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Cultural Issues in Play Therapy

The Guilford Press

Chapter One

ELIANA GIL

I have always felt that the action most worth watching is not at the center of things but where edges meet. I like shorelines, weather fronts, international borders. There are interesting frictions and incongruities in these places, and often, if you stand at the point of tangency, you can see both sides better than if you were in the middle of either one. This is especially true, I think, when the apposition is cultural. -Anne Fadiman, The Spirit Catches You and You Fall Down (1997, p. x)

Ahnna was adopted at the age of 41/2 from an orphanage in China. Her history prior to that age was virtually unknown, except that her mother had died during childbirth and her birth father was unable and unwilling to care for her (he apparently held the infant responsible for his wife's untimely death). Uncharacteristically, a grief-stricken extended family was not available to raise Ahnna. The maternal grandmother was widowed and had cared for Ahnna from infancy until 11/2 years of age. When Ahnna's grandmother died, of lymphatic cancer, the father had remarried, and his wife had just given birth to a son. Ahnna's father remained unwilling to provide her with a home, and thus Ahnna was placed in the orphanage.

Ahnna was brought to the United States by her adoptive parents, Scott and Joelle, whohad gone through years of infertility treatment and had waited to adopt a child for over 3 years. Scott and Joelle were college sweethearts and had both been raised in the Midwest. When Scott secured a position with a national high-tech company, he and his wife relocated to the East Coast. They quickly discovered that the metropolitan area in which they had settled was very fast-paced, and they were homesick for their families. They planned to return to their home state as soon as Scott could establish a good work record, save money, and find another work position closer to home. They traveled to China with great anticipation and chose Ahnna due to her compliant behavior in the orphanage, as well as her "sweet appearance."

A few months after the adoption, Scott and Joelle brought Ahnna to therapy because she was smearing feces, wetting the bed at night, hitting other children in kindergarten, whining and complaining of stomachaches, and becoming aggressive with the family dog. Ahnna was also masturbating in her bed, distressing both her parents, who panicked that this suggested that Ahnna had been sexually abused. They were distraught, weary, and desperate. Their dreams of a happy family had dissipated into a sea of distress. Although they had anticipated some difficulties with the child, they were shocked and somewhat disgusted with Ahnna's behavior. Their expectations were gravely challenged, and they felt incompetent and ashamed.

A number of issues are highlighted in this case, to which I return later in this chapter.

CHANGING VIEWS OF WORKING ACROSS CULTURES

When I first started taking courses on "cultural issues" in the 1970s, there was a predictable and exclusionary focus on ethnicity. Most conferences and workshops that I attended utilized a panel format in which individuals from different ethnicities would speak about their particular ethnic groups. I clearly remember that the speakers would offer similar introductory statements and emphasize the limitations of their presentations. In fact, it was made resoundingly clear that each individual could only speak to his or her experience within a specific ethnic group or culture, and all speakers took great caution not to generalize. Inevitably, audience members left with a perception that they had been trained in cross-cultural sensitivity, when in fact they had been exposed to an extraordinarily narrow view of culture.

This approach was used in the literature as well, and more and more information appeared about specific ethnic groups (Boyd-Franklin, 1989; Falicov, 1998; Gopaul-McNicol, 1993; Koss-Chioino & Vargas, 1999; Sue & Morishima, 1982; Uba, 1994). This was a worthwhile and important first step, in that it allowed readers to become familiar with rather global aspects of cultural diversity. However, as McGoldrick (1998) states emphatically, "theoretical discussions about the importance of ethnicity are practically useless ... as are 'cookbook' formulations" (p. 22). She cautions that the systematic integration of material on ethnicity in any mental health professional training "remains a 'special issue,' taught at the periphery of psychotherapy training and rarely written about or recognized as crucial by therapists of the dominant groups" (p. 5).

