Die folgenden Textstellen, Exzerpte und Zitate zu Fragen der interkulturellen Wahrnehmung von Trauma und den kulturell bedingten Differenzen wurden von Dr. Angelika Birck, wissenschaftliche Mitarbeiterin am bzfo, zusammengestellt, bevor sie unerwartet in jungem Alter verstarb. Die Fragmente aus Artikeln und Büchern sollten den Grundstein für eine große Studie zur Interkulturalität im Traumafeld bilden. Sie werden hier aufgeführt, da es sich um einen Werkzeugkasten zur Bearbeitung von Themen handelt, die aus ihrer Tätigkeit resultierten. In ähnlicher Weise wie in den aufgeführten Essays können sie als Anregung für weitere Bearbeitungen dienen.

 

Brislin, R. & Yoshida, T. (1994) (Eds.). Improving intercultural interactions. Modules for cross-cultural training programs. Thousand Oaks, London, New Delhi: Sage.

 

B & Y, p. 5-9 (Einleitung): Recommended contents of cross-cultural training:

• Awareness of culture and cultural differences: Most people are unaware about the influence of the own culture, they take their beliefs and behaviours as „normal“. They are surprised when their behaviours and beliefs are totally inappropriate elsewhere. Becoming aware of differences is the first Step in intercultural success.
• Knowledge of „facts“ accepted within a culture necessary for adjustment: varying views of reality (punctuality),
• Emotional challenges  that intercultural experiences inevitably bring (confusion, frustration, anger...)
• Opportunities to identify and to practice various skills (behaviour) that can be helpful in cross-cultural communication.

 

„culture shock“: inevitable,

Barna, L. (1983). The stress factor in intercultural relations. In D. Landis & R. Brislin (Eds.) Handbook of intercultural training, vol. 2: Issues in training methodology (pp 19-49), Elmsford, NY: Pergamon.

 

 

Brislin, R. W. & Yoshida, T. (1994). The content of cross-cultural training: an introduction. Pp 1-14 in B&R

Modules  for training programs:

Self-assessment exercices: to discover what the reader knows, own attitudes

Case studies, critical incidents: to empathize

Presentation of key concepts: to develop knowledge

Exercises: role-plays, group discussions etc., homework assignments.

 

Hall, Edward T. (1976). Beyond culture. New York: Doubleday. (pp43 in B&R)

High-context-communication: most of the information is in the context, very little is encoded

and transmitted as part of the articulated message. More collective, little is

communicated directly, much is indirect and ambiguous.

Low-context-communication: the mass of the message is explicit coded (content of the

words.)

 

Für Workshops: S. 51ff Gutes Rollenspiel zu Attitudes etc., lustig! (2 Gruppen, 2 verschiedene Ethnien, mit Arbeitsauftrag, klaren Rollenanweisungen etc.)

1. Gruppe: darf nur ja- und nein-Antworten stellen, soll viel über Regeln erfahren

2. Gruppe: dürfen nur mit dem selben Geschlecht sprechen, ja-Antworten immer dann, wenn der Fragende lächelt, sonst nein.

1. Gruppe soll hinterher die 2. beschreiben: was ist das für eine Kultur, was sind die Regeln?

 

S. 71 B&R: Fragebogen zu individualistischen und kollektiven Einstellungen und Verhaltensweisen, typische Dinge.

 

 

N. R. Goodman (1944). Intercultural education at the university level: teacher-student

interaction. Pp 129-147, in B&Y

Pp 136ff: Hofstede describes 4 dimensions of national culture:

• Power distance: the degree to which a society accepts the idea that power is to be distributed unequally. The more this is accepted, the higher is the power distance.
• Individualism – collectivism: the degree to which a society feels that individuals’ beliefs and actions should be independent of collective thought and action. Personal goals vs. the goals of the group.
• Uncertainty avoidance: the degree to which a society feels threatened by ambiguous situations and tries to avoid them by providing rules and refusing to tolerate deviance.
• Masculinity: the degree to which a society focuses on assertive ness, task achievement, the acquisition of things as opposed to quality of life issues such as caring for others, group solidarity, helping the less fortunate. Competition and ambition are „masculin“.

 

G. Hofstede (1991): Cultures and organizations: Software of the mind. London: McGraw-Hill.

Hofstede, G. (1986): Cultural differences in teaching and leaning. International journal of intercultural relations, 109, 301-320.

 

 

Mullavey-O’Byrne, C. (1994). Intercultural communication for health care professionals. In B & Y, pp 171-196.

Focus on different explanatory models of illness (health  beliefs), attributing causes to ill health (supernatural world, germs, ... balance of cold and hot substances in the body...) – food balance,) - kopiert

Pp 206: disconfirmed expectancies: If a cultures holdes strong beliefs about how the future and the life will be, a disruption can be very stressful, life and things are not how they were meant to be.

 

Migration can change roles in families (gender roles), relationships at work. Role confusion can lead to stress. Role expectations, functions etc. are different in cultures.

 

Pp211: Saving Face, Facework: Face is the public self-image people present when relating to others, it is the self the individual wants others to see. Authentic self vs. social self: cultural values decide which is more important.

Individualistic cultures belief it is important to maintain consistency between public and inner private self, to be authentic. Collectivist cultures base their self on the relationships to members of the group, to relations to others. People help others to maintain an appropriate public image. To suffer a loss of face is a serious matter that brings shame on oneself ant one’s family.

 

Pp231: If cultural groups end up stereotyped, within-group differences are ignored.

If similarities across cultures are overemphasized a new form of racism can emerge.

All forms of counselling may be rejected by minorities because of their past oppression by a dominant culture.

Examples of racism: Colour blindness, ignoring cultural issues, attributing problems to a client’s culture in a deficit hypothesis, blaming him, „help“  to  maintain power and dominance.

Pp 233: 3 areas of competencies: awareness, knowledge, skills.

 

Yoshida, T. (1994). Interpersonal versus non-interpersonal realities: an effective tool individualists can use to better understand collectivists. Pp 243-267, in B&Y

Pp 253: independence versus inter-dependence.

In collectivist societies, nature adults think of their own personal needs as being secondary to the needs of the group. Giving in is not passive or weak, but a sign of tolerance, self-control and maturity. „Individualists“ who would be independent would be perceived as lacing maturity. But: in an individualist society, autonomy, independence and assertiveness are necessary for career success.

Collectivists see people as interdependent, existing only in conjunction with others.  Relations are reciprocuous, other-directed, harmony is important, conflicts are avoided, conformity is necessary.  Also in industrialized countries, collectivism exists: people in rural communities and women often display similar characteristics.

Smolar, A. I. (2002). Reflections on gifts in the therapeutic setting: the gift from patient to therapist. American Journal of Psychotherapy, 56(1), 27-45.

 

Smolar (2002) Pp 39: Cultural differences in the giving and receiving of gifts have to be taken into account. In some cultures, giving a gift to a person held in high esteem is standard, not to do so would be considered as an affront. In other cultures, a gift from one to another places responsibility on the receiver to return some kind of gift of equal value. Not accepting a gift may be offending because it has the significance that the gift (and the giver) are not worthyful.

We accept small gifts.

Von mir: Some of our patients bring traditional meals or handmade cakes to therapy hours, not accepting these gifts may signify also offending the culture of the giver. Eating together is an act of closeness and friendship in most cultures.  Joining in meals is something we sometimes use ritually in psychotherapy termination ceremonies.

 

 

Sato, T. (2001). Autonomy and relatedness in psychopathology and treatment: a cross-cultural formulation. Genetic, Social and General Psychology Monographs, 127 (1), 89-127.

 

Individualized autonomuous vs. collective related cultures, our therapy concepts focus on the establishment of autonomy, neglect the relatedness-aspect, therefore, they are sometimes not very helpful for persons from collective cultures.

What do persons suffer from? Loss of autonomy vs. loss of relatedness.

 

Sato (2001) offers a systematic framework integrating motivation and cognitive processes with cultural factors to understand psychological disorders, esp. depression.

 

Different cultures put different emphasis on different aspects of the self: independence/autonomy vs. interdependence/relatedness.

Autonomy: the sense of competence, control, achievement, agency. Control over one’s environment and bodily functioning. Other people are obstacles or tools for achieving personal goals.

Relatedness: the sense of being „at one with others“, communion, affiliation, self-surrender. The unit of thought is not the person as an individual, but the group to which the person belongs. Western attachment theories (Bowlby) focus mainly on the emotional attachment of the caretaker-child relationship during early developmental stages of the child, but there are some similarities with the attachment/relatedness of collective adults: a lack of a sense of separateness from another individual. (pp91-93)

Identification with groups as discussed in social identity theories – difference: for relatedness, the goal is not to receive personal gratification from others through any type of interaction, but the actual „being associated“ with the other person or the group is a goal in itself (vs. identification with a group to reach personal goals).

 

2-dimensional framework: autonomy – relatedness. Human beings must have both in order to achieve a consistent sense of self-worth and to maintain healthy, but different cultures have different emphasis.

 

Pp 99: Cognitive Therapy (Beck): much emphasis on autonomy. Autonomous individuals derive their self-worth through their personal achievements and their control over their environment. They become depressed, if they are too dependent on others, get disapproval from others and are motivated to please others. Western psychotherapy emphasizes a strong sense of autonomy but not relatedness – the importance of relatedness for non-Westerners is therefore underestimated. Little emphasis is given to the development of relatedness.

But highly related persons may not get depressed under these circumstances but in cases of social isolation ...

