In part because of the way the brain and body work together, what a person believes to be true affects his or her health, well-being, behavior, and reactions. We all choose a, sometimes fluctuating, set of beliefs and disbeliefs. Failing to recognize the importance to their functioning and sense of wellbeing of another person/group's beliefs can result in many difficulties during attempts to assist them. In fact, such failures have promoted difficulties in the world's wellbeing. It is unlikely that one has truly understood a set of beliefs until the beauty of its meaning within a belief system and to the individuals who hold the beliefs is clearly understood.
Alexander, Eyerman, Giesen, Smelser, & Sztompka (2004) remind us, "Human beings need security, order, love, and connection" (p. 3). In addition, humans need to be valued in order to thrive and to heal. Providing treatments for people of other cultures (cultures other than one's own) is a process of honoring (i.e., respecting, valuing) the individual in the context of his or her personal cultures-national, ethnic, family, business/school... Even treatments that are clearly defined acknowledge the need for adaptations for cultural and personal variations.
This paper briefly examines the impact of failing to value others. It provides a brief summary of areas that need attention when preparing to intervene with cultures that have not become one's own culture. Rather than a thorough examination of any culture, this work is intended to point to areas that will need additional study and learning. References are included for the reader's additional exploration of important issues. Readers have been invited to participate in developing tables of cultural information (see tables at end of document).
Valuing the Individual, Family, and Culture
Respect is essential to the success of work with any individual or group. Therapist warmth and empathy are qualities that have been repeatedly found to benefit treatment outcomes (Loneck, Banks, Way, & Bonaparte, 2002; Marshall et al., 2002). The lack of respect and even an unintentional ignorance of the requirements of respectful behavior may undermine interventions.
The Power of Devaluation
Numerous studies such as those related to infant-parent attachments, resilience, and self-esteem as well as an examination of the conditions conducive to creating a terrorist or violent criminal have demonstrated the power of devaluation in a person's life (Nader, 2008). That is, a plethora of evidence suggests the negative effects of experiences that make a person feel devalued. Infants and children who are valued and sensitively cared for develop qualities-such as good self-confidence and self-esteem, reasonable trust, and the capacity to self-reflect (see Fosha, 2003; Knox, 2003, 2004; Main, 1995; Nader, 2008)-that enhance the ability to be productive, competent, and resilient (i.e., the facility to do well in the face of adversity). In contrast, insensitive, frightening, or confusing care may result in the lack of resilience and in behavioral, temperamental, and emotional difficulties. Experiences that add to feelings of being of little value may contribute to a variety of personal and mental health disturbances (Nader, 2008). For example, conversations with and observations of terrorists, death row inmates, and soldiers who inflict unnecessary cruelties have found a link between devaluing experiences such as humiliation, shame, and/or abandonment and the evolvement of violent behaviors (Garbarino, 1999; Gilligan, 2003; Scheff, 1997; Volkan, 2001). Shame and humiliation have been associated with increased and prolonged trauma symptoms (Feiring, Taska, and Lewis, 1998). Ethnic and cultural discrimination or prejudice may add to or create feelings of shame and humiliation.
Preparing for Interventions with other Cultures
Working with a culture that is not one's own requires knowing about their beliefs and traditions, ways of thinking, habits, humor, group hierarchies, important historical events, acceptable modes of expression, what to ask, how to ask, and what to notice as well as an awareness of one's own personal attitudes, biases, traditions, and norms (Bird, 2002; Dubrow & Nader, 1999; Laird, 1998; McGoldrick, 1998; Nader, 2003; Nader, Dubrow, & Stamm, 1999; Suntum, 2001; Westermeyer, 1987; Wilson & Tang, in press). Learning these aspects of a culture includes training, supervision, reading, and work within a culture.
