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Clinical Ethnocultural Transference and Countertransference in The Amer. J. Orthops-ychiat. 61(3), July 1991 CLINICAL ETHNOCULTURAL TRANSFERENCE AND COUNTERTRANSFERENCE IN THE THERAPEUTIC DYAD Lillian Comas-Diaz, Ph.D., and Frederick M. Jacobsen, M.D., M.P,H. The relevance and validity of ethnocultural factors in transference and countertransference reactions are proposed. Some of those prevalent in dyadic psychotherapy are described, focusing on intra-ethnic and inter-ethnic dyads. Case vignettes are presented to illustrate the ways in which et/rnocultura.lfactors serve as catalystsfor such major therapeutic issues as trust, ambivalence, anger, and acceptance of disparate parts of the self he influences of culture and etlmicity tients since social images of blacks make T on the psychotherapeutic process have them easier targets for therapists’ projec- been previously acknowledged (Devereu.x, tions. Similarly, Spiegel (1965) asserted that 1953; Gr~7th,1977; Tic/to, 1971), and have working with patients from different cul- recently been recognized as key factors in tural backgrounds engenders a very com- therapy(Comas-D(az & Gr(ffith, 1988; Dud- plicated strain within the therapist. Psycho- ley & Rawlins, 1985; Goleman, 1989; therapy with the ethnoculturally different McGoldrick, Pearce, & Giordano, 1982). patient frequently provides more opportu- While some of these influences are imme- nities for empathic and dynamic stumbling diately available to the senses (sights, blocks, in what might be termed “ethno- sounds, smells, etc.), it has been postulated cultural disorientation.” that every culture also has its own unique In traditional therapeutic orientations,pa- form of unconscious (Hall, 1981), which tients’ racial and ethnic remarks in therapy may have powerful effects on the process have been attributed to a defensive shift of psychotherapy. Ethnicity and culture can away from underlying conflict, and the ther- touch deep unconscious feelings in most apist’s role has been to interpret them as individuals and may become targets for pro- defense and resistance (Evans, 1985). How- jection by both patient and therapist, thus ever, inour own clinical experience we have becoming more available in therapy. For found that this approach hinders the explo- example, Jones (1985) stated that black pa- ration of conflicts related to ethnicity and tients often evoke more complicated coun- culture. By encouraging the elaboration of tertransferential reactions than white pa- ethnoculturally-focused devaluing concepts Based on a paper presented at the 1989 Confrrence on Psychotherapy of Diversity: cross-cultural Treatment Issues, Harvard Medical School, C~bridge,Mass. Authors are at the Transcultural Mental Health Institute, Washington, D.C. 392 © 1991 American Ortho~sychiatricAssociation, Inc. COMAS-DIAZ AND JACOBSEN 393 and feelings, the therapist can offer patients ference are influenced by a feeling of es- a richer opportunity to know and resolve trangement that afflicts both therapist and their own ethnocultural and racial conflicts patient as each of them is inclined to mis- (Evans, 1985). For instance, Comas-Diaz interpret the other’s nonverbal communica- and Jacobsen (1987) reported that in cross- tion in terms of his or her own cultural cultural psychotherapy, projective identifi- reality. However, it is important to remem- cation may be shaped by ethnocultural val- ber that factors such as gender, sexual ori- ues. These identifications frequently occur entation, physical appearance, and per- spontaneously, as when the patient at- sonal experience also influence the process tributes to the therapist certain qualities or of cross-cultural psychotherapy (Jones, features characteristic of the patient’s own 1985). Given the complexity and multiplic- ethnocultural identity. This process of eth- ity of ethnocultural factors, therapists need nocultural identification may be facilitated an understanding of their own ethnicity and by the fact that identification is one of the culture as well as of their patients’ so that chiefmanifestations of culture(Hall, 1981), they can achieve effectivecross-cultural psy- as well as a major dynamic force in therapy chotherapy (Jacobsen, 1988; Jones, 1984). (Erikson, 1959). In order to examine the ethnocultural trans- As they do in the traditional psychother- ference and countertransference in greater apeutic dyad, transference and countertrans- detail, it is helpful to explore these pro- ference have critical significance for the cesses within the framework of the patient- cross-cultural clinical encounter. The ac- therapist dyad from both interethnic and in- knowledgment of ethnic and racial factors traethnic perspectives. in the psychotherapeutic relationship often To illustrate the relevance and validity of appears to