 

Pp 107: Beck, A. T. (1983). Cognitive therapy of depression: new perspectives. In JP Clayton & JE Barrett (Eds.). Treatment of depression: Old controversies and new approaches, pp 265-290. New York, Raven Press.

Beck (1983) claimed that autonomous and sociotropic/related clients should be treated differently. Therapists should fist create a stable, trusting relationship, sharing personal experiences and show that the therapist genuinely understands the client. Only after the relationship is established, both should focus on change and maladaptive thought processes.

Pp108: Cognitive therapy has been criticized for not adequately considering life events and interpersonal interactions in the aetiology of depression. CT achieves a state of experiencing autonomy but not necessarily relatedness. CT seem to be relatively inefficient in treating all types of depressed patients because it pays little attention to the relatedness aspect of the self, this is often essential to a person’s sense of well-being.

Therapy with related individuals should strengthen the sense of relatedness with significant others.

 

Pp 101: Benedict (1946) differs guilt (autonomy, individualism) and shame (collectivism, relatedness) cultures.  (Absence of the feeling of guilt in depressed individuals in collectivistic cultures – Draguns 1990).

 

Related cultures: the self focuses on the fundamental relatedness of individuals to each other, emphasizes attending to significant others to achieve and maintain harmonious relationships.

People with independent and interdependent self-construals differ in what they need to maintain a positive view of the self:

Independents: success, winning, being in control – includes competition, think of themselves as better than others.

Related: would not separate themselves from others by seeing oneself as better than others.

Pp 102: „For people with interdependent self-construals, feeling good about oneself is not achieved by seeing oneself as better than others or by achieving personal success.“ Instead, the sense of acceptance from others is correlated with a sense of well-being (empiric results in Japan).

 

Eigene Überlegung zu westlichen Diagnosesystemen: es gibt eine abhängige Persönlichkeitsstörung, aber keine unabhängige!

 

Pp 110: „Individuals with self-structures that are considered normal and healthy in some cultures may be considered dysfunctional in other cultures.“

Eastern society: „A person without a strong sense of relatedness is often considered a dysfunctional member of society.“

 

Gender differences: Women (also in the West) put more emphasis on relatedness as do collective cultures.

 

2 forms of therapy to enhance relatedness in Japan:

Morita therapy: 4 stages total 4-5 weeks, 1st stage: just rest in bed, do nothing, just function biologically – to suffer and worry. Next 3 stages: keep a diary. Patient is told that a person’s meaning in life results from work and not from emotions and symptoms, the goal of Morita therapy is to work and fit in, become a constructive member of society by behaving correctly, this is the key to recovery and a good life. Morita assists the patient in taking thoughts away from trying to experience control over the self and environment, just accept it. „The object of life is to become a constructive member of society and accept one’s negative feelings.“

Naikan therapy: patients are instructed to just sit in their room, do nothing but function biologically. They are told to examine their relationships with significant people in their lives through past experiences. Think about how indepted they are to these people, learn to be more accepting of significant others (this enhances feelings of grief, hatred, love etc. towards these people). Think about what other people have done for them, what others think and feel about them – they are shifting from the depressed stated to a relatedness state. Pp114. „When patients realize how much they owe to other people, they feel thankful and want to fulfill their obligations to others.“ They realize and accept interdependence by focussing on the feelings and thoughts of others.

The central goal of these therapies is to develop a sense of relatedness. The function of the individual in the group is the central goal of therapy, p115: „A group in a collectivistic society may have problems functioning if even one member of the group is not experiencing a sense of relatedness with the others in the group.

 

PTs were developed to assist patients to adapt to their respective cultures. Vereinfacht: Psychotherapy should make people „fit“ for the society they life in, therefore: competitious, autonomous in the west, related and self-surrendering in the east.

 

Pp116: Investigate in further detail the applicability of the present cross-cultural model to other psychological disorders (not only depression). PTSD

 

Western psychology focuses on the negative aspects of relatedness  (group-think, risky shift, conformity, obedience, ...), relatedness is understood as weakness of the human mind. Other theories should see the positive qualities of communion, affiliation and relatedness, they are essential to maintain a person’s mental health.

Pp117f: „People in collectivistic societies require high levels of relatedness but do not necessarily require high levels of autonomy to maintain mental health. ... In contrast, individuals in individualistic cultures require high levels of autonomy and also moderate levels of relatedness to escape the dangers of losing one’s mental health.“

 

 

Hall, G. C. (2001). Psychotherapy research with ethnic minorities: empirical, ethical, and conceptual issues. Journal of Consulting and Clinical Psychology, 69 (3), 502-510.

 

Hall (2001): EST: empirically supported therapies; CST: culturally sensitive therapies

Not adequate empirical evidence that any of the Ests is effective with ethnic minority populations. Almost all ESTs involve behavioral or cognitive interventions.

Blind control studies (of treatment outcome) Vs. alternative approach: patient-focused psychotherapy research that monitors individual patient progress in treatment and uses patient feedback to tailor treatment to the individual’s needs (Howard et al, 1996).

Howard, KI, Moras, K, Brill, PL, Martinovich, Z. & Lutz, W (1996). Evaluation of psychotherapy: efficacy, effectiveness, and patient progress. American Psychologist, 51, 1059-1064.

 

Ethnic minority patients who are matched with therapists of their own ethnicity and who speak the same language tend to remain in therapy longer than those who have therapists who are not matched on these variables (Sue et al, 1991).

 

Epidemiologic and clinic research: universal position, few ethnic differences in pathology are found. But these measures are all developed within the European American context! Cultural differences are unlikely to be detected unless there is a conceptual rational to expect such differences and measures to assess relevant culturally related constructs. Bias towards universal pathology (Neigung, Tendenz zur Universilisierung der Psychopathologie) by using American measures.

 

Ethnic minorities: they differ not only in culture, but are also socio-economically disadvantaged, this may be measured.

 

Conceptual definition and measure of ethnicity or culture: ethnic minority persons face life experiences such as discrimination that ethnic majority persons do not face – therefore, ethnic similarities may be found also in two ethnic groups which are not similar.

 

How tolerant are cultures towards externalizing disorders/problems? Acceptable behaviours in one culture might be considered pathological in another cultural context.

 

Bicultural identities, adaptions – keine „reinen“ Kulturangehörigen

 

What is cultural competence? „Dynamic Sizing“ (Sue 1998): skill to know when to generalize across cultures and when to individualize, when to refer to culture. Cultural competence is not stereotyping.

 

Sue, DW, Ivey, AE, Pedersen, PB (1996). A theory of multicultural counselling and therapy. Pacific Grove, CA, Brooks/Cole.

 

Which constructs differ minority and majority ethnic groups?

Interdependence: reputation is important. „Helping the person find a prosocial group to identify with might be an important component of a therapeutic solution.“

Spirituality: integrate religion, this is not only beliefs, but churches offer also social networks, community support. Spirituality should not be reduced to religious beliefs and behaviors only. Integrate spiritual healing experiences from cultural traditions, religious metaphors, prayer etc.

Discrimination: has to be addressed not intrapersonally (how to live with it), but on a political and social level (how to prevent and change, go to the police, find support..) within therapy.

 

The therapist’s credibility may be more critical than his or her ethnicity.

A therapeutic goal of less dependence on others for definitions of self-worth for someone who is depressed may be incompatible with cultural values of interdependence.

 

 

Bernal, G. & Scharron-del-Rio, M. (2001). Are empirically supported treatments valid for ethnic minorities? Toward an alternative approach for treatment research. Cultural Diversity and Ethnic Minority Psychology, 7 (4), 328-342.

 

Bernal & Scharron-del-Rio (2001). Psychotherapy is in itself a cultural phenomenon – reflecting western values (individualism, spiritualism is unconsidered…)

Ethnic minorities cannot afford to “choose” their treatment because of their socioeconomic and minority status, they are experiencing major mental health problems but have less access to health care, the care they receive is often of poorer quality  S. 332

 

“To the extent that a specific theory of psychotherapy is developed, constructed, and tested in a particular cultural group, packaged as empirically sound, and imposed on another, there may be a new form of cultural imperialism.” S. 333  Imperialist fallacy occurs when people insist that others adopt their belief or model.

Would westerners accept a health care model developed and empirically tested only in Africans, Asians, native Indians etc.?

 

Why ESTs are not valid for minorities: Cultural and ethnic factors mediate psychotherapy seeking behavior, treatment, satisfaction, and outcome – but they are variables not considered in randomized control trials RCTs. The RCT methodology was developed within the western thinking: positivist paradigma of science, one-way linearity, simple causality etc. – cultural differences are minimized or ignored. More adequate research model for minorities: discovery-oriented research.

 

Recommendation p 338: Document what treatment works with which minority group and why, what makes it work, what are the outcomes. How was a treatment modified to be cultural and ethnically sensitive (criteria?) within a particular ethnic minority group?

 

 

Steele, K.; Van der Hart, O.; Nijenhuis, E. (2001). Dependency in the treatment of complex posttraumatic stress disorder and dissociative disorders. Journal of Trauma and Dissociation, 2 (4), 79-116.

 

Dependency: different sociocultural and theoretical beliefs regarding dependency

Gender differences

American and Western European culture generally views dependency as a negative, pathological and undesirable state in an adult individual. (seen as unhealthy, immature, resistant, regressive, manipulative …)

 

Strong social support following trauma (implying some degree of dependency) is essential to prevent further difficulties with trauma-related disorders (King et al, 1998;  Runtz & Schallow, 1997)

 

“In cases of trauma, dependency on a parent (and in therapy, on the therapist) may be healing and protective.”  Dependency is associated with some attributes that enhance therapeutic movement: cooperativeness, compliance, suggestibility, help seeking, interpersonal yielding. Dependency is not synonymous with passivity and submission, but may be active help seeking behavior.

