In doing psychotherapy with African-Americans, one must understand well the stress they face and their coping and adaptation styles. While sociological changes have gradually begun to shift the balance in some ways, the residuals of segregation and racism create, in the psychotherapeutic setting, a chronically stressful environment for African-Americans. It remains a social milieu in which they must continually demand equal status, equal resources, and equal opportunity, and then prove their worthiness. African-Americans must work harder to find ways to affirm and validate the self, struggle constantly against negative stereotypes, and must continue to function despite a sense of emotional vulnerability. Many succumb to despair and all of its self-destructive influences (substance abuse, violence, crime, etc.) in a desperate search for self, while simultaneously externalizing the internally felt defective sense of self. Others have found creative ways to cope and to adapt.

Greene (1994) describes the multiple social stressors, cultural imperatives, and psychological realities faced by the African-American woman as she attempts to fulfill her role as provider, protector, caretaker, and nurturer, with little external validation, personal nurturing, comfort, or support. African-American women have attempted to cope with these stresses through a sense of connectedness with family and community, through hope in a better life for their children, and through their spirituality. A major form of adaptation for many African-American women has been stoicism, the internalized ego ideal of the ‘strong black woman’.

The struggle for African-American men is even more tortuous. Grier and Cobbs (1980) describe the conundrum that the African-American man faces from early childhood at the hands of his own mother. The African-American mother must rear her son in such a way that inevitably crushes his natural ambition, defiant spirit, and aggressiveness, and discourages his maturity and independence in order to assure his physical survival. Subsequently, from birth to death the African-American man must fight for his physical and psychological survival, while on a journey of self-discovery, personal empowerment, and reconciliation with his past and the realities of his existence. White and Cones (1999) define this task as consisting of: (1) a search for self and masculine identity; (2) the challenge of sustaining intimacy and involvement in relationships; (3) coping with the realities of racism; (4) maintaining black consciousness; and (5) finding adaptive possibilities within the African-American way of being, while integrating African-American and European American life-styles. Many African-American men have made this journey channeling their passion and anger into intellectual and creative contributions, sociopolitical activities or Afrocentric community involvement. Many others continue to search for self and to define their masculinity through gang activities, an endless cycle of projected self-hatred, or ‘go for bad’ masculinity (White and Cones, 1999). Still others succumb in despair, immobilized, having given up, subsumed in drugs and alcohol.

Although influenced by a particular culture, the basic role of the family is universal. The role of the family is to provide basic physical resources for its members; loving affection; a sense of safety and security; to define values, roles, responsibilities, and competencies; and to serve as positive mirrors and models of idealization to facilitate consolidation of self-esteem in their children. The balance of stresses are different for poor and middle class African-American families, but both must cope with societal barriers that limit access to needed resources and the struggles and burdens of its individual members to maintain some sense of self and human dignity, which in combination undermine the family's ability to develop fully the system functions that it must serve.

The ascension into the middle class has created a different challenge and burden, and with it the fantasy that having arrived with education and financial resources, that race would not matter. A new challenge of adaptation has been necessary for the black middle class. Coner-Edwards and Spurlock (1988) examine the stress and crisis that this ascension has created for African-American families, and the multiple ways in which they have attempted to cope and adapt to their new found status, particularly their ‘survivors guilt’, and issues regarding identity and class affiliation.

For some time African-Americans were systematically excluded from psychotherapeutic interventions solely based on race and social class (Yamamoto and Steinberg, 1981). Therapists low expectations, interactive factors with patients, e.g., problems developing the therapeutic alliance, or difficulties for majority therapists in working through troubled transactions with African-American patients led to early dropouts (Mohl et al., 1991). Still today, access to psychotherapeutic treatments are restricted by patient mistrust, lack of awareness and education about the effectiveness of these interventions, limited financial resources, and by the therapist bias and selection factors. Additionally, a large percentage of African-Americans are uninsured and dependent on public mental health services in which access to psychotherapeutic treatments are limited or nonexistent.

