What is Clinical Practice? The Interrelationship between Cultures, Theories and Approaches

1. What is Clinical Practice? The Interrelationship between Cultures, Theories and Approaches Irene Chung, LCSW, PhD Associate Prof. Silberman School of Social Work at Hunter College

2. What is Clinical Practice? • The process of helping individuals and families through the “professional use of self and application of clinical knowledge and skills to restore, maintain, and enhance the biological, psychological, social, and spiritual functioning of our clients” (Council on Social Work Education, 2009).

3. What are Clinical Theories? • Bodies of knowledge in behavioral sciences that offer insights to human nature and behavior. • They inform the practitioners’ assessment of their clients’ thoughts, feelings and behavior as well as therapeutic interventions.

4. Cultural Meanings embedded in clinical concepts and theories • Clinical theories are generally infused with cultural meanings when theorists, influenced by their background and social times, emphasize and de-emphasize certain foci in their theoretical elucidation. • The predominant influences of Euro-American values on clinical theories tend to deviate from collectivistic world views.

5. Cultural Meanings embedded in clinical concepts and theories Examples: • Maslow’s “hierarchy” of human needs • Self-actualization versus social needs. • Mahler’s childhood development of “separation and individuation” • Emphasis on the child’s autonomy, self-sufficiency and self expression versus prolonged bonding with caretakers and development of keen awareness of the needs of other. • Somatization as an ego defense • Dichotomous view of mind and body in Western medicine versus the belief that emotions and bodily changes are interrelated through the circulation of qi or pranain Chinese and Ayurvedic medicines.

6. Cultural meanings Embedded in Traditional Counseling Approaches • “The talking cure” and “insight-oriented counseling” as influenced by Euro-American values and communication style: - Practitioner maintains a “blank screen” to facilitate the client’s free association of thoughts and feelings, and re-enactment of transference toward the practitioner; - Direct probing and interpretation of the client’s thoughts and feelings. - Empathy offered in affective and professional terminology.

7. Cultural Meanings embedded in Case Management Practice • Use of agency protocol in the exploration of the client’s presenting problems and background. • Clear delineation of the practitioner’s role and responsibilities. • Minimization of the practitioner’s self disclosure of personal information, thoughts and feelings to maintain professional boundaries.

8. Cultural dissonance in using Western approaches with Asian Clients • Asian values: - Introspection and articulation of personal feelings are considered to be ego-centric and detrimental to one’s health and harmonious relationship with others. - Being thrifty with words and intuitive to other’s needs and feelings in interpersonal communication are virtues under the teachings of Confucianism, Buddhism, Hinduism and Taoism. - Interpersonal relationships are defined by mutuality and reciprocity between individuals.

9. Cultural dissonance in using Western approaches with Asian Clients • Asian communication style: indirect and high context • Asian cultural norms: disclosure of personal and familial information to individuals outside of the kinship network is deemed inappropriate. • Asian languages: limited vocabulary in conversational lexicons to describe or explore feelings; affective lexicons are generally somatic complaints or metaphorical expressions of feelings.

10. Common Practice Dilemmas If we adhere to the Western clinical model: • What do we do when Asian clients seem reluctant or evasive to disclose their feelings or minimize them in regard to their presenting problem? • How much do we help Asian clients articulate their thoughts and feelings? • Should we ask “intrusive” questions, and if so, how? • How do we communicate empathy? • How much do we do for our Asian clients? • How should we respond if Asian clients ask us for “advice”? • What do we do when Asian clients bring us gifts? • What do we do when Asian clients inquire about our personal background?

11. A clinical perspective of cultural differences • Cultural values and norms are culture-specific “constructs of well-being and distress” that often influence and shape individuals’ subjective experiences. • There are adaptive purposes underlying the cultural values associated with the Asian interdependent/collectivistic and the Western individualistic world views.

12. The Interrelationship between cultures, Clinical theory and Approaches Euro-American Practice Model: Clinical Theories ì Culture î Clinical Approaches Cross-Cultural Practice Model: Clinical Theories èchanging socio-cultural values, universal And culture-specific human needs, emotions and behavior ê Clinical Practice

13. De-constructing and Re-constructing Clinical concepts and Approaches Let’s start with the basic premise! What are the therapeutic objectives in working with clients across cultures and service modalities? • Support them through their life crisis and restore their level of functioning • Ameliorate their emotional distress and renew their sense of hope in life • Facilitate them in making lasting positive changes in their life roles, coping mechanisms and relationship with others.

14. De-constructing and Re-constructing Clinical concepts and Approaches: A Relational Framework • From “talking cure” to “communication cure”. • From “one-person” to “two-person” psychology: The Relational Model that emphasizes - Implicit therapeutic communication within the helping relationship; • Corrective experiences as interventions to modify the client’s sense of self and others and coping mechanisms; - An egalitarian relationship characterized by reciprocal dynamics and permeable boundaries between the client and the practitioner.

15. Relational Model: The Change Process • Different conceptualization of the client’s “change process”” - Psychological growth can occur in a purposeful relationship without delving into the client’s repressed thoughts and feelings. - Clients will be more inclined to reflect on their issues and circumstances when they feel accepted, supported and empowered in their interactions with practitioners.

16. Relational Model: A cross-cultural practice Framework • Attunement to the client’s subjective experiences and specific emotional needs: inclusion of culture as a moderating factor in the helping process. • Emphasis on authentic and spontaneous interactions: development of professional yet culturally relevant communication, relationship and boundaries. • Creative and purposeful use of self in engagement, assessment and intervention with client.

17. Efficacy of relational approaches • Studies have found that strong therapeutic relationships are associated with positive treatment outcomes (Martin, Ganke, & Davis, 2000; McCabe & Priebe, 2004). • Neurobiological and infant research findings indicate that growth in the right brain structure (the realm of affective and intuitive, mind-body communications) is stimulated by non-verbal communications between infant and care-taker. Implications: The nurturing and interactive relational approaches in clinical practicecan have similar benefits (Schore & Schore, 2008).

18. Relational approaches in working with Asian Clients Opportunities: • More effective engagement of clients who are not familiar with or reluctant in the utilization of counseling and social services. Challenges: • Management of permeable boundaries; • Management of ethnocultural transference and countertransference issues; • Documentation of the efficacy of our work: building an Asia-centric practice model.

19. Thoughts for further discussion • Theories are only as good as when we can apply them in our practice with clients! • We can own our practice, broaden our skills and approaches to make them meaningful to our clients when we understand and appreciate the pervasive cultural influences embedded in theories and practice!

20. References • Chung, I. W. & Shibusawa, T. (2013). Contemporary Clinical Practice with Asian Immigrants: A Relational Framework with Culturally Responsive Approaches. New York: Routledge. • Martin, D., Garkse, J., & Davis, M. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting Clinical Psychology, 68, 438-450. • McCabe, R. & Priebe, S. (2004). The therapeutic relationship in the treatment of severe mental illness: A review of methods and findings. International Journal of Social Psychiatry, 50, 115-128. • Schore, J. R. & Schore, A. N. (2008). Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal, 36, 9-20.