 

Trauma has an impact on basic psychological and physical needs, dependency reflects this need!

 

Traumatic state: cannot be represented, therefore cannot be interpreted. It can only be modified by interactions with other objects which meet survival needs! Patients may experience dependency as directly related to survival needs – they may act as if their lives depend on urgently having needs met by the therapist. These patients need secure attachment and dependency in therapy! In the face of trauma, basic survival needs have to be met. Extreme dependency is part of the insecure attachment that results from trauma and neglect.

 

Definition of dependency (opposed to attachment in general): to procure care taking, i.e. needed direct support and guidance, from an attachment figure.

 

Phase oriented trauma treatment: 1: symptom reduction, stabilization,

2: treatment of traumatic memories, 3. personality (re)integration and rehabilitation

 

 

Jordan, J. V. (2001). A relational-cultural model: Healing through mutual empathy. Bulletin of the Menninger Clinic, 65 (1): 92-103.

 

Jordan (2001):

Ethnocentric cultural bias: most psychological theories suggest that people grow from dependence to independence, that mature functioning means logical, abstract thought, autonomous thinking, separation of thought from emotion, logic superior to affect, and independence.

Clinical paradigm:  “Separate self” model of human development. Relationships are acknowledged as important, but secondary to the primary condition of separateness.

 

Alternative suggestion: maturity involves growth toward connection and relationship throughout the life span. Relational perspective – boundary is seen as a place of meeting and exchange with the surrounding milieu (vs. a place of protection from it).

 

Impetus for this model: evidence that women were being misunderstood and misrepresented by traditional psychodynamic models.

 

Relational-cultural theory suggests that the primary source of suffering for most people is the

Experience of isolation, healing occurs in growth-fostering connection.

Individual and societal disconnection from own feelings etc. occurs: p96f: “All the ways that the dominant groups shame and silence nondominant groups contribute to disconnection at a societal level. (…) Chronic disconnection is accompanied by a drop in energy, lack of clarity, withdrawal from social engagement, feelings of depression, and lower levels of creativity and productivity.”

 

Jordan (2001):

Growth occurs in connection and that we grow, learn, expand and gain a sense of meaning in relationship.

Mutual empathy: the person of the therapist is affected by the patient, the therapist suffers, is happy etc. as result of what a patient says or does and shares parts of it (which are considered helpful for the patient) with him. The therapist works with the impact of the patient on the therapist – this is not total spontaneousness or openness, instead selective, but authentic sharing of helpful information – clinically informed responsiveness. The therapist is affected by the patient. P 99: “The patient feels that he has an impact, has emotionally affected the therapist, matters personally, is relationally competent and effective, and can make a difference in this relationship.”

 

Shame: “a sense of unworthiness to be in connection” p 100, “there is a despairing feeling that one is beyond empathic possibility. Shame is about one’s whole being. (…) One feels unworthy of love, of connection. One feels that something about one’s being locks one out of connection. In guilt, there is a sense that one has done something that violates standards or hurts other people. When guilty, one can make amends. Shame feels more total, more encompassing, and more immobilizing. One feels that there is an inherent defect that makes one unacceptable, unlovable. In shame, people begin to keep shamed parts of themselves out of connection.”

Shame leads to isolation. Empathic connecting with shamed parts, without rejection, judgement etc. can lead to growth. Empathic connection is the healing part for shame – patients must develop empathy with themselves (with shamed parts, e.g. feel sad for themselves) and with others.

 

Societal dimension P 102: “Shame is not just an intrapsychic experience, an individual affect; it is also used to alter people’s behavior, often to silence and to exercise power over them. Working to reduce the marginalization of groups is paramount to fostering enhanced mental health.”

 

 

Van Quekelberghe, R. (1991). Klinische Ethnopsychologie. Einführung in die transkulturelle Psychologie, Psychopathologie und Psychotherapie. Asanger, Heidelberg.

 

Transkulturelle Test-Diagnostik: S. 31. Auch nicht-sprachliche Tests sind kulturspezifisch:

            Tests, die auf räumlicher Wahrnehmung basieren, begünstigen abstrakte und analytische

Denkstiele, die charakteristisch für westliche Mittelklasse-Kulturen sind.

Aufgaben, die unter Zeitdruck gelöst werden müssen: problematisch in Kulturen, in denen

Menschen fast nie unter Zeitdruck geraten (und stattdessen lernen, gewissenhaft und nicht

nach  der Zeit zu arbeiten) – Geschwindigkeits-Anforderung steht dann im Widerspruch zu

kulturellen Werten.

Westliche Werte: individuelle Leistung, Problemlösen unter Zeitdruck, Wettbewerb statt Kooperation – daran orientieren sich viele Tests.

S.46:    Multiple  Choice, aber auch einfache Häufigkeitsschätzungen (Anzahl von.. in der letzten Woche) sind oft nicht durchführbar, wenn Zeit nicht nach  abstrakten Einheiten (Wochen, …) strukturiert wird.

Interviews: in manchen Kulturen kann man mit Familienmitgliedern nur bei Anwesenheit des Haushaltsvorstandes sprechen.

 

S.47 Warum finden klassische Psychotherapiemethoden oft wenig Resonanz?

Respekt gegenüber Autoritätspersonen, stark reglementierter Ausdruck von Gefühlen, wohl definierte und hierarchische Rollenerwartungen, eine gemeinsame Gruppenverantwortung etc.

Quekelberghe (1991) S. 47: “Die Idee einer von sozialen Rollen und Situationen unabhängigen “Persönlichkeit oder Individualität”, die in der modernen, westlichen Kultur vorherrscht, wird man wohl (…) in Ländern, die durch Traditionen des Konfuzianismus, Taoismus, Buddhismus oder Hinduismus geprägt sind, kaum antreffen.”

 

Mitteilung von Gefühlen, Konflikten gilt als beschämend (z.T. in Asien): Gesichts- und Wertverlust,

noch dazu vor einer Autorität (dem Therapeuten)

 

Sprache der Emotionen: S. 52. in vielen nicht indogermanischen Sprachen fehlen Wörter für unangenehme Emotionen, stattdessen werden Wörter oder Sätze benutzt, die sich  auf Körperteile beziehen (insbes. das Herz, die Brust).

 

Quekelberghe (1991) Empfehlungen: S. 72ff:

• Direkte, active, stark strukturierende Vorgehensweise des Therapeuten wird empfohlen – zu egalitären, partnerschaftlichen Stil vermeiden. (Pat. Wünschen konkrete Ratschläte), pragmatische Sicht des Lebens, Therapeut als Autorität.
• Aufmerksamkeit auf externe Faktoren richten: Familiensystem,… bis ein Vertrauen geschaffen ist
• Anfangsphase: eher pädagogischer Umgang, stark strukturierendes Vorgehen des Therapeuten
• Konkrete Hilfen für Lebensprobleme anbieten
• Berater sollte seine eigenen Gefühle und Probleme hin und wieder kurz ansprechen – signalisiert dem Klienten, keine Scheu zu haben, über eigene Gefühle zu sprechen.
• Traditionelle Gesundheits- und Krankheitsvorstellungen kennen und berücksichtigen.

 

Klassische PT-Interaktion kann man nicht problemlos auf nicht-westliche Patienten übertragen!

 

 

R. van Quekelberghe: Transkulturelle Psychopathologie und Psychotherapie. Unveröffentlichtes Manuskript, 2003, Universität Koblenz-Landau.

 

Entstehung, Aurechterhaltung, Prävention und Behandlung versch. Erkrankungen, vor allem psychischer, können erheblich über die Kulturen hinweg variieren: emprirische Befunde, S. 5

 

“euro-amerikanische” Kulturen: Verhalten, das sie als krank oder abnormal definieren, kann anderswo als gesund und normal gelten, z.B. gilt das für einige dissoziative Zustände in nicht-westlichen Kulturen S. 7

 

Affektive Störungen: nicht-westl. K: Fehlen von Schuldgefühlen, Somatisierung.

 

Bestimmte Sprachen (z.B. Chinesisch) können emotionale Zustände nicht genau differenzieren (wie ist das in kurdisch, türkisch, kroatisch?) Arabisch: sehr differenzierte Emotionswörter

 

Kurze psychot. Episoden: 10x häufiger in Entwicklungsländern  S. 12

Varianzen im Krankheitsbild: sind das grundlegende Unterschiede im Erkrankungsprozess oder aber unterschiedliche Manifestationen derselben Erkrankung? Noch unklar.

“expressed emotions”: Feindseligkeit in westlichen Familien ist höher, nimmt Einfluss auf Erkrankungen S. 13

 

Verschiedene Symptome = analog zu verschiedenen sprachlichen Ausdrucksmitteln, Metaphern etc.

 

Kulturvergleichende Psychotherapie: S. 27

Verschiedene Kommunikationsstile, Individuum vs. Gruppe, versch. Problemlöseansätze, Selbstmitteilungsmodalitäten.

“Die modernen Psychotherapieverfahren zugrunde liegenden konstrukte und Zielsetzungen sind durch bestimmte Annahmen, Einstellungen oder Wertungen geprägt, die mit diesem soziokulturellen (Anm: das von Westeuropa und Nordamerika) einhergehen.” PT muss nicht für die Behandlung von Pat aus anderen Kulturen geeignet sein.