Jackson and Greene (2000) consider psychodynamic theories to be ethnocentric, based on white, upper middle class, European standards, which perpetuate sex-role stereotypes, pathologize difference, and fail to provide a depth understanding of the ‘experience of the other’. They attempt to analyze and reformulate traditional psychodynamic theories regarding African-American women, to explicate the complexities, and to dispel myths. They agree, however, that African-Americans function no differently on an unconscious level, psychologically, than others. Also, that the real task is to expand our theoretical paradigms and therapeutic inquiry to take into account the impact of historical, social, political, and real life experiences of African-Americans, to understand better the psychodynamic underpinnings of their psychological experiences, and to more accurately guide the education and training of future clinicians. Foulks et al. (1995) develop the argument that a supportive-expressive psychotherapy that conforms to standardized guidelines is more effective and discuss factors that can lead to optimal outcomes in a cross-cultural context. Although they do not negate the usefulness of ‘ethnic specific’ therapies where feasible, they do caution against the proliferation of an array of ‘ethnic-specific’ therapies that avoid the task of the effective application of psychotherapy across cultures.

Regardless of the specific type of psychotherapeutic treatment, no effective process can occur without engagement and the establishment of a therapeutic alliance with the patient. Bland and Kraft (1998) examine the therapeutic alliance from a psychoanalytic perspective, and demonstrate common problems in its development across cultures. They illustrate how clearly perceived differences (such as race with a black patient and a white therapist) create an experience of social distance for both patient and therapist. This mobilizes mistrust and anxiety in the patient thus decreasing self-disclosure, and causing anxiety in the therapist that leads to potential countertransference enactments. Only by openly acknowledging this potential impediment is the therapist able to gain credibility with the patient, which can facilitate empathic bonding, development of the therapeutic alliance and ultimately leads to a successful treatment outcome (Bland and Kraft, 1998).

The therapist's empathy, ability to listen, experience, and skill are the best determinants of the effective application of psychotherapy, including with African-American patients. While no empirical comparative studies have demonstrated the differential superiority of racially matched versus cross-matched therapeutic dyads of patient and therapist, some articles have suggested certain advantages in the conduct of psychotherapy when the patient and therapist are alike, and there is the perception of commonality (whether real or imagined) on the part of the patient. Foulks et al. (1995) in a study of more than 120 African-American, cocaine-dependent men treated with supportive-expressive psychotherapy in a racially matched therapeutic dyad, observed ease of engagement, more natural establishment of empathy, and lessen negative countertransference. Patients also appeared to experience affirmation of self and racial identity, which facilitated the therapeutic process. Jones (1982) found no differences in psychotherapy outcome as a function of client–therapist racial match, although there were differences in therapy process. Comas Diaz and Jacobsen (1991) caution against potential over-resonance, overidentification, and countertransference collusion in racially matched therapeutic dyads. Racial match may be more critical under specific circumstances, e.g., when there are high levels of mistrust, narcissistic issues, identity conflicts or extreme tentativeness in the commitment to therapy (Bland and Kraft, 1998).

Because of their history, experiences, and struggles with prejudice and discrimination, African-Americans may enter psychotherapy with white therapists with several plaguing questions (at times conscious, at times unconscious): (1) Can I trust this person? (2) Can I reveal my true self? (3) Will I be understood? (4) Will I be judged negatively? (5) Will I be exploited? While these may be similar to questions of any patient, African-Americans’ real and pervasive experiences with racism give these questions unique meaning and intensity. This, in conjunction with the individual's specific intrapsychic conflicts, may lead to transference and early phase resistance manifested as anger and failure to self disclose. This creates anxiety in the therapist, whose need to be helpful is thwarted and if not correctly understood can result in countertransference enactments. The therapist may prematurely judge the patient as unmotivated, unpsychologically minded, and unsuitable for treatment (Bland and Kraft, 1998). By rejecting the patient before being rejected, the therapist contains his own anxiety, avoids acknowledging his anger, and wards off rejection and the associated narcissistic injury. Evans (1985) cautions against premature interpretation of race focused content in treatment as defense and resistance, and encourages deeper exploration of these issues. Grier and Cobbs (1980) suggest that, although for different reasons, both white and black therapists may unconsciously avoid exploration of these issues because it is too painful. Black therapists may fear overidentification and resonation with their patients’ vulnerability, despair, and anger, while white therapists may fear mobilization of feelings of guilt and an assault from the patient's angry feelings. Whether white or black, the therapist must be aware of and able to manage his own countertransference reactions. Only then is he/she able to be available to the patient and to provide a secure container for expression of the patient's affective experiences (including race focused issues), to help the patient work through conflicts, to develop more effective coping mechanisms, to work through negative internalizations, and to develop a more positive, confident, and competent sense of self.

