4. Watss A. Psychotherapy East and West.

, in http//
Users. compaqnet.be./cr111132/Watss/psychotherapy in east and west
5. Ahmad K.Islam, its meaning and message. This Islamic Foundation, London. 1996: 1, 217

Assimilation of Current Western Psychotherapy Practice in Asia

T. Maniam
University Kebangsaan Malaysia, Kuala Lumpur
Introduction
Psychotherapy in its many form seeks changes in the individual. Whether it is
psychoanalytically oriented therapy with the objective of giving insight into unconscious
conflict, or behavioral therapy seeking to modify behavior or cognitions trying to inculcate
different ways of thinking, they, to a greater or lesser extent seek to produce significant changes
in the person. Each of these areas carries profound meaning for personhood. Physiotherapeutic
intervention, more then any other form of intervention, touches the person in deep ways
involving sense of self-understanding, self-esteem, self-fulfillment, goals and values. Many
factor interact in producing changes in patients are not inert objects upon whom techniques are
administered (or) dependent variables upon whom independent variables operate. (1)
They are active agents seeking change in ways that are consonant with their worldview.
In this paper I would like to discuss there areas that I believe are of particular interest to
the Asian practitioner.
i.
ii.
iii.

The philosophical assumptions of western psychotherapies

The concept of therapeutic boundaries as appllied in western psychotherapeutic
practice
The need for a distinctively Asian psychotherapy

Much of what I have to say would touch on the ethics of therapheutic practice as well.
This is unavoidable as the reader would appreciate. I would like to begin with a note of caution
when we talk of diverse cultural and religious groups. There is a tendency to lump a people who
belong to a subgroup together as if they are homogenous. This often arises because we tend to at
the modal characteristics of the group, that is, when we take a summary statistic (the average
value for that group) of a particular variable (2). This ignores individual variability and gives rise
to stereotyping ( all Asians, or al Westerners, are like that). The truth is there is considerable
variability between individuals belonging to the same cultural subgroup. This, I have observed, is
a particular problem when the therapist and the patient belong to the same subgroup. In such a
situation the patients expectation of the therapist is not met and the therapeutic relationship
becomes a problem. Conversely a therapist who is very religious may impose his values and
approach on to a patient who is not quite ready for it. There are many things that divide Asians.
Their religious belief is a case in point. Asians who are Hindus and Buddhist may hold very
different approaches to life when compared to Asian Christians and Muslims. Needless to say,
within these groups too, there are enormous differences. It must also be noted that sometimes the
social class differences between the patient and the therapist could be very significant. It might

even be the case that an upper class Asian might be closer to an upper class European than to his
lower class Asian neighbors. This of course, is not peculiar to the Asian setting.
i.

Now I shall address some of the philosophical assumptions of Western psychotherapies and how
these may present challenges to the practice of psychotherapy in the Eastern setting. Our
understanding of who and what we are as persons is to the great extent by our cultural and
religious backgrounds. Our practice of psychotherapy of any modality may bring us into conflict
with the patients own value system.
The assumptions of the major schools of psychotherapy an the West were heavily influenced by
the rise of modernism and humanism since the Renaissance, and more recently by post
modernistic ideas. As modernism abounded in confidence in the tenets of science to discover and
describe reality, its adherents largely disparaged the spiritual/religious approach to the
understanding of man and consequantly to healing. Philosophical humanism makes man the
measures of all things and belief in God is either considered unnecessary or is actively opposed.
Such attitudes are reflected in the writings of Freud among others. McLemore (3) says, Some
therapist regard therapy/counseling primarily as a means to giving people new philosophies of
life. Cognitive therapist like Ellis Would actively challenge patients religious belief if, in their
opinion, these were considered unhelpful to patients recovery. Changing peoples philosophy of
life changing their worldview would make deep inroads into how a person develops priorities
in life. If I may use an example from the Cristian perspective, conservative Cristians would agree
that their Faith set three basic priorities the priority of seeking God, the priority of caring for
others an of sharing theirs faith. Other religious system might have somewhat similar ideas too.
This would be, quite early antithetical to the humanistic approach to life. The Secular Humanist
Manifesto, for example, has religious skepticism as one of its 10 main points. Therefore a
therapeutic approach that seeks to apply western forms of therapy without an appreciation of the
religious/cultural milieu of the patient would not be in the latters best interest.
Since the late 1950as an early 60s the rises of postmodernism has dented the influence of
modernism somewhat but healing practices continue to be based largely on the theories of its
founders. In contrast religious/spiritual ideas heavily influence the Eastern way of life and
thought. Orthodox Asian religious adherents, including those of the revealed religions. Take
their religious belief very seriously indeed, so much so their identity and their way of life are to a
great extent inseparable from their religion. An insult to their emphasis on individual rights and
freedom and, perhaps a different postmodern view of truth. [Some of the so-called civilizational
clashes we have seen, over issues of free speech and so on, are partly do this completely different
ways of thinking.]
Western approaches place great emphasis on the individual. I do appreciate that not all
Westerners are individualistic, and it is just as true that there are large numbers of Easterners who
are highly individualistic. The attainment of individual goals, the idea of becoming independent
from ones parents by late adolescence, and other aspect of personal autonomy are almost
sacrosanct for many western oriented people. Their self-image and self-esteem are often tied to
it. Much of are anathema to the Eastern mind where interdependence is highly valued. It is not
uncommon for community is highly valued. I remember a western-trained therapist being
roundly criticized by colleagues for describing a Malaysian male patient as being overly
dependent on his parents on the grounds that he was still living with them. The extended family
system, however, is not without problems and there are many couples in my practice who suffer
because of interfering in-laws.