 

Gemeinsame Kernannahmen aller westlichen Therapiemethoden: Hervorhebung des Individuums, das für Planung und Kontrolle von Erleben und Verhalten weit gehend selbst verantwortlich ist, damit Fähigkeiten selbstreflexiver Introspektion und Eigeninitiative bei der Lösung von Problemen. 

 

Transkulturelle Trainingsziele: S. 28

• Sensibilisierung für die Werte, Annahmen, Normen der Kultur der Patienten
• Kulturelle Faktoren und Bedingungen kennenlernen, die als Stressoren fungieren können (z.B.: von mir: Rituale, die als lebenswichtig erachtet werden – Begräbnisse –nicht durchführen können)
• Aufbau eines breiten Repertoires an Kommunikationsfertigkeiten mit Pat aus sehr unterschiedlichen Kulturen.

 

In östlichen Kulturen gilt die generelle Vermeidung einer Auseinandersetzung mit negativen Gedanken und Gefühlen als psychologisch gesund.

 

 

R. van Quekelberghe: Kulturelle Aspekte: Einflüsse der Kultur. Unveröffentlichtes Manuskript, 2003, Universität Koblenz-Landau.

 

S. 15 Einstellungen und Erwartungen von türkischen Migranten und Therapeuten

 

                                                           Patient (Migrant)                   Therapeut

                                                          

Befriedigung des Hilfsbedürfnisses    umgehende Hilfe durch                      Aufschieben, Mobilisieren des

                                                           die Autorität                            eigenen Potentials

 

Beziehung zur Gruppe,                                  Gruppe als Ort der Identität    Autonomie, Selbstverant-

Selbstbewertung                                 und Selbstbewertung,              wortlichkeit, innerer

                                                           Verhaltensregulierung durch   Ort der Selbstbewertung

                                                           das Ansehen in der Gruppe

 

Beziehung zum Therapeuten              familiars Autoritätsverhältnis  sachliche oder personale

                                                                                                          Arbeitsbeziehung

 

Lokalisation von Problemen               äußere Faktoren zwischen-     in der eigenen Person,

und Konflikten                                               menschlicher Beziehungen     Introspektion

 

Verhältnis  zum Körper                                  Erleben und Ausdruck                        körperfern, beherrscht

                                                           Körperzentriert

 

 

R. van Quekelberghe: Ansatz Kultur: Einflüsse der Kultur auf die Psychotherapie. Unveröffentl. Manuskript, 2003, Uni Koblenz-Landau.

 

Europäische Betonung der individuellen Lebensplanung und –kontrolle, Bedeutung der introspektiven Reflexion, Eigenverantwortung, partnerschaftlicher Kommunikationsstil als kulturelle Werte

S. 2: Tips für eine kultursensitive PT:

• Sich Infos über die Kultur einholen
• Westliches Konzept der abgegrenzten dyadischen Klient-Therapeut-Beziehung flexible handhaben (von mir: Familien einbeziehen etc.)
• Blickkontakt, verbale und nonverbale Kommunikation: Infos und Rat eines Kulturkenners einholen
• PT-Form soll möglicht modifizierbar sein: Aktivitätsgrad und Direktivität des PT, Definition von Therapiezielen, Anpassung von PT- und Evaluationsverfahren
• PT-Beziehung auf kulturelle Einflüsse hin reflektieren: bei Klienten aus traditionellen Kulturen könnte das “freundlich-egalitäre Interaktionsmuster” moderner Therapeuten als distanzlos oder kontraproduktiv gelten!

 

Was wir aus traditionellen Methoden lernen können: S. 3 Integrative, ganzheitliche Sicht; Einbeziehung der Familie in alle Phasen der Behandlung; Gestaltung der Behandlung mit Ritualen und Zeremonien.

 

Verschiedene Werte:

Persönliche Kontrolle über das Leben, die Umwelt               Schicksal, Gottes Wille

Veränderung                                                                          Tradition

Konkurrenz                                                                           Kooperation

Zukunftsorientierung                                                             Vergangenheitsorientierung

Direkte Kommunikation                                                        indirekte K.

Informelle, egalitäre K.                                                                      formale, hierarchische K.

Zeit ist wichtig                                                                       Beziehungen, Interaktion ist wichtig

Dauer des Lebens verlängern                                                 Qualität des Lebens

 

What  is appropriate to be asked during an interview? (personal questions….) Direct questioning may be considered  inappropriate

 

 

De Vries, M. W. (1996). Trauma in cultural perspective. In B. Van der Kolk,  A. McFarlane, L. Weisaeth (eds.) Traumatic Stress. The effects of overwhelming experience on mind, body, and society. pp. 398-413. Guilford Press, New York, London.

 

P 399: PTSD: funded on the belief that individuals can control their own destinies this belief has only emerged in recent generations. Decline of religion – rise in the illusory hope that human beings can be in charge of their own future. Eastern religions do not offer such a promise: Islam and Hinduism teach that life is entirely determined by fate and that one has to submit oneself to god’s will.

Western belief: people can have control over their fate – a decidedly optimistic position.

PTSD: A-criterion: event. A description of an illness process based not on the intrinsic nature of the person alone, but rather on the person’s socio-cultural interaction over time.

 

P 400 Culture: Social support corrects the negative effects of stressful events. “The interactions between an individual and his or her environment/community play a significant role in determining whether the person is able to cope with the potentially traumatizing experiences that set the stage for the development of PTSD. – PTSD reflects the socio-cultural environment in which it occurs.”

P 400f: Culture furnishes social support, provides identities in terms of norms and values, and supplies a shared vision of the future. Rituals, legends and religion allow individuals to reorganize their often catastrophical reactions to losses. Culture, as a source of knowledge and information, locates experience in a historical context and forces continuity on discontinuous events. 

“Trauma, in contrast to stress, profoundly alters the basic structure not just of the individual, but of the cultural system as a whole: Society will never be the same again.”

P 402: Culture creates meaning systems that explain the causes of traumatic events. “Fatalistic” cultures believe in external causes (god’s will, witchcraft, ancestors – because of breaking rituals or taboos…) that must be faced during life, causes and consequences do not disappear. Rituals and symbolic places are necessary to reify and support group members during times of inevitable difficulty. Concepts of external causation link the individual’s experience of illness and trauma directly to the lager society – responsibility and dependence on others are evoked by the communication of suffering. Rituals and symbolic places are important: “Rituals support the individual, repair rents in the social fabric, and re-establish the group.”

Western medicine: assesses individual risks and expects compliance, but illness is the individual’s responsibility, “duty to be healthy”. Other culture’s concepts: differ in dependence, family roles, care-seeking behavior, life cycle expectations.

 

P 403: how cultures organize grief: customs, symbolic places, restitution.

P 404: “grief rituals are designed to help bereaved people return to being able to make reasonable contributions in their social and work lives.” Loss is in many cultures not “worked through” as in the west, but endured.

P 405: “Death customs are rites of passage and initiate a change in status for both the dead and the bereaved. As the dead person is ceremonially passed from the realm of the living to that of the dead, the bereaved person is passed from the state of mourner to the state of nonmourner.”

“Cultural customs and rituals help individuals control their emotions, order their behavior, link the sufferers more intimately to the social group, and serve as symbols of continuity. Such processes or restitution (z.B. eulogies – gute Grabreden, gäbe es fast überall, geben den Trauernden etwas Ehre) are disrupted when cultures as a whole are traumatized.”

 

P 406: Stress experience – manifested at the individual level, transformed into a diagnosis – this legitimizes the suffering through the experience, suffering becomes meaningful. 

P 407: “A medical label justifies and opertionalizes social interventions and resource allocation.” – suffering becomes understandable and under control.

 

P408: “When cultural protection and security fail, the individual’s problems are proportional to the cultural disintegrations. The avenues of vulnerability resulting from trauma follow the routes vacated by culture: Paranoia substitutes for trust; aggression replaces nurturance and support; identity confusion or a negative identity substitutes for a positive identity. Social bonding becomes a regression to nationalism and tribalism, thereby permitting individuals to deny the experienced losses or to defend themselves against expected additional losses.”

 

P 408f: Cultural self-help strategies: (PEGI!)

When culture is not able to maintain individual support and social resources: self-help strategies. Sufferers are brought from the isolation of their sickness together with others with the same affliction, and give one another mutual support to reenter society, members even become specialized healers of their affliction. In the group process, sufferers are gradually transformed into healers. P 409: “In striking contrast to orthodox professional medical models, evil is somehow converted into a virtue. Self-help groups emerge when permanent maintenance of help and resources is required and one-time solutions will not do.” In traditional settings, the sufferer never fully loses the illness, it is seen as a permanent characteristic that the sufferer cannot eliminate. Ongoing therapy is therefore necessary – self-help groups are a widespread mode of healing, particularily useful when social systems fail.

 

P 410: trauma reaction: psychological level of explanation is useful for immediate reactions to the trauma. “he explanations of posttraumatic reactions have more to do with the process of recovery after the event. It is here that culture and social support become important explanatory paradigms. ‘Culture cannot prevent calamity, nor can it blunt the immediate physical power of violence and the emotional shock of betrayal. It can only help with building up resilience before such events, or with providing validation, restitution, and rehabilitation afterward. Cultural processes such as social support and self-help groups are powerful forces for restitution, particularly when combined with formal cultural acceptance of the traumatic experience.”

Aim: to bring order and continuity into the posttraumatic period. “Rituals and the places required to carry them out should be incorporated in rehabilitative programs whenever possible. Following major social disruption, the reestablishment of symbolic places (churches, mosques, trees for gathering under ….) is an important goal. Symbolic places make visible the normal demographic age distribution of a community, the range from young to old. This helps re-establish previously learned cultural rules and reinstate members of the community in role functions appropriate to their places in the life cycle. Symbolic places and the culturally prescribed behaviours within such places help reinstitute traditional social relationships.”