Most scholars are beginning to agree that race is a cultural invention that serves to stratify the social system and has no intrinsic relationship to actual human physical characteristics (Smedley, 1999). Negative stereotypes have been attached to the physical, mental, and moral characteristics of African-Americans based on race. Despite its negative effect, racial identity for African-Americans is an important part of their sense of self and identity. The sense of connectedness as members of a group with a shared history, experiences, and world view has helped them to bear the common struggles of their black reality. At the same time, it has created psychological distress and conflict, which has interfered with the internalization and consolidation of a positive sense of self and racial identity. Thus, in psychotherapy, the formation of a positive sense of self and racial identity for African-Americans is a dynamic process over time involving a transformation of an internalized negative sense of self and various levels of conflict about ‘blackness’, to a more positive integrated sense of self and racial identity. Cross (1991) has described four stages in this process of racial identity formation, each corresponding to a set of feelings, beliefs, and attitudes of the individual regarding being black. Stage 1 (preencounter): there is a sense of neutrality or the denial of blackness, ‘human beings who just happen to be black’; stage 2 (encounter): a series of positive or negative, but decisively felt experiences compel the individual to turn to his racial group membership and identification with his blackness; stage 3 (immersion): there is a vortex of change with idealization and immersion in black interests, involvements, activities, in search of self and black group membership; and stage 4 (internalization): there is a resolution of conflicts and transformation of negative self feelings, firmly grounded in a sense of pride, self-acceptance, and deep sense of connection to the black community with a tolerance of diversity and acceptance of others and their views. Wherever the individual African-American is or settles along this continuum has a decisive influence on his sense of self, group membership, and resolution of conflicts about his blackness. This issue thus needs to be understood and addressed when doing psychotherapy with African-American patients.

African-Americans cannot be divorced from their history or their real life experiences with racism. Our knowledge base and the literature continue to expand regarding the interface of black reality and the psychology of African-Americans. We need to utilize this knowledge to expand our theoretical paradigms, and to guide psychotherapeutic inquiry in order to provide more effective applications of psychotherapy with African-Americans. Clinical reports suggest that African-Americans respond favorably to psychotherapy treatments. More research is needed to demonstrate clinical effectiveness, as well as how treatments may need to be modified (US Department of Health and Human Services, 2001a).

In psychotherapy, the concept of symptom formation has a very important meaning and significance. In this respect, it is important to understand the meaning of symptoms for a large number of Hispanics. For many Hispanics, some psychiatric symptoms are perceived as manifestations of strength, and thus to be cherished and retained (Ruiz, 1982). For instance, hallucinatory experiences could be perceived as a manifestation of ‘mediunity’, and therefore as a religious gift with potential healing powers. Attempts to eradicate this type of symptomatology in a psychotherapeutic setting might lead to resistances and challenges to the appropriate development and maintenance of the therapeutic alliance. From a different perspective, certain other symptoms can manifest themselves differently among some Hispanic patients. For instance, depressive symptomatology may be manifested by Hispanics as fatigue, headaches, body aches, and feelings of weakness and exhaustion; that is, primarily about somatic lines. Likewise, anxiety, in and of it self, may not be recognized well by some Hispanic patients. In these cases, anxiety could be manifested as dizziness, heart palpitations, and feelings of fainting (Abad and Boyce, 1979). Similarly, anger may be manifested among Hispanics as nervousness or malaise. Also, manifestations of aggression are not well tolerated or socially acceptable. In all of these situations, the meaning of symptoms needs to be well understood, and thus managed accordingly in the psychotherapeutic setting.