Learning About a Culture
Books and courses (e.g., History, Anthropology) provide information about a culture's history and habits. A culture's shared history, beliefs, and manner of thinking and expressing also can be found in their books, songs, local humor, and folklore (Danieli & Nader, 2006; McGoldrick, 1998; Nader, 2003; Nader, Dubrow, & Stamm, 1999; van Suntum, 2001). Folklore, such as myths, legends, magical tales, songs, and religious stories, helps to preserve and reveal cultural identity, roles, and rituals (Ogundele, 2002; van Suntum, 2001). Each generation modifies, adds, and deletes aspects of the cultural narrative according to its own needs (Alexander et al., 2004; Ogundele, 2002). Language and literature can provide only a part of understanding a culture. Westermeyer (1987) recommends working among the members of a culture for a minimum of 1 to 2 years in order to learn about them.
For interventions to be effective, a good relationship with community members and leaders is essential (Danieli & Nader, 2006; Nader, 2003, 2008; Stamm & Stamm, 1999; Yee, 2003). Community leaders may include respected members of religious, business, and familial groups and may also include traditional healers and/or clergy. In some cultures, their sanction is necessary. Finding a knowledgeable person from a culture to act as mentor can be very helpful.
Clinician/Diagnostician Qualifications In order to be accepted by a culture as someone who is qualified to provide assistance, specific requirements might be considered essential. In the United States, qualifications for mental health professionals include education and licensure or supervision. Age and gender may be important factors in cultures with age hierarchies (Gerber et al., 1999; Nader, Dubrow, & Stamm, 1999; Stamm & Stamm, 1999; Wilson & Tang, 2007). A clinician or diagnostician's initial and ongoing manner and methods are important to acceptance as well (Hancock, 2005; Ramirez et al., 2005). Cultures are comfortable with varying degrees of familiarity, formality, physical proximity, and eye contact (Nader, 2007b). Some cultural groups are only comfortable with a member of their own culture who speaks their language (Yee, 2003).
Understanding Another Culture
There are a number of areas in which national cultures may vary (Hodgetts, 1993; Hofstede, 1980; Nader, 2008; 2007b). Some of the possible cultural differences are discussed here.
Individualism vs. Collectivism
Cultures are influenced in relationship to a primary focus on independence or on connectedness (Markus, Kitayama, & Heiman, 1996; Kranz et al., 2005; Nader, 2008; Shiang, 2000; Shiang, Kjellander, Huang, & Bogumill, 1998; Triandis et al., 1986). For independence-oriented nations (e.g., Western cultures such as the U.S., northern Europe, and Australia), individuality, autonomy, competitiveness, and conquering new frontiers are valued. Collectivistic (interdependence-oriented) nations such as Asian, Latino, and African cultures, stress the needs of the group before individual needs.
Individuals are influenced by their cultural heritage. Although the U.S. is primarily an individualistic nation, many American subcultures (e.g., African and Chinese American) include values of interdependence (Boyd Franklin & Franklin, 1998; Nader, 2003, 2008; Nader, Dubrow, & Stamm, 1999; Watson, 1998). These values affect parenting practices (Watkins & Williams, 1992), and shape temperaments, behaviors, and symptoms (McDermott, 1991).
The Importance of Family and Other Support
Perry (2006) points out that for most of our history, humans evolved as a part of group cultures that lived together in extended families, tribes, or clans. The survival of an individual depended upon group members' cooperative efforts. A child's survival depends upon his or her value and connection to others-to his or her attachment figures and, when he/she enters the outside world, to the collective (Nader, 2007b, 2008). Even in cultures that value independence, the ease of functioning in life and access to privileges and resources is enhanced by one's increased value to others. Perceived value to others influences self-concept, social ease, and emotional well-being.