 

 

Summerfield, D. (1995) Addressing human response to war and atrocity: Major challenges in research and practices and the limitations of western psychiatric models. In RJ Kleber, CR Figley & BP Gersons (eds.), Beyond Trauma. Cultural and societal dynamics. pp 17-29. Plenum Press, New York, London.

 

P18:  Underlying the concept of PTSD is the assumption that the essence of human experience of war and atrocity cann be captured by negative psychological effects as they are understood and categorized in the West, to be elicited in the mental life of each individual victim. This view of trauma as an individual-centered event bound to soma or psyche is in line with the tradition in theis century in both Western biomedicine and Western psychoanalysis of regarding the single human being as the basic unit of study.

 

P 19: Category fallacy: same signs and symptoms do not mean the same thing across cultures: recurrent nightmares may be irrelevant for one, may indicate a need for treatment for another, to a third, they may represent a helpful message from his or her ancestors.

(Anm von Sita. Ich freue mich, wenn ich im Alptraum meine Heimat sehe).

 

P20: Medical models do not embody a socialized view of mental health.

Torture does not take place as an isolated act but in the context of the destruction and terrorization of whole communities. The meaning of torture to many victims relates to the familial and societal rupture accompanying it.  Rape: the catastrophic injury may be a social one as there is no place for raped women in society (they lose their worth as human being, .. Ehre…)

 

P21. “The distinction between the trauma and the post-trauma-phase is often unclear or artificial. For some, notably those with lives mired in regions with endemic conflicts  (…), it is nonexistent.”

P22: “… traumatic experience needs to be conceptualized in terms of a dynamic, two-way interaction between the victimized individual and the surrounding society, evolving over time, and not only as a relatively static, circumscribable entity to be located and addressed within the individual psychology of those affected.” Reparative power of social justice

“one of the pressures of refugeedom is fear of deportation”

P 24: Socially held beliefs about trauma outcomes influence individual victims, these may be different from culture to culture (what does deserve treatment, what is normal, what is necessary to function within society…)

 

Western conception of a person as a distinct and independent individual capable of self-transformation in relative isolation from social context. The notion that traumatic experience is better dealt with if thoughts and feelings associated with it are ventilated, often in a professional setting, has only recently become familiar to the general public in Western countries. Other cultures may have little place for the revelation if intimate and personal material outside the close family circle.

P 25: It may be that non-specific elements of PT which amount to a validation of what they have endured, the chance to be heard and believed in a place safe enough to permit the expression of emotion and the regeneration of hope are relevant.

 

P25 “Collective recovery over time is intrinsically linked to reconstruction of social and economic networks and of cultural identity.”: material support, allow traditional burial rites, advocacy etc.

P 26: “Posttraumatic symptoms are not just a private and individual problem but also an indictment of the social contexts which produced them.”

P27: “Justice, even if long delayed, is reparative.” – there is a link between psychological recovery and societal reparation and justice!

 

Gottschalk-Batschkus, C.D. & Rätsch, C. (1998). Ethnotherapien. Therapeutische Konzepte im Kulturvergleich. Ethnotherapies. Therapeutic Concepts in Transcultural Comparison. VWB Berlin.

 

In G-B + R: Dech, H. (1998). Krankheitserleben und therapeutische Versorgung: Die kulturelle Dimension der Psychiatrie. Perception of illness and therapeutic care: The cultural dimension of psychiatry. Pp 158-161

 

Marsella (1988): Kultur ist “gemeinsames und gelerntes Verhalten, das von Generation zu Generation weitervermittelt wird mit dem Zweck individueller und sozialer Entwicklung und Anpassung. Kulru wird external durch Kunstgegenstände, soziale rollen und Institutionen und internal durch Werte, Glaubensvorstellungen, Haltungen, Bewusstsein und biologische Funktionen repräsentiert.”

 

• Kultur als verstehendes und erklärendes Element für die Symptomatik: z.B. werde Demenz nicht  als Krankheit eingestuft, wenn man hohe Achtung gegenüber alten Menschen habe.
• Kultur als pathogenetischer und pathoplastischer Faktor: unterschiedliche Kindererziehung in versch. Kulturen: z.B. Schlüsselkinder von Alleinerziehenden in Industrienationen, oder unterschiedliche Geschlechterrollen. Somatisierung als Tendenz, seelische Belastungen körperlich wahrzunehmen und über den körperlichen Ausdruck zu kommunizieren: über körperliche Symptome wird anderen der Zustand des Distress mitgeteilt.
• Kultur als diagnostischer und nosologischer Faktor: Symptome werden unterschiedlich bewertet. (Unterschiedliche kulturelle Toleranz gegenüber Leistungseinschränkungen, z.B. durch Depression).
• Kultur als therapeutischer und protektiver Faktor: WHO-Studie: keine Unterschiede  im Auftreten von Psychosen in versch. Kulturen, aber Unterschiede im weiteren Verlauf und der Prognose. Großfamilien, soziale Netze, religiöse Praktiken etc. sind gerade bei psychischen Erkrankungen wichtig.
• Kulturelle Einflüsse beim “help seeking behavior” und Versorgungsstrukturen: in nicht-westlichen Kulturen gibt es oft 2 Systeme nebeneinander, das traditionelle und das westliche, oft bei wenig Kooperation miteinander. Der Status der traditionellen Heiler ist in vielen Staaten ungeklärt oder illegal, Patienten in der “Regelversorgung” werden wenig danach befragt.

 

 

In G-B + R: Albers, L. (1998): Natur – Sprache – Medizin – Kultur. Therapeutische Konzepte aus semiotischer Perspektive. Nature – language – medicine – culture. Therapeutic concepts from the semiotic perspective. Pp 184-189.

 

Griechisch “therapon”: Diener, Gefährte.  (Therapeut)

Therapie als Zeichenwahrnehmung (Symptomerfassung), Bedeutungserteilung (Diagnosestellung) und Handeln bzw. Übersetzen (z.B. Zeremonien, Medikamente…), um die Bedeutung zu ändern.

Therapie versucht, Zeichen und Bedeutungen gegen eine bedrohliche Bedeutung zu geben, die davor die Zeichen für den Kranken hatte. Zentral ist, die erlebte Betrohung und das beeinträchtige Vertrauen in die eigene Fähigkeit, das aktuelle Gesundheitsproblem zu meistern, günstig zu verändern.

 

 

In G-B + R: Bolle, R. (1998). Analytische Psychologie als eine moderne Form des symbolischen Heilens. Analytical psychology as a modern form of symbolic healing. Pp 195-203.

 

Umwandlung von psychischer Energie durch den Gebrauch von Symbolen als zentraler Aspekt der PT nach CG Jung. Vorstellung seelischer Konflikte zwischen bewussten und unbewussten Anteilen führe zu Krankheitssymptomen – hier schließt die PT an den kosmischen Kontext an, in dem das symbolische Heilen erst wirksam erden kann.

S. 196: “Ringen um seelische Heilung” hat viel gemeinsam mit archetypischen Krankheitsursachen:

Seelenverlust, Besessenheit durch eingedrungene Geister (z.B. der Ahnen),

Große Themen symbolischen Heilens: Rückkehr zum Ursprung, Tod und Wiedergeburt, Wiederherstellung des stabilen Universums. Im Zentrum therapeutischen Handelns steht die Beziehung zw. PT und Patient und das Symbol als (nach Jung) bester Ausdruck unbewusster Inhalte.

 

S. 203: Die Grundstruktur symbolischen Heilens bildet sich im analytischen Setting ab, aber nicht in einer Sitzung, sondern im gesamten Verlauf:

Vorbereitung und Reinigung                                      Therapiebeginn, Indikationsstellung, Focus

Beschwörung, Anrufung der wirksamen Kräfte                     Aktivierung des Unbewussten

Identifikation                                                             I. mit den zuvor unbewussten Inhalten

Transformation                                                                      in neue seelische Symbole

Ablösung                                                                   Übertragungslösung, Therapieende.

 

 

In G-B + R:  Bolle, R. (1998). Symbol und Heilung. Zu den archetypischen Strukturen des symbolischen Heilens. Symbol and healing. Archetypal structures of symbolic healing. Pp 204-208.

 

In G-B + R: Kohnen, N. (1998). Methoden in der Ethnomedizin: Untersuchungsmethoden von Therapieformen. Untersuchungsbereiche (gut), Allgemein-methodisches (mäßig spannend)

 

In G-B + R: Van Quekelberghe, R. (1998). Wiederbelebung archaischer Vernunft und schamanischen Heilungsbewusstseins durch transformatives Lernen. Revitalization of archaic reason and shamanic healing consciousness through transformative learning. S. 251-253.

 

2 Mio Jahre Menscheitsgeschichte, 50.000a moderner Mensch (homo sapiens sapiens) bei praktisch gleich beleibendem Gehirn und Intelligenzpotential. Ethno- und Antrophozentrismus unserer “modernen Vernuft”.

 

S. 251: “Den Mensen der sog. Naturvölker geht es um ein Leben im Einklang mit den Kräften und Wesen der Natur, wobei ihre Auffassung von der Natur oft als eine elaborierte kultuelle Errungenschaft anzusehen ist. Ein wichtiger Unterschied zu  unserer modernen high-tech Kultur liegt wohl darin, dass sich die kulturellen Produktionen schamanischer Gemeinschaften an die Natrusysteme anpassen und dass sie bei ihren kulturellen Produtionen mitten im gesammten Naturgeschehen bleiben und darauf bedacht sind, nicht aus dem dydamischen Kreislauf natrürlicher Prozesse auszuscheren.” Kosmo-pscho-soziale Einheit.

