14.7 Psychotherapy Today
LO 10 Describe how culture interacts with the therapy process.
WHEN TO LISTEN, WHEN TO TALK
One of the challenges of providing therapy in a country like the United States, where ethnic minorities comprise over a third of the population (Yen, 2012, May 18), is meeting the needs of clients from vastly different cultures. A therapist living in a diverse city like Houston or San Francisco may serve clients from multiple cultures in a single week, and each of those cultures has its own set of social norms dictating when to be quiet, when to speak, and how to express oneself.
For Dr. Foster, this part of the job is relatively straightforward. All his clients are Northern Plains Indians, which means they follow similar social rules. Because Dr. Foster belongs to this culture too, its norms are second nature to him. He has come to expect, for example, that a young Lakota client will not begin talking until he, the therapist, has spoken first. Dr. Foster is their elder, and elders are shown deference. Thus, to make a younger client feel more comfortable, he might begin a session by talking for 3 or 4 minutes. Once the client does open up, he limits his verbal and nonverbal feedback, sitting quietly and avoiding eye contact. In mainstream American culture, people continuously respond to each other with facial animation and filler words like “wow” and “uh-huh,” but the Lakota find this ongoing feedback intrusive. “I might even shut my eyes so they’re not feeling influenced by my responses,” Dr. Foster says. “I’m not going to respond to what they’re telling me, out of respect to their story.”
Another facet of Lakota communication—one that often eludes therapists from outside the culture—is the tendency to pause for long periods in the middle of a conversation. “In the Northern Plains, silence is pretty comfortable for us,” Dr. Foster says, “but our silences are active silences. They’re not passive.” If he poses the question, “How are you doing?” a client might take 20 to 30 seconds to respond. “They are not going to answer me on a superficial social level,” he explains. “They’re going to go inside”—meaning really take the time to consider the question and formulate an answer (How am I doing?). These long pauses make some non-Indians very uncomfortable, according to Dr. Foster. “I’ve found that an outside provider will feel awkward, will start talking within 3 to 5 seconds,” he adds. “The client will feel that they never have a chance to speak, and they’ll leave frustrated because the person wouldn’t be quiet [and] listen.”
across the WORLD
Know Thy Client
Clearly, it is important for a therapist to know the cultural context in which he works. But does that mean therapists and clients should be matched according to race, ethnicity, or gender? Some clients feel more comfortable discussing private thoughts and feelings with a therapist who shares their experience—someone who knows firsthand how it feels to be, say, a Mexican American woman or a Japanese American man. A study in Los Angeles County found that non-English-speaking Mexican and Asian Americans were more likely to stick with and benefit from therapy when matched with a therapist of the same ethnicity and native language (Sue, Fujino, Hu, Takeuchi, & Zane, 1991). Working with a therapist of the same background may be helpful, but it is not essential.
Dr. Foster: What are the risks if a psychologist fails to pay appropriate attention to both therapy methods and cultural traditions?
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When the therapist and client do come from different worlds, it is the therapist’s job to get in touch with the client’s unique perspective. That includes being respectful of cultural norms. Western therapists working in India or sub-Saharan Africa, for example, may find that clients are unfamiliar with psychotherapy and reluctant to discuss personal matters (Bolton et al., 2007; Manickam, 2010). Therapists must also be sensitive to the many forms of prejudice and discrimination that people can experience.
Within any group, there is vast variation from one individual to the next, but cultural themes do emerge. The Sioux and Blackfeet Indians, for example, are very relationship-oriented. “What kind of car you drive or how nice your home is, and so forth, is not even important,” Dr. Foster says. “Relationships matter.” Some therapists working with American Indian groups report that entire families may show up at sessions to express support for the client (Prochaska & Norcross, 2014). Similarly, Latino American cultures place a high value on family, often prioritizing relationships with relatives over individual needs (Romero, Cuéllar, & Roberts, 2000). These groups tend to be more collectivist, or community-minded, whereas European American cultures tend to place a high premium on individualism (Oyserman, Coon, & Kemmelmeier, 2002).
Immigrant populations face their own set of challenges. Men often have a difficult time adjusting to the declining social status and income that comes with moving to a new country. Women tend to fare better, adapting to the new culture and finding jobs more quickly, which can lead to tension between spouses (Prochaska & Norcross, 2014). Keep in mind that these are only general trends; assuming they apply to an entire population promotes stereotyping.
