection, self-esteem, and self-actualization, are forces that drive and shape human behavior. His theory is a source of clinical meanings that enhance our assessment of and intervention with all clients in our practice. For example, an appreciation of these needs would help us formulate a more in-depth assessment with a client who presents with complaints of anxiety or depressive symptoms and yet is unable to articulate insights and information other than her personal background and physical complaints. Listening to the client's narratives for themes of these human needs and posing relevant questions will help to illuminate the nature of her emotional distress around her circumstances. So if this client's responses indicate that she is disappointed at her inability to care for herself, we can explore further her sense of deficiency in the mastery of her life roles and tasks. Or if this client expresses her fear of criticism and rejection by others, we will explore circumstances in her family and social life that may undermine her sense of belonging. Such focused exploration will help us make reflections of the client's concerns and emotional needs. This is an important clinical intervention in initiating empathic connections with any client and sustaining her motivation to stay in the helping process.
What is the cultural meaning embedded in Maslow's theory that may interfere with working with culturally diverse clients? His postulation that there is a hierarchy among these human needs and the ranking of self-actualization needs as the most desired is essentially a reflection of the Western values of rugged individualism – self-reliance, autonomy, and so forth that have been celebrated throughout American history. Theorists from a collectivistic cultural background, on the other hand, will likely focus on social needs such as the sense of belonging and acceptance by one's reference group over self-actualization needs. Thus a practitioner's strict adherence to a culturally defined hierarchy of needs without an understanding of the client's belief systems may risk alienating the client by imposing irrelevant questions and making conclusions that are unsubstantiated.
Obviously there are no absolute truths in any clinical theory, and no single theory can afford sufficient insights in understanding the complexities of human emotions and behavior. As clinicians, we are drawn to certain theories based on our background and professional experiences. We can only strive to be aware of our own biases and the cultural relevance of the theories we choose to inform our practice. It is important to keep in mind that our use of theories should be driven by a differential and holistic approach that contextualizes client's thoughts, feelings, and behavior.
The interface of cultural and clinical meanings
How do cultural values evolve? What purpose do they serve from a clinical perspective?
Cultural and clinical meanings are invariably intertwined. As illustrated by our discussion of Maslow's theory, cultural meanings, rooted in specific belief systems, are the organizing principles of clinical information. They shape the clients' perception of their stressors as well as the practitioner's foci of assessment and intervention in the helping process. However, cultural meanings do not exist in a vacuum. From a psychological and anthropological perspective, values, norms, and conduct of life in each culture generally evolve from the group's historical experiences in coping with challenges in their environments, for example, prevalence of resources, natural disasters, intra- and inter-group conflicts, as well as their fears and aspirations as a group. So cultural meanings are reflections of how groups of individuals make sense of their experiences and adapt to their unique environment (Sarri, 2008; Schamess and Shilkret, 2011). The universality of such human coping mechanism is “clinical” information, whereas the different paths each cultural group undertakes to pursue these needs become “cultural” values and norms (Hughes, 1993; Nye, 2005).
As an illustration of the intersection between cultural values and human coping mechanism and adaptation, we will briefly review the themes of American and Asian history and identify the collective psyche underlying the drastically different values and norms between the two cultures.
Since the overturning of British colonialism and the founding of the country in the eighteenth century, US history has been marked by expansion of its frontiers, victories in the pursuit of democracy, freedom of speech and equality for minority members of society, successful entrepreneurship by immigrants, and leadership in the world's arms and space races and our current information age (Tignor et al, 2008). Such accomplishment is both a reflection and reinforcement of the ideology of individualism, whereby the actualization of one's goals and interests, as Maslow puts it, is of utmost importance. It is no surprise that the history of social policies in the US has always been a political struggle to define and balance individual and public responsibility for the underprivileged (Blau, 2010; Fraser and Gordon, 1994; Karger, 2003). Socially, direct expression of one's thoughts, desires, and feelings and the challenging of opposing views are valued as a desirable communication style (Hall, 1977; Roland 1996).
Asian values are substantially different from the mores of American individualism. Asian history, which spans 4,000 years, is punctuated by political strife, rebellions, wars, colonization, and natural disasters that led to widespread poverty, sufferings, and loss of family ties. Unlike Western countries, industrialization and modernization did not occur in most of these countries until the last 30 years. As agrarian societies that depended on collective labor forces to ensure successful harvests, the ideology of Confucianism and Hinduism, which emphasize the virtues of maintaining harmony with others, loyalty to a hierarchical structure within familial and social institutions, fulfillment of responsibilities and obligations defined by one's roles, and pursuit of the prosperity of collective welfare through self-sacrifice and discipline, became the logical core influence of Asian cultural values and norms that offer hopes of order and stability (Bhela, 2010; Kagitcibasi, 1997; Tignor et al, 2008).
From a psychological perspective, American and Asian values and norms are examples of cultural organizing principles that shape individuals' perceptions of events in their lives, emotional reactions, coping mechanisms, and behaviors. Rooted in different historical experiences, they are unique sets of meaning systems that help to create continuity and cohesion for individuals to make sense of past occurrences and resolutions for the future. While clinical theories provide parameters to examine the human psyche and behavior, cultural meanings often play a key role in shaping, amplifying, or attenuating the foci of the theorists and practitioners as well as the experience of the clients (Roland, 1996; Chung, 2012).