“Der Turm von Babylon kann als Metapher eines Wendepunktes in der Geschichte des homo sapiens begriffen werden. Eine der Natur trotzende Struktur erhebt sich in Form eines Riesenturmes. Hierdurch verliert der Mensch zunehmend den engen Kontakt zur Natur und somti zu einer Kultur im Einklang mit dem rhythmischen, natürlichen Kreislauf.” Abstrakte, kontext-insensitive “Wahrheiten” tauchen auf.

S. 252: Merkmale der archaischen Vernunft: Anteilnahme an einer ursprünglichen Ganzheit.

• nonlinear-holographisch (ganzheitlich, zirkulär, partizipativ-holistich, intuitive-visionär, pragmatisch, integrative, empathisch, selbstähnlich)
• Ich-Du-Verhältnis: Natur als Partner, erfahrungszentriert, körperzentriert, verwandtschaftlich, egalitär, kooperativ, Teilen-Sein.
• Harmonie-zentriert: ursprungsorientiert, Subsistenz, Kultur in der Natur, Gleichgewicht halten, spirituell, Ich-Entwicklung nach innen.

Dies könnten auch moderne “Stadtschamanen” wieder lernen.

 

 

In G-B + R:  Scharfetter, C. (1998). Heilen – was geschieht da? Das Heilungsgeschehen als symbolische Interaktion und die Frage nach gemeinsamen Wirkbereichen. Healing as Symbolic Interaction. Pp 258-256.    

 

Symptome des Patienten sind Symbole für sein Leiden

S. 260: Sickness: kulturelles Konzept von Krankheit

Illness: subjective Seite, Kranksein

Disease: objektivierbarer Anteil der Krankheit.

Der Heilungsvorgang kann den Illness-Anteil reduzieren,  ohne dqass der Disease-Anteil davon berührt wird.

Westliche Krankheitskonzepte sind Defizit-Modelle: Krankheit ist Schwäche, morphologischer Fehler, falsche oder fehlende Funktion. Dem entspricht die Therapie: directive Korrektur.

Krankheitsdeutungen anderer Kulturen: in der Krankheit zeigt sich das Wirken transintelligibler, numinorser Kräfte, in der Behandlung müssen diese beeinflusst werden.

 

Schamanen als ursprüngliche Heiler: während des Heilungvorgangs oft gemeinsam mit dem Patienten in außergewöhnlichen Bewusstseinszuständen. Moderne PT gebraucht Rituale und Methoden, um soche Zustände zu erzeugen (Trancen…) Traditionelle Kuren für psychische Störungen kombinieren Techniken des Körperkontakts (Handauflegen, Berühren, Massieren, Drücken…) mit magischen Elementen (Bohren…, um das Entweichen von etwas zu ermöglichen, beblasen, anspucken… um böse Geister zu vertreiben). S. 261: “Der Körperkontakt bedeutet Annehmen des Kranken, Übertragungs-induktion von Heilkräften, Wegnahme von Krankheiten und Reinigung. Im Gesamtprozess wechselt die Hingabe der Relaxation mit der Stimulation der autotherapeutischen Kräfte ab. In vielen Ritualen traditioneller Heiltechnik (Opfer, Gebete, Rezitationen, Gesang, Amulette, Pigerfahrten, Fasten, Bäder) können apotropäische und restaruativ-resynthetische Elemente gesehen werden.”

 

Common factor Forschung: gemeinsame Wirkbereiche verschiedener Heilverfahren

S. 262: Durch sehr verschiedene Heilverfahren findet in der Interaktion von Klient und Therapeut eine Einstellungsänderung im Patienten statt, “dergestalt, dass seine Haltung zu sich selbst und zu seinen Beschwerden, zu seiem sozialen Netzwerk, zu den transpersonalen Kräften geändert wird. Damit erfahren die Bewschwerden und Behinderungen eine Relativierung, andere Gewichhtung, Sinngebung, Einordnung, Integration. Im Rahmen einer solchen Umstellung kann autotherapeutisches Potential geweckt werden.“

Therapeut. Kraft der Suggestion, Freisetzung unterdrückter Emotionen, Reinigung von Schuld und Neuintegration. Common factors:

1. Emotional: Glaube und Erwartung. Wirkt Demoralisierung (Gefühlen von Versagen, Ohnmacht, Ausgeliefertsein, Selbstpreisgabe) entgegen – wirkt gegen Angst, Unsicherheit, H offnungslosigkeit, Selbstentmutigung. Induktion von Glauben, Vertrauen, Hoffnung und Selbstbewusstsein. Z.t. direkter Einfluss auf Beschwerden, z.T. Wirkung über Steigerung des Selbstbewusstseins – dadurch wird eigene Aktivität gezielt beeinflusst.
2. Kognitiv: angemessene Umdefinition der Annahmen des Patienten, korrektives Lernen, korrigierende Erfahrunge. Kognitive Erklärungsmodelle als kulturabhängige Mythen. Gefühlsüberflutung, Katharsis, emotionaler Schock, Abhängigkeit vom Therapeuten: dies mache den Patienten bereit für eine innere Umstellung, für ein Neulernen.
3. Aktionen: Wort, Be-Handlung, Verhaltensmaßnahmen etc. – so werden Krankheitsvorstellungen und –erklärungen praktisch in therapeutische Konzepte übermittelt. (Fasten, Beten, Pilgerfahrten, Rituale, Opfer, ...)

Bedeutung von Hoffnung und Heilserwartung: Klient und Therapeut teilen ein gemeinsames explanatorisches Krankheitsmodell ihrer Kultur – dann wird die Suggestibilität durch die Erwartungen des Klienten an die Heiltechniken des Helfers erhöht. Weiterer Wirkfaktor: Externalisation des Krankheitsproblems von einem persönlcihen zu einem sozialen, kosmologischen Problem. Heilvorgang als symbolisches Ritual der Überwindung, das 3 Stufen habe:

1. Labeling der Krankheit in gegebenen kulturellen kategorien
2. Kulturelle Transformation
3. Neues Labeling (als geheilt).

„Heilung bewirkt eine Wandlung, eine Perspektivenänderung, eine neue Sicht auf das Selbst in seinem Verhältnis zum Ich und zur Welt. In diesem Sinne kann man Heilung interpretieren als Integration, als Versöhnung mit den eigenen inneren Kräften, mit der Gemeinschaft von Familie und Sozialgruppe, mit der Natur, mit den Göttern, den Geistern und dem Kosmos. Der Heilvorgang enthält einen Einstellungs-, Haltungs-, Perspektivenwechsel, welcher Reorganisation, Resynthese, Reintegration ermöglicht. Damit ist – individuums- und kulturabhängig – das Selbstheilungspotential des Bewusstseins angesprochen. Der Therapeut ist Medium dieses Prozesses.“

Goldberg, N. R. & Veroff, J. B. (1995) (Eds.). The culture and psychology reader. New York University Press, New York, London.

 

In G+V: Riger, S. (1995). Epistemological debates, feminist voices. Science, social values, and the study of women. Pp 139-164.

 

Social science reflects the values not only of individual scientists but also those of the political and cultural milieus in which science is done. Knowledge has ideological functions.

Subjects of relevance to women, e.g. housework or rape, have been considered either taboo topics or too trivial to study – marginal to such topics as leadership and power.

Pp 141: When women are studied, their actions often are interpreted as deficient compared with hose of men. Theories reflect a male standard.

Pp 141: Psychological research on women often contains another source of bias, the lack of attention to social context. The experimental paradigma assumes that subjects leave their social status, history, beliefs, and values behind as they enter the laboratory, or that random assignment vitiates the effects of these factors. Instead of being contaminants, these factors may be critical determinants of behavior. Pp 143: Causes of behavior are viewed as being inside the person. When social context is ignored, the political is misinterpreted as personal.

 

Pp 155: Central tenets of a feminist research method (Gergen, 1988):

1. Recognizing the interdependence of experimenter and subject,
2. Avoiding the decontextualizing of the subject or experimenter from their social and historical surroundings,
3. Recognizing and revealing the nature of one’s values within the research context,
4. Accepting that facts do not exist independently of their producers’ linguistic codes,
5. Demystifying the role of the scientists and establishing an egalitarian relationship between science makers and science consumers.

 

In G+V: Triandis, H. C. (1995). The self and social behavior in differing cultural contexts. Pp 326-365.

 

Pp 327: Self definition results in behaviours consistent with that definition.

Pp 328. “Contradictions among elements of the self are apparently more tolerated in some cultures than in others.” India: the self contains many contradictory elements, because all elements are seen as aspects of unitary universal forces.

Self: may be coterminous with the body (western view), or with a group such as the family or the tribe (African, Asian view), it may be conceived as independent of groups or as a satellite of groups. Corresponding to a body-bounded self may be a name (as in the west), or a person’s name may be a nonsense syllable that is rarely used, and instead, people are referred to by teknonyms (e.g. mother of X).

 

Private, public and collective self:

 

Pp 329f: Child rearing:

In families in which children are urged to be themselves or in which self-actualization is emphasized, the private self is likely to be complex. In cultures in which families emphasize “what other people will think about you”, the public self is likely to be complex. In cultures in which specific groups are emphasized during socializaiton (e.g. “remember you are am member of this family,… you are a Christioan). The collective self is likely to be complex, and the norms, roles, and values of that group acwquire especially great emotional significance.