SHOULD THERAPISTS AND CLIENTS BE MATCHED IN TERMS OF RACE, ETHNICITY, OR GENDER?
This brings us to one of the key themes of the chapter: When it comes to psychological treatment, there is no “one-size-fits-all.” Every client has a unique story and a singular set of psychological needs. Responding to the needs of the person—her culture, religious beliefs, and unique personal qualities—is one of the keys to successful therapy (Lakes, Lopez, & Garro, 2006; Norcross & Wampold, 2011).
Does Psychotherapy Work?
LO 11 Summarize the effectiveness of psychotherapy.
Now that we have familiarized ourselves with the strengths and weaknesses of various therapeutic approaches, let’s direct our attention to overall outcomes. How effective is psychotherapy in general? This question is not easily answered, partly because therapeutic “success” is so difficult to quantify. What constitutes success in one therapy context may not be the same in another. And for therapists trying to measure the efficacy of methods they use, eliminating bias can be very challenging.
That being said, there is solid evidence suggesting that therapy usually “works,” especially if it is long-term. In one large study investigating the effects of psychotherapy, all therapeutic approaches performed equally well across all disorders. But there is one caveat: Individuals who were limited by their insurance companies in terms of therapist choice and duration of treatment did not see the same improvement as those who were less restricted by their insurance (Seligman, 1995). Another important finding is that people who start therapy but then quit tend to experience less successful outcomes (Swift & Greenberg, 2012). As such, around 50% of clients show “clinically significant improvement” after 21 psychotherapy sessions, whereas some 75% show the same degree of improvement after twice that many sessions (Lambert, Hansen, & Finch, 2001). Given the many types of therapeutic approaches, the uniqueness of the client, and the variety of therapists, it is challenging to identify an approach that works best for every client (Pope & Wedding, 2014). But we can say this with relative confidence: Psychotherapy is “cost-effective, reduces disability, morbidity and mortality, improves work functioning, decreases the use of psychiatric hospitalization, and…leads to reduction in unnecessary use of medical and surgical services” (APA, 2012a.
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I Think I Need Help. What Should I Do?
If you suspect you or someone you care about is suffering from a psychological disorder or needs support coping with a divorce, death, or major life change, do not hesitate to seek professional help. The first step is figuring out what kind of therapy will work (individual, family, group, and so on). Then there is the issue of cost: Therapy can be expensive. These days, one 60-minute therapy session can cost anywhere from $80 to $250 (or more, believe it or not). If you are a student at a college or university, however, your student fees may cover services at a student counseling center.
Many people have health insurance that helps pay for medication and psychotherapy. In 2010 the Mental Health Parity and Addiction Equity Act (MHPAEA) took effect, requiring all group health insurance plans (with 50 employees or more) to provide mental health treatment benefits as part of their insurance plan—with benefits equal to those provided for medical treatment. Essentially, this means that mental health problems merit the same treatment benefits as physical health problems. Co-payments must be the same, limits on treatment must be the same, and so on. If your insurance plan does not restrict the number of times you can see your family physician, it also cannot limit the number of visits you have with a psychologist (APA, 2010a). For those without insurance, community-based mental health centers provide quality care to all in need, often with a sliding scale for fees.
The next step is finding the right therapist, that is, the right qualified therapist. Helping others manage their mental health issues is a tremendous responsibility that only licensed professionals should take on. But who exactly meets the criteria for a “qualified professional”? It depends on where you live. Different states have different licensing requirements, and because these requirements vary from state to state, we encourage you to verify the standing of a therapist’s license with your state’s Department of Regulatory Agencies. The pool of potential therapists might include clinical psychologists with PhDs or PsyDs, counseling psychologists, individuals with EdDs, psychiatrists, psychiatric nurses, social workers, marriage and family therapists, pastoral counselors, and more. (See Appendix B for more information about education and careers in psychology.) If you don’t seek psychological help from a trained and certified professional in person, you should be very cautious about seeking assistance online.
Nonstandard Treatment: Self-Help and e-Therapy
Type “psychology” or “self-help” into the search engine of Amazon.com, and you will come across thousands of books promising to eliminate your stress, boost your self-esteem, and help you beat depression. Although some self-help books contain valuable information, others are packed with claims that have little or no scientific basis. Keep an open mind, but approach these resources with skepticism, especially when it comes to the research that authors cite. As you have learned, determining the effect of therapy is a difficult business, even when studies are impeccably designed. Reader beware.
