Throughout the past 18 months of practice as an existential therapist I have found myself contemplating the challenges and opportunities of cross-cultural work increasingly. These thoughts have arisen due to the area of London I practice in and the large proportion of BME communities using the services. In addition, being from the Jewish community, and therefore from a minority culture myself I am aware of often being attuned to issues of difference and otherness.
In this essay I will explore the ethical issues that arise when working with clients who come from cultures and places markedly different to my own. I will propose that the existential approach offers a unique way for a practitioner to engage openly and curiously with such issues. I will present a scenario where I believe working cross culturally gave rise to ethical dilemmas for me as a practitioner and as a person, I will show how the ethical guidelines we are required to follow as counselling psychologists create tension when dealing with such dilemmas and how the setting, society and the existential tradition contribute also to the same discussion. This is a vast and complex area of work that due to the scope of this essay may at times seem oversimplified and stereotyped.
In the reading I have done regarding working with clients whose cultures are different to my own, the assumption is often that the therapist is from the majority culture and the client, who is culturally different is from an ‘ethnic minority’ (e.g. Eleftheriadou, 1997). However, as a therapist who is themselves from a minority culture I am often aware of sitting with clients from quite the opposite perspective, I am always working in a sense ‘cross culturally’. This for me has offered interesting insights in terms of being aware of my own assumptions about the majority culture, my assumptions about how others view my own culture and the way in which I transmit a sense of understanding to clients who are from ethnic minorities, albeit ones very different from my own. In addition, my experiences of finding and working with therapists as a client, both from the same and different community as mine has given me a sense of the challenges and opportunities that may arise for a client when working with a therapist who is culturally familiar versus one who is ‘other’.
Eleftheriadou (1994: 1-2) defines culture as: “a way of creating shared ways of functioning in order to communicate effectively . . . we create shared events, practices, roles, values, myths, rules, beliefs, habits, symbols and realities”. These culturally dependent ways of functioning and communicating will have clear implications for practitioners working from a mental health model. It is commonly acknowledged that the DSM’s main flaw is that it is culturally dependent. Much of what gets diagnosed as ‘pathology’ in the West, such as hearing voices may be conceptualised as ‘gifted’ or ‘enlightened’ by other cultures. While counselling psychologists do not always work from such conceptualisations of mental illness, there is a rising interest in Cultural Psychology (Schweder, 1991; Ratner, 2008). This relatively new field may offer something to counselling psychologists who find themselves working in culturally diverse areas and societies, such as London. Indeed, both of my placements give me the opportunity to work with clients who are culturally different to me, and for whom English is not their first language. However, while cultural psychology is based on the preposition that everything must be understood within its framework, “if the framework is removed, it becomes senseless” (Eleftheriadou, 2010: 199), as an existential counselling psychologist I feel as though this is a fundamental guiding theory of my practice regardless of whether a client is from a markedly different culture to my own.
Why do ethical dilemmas occur?
Working with clients whose cultures are markedly different to my own has given rise to ethical dilemmas most notably when ethical tenets of psychotherapeutic practice appear to come into conflict. This may happen when a client’s experience of distress in their life appears to the therapist as almost a direct result of their cultural norms.
The ethical guidelines of the BPS, UKCP, BACP and HCPC all emphasise a commitment to upholding the clients autonomy, right to self govern and respecting: “individual, cultural and role differences, including (but not exclusively) those involving age, disability, education, ethnicity, gender, language, national origin, race, religion, sexual orientation, marital or family status and socio-economic status” (BPS). Additionally, each of these ethical guidelines require counseling psychologists and psychotherapists to take responsibility: “for respecting their client’s best interests when providing therapy” (UKCP),“protecting the safety of clients” and “alleviating personal distress and suffering” (BACP).
In my experience of working with people from different cultures, I have found myself in an ethical dilemma when these guidelines appear to suggest different courses of action. Where respecting cultural differences does not necessarily lead to protecting safety or “alleviating personal distress and suffering”, and where it is not clear whether challenging a clients cultural norms will or will not lead to increased distress.
My experience of working in West London where there is a large BME community, in 2 very different settings has encouraged me to become conscious of the underlying philosophies of the settings in which I work and the way in which they conceptualise working cross culturally. (At this point it is necessary to state that I do not wish to polarise or stereotype particular settings, however due to the scope of this essay I may oversimplify what is more nuanced in reality).
At the Woman’s Trust I see clients who are victims of domestic abuse. This is a purely person-centred service, based on the premise that victims of domestic abuse have often lost touch with their sense of autonomy and their sense of their ability to make choices that are best for themselves. This premise it would seem would enable me to allow all clients in abusive situations to make their own decisions based on what they feel is best for them, without interference and regardless of how I perceive their cultural norms. However, my other placement, in NHS primary care would not afford the client as much freedom. With an underlying philosophy of minimising risk, when a person reports domestic abuse to me in the NHS I am required to let them know they are being abused and report it to another agency such as social services.
The various ethical guidelines coupled with my 2 settings give me different options for action when faced with the following scenario: “I deserved to be beaten last night, I had not done everything I was supposed to do and he had the right to punish me for that, that’s not to say I don’t hate the punishment, but he is a good man, a good husband and he provides for my kids.”