Sampling method to study the self: 20 sentences beginning with “I am!” – KOPIE!!

 

Pp 337. Child rearing patterns: The primary concern of parents in collectivist cultures is obedience, reliability, and proper behavior. The primary concern of parents in individualistic cultures is self-reliance, independence, and creativity. Thus, we find that in simple, agricultural societies, socialization is severe and conformity is demanded and obtained. Similarly, in working-class families in industrial societies, the socialization pattern leads to conformity.

Pp 338: The smaller the family size, the more the child is allowed to do his or her own thing. In large families, rules must be imposed, otherwise chaos will occur. As societies become more affluent (individualistic), they also reduce the size of the family, which increases the opportunity to raise children to be individualists.

 

Collectivism = common fate, limited resources that must be divided in order to survive,

tightness = cultural homogeneity, isolation from external cultural influences.

 

Thight vs. loose cultures: cultures develop tolerance for deviation from group norms. Thight cultures have clear norms, little deviation is tolerated, severe sanctions are administered to those who deviate. Loose cultures either have unclear norms or tolerate deviance.

 

In G+V: Kitayama, S. & Markus, H. R. (1995). Culture and self: Implications for internationalizing psychology. Pp 366-383

 

Self enhancement vs. self-effacement: different cultures have different causal attributions of success and failure. US: success is attributed do ability and effort, internal aspects – failure is attributed to bad luch, high task difficulty etc. (esp. by men), they overestimate the own positive uniqueness

Japan: this is very different: Success = good luck, help of others, easy task etc.; failure: lack of own effort.

Collective cultures: it is important to convince others that one is modest – a desirable trait. Self-effacement leads to a sense of fitting-in, to a ultimate sense of satisfaction as a worthy member of community.

Individualist cultures: self-enhancement is indispensable for self-esteem: be better than others.

Pp 375: “General happiness seems to have very different meanings across cultures. In the United States, general happiness was more highly correlated with feelings based on individual or personal achievement than those based on close interpersonal relationships. In Japan, however, this pattern was completely reversed. In fact, there was no correlation between general happiness and good feelings derived from individual or personal achievement. Thus, individual achievement or accomplishments in Japan (…) may be relatively detached and separated from a general sense of happiness.”

 

In G+V: Kleinman, A. (1995). Do psychiatric disorders differ in different cultures? The methodological questions. Pp 631-651.

 

WHO etc: strong bias toward discovering cross-cultural similarities and “universals” in mental disorders. Critique of the WHO cross-cultural depression and schizophrenia studies:

The use of western assessment instruments stamps out a pattern of complaints, produces a more or less homogeneous sample whose similarity is an artefact of the methodology.

When similarities and differences are found, similarities are highlightened, differences are deemphasized.

Broad samples are restricted (“Ausreißer”) – not all persons are included. The restricted samples are artifactual, since it place a clinical template on the original population that excludes precisely those cases that demonstrate the most cultural heterogeneity. This methodology effectively transforms population-based data into clinic-based data, a distortion occurs.

 

Schizophrenia study: importance of expressed emotion (critical for relapses).

How to measure expressed emotion (EE?) verbal critique … in the US. But what does EE mean in a different context? e.g. nonverbal or indirect critizism – this cannot be measured by US EE-questionnaires. “Culture creates alternative channels for communicating and distinctive idioms for expressing negative feelings. Evaluation of only the verbal channel and the direct idiom may well underestimate the extent to which other cultures communicate negative EE.

 

Mind-body-Dichotomy: biology is thought to be the source of pathogenesis, and psychological and social (cultural) influences are held to  be epiphenomenal. The “real” disease is biological. This understanding may hide the cultural “illness”.

Pp 639f: “The anthropological gaze picks out an alternative model. Depression experienced entirely al low back pain and depression experienced entirely as guilt-ridden existential despair are such substantially different forms of illness behavior with distinctive symptoms, patterns of help seeking, and treatment responses that although the disease in eache instance may be the same, the illness, not the disease, becomes the determinative factor. And one might well aks, is the disease even the same?”

 

Bodily complaints can be metaphors of personal, social, and even political distress.

Pp 646f: Bodily states and psychological experiences are monitored (i.e., perceived), assessed, and reported differently by members of different cultural groups. Degree of expressivity, pain tolerance, and worries over the significance of the experience may be different. Social (un)desirability of reporting distressing symptoms: perceived as “complaining” in the West (tradition to underestimate own troubles and to emphasize continence and austerity), but this “complaining” may be positively valued and rewarded in other cultures.

Cultural convention sometimes makes it virtually impossible to ask questions in surveys about sexuality and other highly charged topics.

 

 

In G+V: Jones, E. E. & Thorne, A. (1995). Rediscovery of the subject: Intercultural approaches to clinical assessment. Pp 720-740.

 

The meaning of psychological constructs may be very different, eg. Rotter (1966). Internal-External Locus of Control: external in the west: helpless, depressed. This may not be the case everywhere. Studies report higher external LOC in women, non-westerners etc. The meaning of this difference is unclear. Attitude structures and meanings in groups vary.

Evaluation of psychic dysfunction:

Questionnaires etc. may impose western categories and schemas to other cultures, in the errouneous belief that they are universal.

Culture specific measures: Emic research. But: there are important differences within cultural groups, e.g. gender! Disregard of socioeconomic status and education as important mediator of cultural experiences. Minority groups (migrants…) may be extraordinarily heterogeneous, they reside within an ever-changing sociocultural context. The process of acculturation must be considered.

Recommendation: Research as “joint inqiry with the subject” (p730): use target groups to construct measures, verify interpretations in group discussions etc.

 

In G+V: Sue, S. & Zane, N. (1995). The role of culture and cultural techniques in psychotherapy: A critique and reformulation. Pp 767-788

 

Ethnic minority clients frequently find mental health services strange, foreign, or unhelpful.

Modifications have to be made:

At the system level: interpreters, culture education…

At the individual client-therapist level: knowledge, traditional forms of treatment (classic behavior therapy…) have to be modified because they are geared primarily for mainstream Americans. P770

 

P 771: “In working with ethnic minority groups, ,no knowledge of their culture is detrimental; however, even with this knowledge, its application and relevance cannot always be assumed because of individual differences among members of a particular ethnic group.”

Technique oriented recommendations: e.g. be more structured, direct… with Asian Clients, do not emphasize the necessity for self-disclusure.

But: Psychoanalysts etc. will find it difficult to abandon some extent of insight or reflective techniques they normally use. Some Asian clients will be quite willing to talk about their emotions and work with little structure.

 

P 772: “The major problem with approaches emphasizing either cultural knowledge or culture-specific techniques is that neither is linked to particular processes that result in effective psychotherapy. … Knowledge must be transformed into concrete operations and strategies. This is why recommendations for knowledge of culture are necessary but not sufficient for effective treatment. That is, given knowledge of clients’ culture, what should therapists do?”

P 773f. Knowledge of culture should lead to formulations of culturally consistent tactics such as providing structure to clients, being directive etc. These tactics occupy an intermediate distance because they do not magically lead to effective therapy. Rather, they presumably result in a process such as increased therapist credibility. Therefore, it may be wiser to focus on the proximal process of therapist credibility than on the more distal techniques. Instead of learning how to be authoritarian, directive, or structured with Asian-American clients, we should lean how to become credible with clients.”

 

P774: Credibility refers to the client’s perception of the therapist as an effective and trustworthy helper. Giving is the client’s perception that something was received from the therapeutic encounter.

Credibility and giving are concepts related to expectancy, trust and effectiveness in therapy.

 

Credibility

Ascribed status: position or role that one is assigned by others, governed by factors such as age, sex, expertise.

Achieved status: therapists’ skills, the patient learns about it through interactions and the actions of the therapist, the client may come to have faith, trust, confidence or hope.

Lack of ascribed credibility may be a reason for underutilization of therapy, lack of achieved credibility may explain premature termination.

 

How to achieve credibility? P 777

• Conceptualization of the problem: If the client’s problems are conceptualized in a manner that is incongruent with the client’s belief systems, the credibility of the therapist is diminished.
• Means for problem resolution: If the therapist requires from the client responses that are culturally incompatible or unacceptable, the achieved credibility of the therapist is diminished (e.g. directly express anger is ego dystonic in many cultures).
• Goals for treatment: If the definitions of goals are discrepant between therapist and client, credibility of the therapist will be diminished. E.g. facilitating insight into underlying dynamics and motives may not be a goal of many patients. Therapist and client may judge the effects of treatment on different criteria.

Of course at times client’s beliefs or goals may be inappropriate. Nevertheless, therapists should realize that incongruities in conceptualization, problem resolution, or goals often reduce credibility. This diminished credibility needs to be restored or increased by demonstrating the validity of the therapist’s perspective.

 

P 778: By linking the cultural knowledge of the therapist to the process of credibility, therapists can avoid confounding the cultural values of the client’s ethnic group with those of the individual client. The knowledge is used in the service of developing credibility. Because credibility is the central process of interest, it remains the focal point even when the client may be quite acculturated in perspective.

 

Giving

Explain treatment! To provide a rationale and to alter clients’ expectations so that they fit the therapy process.

Almost immediately, clients need to feel a direct benefit from treatment (= gift). Direct benefits must be given as soon as possible: to demonstrate the achieved credibility, to remove scepticism toward Westerners. Gift giving demonstrates to clients the direct relationship between work in therapy and the alleviation of problems.

Different gifts:

Alleviation or reduction of negative emotional states, e.g. crisis intervention.