ii.

I think long before the rise of postmodernism in the West, some sections of Eastern
society has always, to the certain extent, been post modernistic. The Eastern mind is more
comfortable with contradictions. What the Western trained person would consider to be mutually
contradictory may not necessarily be so the Easterner. This may partly explain the enormous
popularity of many traditional treatments. It might even be an expression of refusal to face or
outright denial of the real problems. Much of this popularity is due to the closeness of the
traditional healers approach to the worldview of the patient, whereas the Western-trained
therapists approach is seen as somewhat alien. However, let me say at this point that this Eastern
practices are not always helpful. The Asian patient is sometimes better helped by a ood dose of
rational, thesis versus antithesis, type of thinking. A short case vignette will illustrate this.
A young couple, both university graduates, sought marital therapy because of frequent
disagreements leading to the wife experiencing depression. They found the task of working out
their differences tough-going. In between therapy sessions they sought the help of a religiousbased traditional healer (a bomoh) who, by rolling an egg on the torso of the wife, divined thet
she had been charmed. She was given holy water to drink and lime juice to bathe in. for the next
three days she felt very well but all her difficulties gradually resurfaced after that. However they
continued to hold firmly to the belief in the validity of the traditional healers diagnosis, when in
actual fact he might have only postponed their facing the truth about the causes for their frequent
disagreements. In that sense their visit to the bomoh, while heaving a placebo effect, was actually
harmful.
To help the Asian, one must understand her worldview and take into account her concerns
about God, spirit sin, and forgiveness. Western psychotherapy might doff its hat in this direction
but has, in my experience, little pace for seriously addressing these concerns. We Asian therapists
must seriously consider this to make therapy more acceptable.
A second areas of interest is the concept of therapeutic boundary. In Western practice therapeutic
boundaries are more rigidly drawn, no doubt for good reasons. Boundary violations adversely
affect the course of therapy and may harm patients in very serious ways and may even
permanently scar them. So there are very cogent reasons to be circumspect about therapeutic
boundary. But in the East patients tend to see the doctor/therapist as more than a fee-for-service
practitioner. The therapist, like the traditional healer, is part of the community, and the is seen as
being equally accessible. Her presence is sought at community functions such as weddings of
patients children; her advice is sought on areas outside of the immediate concerns of therapy. She
is plied with gift during festivals, and declining to receive them is deemed to be insulting. Some
patients of course, might abuse this, and use the friendship of the therapist as a reason to avoid
bringing up difficult issues, or to seek favors that might impinge on the therapists time ets. So
the Asian therapist needs to walk a tight time protecting patients from harmful boundary
violations.
How then shall we protect our patients, maintain reasonable boundaries and still manage
not to appear stand-offish? The therapist must wisely decline to advice patients on areas that are
beyond their expertise, even when such advice is sought. We must refuse the seduction of the
inherent flattery when our advice is sought on subject far and wide. Patients must be redirected
to relevant experts. We must also anticipate situations that may lead to the crossing of proper
boundaries.
There are Ethical Codes in each country. Those who belong to the medical profession are
subject to the Code of Conduct of the profession which is legally enforceable. In many countries
counselor and non-medical psychotherapists have governing bodies to provide and enforce

iii.