For many Hispanics, the conceptualization of mental illness is different than for other ethnic groups, especially Anglo-Saxons. Etiologically, Hispanics might perceive mental illness either as a supernatural phenomenon or associated to certain religious beliefs. For instance, psychosis may be explained by Hispanics as a manifestation of being possessed by spirits (Ruiz, 1977). This belief tends to be quite common among Hispanics from the Caribbean basin who believe in Spiritism (Ruiz, 1985). Likewise, some Hispanics might perceive mental illnesses as a result of God's punishment (Ruiz, 1998a). In these cases, the appropriate management of ‘guilt’ within the psychotherapeutic relationship is of paramount importance. In certain religions, as in the Pentecostal Church, psychiatric symptoms such as hallucinations might be perceived and conceptualized as ‘miracles’. For many Pentecostals, ‘miracles’ are a welcomed expectation rather than a manifestation of psychiatric illnesses. The appropriate understanding and management of these situations will certainly lead to a good outcome when doing psychotherapeutic interventions with Hispanic patients.

As in any other ethnic group, family dynamics are very unique, and require appropriate understanding and management when doing psychotherapy with Hispanic patients. Hispanics place high value on the family as a central point of their lives (Ruiz, 1982). Contrary to the American culture where the nuclear family represents the core element of the family structure, the extended family network tends to predominate among Hispanics and, thus, given high priority and relevance by them (Ruiz, 1982). Among Hispanics, the extended family includes not only all relatives, but friends, neighbors, and coworkers as well. This extended family network system can be very beneficial among families from low socioeconomic levels.

For Hispanic children who reside and grow up in the USA, this type of extended family network system offers them the opportunity to bond at an early age not only with his/her parents but with grandfathers, cousins, aunts and uncles, and even godparents and friends as well (Pumariega and Ruiz, 1997). Contrary to the American culture, which is individualistic and gives a high priority in achieving independence, the Hispanic culture is oriented towards a strong family and an extended family unity and gives a high priority to the achievement of interdependence. These cultural differences need to be taken in full consideration when offering psychotherapy to members of a Hispanic family; particularly, among first and second generations of Hispanic families. However, as members of Hispanic families achieve high levels of acculturation in the USA, a different psychotherapeutic perspective should also be entertained.

A dynamic factor that must also be taken into consideration when doing psychotherapy with Hispanic patients is that of ‘machismo’ (Ruiz, 1995a). Among traditional Hispanic families, it is common to observe a male-oriented hierarchical system. In these families, the father is sought when discipline of the children is needed; the mother is always a source of support and nurture; boys and girls are raised with different behavioral and occupational expectations; also, the expectation of ‘male responsibility’ is an issue of honor. While acculturation and generations tend to change Hispanic families substantially, the impact of traditional values needs to be given full consideration when psychotherapeutically treating Hispanic patients.

When doing psychotherapy with patients with a native language different than the language of the therapist certain factors need to be considered. It is known that Hispanic patients who speak in a language different than their native language are likely to be perceived as more depressed, more psychotic and with more cognitive impairment than patients who speak the same language of their therapists (Marcos et al., 1973). Language barriers can also lead to underutilization of mental health services, diagnostic errors, and poor mental health care (Gomez et al., 1985). However, it has additionally been reported that psychotherapeutic success can also be achieved when treating patients in their own language or using an acquired language (Gomez et al., 1982). It must be acknowledged, however, that patients could switch from the native language into the acquired language when dealing with emotionally charged psychotherapeutic issues. This is a way of avoiding affectively charged discussions; that is, as a manifestation of resistance (Marcos and Albert, 1976). It must also be noted that the use of interpreters do not offer a good solution to the problem of language barriers as interpreters tend to bring distortions into the translation process; this is primarily based on their own emotional needs and conflicts (Marcos, 1979; Laval et al., 1983).

Finally, the pattern of ‘small talk’ (la platica) observed among the Hispanic population at large must also be acknowledged. Among Hispanics, it is common to observe them speak for a while about irrelevant topics before they proceed to discuss serious and important matters (Ruiz, 1998b). The knowledge of this communication pattern is of great importance in the psychotherapeutic setting; otherwise, therapists might blame ‘resistance’ as the cause of this phenomenon or as a lack of interest in the psychotherapeutic treatment.