Normalization: clients come to realize that their thoughts, feelings or experiences are common. This is important in cultures where persons are reluctant to share thoughts with others (outside the family).

Some type of meaningful gain early in therapy: anxiety reduction, depression relief, cognitive clarity, normalization, reassurance, hope and faith, skills acquisition, a coping perspective, goal setting.

 

P 780: We believe that the mental health profession, in its attempts to find effective means of treatment, has lost sight of some basic processes that are crucial. Most investigators have focused on distal considerations (e.g., knowledge of culture or culturally consistent tactics) rather than on the processes that underlie these considerations.

 

P784: Minimization of cultural problems does not imply that tratment should always match cultural expectations and norms. The primary purpose of therapy is to provide clients with new learning experiences. Often these involve prescriptions that run counter to cultural beliefs and/or accepted patterns of behavior.

 

Research:

Do therapist-client discrepancies in problem conceptualization, means for problem resolution, and goals for treatment reduce therapist credibility and positive outcomes?

Given the complexity of therapeutic processes, it is important to investigate the relative significance of the three aspects of achieved credibility, the influence of one aspect on another, and the critical time periods that may exist in developing these aspects of credibility.

 

 

In G+V: Tyler. F. B.; Sussewell, D.R. & Williams-McCoy, J. (1995). Ethnic validity in psychotherapy. Pp 789-807.

 

Culture: different sense of self-efficacy, sense of self-world relationships, a characteristic pattern of coping.

Culture: in each culture, there are dominant views and others. Individuals may have convergent, divergent or conflicting values and views in regard to the dominant culture they life in.

Therapist-client-matchs may be dominant-dominant, dominant-minority, minority-dominant, minority-minority.

Therapist and client should view their different perspectives and discuss them in a way that preserves each other’s integrity. Therapists need to learn how to accept the validity and value of different perspectives of lives and situations, how to validate client goals which are different from those therapists themselves prefer and how to evaluate the effectiveness of the work in relation to these outcomes. 

 

 

Azhar, M. Z. (1997). Einbeziehung der islamischen Religion in die kognitive Verhaltenstherapie in Malaysia.  Verhaltenstherapie (7), 34-39.

 

Tiefenpsycholog. Methoden stoßen bei islamischen Patienten oft auf Widerstand: sie leiden nicht an (unbewussten) inneren Konflikten, schon gar nicht an sexuellen, sondern an unpassenden Idealen und Wertvorstellungen. Der Koran kann helfen, adäquatere Überzeugungen zu finden.

Ziel der PT ist daher keine Konfliktlösung, sondern eine Veränderung innerer Werte.

 

Ursachen von Symptomen in malayischer Sicht:

Verlust von Seelensubstanz, Einfluss von bösen Geistern.

Heilmethoden, die dagegen helfen: Verse aus dem Koran, Suren werden rezitiert, um die Geister einzufangen oder um gute Geister herbei zu rufen.

 

Erfahrungen mit religiös orientierter Psychotherapie bei malaysischen Patienten mit Angststörungen, Depressionen – in Studien signifikante Verbesserungen.

 

Veränderung innerer Werte und Überzeugungen: analog der Beck’schen Techniken im sokratischen Dialog. Der PT darf nicht predigen oder belehren! (also nicht übermäßig direktiv sein – im Widerspruch zu sonstigen Ratschlägen, Anm. AB), sondern soll gemeinsam mit dem Patienten Überzeugungen empirisch überprüfen:

Welche beobachtbaren Beweise gibt es?

Was sagt der Koran? Darin lassen sich Argumente finden für adäquatere Überzeugungen (Suren, Verse zu bestimmten Themen…).

Gott als Sicherheit, einzige Instanz, der Dinge vorbestimmt: der Islam fordert, sich in Gottes Hände zu begeben, er bestimmt Wohl und Weh der Menschen. D.h. der Gläubige soll sich über Gewinn weder zu sehr freuen noch durch Verlust zu sehr entmutigt werden, da dies in Gottes Händen liege und vorbestimmt sei.

Religion als Quelle der Anleitung und der Beweise (von Überzeugungen etc.)

 

 

Nader, K.; Dubrow, N. & Stamm, B.H. (1999) (eds.). Honoring differences. Cultural issues in the treatment of trauma and loss. Brunner & Mazel, Philadelphia

 

P XVII: Recovery from trauma requires the reconstruction of meaning, the rebuilding of hope, and the senses of empowerment needed to regain control of one’s being and life. The imposition of Western, decontextualized views marginalizes local voices and cultural traditions, disempowers communities, and limits healing.

 

In some cultures, men may be disgraced by normal traumatic emotions: men must not admit that they were helpless, afraid etc.

Some cultures may not allow the expression of rage as this may result in fantasies of revenge

Some events may be traumatic on a cultural level: not being able to perform proper burial ceremonies may mean that neither the living nor the dead can live in peace.

 

Patients may be reluctant to speak of their traditional means of coping or talk openly about what really feels right for them because they feel inferior to the professional’s expertise. They may need permission to talk about prophetic dreams, spirits, their family… p 41

 

Im Buch werden Glauben, Familiensystem, traditionelle Heiler … verschiedener Kulturen (African American, Asians, Hispanics… ) dargestellt – Ziel: mehr Wissen über Kulturen. Wenig Anknüpfung an Therapie außer Gemeinplätze (Tabus beachten, Bedeutung von versch. Verhaltensweisen -  z.b. im Orient geschenke mit der sauberen linken Hand reichen…), keine klinischen Anweisungen.

 

Etiquette in Kaukasischen Gesellschaften (Tschetschenien…): großer Respekt vor Älteren. Jüngere dürfen mit Älteren nicht sprechen, es sei denn, die Älteren beginnen das Gespräch und fragen die jüngeren.

 

Many muslims believe only god, not human beings, can assist people – therefore, they may refuse to seek assistance by mental health professionals, they pray instead.

 

 

Watanabe, N. (1999). Zeitgeist und Morita-Therapie. In L. Katz & N. Watanabe (Hg.), Die Morita-Therapie im Gespräch. Psychotherapeutische und transkulturelle Aspekte zwischen Ost und West. S. 173-183. Psychosozial, Gießen.

 

Kreis-Denken: die Sonne geht auf und unter, es gibt Lust und Unlust, Tod und Leben – das Gleiche wiederholt sich im Kreislauf. Grundlage der Morita-Therapie.

Mensch als Teil der Natur, daher soll er sich den Bewegungen des Kosmos überlassen – es ist natürlich, dass es im Sommer heiß und im Winter kalt ist. Es ist natürlcih, sich der Weisheit Buddhas… zu überlassen. Der Mensch befindet sich inmitten der Bewegungen des Kosmos, diese wiederholen sich ununterbrochen, ohne Anfang und Ende. Man soll mit Gelassenheit alle Wandlungen hinehmen und als Teil des Schicksals bejahen, d.h. akezptieren.

Morita: sich durch geistige Aktivitäten selbst weiterentwickeln, durch Bemühungen, die auf Grund der Bedürfnisse im Leben aus sich selbst entstehen – d.h. das ist kein Fatalismus.

 

Pfeil-Denken: “Alles hat einen Anfang und ein Ende, dazwischen gibt es den stetigen Fortschritt, der sich auf ein Ziel richtet.” Psychoanalyse und andere westliche Therapieverfahren mit der Vorstellung von der Entwicklung und Stärkung des Ichs, Individuation, Ursachen, Diagnosen, Therapieverfahren, Zielen, Genesung.

Selbstreflexion, Mathematik etc. sind wichtig, um einem Ziel näher zu kommen. Christliche Vorstellung von der Erbsünde, der Vertreibung aus dem Paradies und dem Jüngsten Gericht.

 

 

Erdheim, M. (1993). Therapie und Kultur. Zur gesellschaftlichen Produktion von Gesundheits- und Krankheitsvorstellungen. In: Ethnopsychoanalyse, 3, Körper, Krankheit und Kultur, S. 75-89, Brandes & Apsel, Frankfurt a. M.

 

Einstellung zum Kulturwandel: Kulturen, die ihn vermeiden wollen (“kalt”) und solche, die ihn beschleunigen wollen (“heiß”) – Einteilung von Levi-Strauss

Heilungsrituale von traditionellen Kulturen: zeigen Risse im sozialen Gefüge auf, wollen diese beheben und die Symptome des Kranken heilen. Die ganze Gemeinschaft ist in das Heilungsritual einbezogen, Konflikte in der Gemeinschaft drücken sich in der Krankheit und im Ritual aus und werden mit diese Ritualen behoben.

S. 79: “Funktion der Kulte ist es, sowohl den Kranken in die Gesellschaft zu integrieren als auch die für den Zusammenhalt der Gruppe bedrohlichen Konflikte zu thematisieren. Diese Wiedereingliederung wird ebenso wie die Symbolisierung sozialer Konflikte durch die gemeinsame Weltanschauung ermöglicht, das heißt durch die allgemein akzeptierten Werte, die durch die Zeremonien wieder aktualisiert werden.”

S. 83: “Während in “kalten” Kulturen die Erkrankung eines Individuums gleichsam benützt wird, um soziale Spannungen zu thematisieren, ist es in “heißen” Kulturen gerade umgekehrt: soziale Spannungen werden somatisiert; sie werden nicht als solche erkannt, sondern als Schuld bzw. Als individuelles Schicksal erfahren.” – Krankheit wird damit dekontextualisiert: z.B. wird gegen Arbeitsstress Yoga empfohlen, aber nicht die Arbeitskultur kritisiert, die diesen Stress immer wieder auslöst.