Over time, more sophisticated debate has resulted in careful consideration and discussion of how mental health professionals and others who provide service delivery to the general public can become more sensitive and indeed more responsible in their interactions with clients or patients of different cultural backgrounds. Numerous books on working cross-culturally have enriched the literature with various philosophical, political, and social approaches (Carter, 1995; Lee, 1997, 1999; McAdoo, 1993; Paniagua, 1994; Pinderhughes, 1989; Tseng & Hsu, 1991). Recent efforts seek to examine and ponder the issues in our contemporary context, and advocate more action to demonstrate increased awareness and expressed good intentions (Mason & Sawyerr, 2002; McGoldrick, 1998). Fewer books have focused on cross-cultural work with children (Canino & Spurlock, 2000; Gibbs, Huang, & Associates, 1998; Webb, 2001).

Historically, this issue has not been embraced easily. Many of my colleagues initially resisted cross-cultural training, stating that the training was irrelevant because "I don't do that kind of work.... I don't see minority groups in my agency or practice." Allen and Majidi-Ahi (1998) note that "on the therapist's part, there may be a tendency either to deny that race is an issue in the interaction [with clients] or to overcompensate by attributing all of the client's problems to cultural and racial conflict" (p. 153).

The current climate of acknowledged deficits and a move toward the development of cross-cultural competence reflects the need to take more concrete action, and to remain vigilant to many therapists' resistance to and discomfort with integrating cross-cultural thought and action into their service delivery. There is a consensus that a first step in becoming cross-culturally competent is for a therapist to develop an understanding of his or her own ethnic identity and cultural values. McGoldrick (1998) states, "We are all migrants, moving between our ancestors' traditions, the worlds we inhabit, and the world we will leave to those who come after us. For most of us, finding out who we are means putting together a unique internal combination of cultural identities" (p. 8).

It has become clearer and clearer over time that reading about different cultures is not sufficient to elicit a change in behavior (in either therapists or clients), and it is irresponsible to believe that service delivery does not need to shift or expand in order to be effective with diverse populations.

THE EXPANDING DEFINITION OF "CULTURE" AND ITS IMPLICATIONS FOR TREATMENT

Falicov (1998) has best defined a broader view of "culture": "Culture is those sets of shared world views, meanings, and adaptive behaviors derived from simultaneous membership and participation in a variety of contexts, such as language; rural, urban, or suburban settings; race, ethnicity, and socioeconomic status; age, gender, religion, nationality; employment, education, and occupation; political ideology; stage of acculturation" (p. 14). Within this context, attention to culture occurs in all service delivery situations.

Certain issues have been articulated as critical in the provision of cross-cultural treatment. Giordano and Giordano (1995) provide the following key organizing guidelines for therapists:

Assess the importance of ethnicity to patients and families.

Validate and strengthen ethnic identity.

Be aware of and use clients' support systems.

Serve as a "cultural broker."

Be aware of "cultural camouflage."

Know that there are advantages and disadvantages in being of the same ethnic group as a client.

Don't feel you have to "know everything" about other ethnic groups.

Try to think in categories that allow at least three possibilities.

Other authors have highlighted additional salient issues. Ramirez (1998) discusses personal distance, self-disclosure, and the process of entering treatment as critical concerns for culturally competent therapists. Gibbs and colleagues (1998) note that research has identified many client variables as relevant to cross-cultural therapy-for example, "attitudes toward mental health and mental illness; belief systems about the causes of mental illness and dysfunctional behavior; differential symptomatology, defensive patterns, and coping strategies; help-seeking behaviors; utilization of services; and responsiveness to treatment" (p. 8). Inclan and Herron (1998) underscore the importance of delving into such issues as immigrant status, poverty (and socioeconomic strata in general), status changes, and generational issues. In addition, LaFromboise and Graff Low (1998) point to the need for cross-cultural therapists to make decisions about collaborating with traditional healers and evaluating their clients' desire for "ceremonial healing" (p. 133).