Hispanics tend to use a lot of nonverbal means of communication when trying to speak with other persons (Ruiz, 1998b). Unfortunately, this pattern of communication often leads to recommendations for somatic therapies rather than psychotherapy. This pattern is, however, culturally related. Thus, once understood it does not represent a deterrent for psychotherapeutic intervention. In many ways, this phenomenon could also be related to another phenomenon that is commonly observed among Hispanics; that is, an increased manifestation of functional somatization. This somatization phenomenon has been well studied among Hispanics and reported in the medical literature (Escobar, 1987; Canino et al., 1992). This cultural characteristic among Hispanics certainly has a major impact on the manifestation of symptoms among Hispanics. For instance, during the manifestations of depressive and anxiety symptomatology as previously discussed. Once understood, it should not represent a barrier to psychotherapy interventions among Hispanic patients.

Culture can play a beneficial as well as nonbeneficial role vis-à-vis the development and maintenance of a strong therapeutic alliance. For therapists who have little expertise about the cultural heritage of his/her patients, the development of a strong therapeutic alliance will be a major challenge, and most probably will lead to noncompliance with the recommended psychotherapeutic interventions. Actually, it has been demonstrated that among patients in psychotherapy who have rooted nonmedical beliefs about the causes of their illnesses, the rates of noncompliance and psychotherapy termination is much higher than among those who do not have it (Foulks et al., 1986). Kernberg (1968) understood quite well these problems when he underlined the importance of understanding both the latent and the manifested transference within a cultural matrix.

Hispanic populations, like any other ethnic groups, have their unique cultural characteristics. Thus, when psychiatrically treating Hispanics, particularly along the lines of psychotherapy interventions, it is imperative that psychotherapists be vested in these culturally related characteristics. This cultural understanding and sensitivity on the part of psychotherapists is essential to achieve a beneficial psychotherapeutic outcome.

Asian-Americans have the lowest rates of mental health utilization among US ethnic populations. This underrepresentation in mental health care is characteristic of most Asian groups, regardless of gender, age, and geographic location (US DHHS, 2001b). As Asians tend to underutilize or even avoid mental health care, they have been perceived as a well adjusted ‘model minority’ and with little or no need for mental health services. However, so far, there is a lack of data specifically addressing the utilization of psychotherapeutic intervention among Asians.

While the majority of people with mental health problems, regardless of race or ethnicity, demonstrate a reluctance to receive treatment, the stigma and shame surrounding mental illness are particularly powerful barriers for Asians to utilize mental health services. As mental disorders are considered taboo, it is stigmatizing to admit psychopathology and to utilize mental health services, even among third and fourth generations of US Asian families (Yamamoto and Acosta, 1982). Additional barriers and deterrents include the Asian tradition of caring for ill members within the family, protecting the family's name and honor, delayed confrontation, racism, fear of discrimination, and differences in language and communication. Some Asian cultures even view suffering as inevitable, and hence may lack an understanding of the need for early intervention and preventive measures. Among those who use mental health services, their conditions often have become severe and chronic by the time they seek treatment, and thus are more often diagnosed as psychotic disorders than among other ethnic groups. Thus they are more likely to require psychopharmacotherapy (Lin et al., 1982; Sue et al., 1991; Kitano et al., 1997; Pi and Gray, 2000). This suggests that Asians delay seeking mental health services until problems become very serious, and those with less severe symptoms may not seek mental health treatment such as psychotherapy.

Recognizing the heterogeneity and diversity of the Asian population in the USA, caution must be exercised in making generalizations about them. Factors such as demographic variables, cultural backgrounds, generational issues, unique life-styles, and assimilation and acculturation levels must be taken into consideration when doing psychotherapy with Asian patients.

Culturally determined health beliefs and practices can profoundly influence psychiatric treatment. A critical issue is whether or not Asians manifest symptoms similar to those found in Western societies. Cultural influences on symptom manifestation are often observed among Asians, which may mislead clinicians who are not familiar with such a phenomenon (Lin, 1996). For example, Asians with a strong somatizing tendency are likely to express their problems in somatic or behavioral terms rather than in emotional ones (Lin, 1996). Thus, they may receive a physical health diagnosis and fail to receive appropriate psychotherapeutic treatment.