guidelines. Therapist who work with government agencies are subject to the rules and
regulations of service. We note, of course, that rules and regulations not with standing, abuse of
patients, trust does take place. I have a patient now who, while staying overseas in a developed
country where the psychiatry is highly regulated, was abused by a senior therapist, who is a
recognized leader in his field
I do not think we need to develop a uniquely Eastern therapy, but any Eastern therapy approach
should incorporate the many valuable contributions of Western therapy rather than see the latter
as inimical to our practice situation. We may benefit from both the techniques of therapy and the
increasingly scientific approach to testing their efficacy/effectiveness; while we may ignore.
Some anti-religious bias in them. Some Asian therapists claim to have formulated specifically
Asian therapies. Some of them are based on specific religious beliefs which do not appeal to
followers of other religions. Even Yoga, as widely practiced as it is, is not acceptable to all
religious groups. Furthermore any truly new system of therapy should provide a comprehensive
formulation of human personality and psychopathology, not merely consisting of a series of
techniques. I do not see this at yet, though I stand to be corrected.
Psychotherapy is a much sought after treatment modality in many Asian countries. Recently a
Malaysian consumer association urged that Malaysia psychiatrists should provide more therapy
for depressed patients rather than prescribe antidepressants (4). To meet this need we need to
make therapy more acceptable, more in line with the worldview of the patient and make
adjustments in the way we practice.
References
1. Bergin AE, Garfield SL (1994) Overview, Trends and Future Issues, In: Bergin AE,
Garfield SL (Eds.) Handbook of Psychotherapy and Behavior Change; 4th edition,
2. Inkeles A, Levinson SJ (1969) National character: The study of modal personality and
social cultural systems. In G. Lindzey & E. Aronson (Eds.), The Handbook of Social
Psychology. Reading, MA; Addison-Wesley.
3. McLemore CW (1987) Counseling and Psychotherapy: An Overview. In: David G
Benner (ed.) Psychotherapy in Christian Perspective. Michigan, Baker Book House.
4. New Straits Times (March 17, 2008) Use only in serious cases. Letter to the Editor.

The Assimilation of Western Psychotherapeutic Practices in the Phillipines

Alma L. Jimenez
Department of Psychiatry and Behavioral Medicine, College of Medicine
University of the Philippines
Introduction
My task is to describe the assimilation of Western psychotherapeutic practices in the
Philippines. I have decided to focus on boundary setting in clinical practice since I believe that
this concept embodies Western psychotherapeutic practices.
Following Western psychotherapeutic practices, a therapist has to conduct session in
therapists office which is private. Soundproofed, arranged for maximum interaction, with
accessories that do not betray personal circumstances of the therapist; within an appointed period
of time with clear arrangements for payment schedules and confidentiality,
In the Philippines, psychotherapy follows this format in private urban medical centers.
But in public rural hospitals, psychiatrists have had to conduct psychotherapy session in
crowded, noisy rooms, unlocked unappointed with n discussion of fee schedules.
Regardless of setting; urban or rural; private or public; sanitized or disorderly, Filipino
psychiatrists in 7100 islands of the Philippines conduct psychotherapy with a distinct Filipino
flavor. Trained to think in Western approach, Filipino psychiatrists still feel and behave in the
Filipino way. Thus, boundary setting practices are inconsistently applied. This hodge podge of
techniques; principles, values and meanings conglomerate into psychotherapy, Filipino style.
My main message is that in the Philippines, western psychotherapeutic practices,
exemplified by boundary setting in clinical practice have been influenced by cultural forces.
Thus, in clinical practice, psychodynamic tenets co-exist 2ith Filipino values and have evolved
into a distinct perspective.
For next 30 minutes, I will develop this message using the following outline:
1. Pattern of boundary setting in Filipino psychiatrists clinical practice
2. Influence of culture on the application of boundary setting practice
3. Integrating psychotherapy within Filipino culture
Pattern of Boundary Setting in Filipino psychiatrists clinical practice

In 2003, I conducted among 56 Filipino psychiatrists from all over the Philippines to
ascertain the pattern of boundary setting in clinical practice. From this survey, I gathered that

Filipino psychiatrists apply particular boundary setting practices in their clinics in varying
degrees or consistency. Moreover, I learned that the practices were applied consistently if they
jibed with cultural rooms. If certain practices contradicted cultural factors, then, they were not
applied or at best, inconsistently applied.
1. Particular boundary setting practices are consistently applied. These are:
Giving advance notice of anticipated absences.
Enforcing a time limit to session.
Outlining the benefits, risks and alternatives for proposed treatment approaches to
patients.
No sexual activity with the patient.
2. However, some boundary setting practices are inconsistently applied. These are:
Non-disclosure of personal problems to patients
Removing all possible sources of personal information from the office
Not taking repeated phone calls from patients
Confronting an exploitative patient
No barter of patients service for therapy
3. A number of boundary setting practices are not applied. These are:
No complementary treatment for colleagues, religious, friends and relatives.
Refusing gifts from patients
Non-treatment of own relatives and friends
Not testifying as forensic witness for current psychotherapeutic patients.
So you can see that Filipino psychiatrists apply boundary setting in their clinical
practices varying degrees of consistency.
Most of the respondents opinions on boundary setting match the Western norm.
However, their opinion on six practices diverge from the Western standard.
Filipino psychiatrists opinions converged with the Western norms on the following practices:
1.
2.
3.
4.
5.
6.