The importance of social support following traumatic experiences has been demonstrated for collective- and for independence-oriented cultures. In studies of varying age groups, higher levels of social support are associated with lower levels of trauma (Boehlein, 2001; de Silva, 1999; La Greca et al., 1996; Rabalais, Ruggiero, & Scotti, 2002; Westermeyer & Ueker, 1997). For immigrants, gaining a supportive community by joining a structured religion has been linked to lower hostility and lower PTSD scores (Mollica, Cui, McInnes, and Massagli, 2002; Westermeyer & Ueker, 1997).
Collectivistic cultures often stress age hierarchies (Gerber et al., 1999; Falicov, 1998; Nader, 2003). They invest leadership and authority in the older generation. Some nations and groups (e.g., Oriental, Indian, African) include ancestors in the hierarchy (Peddle, Monteiro, Guluma, & Macaulay, 1999). Families may honor the wishes and edicts of the dead. Rites and rituals may include ceremonies for contacting ancestors (Peddle et al., 1999).
In many cultures, gender roles are clearly delineated and deviation may result in difficulties (Danieli & Nader, 2006; Nader, 2003, 2008). Differences in what is tolerated for each gender may affect the sharing of information and the results of sharing it (Nader, in press). For example, in some cultures (e.g., Asian Indian, Hispanic), it is not acceptable for men to complain of distress (Canive, Castillo, & Tuason, 2001; de Silva, 1999). In some cultures, a male may not be willing to describe some of his distressing experiences to a female, sometimes in order to protect her. In other cultures, he may not admit emotions or vulnerability to another male. In some Middle Eastern cultures, admitting rape may be a death sentence for a female. Common behaviors for each gender differ among cultures. Comparisons of the gender traits of activity level, inhibitory control, perceptual sensitivity, and smiling rates were opposite for 6-7 year-old children in the People's Republic of China (PRC) versus those in the United States (Ahadi, Rothbart, & Ye, 1993). Cultures with significant differences in preferred personality traist nevertheless share traits. Although Oakland (2001) found differences in youths' trait preferences among cultures, he did not find significant differences between Chinese and U. S. youths in extraversion.
In some cultures (e.g., Asian), the power hierarchy is age first, and males over females (McGoldrick, 1998). Attitudes about the value of men versus that of women manifest differently among cultures. Stories of infant girls being killed in India and China were well-publicized in the 20th century. A quote from the 1961 film "A Raisin in the Sun" describes how some cultures (e.g., African American; Middle Eastern) "raise their daughters but love their sons" (see Boyd-Franklin & Franklin, 1998).
In the United States, rituals are abundant. To name a few, rituals honor birth, age or coming of age, successes, going to war, religious or spiritual striving and occasions, and death. Most cultures have some ritual(s) for after someone dies, for example. Funerals take many forms. The primary goals of post-death rituals include any of the following: 1) to honor the dead; 2) to aid grieving (e.g., to assist the living to adjust to the loss, to say, "Goodbye," or to express emotion); 3) to assist the dead souls in their transition from life on earth to the afterlife or next life (e.g., out of purgatory, past delusion, into the light, into the presence of their Lord); 4) to purify surroundings or souls; 5) to protect the living from malevolent spirits or angry wandering dead souls; 6) to pray for souls and/or to invoke a protective presence for them (e.g., God, angels, ancesters); 7) and/or to prepare souls for judgment.
After entering a new country, individuals become acculturated to the new country-that is, they absorb and assimilate aspects of the new culture-at differing speeds and to different degrees (Nader, 2008). The level of a family's acculturation may be difficult to predict. Children often assimilate and adapt faster than their parents, for example. Weine (2001) points out that travel, electronic communication (the Internet, radio, television), and the availability of written materials place many of the world's populations in a "complex connectedness." Even before this rapid method of disseminating ideas, members of a culture, in any country, did not all fit the profile of their culture of heritage (Nader, 2003; 2008). Many things-age, nationalization, acculturation, regionalization, peer influence, personal and family histories, personal experience, religion, personality, and more-contribute to an individual's personal profile and reactions to experiences.