In the following section, we will continue to focus on the interface of clinical and cultural meanings by reviewing major theoretical concepts that guide the helping process and discuss their relevance in an Asiacentric context.
The helping process as informed by clinical theories
The helping process begins when a client and a practitioner come together to review the presenting problem and to agree on a course of discussion and/ or action to address the problem. The presenting problem could range from concrete issues such as housing, childcare services, and nursing home placement to psychological distress such as interpersonal conflicts, loss of significant others, and setbacks in job or academic performance. However, as we well know, it is insufficient to focus on a presenting problem without understanding and addressing the underlying issues, which consist of myriad interactive psychosocial factors. To use the aforementioned examples, families or individuals who wish to apply for housing, or childcare, or nursing home placement for their elders, etc. may also be dealing with emotional issues that are compounded by social and cultural meanings associated with the circumstances, family dynamics, and accessibility to formal and informal support. So the process of linking these clients to resources often involves working with their ambivalent feelings and behavior as well as navigating them through a host of social systems. In this regard, theories that characterize the complex interrelationship of the individual's physiological and psychological attributes, as well as the nature of environmental support, offer a universal framework for understanding a client's presenting problem and her coping behavior. The ecological theory (Bronfenbrenner, 1979) adopted by social scientists, and social work's person-in-environment perspective (Greene, 1999; Woods and Hollis, 2000), offer an inclusive paradigm that guides the practitioner in making a preliminary and holistic assessment that in turn informs intervention foci for each client in the helping process.
A multi-dimensional framework for differential assessment
In reaction to an emerging problem, it is part of human nature that individuals will engage in activities to alleviate the distress associated with the problem. They could take steps to resolve the identified problem, enlist the assistance or emotional support of others, and/or resort to relaxation activities to alleviate their stress. The choice and specifics of these stress-reduction venues, i.e., problem-solving, help-seeking, and self-soothing behavior, are shaped by personality traits, the individuals' accessibility to external resources and support, and the pervasive influence of cultural belief systems. The outcome could be positive with the dissolution of the problem and stress, or it could be maladaptive and further undermine the individual's level of functioning and distress. Figure 1.1 is an application of the ecological and systems perspective that captures the dynamics of the various dimensions of general human coping mechanism in the face of stressors, as shaped by their affiliated group values as well as individual needs and proclivities. Theories of human behavior and development, family and group dynamics, as well as social and cultural belief systems illuminate these dynamics and help to create an in-depth understanding of an individual client's behavior and needs.
Figure 1.1 Multi-dimensional framework for differential assessment
Applying psychodynamic theories in an Asiacentric context
We would like to focus our discussion on the individual's inner world dynamics within this multi-dimensional framework. This is the mental process that consists of the interplay of desires, fears, emotions, and cognitions that are rooted in an individual's genetic predisposition as well as learned experiences, and plays a key role in shaping the individual's coping behavior. It is an area that tends to receive little attention in literature on clinical practice with Asians and Asian immigrants. Perhaps there is a tacit assumption that it is not possible or important to access the emotional life of Asians, who are often characterized as reluctant to share their inner thoughts and feelings and more interested in seeking concrete service and advice in the helping process. We believe that such a depiction, if indeed observed among Asian clients, is a clinical phenomenon infused with cultural meanings and values which needs to be understood in the helping process. Like everyone else, Asian clients do get angry or disappointed at their significant others and even their practitioners, sometimes over seemingly benign issues, and their silence or hostile responses are a manifestation of some underlying perceptions, emotions, and unresolved issues rooted in previous experiences. While it is beyond the scope of this book to delve into a thorough discussion of theories that offer insights into the human psyche, we believe that it is important for practitioners to be informed by some key psychodynamic concepts that illuminate the behavior of individuals as they cope with losses, disappointments, and stressful events in their lives. If Asian clients are hesitant in using professional services and could benefit from a more empathic and authentic engagement approach, psychodynamic concepts will be helpful in understanding their inner fears and desires, and the nature of their motivation in pursuing specific changes to reduce their stress. While it is important to distill the Euro-American values embedded in these concepts, we believe that there are universal aspects that can be applied and adapted to understanding human behavior in the Asian cultural milieu.
In the following section, we will discuss two major psychodynamic concepts and their relevance in practice with Asian immigrant clients.
Defense mechanism in the unconcious mind: a dimension of coping behavior
Concept of ego defenses from a Euro-American perspective
Like all clinical theories, the concept of the unconscious mind is infused with cultural meanings and has evolved with the values of the social world over the years. It originated in Europe during the late eighteenth century when Romanticism was the dominant ideology that emphasized individual expression of emotions and imagination. The concept subsequently gained much prominence through the writings of Sigmund Freud, the father of psychoanalysis. Under his classical drive-conflict model, Freud (1911; 1915) postulated that there are instinctual aggressive and sexual forces, wishes and urges that need to be discharged or gratified; those that are in conflict with the self and social norms are subsequently repressed and kept unconscious in the human mind. Freud believed that unresolved intrapsychic conflicts in the unconscious are the primary source of anxiety, neurotic behavior, and psychosomatic symptoms such as panic attacks and phobias. He argued that these conflicts needed to be analyzed and brought into the individual's consciousness. This core belief became the genesis of the “talking cure” and the predominant objective of psychotherapy practice in the Western world (Berzoff et al, 2011; Roland, 1996; Borden, 2009).
Freud's postulation of the...