The Asian population in the USA is diverse. Some Asian families have remained strongly traditional, while others have assimilated to a considerable extent into ‘mainstream’ American culture. Significant differences exist between Asian and Western cultures. Asian cultures emphasize the value of responsibility, moderation, restraint, attending to others, fitting in, and harmonious interdependence with others (Markus and Kitayama, 1991). On the other hand, Western culture values independence, individualism, and spontaneity (Sue and Zane, 1987). Asians under the influence of their traditional cultures and philosophies encourage self/inner control to maintain social and familial harmony rather than openly expressing emotions.

An individual's view of psychopathology influences the seeking of particular treatment modalities. Asians tend to have a multifaceted view of the causation of mental illness. For instance, views such as: hereditary, physiological, biochemical, psychological, social, nutritional, infectious, religious, moralistic, and imbalance of energy (Yin and Yang or cold and hot) explanations. Asians believe that mental illness is associated with organic or somatic factors and that mental health involves the avoidance of morbid thoughts (Sue et al., 1976). Asians are also more likely to express somatic symptoms when seeking treatment, sometimes referred to as ‘somatization overpsychologization’ (Sue and Sue, 1974; White, 1982). Somatization is a ‘face-saving’ mechanism used to gain assistance for emotional problems they dare not openly express (Mattson, 1993). Often what is verbalized is different from the underlying problem. Many Asians also view Western psychotherapies as attributing psychopathology to intrapsychic or interpersonal conflicts, a concept that is incongruent to the Asian emphasis on somatic factors. Asians may prefer to seek biological therapies over psychotherapies (Sue and Sue, 1987). Even in the presence of Western mental health services, Asian cultures are more holistically oriented. Asians frequently use complementary methods of indigenous or alternative remedies, such as herbal medicine and ‘hot’ and ‘cold’ foods. Traditional or folk healing practices such as meditation and religious healing may be relied on as the primary treatment and tried first for psychiatric symptoms. Also, religious values and spirituality are sources of comfort for Asians. Asians who seek Western mental health treatment may still maintain many of their healing traditions, including the notion of brief intervention, magical cures, and concurrent consultation with many other healers. Thus, long-term recovery strategies and persistence with a given treatment modality may not be well understood by them.

One of the most important characteristics of Asian cultures is their family values, such as family cohesiveness and stability. In relation to empathy and transference in the treatment of the family, especially in those who are not acculturated to the mainstream culture, empathy needs to be applied to both the individual and his or her family. A family-oriented approach that recognizes the family unit and getting family members involved in psychotherapeutic interventions is an essential element of a successful healing process; particularly in working with issues involving two or more family generations.

Language plays a very important role in psychotherapy. How to communicate in a culturally palatable, sensitive, or competent way is always a challenging clinical issue when working with culturally and linguistically diverse Asian patients; especially with less acculturated Asian patients who also have limited English proficiency. Bilingual interpreters are often involved in the evaluation and treatment process, but not without difficulties and problems. The best solution may be to match bilingual psychotherapists with Asian patients. Transference and countertransference (both positive and negative) reactions must, however, be carefully addressed (Yamamoto et al., 1993).

Regarding the issue of therapist–patient match or ‘fit’ in the process of psychotherapy, one should not automatically assume that the patient prefers an Asian therapist. For Asians who are already acculturated into the mainstream US majority culture, Western psychotherapeutic modalities can be readily applied with little modification; although the traditional cultural values still need to be considered during the course of psychotherapy.

The issue of which type of psychotherapy should be applied to patients from different ethnic or cultural groups, as well as their appropriateness, has been raised. Psychodynamic psychotherapy has sometimes been criticized as inappropriate and ineffective with nonwhites, and empirically high dropout rates and less than optimal outcomes have been reported (Trujillo, 2000). Many Asians believe that therapists from the traditional US mental health system cannot help them (Root, 1985), and thus are skeptical toward Western forms of psychotherapy. There are, additionally, many common myths regarding the provision of psychotherapy to Asian patients. These include the myth that psychodynamic psychotherapy is inappropriate for patients belonging to different cultural traditions and that long-term psychotherapy is ineffective. Studies have reported that compliance with psychotherapy may, however, be more problematic among non-Western than Western populations. For example, some Asians believe that the Western therapies are too confrontational (Sue and Sue, 1987), and Asians tend to prefer psychotherapists who provide structure, guidance, and direction rather than nondirective advice and interactions (Atkinson et al., 1978).