National cultures and cultural groups may vary in their beliefs, expectations, methods of communication, dominant gender and personality traits, manner of interacting, acceptable modes of expression, and many other qualities. Their readiness to share information with a helping professional, their interpretations of communications, and their needs following exposure to traumatic experiences may be very different than those of the culture with which a professional is used to working. Different cultures have different requirements for those who help to heal them. A number of methods, including culture-specific rituals, may be needed to assist recovery. In order to work effectively with people of cultures other than one's own, professionals must study and walk among the culture in question. This paper presents some of the important areas for a clinician's study in preparing to work with cultures other than his or her own. Please let us know some of the things that you think are important for a clinician to know in working with your own personal culture or complex of cultures. Please email your stories to firstname.lastname@example.org.
Dr. Kathleen Nader is a member of Gift From Within's Professional Advisory Board. Dr. Nader is a clinician and consultant who has worked, nationally and internationally, for over 20 years in the field of Trauma, Violence and Bereavement. Dr. Nader is a humanitarian and scholar whose work with children suffering from the traumatic effects of school violence has been documented in our videotape called "PTSD in Children: Move in the Rhythm of the Child." She has written or co-authored many measures, articles and chapters on child and adult trauma, including a number of interview scales for assessing childhood trauma and traumatic bereavement. Her co-edited book, Honoring Difference: Cultural Issues in the Treatment of Trauma and Loss (1999; Taylor and Francis), examines cultural differences in reactions and interventions following traumatic events. Her new book, Understanding and Assessing Trauma in Children and Adolescents: Measures, Methods, and Youth in Context 2008 Routledge, addresses the many issues important to the assessment and treatment of children, especially after trauma.
Ahadi, S. A., Rothbart, M. K., & Ye, R. (1993). Children's temperament in the U.S. and China: Similarities and differences. European Journal of Personality, 7, 359-377.
Alexander, Eyerman, Giesen, Smelser, & Sztompka (2004)
Boehnlein, J. K., & Kinzie, J. D. (1997). Cultural perspectives on posttraumatic stress disorder. In T. W. Miller (Ed.), Clinical disorders and stressful life events (pp. 19-43). Madison, CT: International Universities Press.
Boyd-Franklin, N., & Franklin, A. J. (1998). African American couples in therapy. In M. McGoldrick (Ed.), Re-visioning family therapy (pp. 268-281). New York: Guilford Press.
Canive, J. M., Castillo, D. T., & Tuason, V. B. (2001). The Hispanic veteran. In W. Tseng & J. Streltzer (Ed.), Culture and psychotherapy: A guide to clinical practice (pp. 157-172). Washington, DC: American Psychiatric Press.
Danieli, Y. & Nader, K. (2006) Respecting Cultural, Religious and Ethnic Differences in the Prevention and Treatment of Psychological Sequelae. In Schein, L., Spitz, G., Burlingame, H. & Muskin, P. (Eds.) Psychological Effects of Catastrophic Disasters: Group Approaches to Treatment (pp. 203-234). New York: Haworth Press.
de Silva, P. (1999). Cultural aspects of post-traumatic stress disorder. In W. Yule (Ed.), Post-traumatic stress disorders: Concepts and therapy (pp. 116-138). Chichester, England: John Wiley and Sons.
Dubrow, N., & Nader, K. (1999). Consultations amidst trauma and loss: Recognizing and Honoring Differences. In K. Nader, N. Dubrow, & B. Stamm (Eds.),Honoring Differences: Cultural issues in the treatment of trauma and loss (pp. 1-19), Philadelphia: Taylor & Francis.
Falicov, C.J. (1998). The cultural meaning of family triangles. In McGoldrick, M. (ed.), Re-visioning family therapy (pp. 37-49). New York: Guilford.
Garbarino, J. (1999). Lost boys: Why our sons turn violent and how we can save them. New York: The Free Press.
