Multiculturalism and the Therapeutic Process (Book Review)

Author:  Mishne. Judith
Publisher: New York: Guilford, 2002
Reviewed By: Mary Ellen Griffin, Summer 2005, pp. 60-62

Here is excellent book for people who want to learn more about how to conduct psychodynamic psychotherapy with clients of diverse racial or cultural backgrounds. Given the demographic trend toward increasing cultural diversity in the United States, that should include most of us! Inside Out and Outside In: Psychodynamic Clinical Theory and Practice in Contemporary Multicultural Contexts, by Joan Berzoff and her colleagues from Smith School of Social Work. But why focus on multiculturalism within psychodynamic treatment? Isn’t the psychodynamic therapist always reaching across a boundary of human particularity and difference, in attempting to appreciate the other person’s subjective experience, from within the constraints of his or her own subjective experience? As Berzoff and colleagues say, it’s not enough to understand a person from “the inside out” by developing a psychodynamic formulation. We must also learn to understand them from “the outside in,” appreciating how sociocultural as well as biological factors contribute to their experience of self and others. This book provides theoretical constructs and clinical examples to show us how we can become more culturally responsive therapists, and thereby increase our empathy for, and thus our clinical effectiveness with clients from whom we are culturally or racially different.

Multiculturalism and the Therapeutic Process, by Judith Mishne, provides a useful complement to the text by Berzoff and her colleagues. While they cover personality theories and understandings of psychopathology, Mishne does an excellent job delivering what her title promises, as she shows how to apply these formulations to conducting cross-cultural psychodynamic psychotherapy. In the Preface, Prologue, and first two chapters, Mishne orients the reader with a substantive yet brief introduction to her topic. She points out that the demographics of the United States are rapidly changing. While the majority of American psychotherapists are white, European Americans from middle class backgrounds, the population as a whole is increasingly non-white, non-European, and indeed, foreign-born. Mishne reviews the clinical literature on cross-cultural psychotherapy (i.e., psychotherapy in which the therapist and client are from different racial and/or cultural backgrounds), to show the growing sophistication of our understanding about how to be multicultural as a psychotherapist. She also introduces key concepts from self-psychology and intersubjective approaches, which provide the foundations for her model of cross-cultural therapy. Mishne believes that these models are most useful for multicultural psychotherapy because they encourage therapists to extend themselves with clinical warmth, to create rapport with the patient based on empathic attunement. These approaches emphasize the quality of the therapeutic relationship as the foundation for therapeutic change. They also focus the therapist’s attention on his or her own contributions to the evolving therapeutic relationship.

From Mishne’s point of view, another advantage of self psychology for cross-cultural work is its conceptualization of the goal of psychotherapy: to help the patient achieve “the cohesion of the self.” She believes that this goal is suitably integrative for individuals who must create cohesion for themselves in a multicultural context, wherein personal psychological experience is shaped by cultural or cross-cultural experiences within American society, with its confounding racism and other forms of social differentiation and oppression.

Migration and acculturation are two concepts that may top Mishne’s list for therapists to understand in order to be effective in cross-cultural work. Always, the goal is to understand oneself as a way to clarify areas of similarity and difference in the cross-cultural therapy dyad. How did the therapist come to live in the United States? How does that story affect the therapist’s sense of self? What is the client’s story of migration? Was it in any way traumatic? To what extent are therapist and client acculturated, or, assimilated into dominant American cultural values, versus identified with cultural values from their countries of origin? How do differential experiences of acculturation affect family relationships, especially between generations, for both therapist and client? To the extent that the therapist is aware of these issues within his or her own experience, he or she will be more attentive to these dimensions of the client’s cultural experience.

In this context, Mishne introduces two additional key concepts, cultural transference and cultural countertransference, which she borrows from Perez Foster (1999). It is her elaboration of these concepts by applying them to specific cases that I feel represents the most valuable contribution of her book. By sharing her own clinical work, Mishne helps us understand the process whereby the therapist can become increasingly conscious of and adept at working with cultural issues in the countertransference and in the transference.