Sue and Zane (1987) have pointed out that the role of culture and cultural techniques in psychotherapy is perhaps the most difficult issue facing the mental health field. Cultural knowledge and techniques are frequently applied in inappropriate ways, with psychotherapists acting on insufficient knowledge or overgeneralizations. They suggest that cultural knowledge and culture-consistent strategies should be linked to two basic processes: credibility and giving. Credibility refers to an Asian patient's perception that the therapist is both effective and trustworthy. Giving refers to the Asian patient's perception that something of significant value was received from the psychotherapeutic encounter. Asians need to feel a direct benefit or ‘gift’ from the treatment and a direct relationship between work in psychotherapy and the alleviation of problems. Some of the ‘gifts’ (immediate benefits) may include anxiety reduction, depression relief, cognitive clarity, reassurance, hope and faith, skills acquisition, developing a coping perspective, and goals setting (Sue and Zane, 1987). Also of normalization; that is, a process to realize that thoughts, feelings, or experiences are common, and that many individuals encounter similar experiences (Sue and Morishima, 1982). A balance between cultural knowledge and these two therapeutic processes is necessary in order to achieve positive psychotherapy outcomes and to prevent Asian patients from dropping out of treatment.

It is not possible to pick one ‘right’ or ‘specific’ form of psychotherapy for all Asians; although there are culture-specific psychotherapies in Asia, such as Morita therapy. Morita therapy is a very unique form of psychotherapy used primarily in Japan. Morita therapy does not address psychological conflicts or use psychotherapy techniques such as transference or dream analysis; its main objective is to free the patient from excessive self-preoccupation and intellectualizations as well as help the patient accept things as they are (Fujii et al., 1993). Also, cognitive-behavioral psychotherapy was found to be effective and accepted by Asians (O'Hare and Tran, 1998; Dai et al., 1999). It should be acknowledged that each psychotherapeutic strategy has its applicability and strengths. Within Asian patients, some will respond and some will not. It is also important to recognize that the inclusion of concepts, values, beliefs, and problem-solving procedures that are congruent with an individual's culture make psychotherapy more effective (Fisher and Jome, 1998).

There is limited evidence regarding psychotherapy outcomes for Asians. It appears that Asians who attend ethnic-specific services and receive culturally-sensitive psychotherapeutic modalities stay in treatment longer than Asians who attend mainstream psychotherapy services. The ethnic matching of therapists with Asian patients has also been associated with an increased use of mental health services and with favorable treatment outcomes (Sue et al., 1991; US DHHS, 2001b). There is increased awareness of the need to provide culturally-competent, relevant, responsive, and meaningful psychotherapy. Cultural sensitivity/competency must avoid stereotyping diverse Asian groups and must also allow therapists to have the ability to empathically connect with people who are different from them. Thus, an exact ethnic or cultural match or fit between Asian patients and therapists may not be necessary except for those patients who are less acculturated. Also, it is not necessary to eliminate any differences that do exist. We should not make groups indistinguishable one from the other, but should make a concerted effort to understand and respect differences. Forcing or imposing assimilation is ineffective in the healing process of psychotherapy.

Certainly there is no single or special psychotherapeutic modality or style for all Asians, for a subgroup of Asians, or for Asians only. Mental health professionals who provide psychotherapy to Asians must not automatically assume that their distinct cultural characteristics require different treatment approaches, to be reinvented for each group and totally different from traditional Western psychotherapeutic modalities. Some psychotherapeutic principles and issues, such as empathy, transference, and countertransference are universal and applicable to all cultural groups. Until we have better research data examining the effectiveness of each psychotherapeutic modality in treating Asians, the standard of practice should go beyond cultural differences and be applied to all ethnic groups.