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Online Psychotherapy
LO 12 Evaluate the strengths and weaknesses of online psychotherapy.
With more people gaining access to the Internet and more therapists trying to specialize and make themselves marketable, online therapies are multiplying. A relative newcomer to the treatment world, e-therapy can mean anything from email communication between client and therapist to real-time sessions via a webcam. Some approaches include a hybrid version of online and face-to-face sessions, whereas others offer virtual support through chat rooms. These digital tools are valuable for serving rural areas and providing services to those who would otherwise have no access. Videoconferencing is a useful supplement to regular therapy, particularly for consultation and supervision. But online psychotherapy and telehealth raise many concerns, including licensing and privacy issues, problems with nonverbal cues, and difficulty developing therapeutic relationships (Barak, Hen, Boniel-Nissim, & Shapira, 2008; Maheu, Pulier, McMenamin, & Posen, 2012; Sucala et al., 2012).
While we are on the topic of the Internet, we cannot resist a tie-in to social media. What role do Facebook, LinkedIn, and other types of social media play in the lives of therapists and their clients?
SOCIAL MEDIA and psychology
Imagine that you are the psychotherapist serving a small community college. You talk to students about their deepest fears and conflicts. They talk to you about their mothers, fathers, lovers, and foes. In some respects, you know these students better than their closest friends do. But your clients are not your buddies. They are your clients. So what do you say when a client asks you to become a friend on Facebook, a professional contact on LinkedIn, or a follower on Twitter?
Our answer to that question is a definitive no. The relationship between therapist and client should remain a professional one, both online and offline. But that doesn’t mean that social media has no place in the mental health field. Psychologists are among the many professionals using social media to connect with colleagues and market their services to potential clients. They may be avid Twitter users, tweeting their latest musings about current events and everyday life. Social media may even come in handy for therapy itself. Kolmes (2012) offered the example of a client with public speaking anxiety who shows his therapist a video of himself giving a speech.
But along with new opportunities come new risks. Psychologists who use social media to communicate with colleagues, for instance, may inadvertently compromise confidentiality in seeking advice about how to tailor therapy for a particular client. (As you well know, what’s said online stays online.) Others may go online to investigate clients’ statements about themselves (He claims to have 400 Facebook friends; let me just take a peek and confirm; Kolmes, 2012).
DOES FACEBOOK HAVE A PLACE IN THERAPY?
As you can see, the emergence of social media presents new challenges and new opportunities for therapists. This is an area in which we would like to see more research. Stay tuned….
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PASSIONATE PROVIDERS
Before wrapping up, we thought you might like to know what Dr. Dan Foster and Laura Lichti are doing these days. Dr. Foster is as busy as ever, working with two other psychologists, one case manager, and one discharge manager to provide mental health services to Rosebud’s 13,000 residents. In addition to working up to 70 hours per week, he and his wife Becky (also a doctorate-level psychologist) have seven adopted children, five of whom are affected by fetal alcohol spectrum disorders (FASDs). Dan doesn’t get more than 5 or 6 hours of sleep at night, but he seems to have a limitless supply of energy and optimism.
It’s been a major period of change for Laura, who began working as a behavior therapist for people with developmental disabilities. On top of her new job, Laura fulfilled the requirements to become registered in play therapy, a type of treatment that uses natural play to help clients—primarily children—communicate their thoughts and emotions. She also launched her own private practice, which focuses on grief counseling for people of all ages. “It’s been a busy year,” Laura says, “and I continue to love the work I do!”
show what you know
Question 14.22
1. A large study in Los Angeles County found that non-English-speaking Asian and Mexican Americans were __________ likely to stick with and benefit from therapy when matched with a therapist of __________ ethnicity and native language.
- less; the same
- more; the same
- more; a different
- equally; a different
Question 14.23
2. E-therapy is a relatively new approach to helping people with psychological problems or disorders. It varies in terms of how much and what type of contact the “client” has with a “therapist.” Concerns regarding online psychotherapy include__________.
Question 14.24
3. If you were trying to convince a friend that treatment for psychological disorders does work for many groups of people, how would you summarize the effectiveness of psychotherapy? What would you say about the role of culture in its outcome?
CHECK YOUR ANSWERS IN APPENDIX C.