catalyze the transference, lead- ethnocultural factors in transference and ing to a more rapid unfolding of core prob- countertransference, several of those that lems (Schachter & Butts, 1968). However, are prevalent in dyadic psychotherapy are cultural and ethnic aspects of behavior of- described in this article, along with the com- ten make the evaluation of transference and mon underlying dynamic themes that char- countertransference difficult (Bash-Kahre, acterize them. Case vignettes are used for 1984; Zaphiropoulos, 1982) and may be a illustration, with identifying data altered to stumbling block to therapeutic progress(Jen- protect confidentiality. kins, 1985), particularly when the therapist fails to acknowledge such differences ETHNOCULTUIRAL TRANSFERENCE (Varghese, 1983). Therapists also tend to lnterethnic Transference bring their imprinting of ethnic and racial There are many possible transference it- stereotypes into psychotherapy (Riess, actions within the interethnic dyad, rang- 1971), and these stereotypes frequently play ing from overcompliance and friendliness a significant role in the manifestation of to suspiciousness and hostility (Jackson, transference and countertransference. Coun- 1973). Transference reactions can occur at tertransference reactions are often compli- any stage of treatment, although they ap- cated by ethnocultural issues such as prej- pear more likely to occur at some than at udice, discrimination, and feelings of guilt others. (Coznas-DIaz & Minrath, 1985). Overcompliance and friendliness. This Ethnic and cultural parameters of trans- type of reaction is frequently observed when ference and countertransference may rein- there is a societal power differential in the force each other, sometimesdeveloping into patient-therapist dyad. Perhaps the most a vicious cycle. For instance, Bash-Kahre common example of such a power differ- (1984) asserted that in cross-cultural psy- ential in the United States is that of a white chotherapy, transference and countertrans- therapist with a patient from an ethnic mi- 394 ETHNOCULTURAL TRANSFERENCE nority. This kind of situation can be seen me?”) is a common transference reaction in in the example of a Latino professional the interethnic dyad. Unacknowledged eth- woman, accustomed to being assertive in nocultural differences promote mistrust and her own professional context, who does not suspicion in the patient. One form this can negotiate the scheduling of her appoint- take is concern on the part of the patient ment with her therapist, even though the about therapist’s “real” motivations in the offered time is inconvenient for her. Asked therapy. For example, a black patient said why she did not attempt negotiation, she to her Hispanic male therapist during the stated: “As a Hispanic professional women, initial interview: “I wonder how good you I did not want to reinforce ethnic stereo- are if you are working with me in this inner types. I did not want to make waves and city clinic.” A more extreme example of was avoiding being labeled as difficult.” mistrust and suspicion is provided by the Thus, the patient overcomplieswiththe ther- following case of a German therapist- apist, compromising the therapeutic alli- Israeli patient dyad: ance. After two years ofintensive psychotherapy, the patient Notwithstanding such power differen- was still struggling with issues of trust. He was ac- tials in our society, the overcompliance and tively fantasizing about his therapist’s possible partic- friendliness type of transference reactions ipation in Nazi military activities. He confronted the can also occur when the therapeutic dyad is therapist, who answered from a classical analytic stance: of an ethnic minority therapist and a non- “You are wondering about my participation in Na- zism,” and left it there. Finally, the patient developed minority patient. In such instances, the a plan to catch the therapist. During a session, he transference reaction can take the form of presented his own experiences as an officer in the concern about being a good patient. For Sinai war. The therapist’s response implied that he example, a white female said to her Chi- understood the activities of an officer, thereby height- ening the patient’s anxiety about the therapist’s pos- nese male therapist: “I wish I could speak sible role in the Holocaust. Shortly thereafter, the pa- Cantonese, so I can be like your Chinese tient dropped out of treatment. When discussing this patients.” therapy with close friends several years later, the pa- Denial ofethnicity and culture. This type tient stated that his therapyhad been disrupted because of reaction involves avoidance by the pa- of his therapist’s refusal to address this issue. tient of any issue pertinent to ethnicity or Mistrust and suspicion can eventually
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