At present, the field of psychotherapy for Asians, as for other cultural groups, ranges from the conventional to the mystical. There is a paucity of empirical information on the effectiveness of therapeutic modalities targeting Asian patients. We must let scientific evaluation make determinations about which psychotherapies and provided by whom are best applied to what types of problems (Kendall, 1998). Given the significant growth in the Asian population in the USA, continuous efforts must be made to expand the science base, including research that confirms the efficacy of evidence-based psychotherapies for Asian patients.

The core of the therapeutic approach at Maudsley Hospital is to ensure that the patient is given a sense of control and responsibility throughout the treatment program. This is to counteract the sense of helplessness induced by traumatic experiences. With ethnic minorities, this means making the individual feel as secure as possible within a foreign context. To achieve this, it is essential to bear in mind the fact that these people may have a constellation of psychological problems that generally fall into three groups: (1) problems arising from displacement, such as cultural bereavement, isolation, unmet expectations of life in the UK, changing roles in the family leading to a clash of values, the stress of the asylum-seeking process, and racism in their new community; (2) major mental health problems; that is, patients may have had mental health problems before their move to the UK or they may have been precipitated by the move such as a psychotic illness (they will often hide such a history as it often means social ostracization in their home communities); and (3) mental health problems stemming from traumatization (in this context, the asylum seekers or refugees may have witnessed or been the victims of torture, rape, or other atrocities in their home country; they may have lost family members or friends through traumatic bereavements or they may have taken part in atrocities with resulting emotional problems). A history of past political oppression will mean that patients will be very worried about issues of confidentiality. These fears must be attended to. Those who have been tortured may feel very anxious in the presence of doctors as the latter are often involved in the torture of political prisoners.

Some of these manifestations reflect a Western categorization of mental health problems and may not reflect the refugees’ perception of their problems and distress. For this reason it is so important to listen and to take note of the patients’ accounts and explanations of their problems, and not to impose the psychotherapists views and beliefs upon them. Similarly, our labeling of an experience as a pathological symptom may not reflect what patients think and feel. For example, a Somalian woman described night visits by her dead family with whom she would communicate; she saw these visions as comforting.

If the patient is known not to speak the language of the therapist, an interpreter is booked in for the session. Family members and especially children should not be used as interpreters as the patients may not want members of the family to know the cause of their distress. For example, many women who have been raped do not want their husbands or members of their communities to know as this would mean being thrown out of their community and thereby add to their sense of isolation and fear. This will have implications in terms of the choice of interpreter as well.

The first obstacle to the doctor–patient attachment relationship with asylum seekers, can be the linguistic divide. If a patient cannot speak good English, they will feel quite helpless and even paranoid in the interview. An interpreter who both speaks the patient's language and who is of the right social group is essential. In some cases, bilingual patients who are proficient in English may choose to use their second language which can act as a ‘linguistic defense’ protecting people from disturbing associations and emotions linked to their mother tongue (Zulueta, 1995).

To counteract the overwhelming sense of helplessness experienced by many patients, they are taught relaxation techniques using tapes, guided imagery, and the establishment of a safe place. These experiences can be comforting and facilitate the attachment process between therapist and patient as well as providing some symptomatic relief. Asylum seekers also need to be given information about their rights, services that are available, and community support groups.

Patients with complex PTSD often resort to destructive patterns of behavior in order to cope with their symptoms. A thorough assessment needs to be done in relation to their capacity for self-harm or the dangers that they might bring upon themselves by engaging in treatment. Sorting this out may require quite a long period of stabilization. For example, with asylum seekers, the need for a home, community services, legal support, and attention to substance abuse and physical health issues is essential before any trauma work can be contemplated. This used to be done by the staff but is now carried out by other services.

Standard trauma work usually requires a patient to confront their traumatic experience as well as the feelings and cognitive distortions that accompany it. To do this asylum seekers are offered a choice of therapies: narrative reprocessing, psychodynamic psychotherapy with a marked cognitive input, focused group therapy, and family therapy. The latter is particularly important for some patients whose irritability and potential for violence can be very frightening for their partner and children. Medication is offered as a ‘life jacket’ to cope with the difficulties of the therapeutic journey.

The treatment of asylum seekers, refugees, and migrant ethnic minorities is one of the most interesting and challenging areas of work in the field of psychiatry. However, techniques and approaches need to be adapted to people from other cultures and languages.