McGoldrick (1998) defines ethnically self-aware and sensitive therapists as those who "achieve a multiethnic perspective, which is open to understanding values that differ from their own, and no longer need to convert others or give up their own values" (p. 22). An emphasis on the building of competence and self-evaluation (with training programs taking the lead) appears to be emerging as this field of study continues to evolve across disciplines (Lu, Lum, & Chen, 2001; Roysircar, Sandhu, & Bibbins, 2003; Zimmerman, 2001).

FROM BUILDING SENSITIVITY TO OBTAINING KNOWLEDGE RESPONSIBLY TO DEVELOPING ACTIVE COMPETENCE

When mental health professionals ponder the daunting task of becoming cross-culturally competent, a number of steps must be taken for optimal outcomes. I view this process as involving three distinct levels of response that build upon each other. In my experience, some therapists fall short of the desired outcome because they achieve the first or second level of response independently of the other two.

Building Sensitivity

Building sensitivity entails introspection and a focus of attention on the interactions between self and others. Most training programs set a foundation for cross-cultural sensitivity by inviting students to explore their own cultural and ethnic identification. Being aware of one's own biases and values will assist in the recognition of client issues in this arena. Making sure that the topic is acknowledged and discussed in one's personal and professional life is also critical, in that it creates conscious attention to this topic. Books that stimulate thinking and discussion in this area are highly recommended and contribute greatly to developing ongoing awareness and sensitivity (Tatum, 1997; Webb, 2001).

I am fully bicultural, with high acculturation in both my cultures. As I have described in the Preface to this book, I moved to the United States from Ecuador full time when I was 14 years old. It was especially distressing to me that my quincianera (a ritual dance/party given for girls in many Hispanic cultures when they reach age 15) was an experience I would miss, after years and years of anticipating this rite of passage. My acculturation caused great family rifts, and my mother's overprotection and mistrust are still palpable when I think back to my teenage years. I know that working with Hispanic youth is a challenge for me, since I tend to sympathize (nonsystemically) with the plight of bicultural youth. At the same time, I learned many heroic values from my parents, especially my mother, who brought her children to a new country to offer them a better education and more opportunities. As I prepared to meet Ahnna, I thought about my own journey here (albeit at a much older age) and the difficulties and rewards of acculturation. I also recognized my hesitation in working with parents of a bicultural child. I worked hard at self-evaluation during treatment with this family, understanding well that my own identity as bicultural would affect how I viewed this child and family. I decided to forgo a set agenda, but rather to continue interacting with Ahnna and her parents, learning about myself and sharing aspects of myself as the therapy progressed.

There are numerous ways of becoming sensitized to (or sensitive of) others' plight. The most obvious way is to empathize with other persons by trying to understand their experiences, their struggles, their resources, and motivations. This is easier said than done, and it is a step that is often skipped partially or entirely. In my mind, an honest exploration at the point of contact is a valuable and rewarding process.

For example, when I first started working with adult sex offenders, I discovered countertransference unlike any I had experienced in the past. I became uncertain of my own ability (or willingness) to work with clients who had this particular problem, and I remember consulting with a colleague about the intensity of these feelings and the way they destabilized me. My colleague counseled me to make efforts to develop sensitivity to sex offenders-something I found challenging but not impossible. I began by listening to her as she described to me the personal histories of many of the sex offenders she had treated. As I listened, I heard stories reminiscent of those told by my clients who were adult survivors of abuse. It didn't take long to realize that we were sometimes discussing the same population. Many sex offenders have their own histories of severe abuse, and although there is no linear causal relationship between past and current behaviors, I came to view the two as connected: Histories of abuse contribute to maladaptive adult functioning, particularly repetition of dysfunctional patterns. As I understood this correlation, my sensitivity grew. It then became apparent to me that I could be sensitive to the history of abuse and its inherent pain, without excusing the behaviors that caused pain to others.

Continues...

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