Gerber, L., Nguyen, Q., & Bounkeua, P. K. (1999). Working with Southeast Asia people who have migrated to the United States. In K. Nader, N. Dubrow, & B. Stamm (Eds.), Honoring Differences: Cultural issues in the treatment of trauma and loss (pp. 98-118). Philadelphia: Taylor & Francis.
Gilligan, J. (2003). Shame, guilt, and violence. Social Research, 70(4), 1149-1180.
Hodgetts, R. (1993). A conversation with Geert Hofstede. Organizational Dynamics, 21, 53-61.
Hofstede, G. (1980). Culture's consequences: International differences in work-related values. Beverly Hills, CA: Sage Publications.
Kranz, P. L., Ramirez, S. Z., Flores-Torres, L., Steele, R. & Lund, N. L. (2005). Physical setting, materials, and related Spanish terminology recommended for play therapy with first-generation Mexican-American children. Education, 126(1), 93-99.
La Greca, A. M., Silverman, W. K., Vernberg, E. M., & Prinstein, M. J. (1996). Symptoms of posttraumatic stress in children after Hurricane Andrew: A prospective study. Journal of Consulting and Clinical Psychology, 64 (4), 712-723.
Laird, J. (1998). Theorizing culture: Narrative ideas and practice principles. In M.McGoldrick (Ed.), Re-visioning family therapy (pp. 20-36). New York: GuilfordPress.
Loneck, B., Banks, S., Way, B., & Bonaparte, E. (2002). An empirical model of therapeutic process for psychiatric emergency room clients with dual disorders. Social Work Research, 26(3), 132-143.
Markus, H. R., Kitayama, S., & Heiman, R. J. (1996). Culture and basic psychological principles. In E. T. Higgins & A. W. Kruglanski (Eds.), Social psychology: Handbook of basic principals (pp. 857-913). New York: Guilford Press.
Marshall, W. L., Serran, G., Moulden, H., Mulloy, R., Fernandez, Y. M., Mann, R., & Thornton, D. (2002). Therapist features in sexual offender treatment: Their reliable identification and influence on behaviour change. Clinical Psychology and Psychotherapy, 9, 395-405.
McDermott, J. F. (1991). The effects of ethnicity on child and adolescent development. In M. Lewis (Ed.), Child and adolescent psychiatry: A comprehensive textbook (pp. 145-159). Baltimore: Williams & Wilkins.
McGoldrick (Ed.), (1998). Re-visioning family therapy (pp. 20-36). New York: Guilford Press.
Nader, K. (2003). Walking among us: Culture and trauma. The Child Survivor of Traumatic Stress, 4, 1-8. [Available on line at www.ummed.edu/k/kfletche/kidsurv.html]
Mollica, R. F., Cui, X., McInnes, K., Massagli, M., P. (2002). Science-based policy for psychosocial interventions in refugee camps: a Cambodian example. Journal of Nervous and Mental Disease, 190(3), 158-166.
Nader, K. (2008). Understanding and Assessing trauma in children and adolescents: Measures, Methods, and Youth in Context. New York: Routledge.
Nader, K. (2007a). Assessment of the child following crisis: The Challenge of Differential Diagnosis. In Webb, N. B. (Ed.), Play Therapy with Children in Crisis: Individual, group, and family treatment (3rd ed., pp. 21-44). New York: Guilford.
Nader, K. (2007b). Culture and the Assessment of Trauma in Youths. In Wilson, J. P. & Tang. C. (Eds,), The cross-cultural assessment of psychological trauma and PTSD, (pp. 169-196). New York: Springer.
Nader, K., Dubrow, N., & Stamm, B. (Eds.). (1999). Honoring Differences: Cultural issues in the treatment of trauma and loss. Philadelphia: Taylor & Francis.
Oakland, T. (2001, November). Different countries: Different types. Paper presented at a meeting of the Myers-Briggs Lunch Group held at the Center for Applications of Psychological Type, Inc., Gainesville, FL.