The client had explained that this was not an unusual form of punishment in her community. - In this scenario while working in the Woman’s Trust, I can take into account the ethical guidelines that stress respecting my clients autonomy, along with working in a person centered way which trusts that the client has the ability to make the best decision about her own life for herself. These considerations mean that when a client reports such a situation I can listen, empathise, and try to understand the experience and world-view of my client. I am not required by WT to take any action and if I don’t I am able to back it up with the ethical guidelines promoting autonomy and respect. In the NHS some may challenge this approach, where the guideline “alleviating personal distress and suffering”, is understood as putting an end to the abuse and reducing risk. My experience of working in the NHS has shown me that when abuse is disclosed, no matter what the context we are required to report and act with the aim of reducing risk.
Questions around moral relativism arise in circumstances such as this one. For many years in the UK cases of honor-based violence against women were treated as cultural issues and ones that the UK justice system did not wish to get involved in for fear of not being sensitive to cultural differences (Walker, 2012). In the field of domestic violence there has been a backlash against this treatment and a call to treat all abuse as equally distressing and criminal. However, when being asked to respect a client’s autonomy and understand the distressing affects also of turning against ones culture, I find myself in some way advocating for the moral relativism that I am so against.
Indeed, it is not clear to me when contemplating the scenario above, to what extent I can say this is abuse and abuse is wrong, while understanding that this client may find it far more distressing and challenging to her identity to stand against the status quo of her community. Dilemma’s for me as a practitioner come about when it is not clear which course of action will exacerbate distress and suffering: respecting such a client’s right to choose her own situation for the benefits it affords her, or helping her to get out of an abusive situation. It is from this nuanced and complex place, where personal ethics, professional guidelines and the guidelines of the setting I am working in collide, that I am required to make an ethical decision as a practitioner. In truth I can only know what is best for my client by asking and listening to her. Accordingly, Bond (2010) suggests that practitioners should be aware of the dangers of undermining a client’s autonomy when a counselor believes they know what is best for a client.
What can the phenomenological-existential approach offer?
As a phenomenological-existential practitioner I feel that I have an underlying theoretical stance that is equipped to work well with clients from different cultures. My own interpretation of existential psychotherapeutic practice leads me to view my clients as ‘different’ to me always. I am always exploring a worldview and way of being-in-the-world that is different to my own and in some way novel, working with clients from other cultures should be no different.
As a phenomenological practitioner, one of my core techniques is bracketing. This skill is one that I employ when sitting with all clients. I require myself constantly to try and be aware of the assumptions I am making about the person in the room, the assumptions I make about myself with them and the assumptions or instinctive responses I have to the material they bring. Indeed, Eleftheriadou (2010) refers to ‘pre-transference’ in cross cultural work, the idea that I approach a person with previous experiences or ideas of who they are based on experiences I have had with people from the same ethnic or cultural group. For me this is a familiar experience, what I understand as an existential practitioner as my worldview and assumptions that I am aware I may need to bracket. Spinelli maintains: “even when the bracketing is not likely or feasible, the very recognition of bias lessens its impact upon our immediate experience” (Spinelli, 1989: 17).
Moreover, working existentially affords me the freedom to be flexible and creative with my way of working. I am always finding out more about how I want to work and the theoretical ideas that are important to me as a practitioner. This freedom of technique means that when faced with the scenario above, I am able to make a clinical decision based on my personal ethics and the person sitting in front of me rather than being governed by a way of conceptualising the scenario given to me from outside, as far as I am able to back up this decision competently. For these reasons I believe that existential counselling psychologists are uniquely equipped to work well with people from cultures markedly different to our own.
While cross cultural work is complex and nuanced, I believe that there is a danger in counselling psychologists become too ‘precious’ regarding this area of work. In my opinion working competently and effectively as a counselling psychologist should be possible regardless of culture or race. Issues of difference arise between counsellor and client always and are the ways in which we begin to find out about and challenge our clients’ worldviews. Creating a sense of specialist knowledge around this type of work may have more drawbacks than benefits, in that less counselling psychologists will feel adequately equipped to work in these areas, and therefore less people from minority cultures will be able to engage in counselling.
Eleftheriadou, Z. (1994) Transcultural Counselling. London: Central Publishing House. Eleftheriadou, Z. (1997) ‘Cultural differences in the therapeutic relationship’, in I. Horton and V. Varma (eds), The Needs of Counsellors and Psychotherapists. London: Sage.
Eleftheriadou, Z. (2010) ‘Difference and Discrimination’, in Woolfe, R., Strawbridge, S., Dryden, D., Dryden, W (eds), Handbook of Counselling Psychology. London: Sage. Ratner, C. (2008) Cultural Paychology. Cross-cultural Psychology and Indigenous Psychology. New York: Nova Science. Schweder, R.A. (1991) Thinking Through Cultures: Expeditions in Cultural Psychology. London: Harvard.
Spinelli, E (1989) The Interpreted World: An Introduction to Phenomenological Psychology. London: Sage.
Walker, S (2012) How is ‘honour’-based violence managed in England and Wales. Internet Journal of Criminology.
 BPS, Code of Ethics and Conduct, 2009: 10.
 UKCP, Ethical Principles and Code of Professional Conduct, 2009: 3.
 BACP, Ethical Framework for Good Practice in Counselling and Psychotherapy, 2010: 2.