Cultural countertransference is that set of experiences and expectations of self and of the patient, which have roots in one’s own cultural experience. As therapists become increasingly conscious of the cultural countertransference they bring to their work, they develop their own multicultural identity. As therapists become multicultural, they become increasingly effective with cross-cultural clients, because they are increasingly able to create a dialogue with the client in which the therapists’ own cultural experiences, values, and beliefs are not held to be normative. Attending to cultural countertransference fosters a therapeutic stance in which the therapist remains ready and able to learn from the patient about the distinctive elements of the patient’s cultural experience. Only by taking this multicultural stance, rooted in understanding cultural countertransference, will the therapist be able to help the patient sort out personal from cultural issues in the therapy, which is to say, the patient’s “cultural transference.” As the dynamic meanings of cultural experiences are explored with the patient, he or she can work through problematic aspects and claim adaptive aspects, to achieve a more nuanced, integrated, and adaptive multicultural identity.

What is so helpful about Mishne’s book is that she takes her basic formula, and shows us how to make it work by walking us through the therapeutic process from initial referral to termination, using her multicultural framework. The majority of Mishne’s chapters address theoretical issues in a stage or aspect of the therapy process, demonstrated via one or more case discussions. She addresses multiculturalism on a deep level, almost without the reader realizing it, because she integrates it into her clinical practice so naturally. She weaves numerous difficult concepts into clinical application, making the concepts come alive. Two cases that highlight issues of migration and acculturation in detail are the case of Carla, an American-born daughter of Mexican-born mother and Ecuadorian-born father, in Chapter 5 (The Treatment Relationship); and the case of Sophia, an Italian-born woman, in Chapter 6 (Resistance).

Two cases with radically different outcomes clarify how Mishne thinks about and makes use of cultural, and, specifically, racial transference and countertransference. Mishne begins to help us understand cultural countertransference by describing her own story of developing a multicultural identity. A white middle class Jewish woman, her first multicultural experiences occurred within her parents’ multicultural, multiracial circle of friends. Cross-racial treatment with African American patients is one of Mishne’s areas of strength. Yet in Chapter Three (Referral, Assessment, and Diagnosis), Mishne presents the case of Laura, a biracial 3-year-old girl. She considers this case a treatment failure, but uses it as an opportunity to explore what went wrong. As she tries to understand “my atypical and striking lack of success with this case” (p. 60), she gives us a candid example of the process she uses to explore her cultural countertransference and the role it may have played in the failed relationship.

By contrast, in Chapter 7 (Fixation, Regression, and Defenses), Mishne presents a very successful therapy with Mike, a bright but disturbed African American boy of 10. She describes cultural transference and countertransference factors, which she believes helped her to establish a sturdy working alliance with Mike and his parents. Mike was a light skinned son of a light skinned mother and dark skinned father. Mishne believed skin color played an important role in Mike’s disturbed self-experience. She cites Boyd-Franklin (1991) in stating that “the issue of skin color is often not raised in cross-racial treatment” (p. 168), but adds, “I could not allow it (race) to be bypassed and ignored in my work with Mike and his parents” (p. 169).

Initially in the treatment, Mike denied racial difference between himself and his therapist, but over time, was able to talk about race: “Mike came to see that over and beyond issues of race were his provocativeness and his passive-aggressive, sly manner of defying and attacking adults. We could effectively engage in what Thompson (1996, p. 125) has called “racial surgery”—namely, helping Mike see the difference between struggles that would be his regardless of ethnicity, and those that were complicated because of his race and color”(p. 168).

Mishne states, “The goal of all treatment interventions is the development of a cohesive self (Kohut, 1971)” (p. 169). For Mike, this increased self-cohesion included comfort with his racial identity as well as a more comfortable masculine identification. He “became more multicultural” (p. 169). He developed an ability to express his intelligence and creativity in pro-social ways that resulted in enhanced relationships with peers and teachers. Initially, Mike was failing in school, but his academic success improved such that he ultimately applied for and was accepted at a high school for gifted students in his city.

This case, and indeed, Mishne’s entire book, demonstrate her skill and her optimism regarding cross-cultural psychotherapy. Mishne makes psychotherapy process accessible to people without a psychodynamic background. Yet it is expected that even seasoned clinicians will gain insights from Mishne about the cultural dimensions of their work, increasing their own cross-cultural effectiveness and optimism about the value of working cross-culturally.

Reviewer Note

Mary Ellen Griffin is in private practice in Sylva, North Carolina, and teaches part-time at Western Carolina University.

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