Not engaging in sexual activity with the patient

Outlining the benefits, risks and alternatives for proposed treatment approaches
Giving advance notice of anticipated absences and enforcing a time limit to session
Not discussing the patient with his own family and friends
Not disclosing their personal problems to patients
Not taking repeated phone calls from patients

Filipino psychiatrists opinions diverges from the Western norm on the following situations:
1.
2.
3.
4.
5.

Not bartering patients service for therapy

Removing all possible sources of personal information from the office
Confronting an exploitative patient
Giving complementary service to colleagues, members of the religious friends and family
Not accepting gifts from their patients

6. Testifying as forensic witness for current psychotherapeutic patiens

So you see that Filipino psychiatrists boundary setting practices converge with the
Western norm in same situations, while they diverge from the Western standard in others.
The Influence of Culture on the Application of Boundary Setting Practices
A review of these two patterns of boundary setting yields some interesting observation
about the role of culture in the application of boundary setting practices.
Firstly, the practices that are consistently applied jibe with culturally held values.
Secondly, the practices that contradict culturally held values and mores are not applied
inconsistently so, at best.
Medical Culture
Some practices are applied because they are part of medical culture. For example, the
practices of giving advance notice of anticipated absences and enforcing a time limit to session
are consistently applied. Psychodynamically speaking, they reinforce the boundary issue of
stability whereby these these behaviors promote a stable and consistent treatment setting
analogous to the holding environment provided by parents in early childhood. However, for
most Filipino clinicians, they are applied because of practical considerations and Good Clinical
Practice.
The same holds true for the practice of outlining the benefits, risks, and alternatives for
proposed treatment approaches to patients. It reinforces the boundary issue of neutrality and
promotes the autonomy of the patient. However, in clinical practice in the Philippines it is
applied because it is a tenet of Good Clinical Practice
Non-discussion of patients with own family and friends is also consistently applied. It
promotes the boundary issue of confidentiality. In contemporary psychodynamic psychotherapy,
patients alone have the right to release information about them in the therapeutic relationship.
The Filipino psychiatrists generally adhere to this rule on the basis of professional ethical
standards rather than psychodynamic values.
Not taking repeated phone calls from patients reinforces the boundary issue on selfprotection and self-respect. This principle is necessary to protect clinicians from abusive patient
as well as to model fairness in relationships to the patient. Filipino psychiatrists appreciate the
psychodynamic underpinnings of these practices. However, it is inconsistently applied because
more respondents put more weight on the impracticality of taking repeated patient phone calls
because these calls are time-consuming.
Abstinence from direct forms of pleasure such as touching or sexuality in the course of
their interactions with the patients is consistently applied. In psychodynamics, when the therapist

has sexual relations with the patient, he appears to violate the patients trust in him as the parent
who is more interested in his patients health rather than his gratifications. The respondents
unanimously adhere to the boundary practice on sexual abstinence. This psychodynamic
interpretation not with standing, the moral dictum against engaging in sex outside of marriage
may very well have determined this value.
Filipino Culture
Filipino psychiatrists are aware that the function of non-disclosure of personal problems
to patients and removing all possible sources of personal information from the office reinforce
the boundary issue on anonymity to prevent role reversal and seducing the patient. But they
refrain from divulging their problems or remove all sources of personal information from their
offices because they are wary of the Filipinos culturally determined tendency to personalize
relationships (Jocano, 2001). And because culture is the driving force behind their behavior, they
tend to apply it inconsistently. Because they are
Filipinos, they also tend personalize
relationships. Accordingly, he feels that self-disclosure to the patient is part part and parcel of
relating to his patient in a real context.
The practice that diverge from the Western norm are either inconsistently applied or not
applied for all.
The admonition to confront an exploitative patient merits further discussion because in
clinical, practice in the Philippines, about 25% of the respondents will not confront a patient who
exploits by his lateness in paying. This divergence from the Western norm bears a distinct
Filipino flavor. In the surveyed literature, (Epstein; Gabbard) practitioners who allow themselves
to be tormented by certain highly demanding patients are interpreted as having an impaired
ability to cope with their own aggressive feelings, resulting in their in their feeling that it wpuld
be sadistic to set limits on their patients. In the Filipino context, non-confrontational behavior is
a cultural norm, termed hiya. Faced with an exploitative patient, a Filipino psychiatrist will not
confront the patient because doing so would cause the patient to lose face. Between the therapist
and the patient, the result is sama ng loob (hurt feelings) which can strain future relations.
The boundary setting practices of not giving complementary service to
colleagues, religious, friends and relatives for professional services; not bartering patients
service for therapy and not accepting gifts from patients reinforce the boundary issue of
compensation. In the psychodynamic context, therapists should be paid for services rendered and
monetary compensation should be the