Ogundele, W. (2001). Devices of Evasion: The mythic versus the historical imagination in the postcolonial African novel. Research in African Literatures, 33(3), 125-140.
Peddle, N., Monteiro, C., Guluma V., & Macaulay, T. (1999). Trauma, Loss, and resilience in Africa: A psychosocial community based approach to culturally sensitive healing. In Nader, K. Dubrow, N. and Stamm, B. (Eds.) Honoring Differences: Cultural Issues in the Treatment of Traumatic and Loss, (pp. 121-149). Philadelphia: Taylor and Francis.
Perry, B. D. (2006). Applying principles of neurodevelopment to clinical work with maltreated and traumatized children. In N. B. Webb (Ed.), Working with traumatized youth in child welfare (pp. 27-52). New York: Guilford Press.
Rabalais, A. E., Ruggiero, J. K., & Scotti, J. R. (2002). Multicultural issues in the response of children to disasters. In A. M. La Greca, W. K. Silverman, E. M. Vernberg, & M. C. Roberts (Eds.), Helping children cope with disasters and terrorism. Washington, DC: APA Press.
Scheff, T. (1997). Deconstructing rage. Retrieved September 17, 2003, from http://www.soc.ucsb.edu/faculty/scheff/7.html
Siegel, D. J. (2003). An interpersonal neurobiology of psychotherapy: The developing mind and the resolution of trauma. In M. Solomon & D. J. Siegel (Eds.), Healing trauma (pp. 1-56). New York: W. W. Norton.
Shiang, J. (2000). Considering cultural beliefs and behaviors in the study of suicide. In R. Maris, S. Canetto, J. McIntosh, & M. Silverman (Eds.), Review of suicidology (pp. 226-241). New York: Guilford Press.
Shiang, J., Kjellander, C., Huang, K., & Bogumill, S. (1998). Developing cultural competency in clinical practice: Treatment considerations for Chinese cultural groups in the U.S. Clinical Psychology: Science and Practice, 5, 182-209.
Stamm, B. H., & Stamm, H. E. (1999). Trauma and loss in Native North America: An ethnocultural perspective. In K. Nader, N. Dubrow, & B. Stamm (Eds.), Honoring Differences: Cultural issues in the treatment of trauma and loss (pp. 49-75). Philadelphia: Taylor & Francis.
Triandis, H., Kashima, Y., Shimada, E., & Villareal, M. (1986). Acculturation indices as a means of confirming cultural differences. International Journal of Psychology, 21, 43-70.
van Suntum, L.A. R. (2001). Creating Jewish Identity through Storytelling: The Tragedy of Jacob Bendixen. Scandinavian Studies, 73(3), 375-398.
Volkan, V. D. (2001). September 11 and societal regression. Mind and Human Interaction, 12, 196-216.
Watkins, J.M. & Williams, M.E. (1992). Cognitive neuroscience and adolescent development. In McAnarney, E., Kreipe, R., Orr, D., Comerci, G.D. (eds.), The Textbook of Adolescent Medicine, (pp. 99-106). Philadelphia: WB Saunders.
Watson, M. F. (1998). African American sibling relationships. In M. McGoldrick (Ed.), Re-visioning family therapy (pp. 282-294). New York: Guilford Press.
Westermeyer, J. (1987). Cultural factors in clinical assessment. Journal of Consulting and Clinical Psychology, 55 (4), 471-478.
Westermeyer, J., & Uecker, J. (1997). Predictors of hostility in a group of relocated refugees. Cultural Diversity and Mental Health, 3 (1), 53-60.
Wilson, J. P. & Tang. C. (Eds,) (2007). The cross-cultural assessment of psychological trauma and PTSD. New York: Springer.
Yee, P. (2003). New York's Asian population following the terrorist attacks of 9/11. An unpublished interview as reported to Kathleen Nader, August 7, 2003.