Counseling in developing countries: Turkey and India as examples.

Turkey and India are developing countries with unique cultural characteristics. The current state of mental health counseling in Turkey and India necessitates new laws, indigenous approaches, adaptations of culture-sensitive approaches, and research projects to validate such approaches. It is the job of mental health counselors to accomplish such complicated and trying tasks in the absence of social and financial resources.

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As globalization continues to bring the world closer, it is imperative to assess the usefulness of transferring Western counseling philosophies to cultures that are very different from the West (McGuiness, Alfred, Cohen, Hunt, & Robson, 2001). The notion that counseling theories and approaches can be transported across cultures is based on certain assumptions: that human beings are similar regardless of their race, ethnicity, or culture; that theories of counseling are fairly culture-free and can be applied to most individuals; and that if therapeutic strategies are used correctly, they can work for any individual (Pope-Davis & Coleman, 1997). Such incorrect assumptions led the authors to collaborate on this article to highlight how counseling works in countries that are very different from Western countries. Although Turkey and India are becoming more Westernized, they are still different from the Western countries in terms of their culture and the state of mental health counseling. Mental health counseling is relatively unknown in these countries and is in its early stages of development.

MENTAL HEALTH COUNSELING IN TURKEY

Turkey is considered a developing country and exemplifies several characteristics of other developing countries such as low levels of education and low income per capita. Only 41% of boys and 34% of girls were enrolled in secondary schools in 2000 (State Institute of Statistics, 2000). University graduates are approximately 1% of the population (Vassaf, 1983). Similarly, income level is low with the income per capita US$2,160 in 2000 (State Institute of Statistics). Given such socioeconomic circumstances, it is not surprising that mental health counseling does not receive the attention and resources it needs. For instance, in 2002, there were a total of 398 mental health units and psychiatric wards at the government hospitals (Health Ministry of Turkey, 2002); whereas in the United States, there were 4,546 mental health units and psychiatric wards in 2000 (National Center for Health Statistics, 2004). Based on these statistics, there is approximately 1 mental health unit per 168,000 people in Turkey, whereas in the United States there is 1 mental health unit per 61,000 people. Thus, the number of mental health units in Turkey is limited for a country of 67 million people (State Institute of Statistics).

Culture and Counseling

In addition to socioeconomic circumstances, cultural factors such as collectivism versus individualism and attitudes toward counseling also have a large influence on mental health counseling. According to Mocan-Aydm (2000), "Turkish people still seem to be close to the collectivism end while at the same time striving for individualism" (p. 282). Turkish people hold cultural values that promote respect toward authority figures and tend not to question or challenge authority. Mental health counseling as practiced in the West, however, requires the client to be independent and self-sufficient. Therefore, individual counseling, during which the client is expected to find his or her own answers and the counselor is not expected to give advice, can be quite foreign to Turkish clients.

Because of cultural values promoting respect toward authority figures, Turkish clients prefer directive, action-oriented counseling approaches such as cognitive-behavioral therapy (Mocan-Aydm, 2000). Other reports support the notion that Turkish clients, especially those from rural areas with a more traditional cultural background, prefer directive, group-based interventions. Vassaf (1983) indicated that 18% of students at a university campus in Turkey were from small towns and rural areas. He added that those students held more traditional values and came from a cultural background that was less Westernized than students from big cities. Vassaf indicated that, even though the students from rural backgrounds experienced more cultural conflicts and experienced identity crises, they were less likely to seek counseling services than students from urban areas. Additionally, students from rural areas preferred counselors with a similar cultural background as theirs and did not feel understood by counselors from an urban background. Vassaf concluded that directive behavioral approaches and preventive mental health interventions were more effective with clients of a rural background.

As Vassaf (1983) suggested, Demir and Aydm (1997) reported that, although there is a high prevalence of psychological problems in Turkey, there is a paucity of mental health service providers, a paucity of research on psychotherapy, and underutilization of the existing mental health resources by the public. Several factors such as low income and alternative folkloric healing methods might contribute to the underutilization of professional mental health services. Moreover, essential needs for food and shelter are often more important than the mental health needs of clients of low income. Under such circumstances, the clients may not have sufficient financial resources and might hesitate to use mental health services unless it is their last resort.

Indigenous Models of Counseling

Turkey is a country where secularism has become the official ideology of the state, yet more than 90% of the country is Muslim from the Sunni sect (Engin-Demir, 2003). Religious practices and interventions have been used to heal the mentally ill for centuries. Religious leaders have provided aid and support for people with mental illness based on the basic principles of Islam such as praying (Koptagel-Ilal & Tuncer, 1981). Many Turkish people seek services from religious healers and folkloric medicine for mental health problems. Depression and somatization are the most common mental health problems for which Turkish people seek help (Ustun & Sartorius, 1995). To relieve depression, a person might, for instance, visit sacred places and tombs to pray and to give adak (i.e., to make vows) to a deceased religious leader (Koptagel-Ilal & Tuncer). One such sacred visiting place is in Sivas, a city located in the central part of Turkey (Gokbel, n.d.). According to a common belief among the local people, three Muslim brothers who were leading a war against non-Muslims died and were buried in Sivas. Today, in addition to visiting their burial place and praying, some people might sacrifice animals such as sheep, dedicated to the soul of the deceased leader, and share the meat with other visitors, friends, and family.

Religious practices such as giving adak are common. In fact, a recent survey of religious practices in Turkey indicated that 52.7% of respondents admitted to visiting sacred places and tombs (Carkoglu & Toprak, 2000). Although such practices are assumed to be Islamic in origin, some Islamic scholars state that giving adak to a deceased person is against Islamic rules and adak should only be dedicated to Allah (Kabirlere Kurban Adamak, n.d.).

Another common Turkish folkloric practice is having religious leaders write prayers on amulets and carrying the amulet on one's body. It is believed that these amulets bring good luck and protect the person from illnesses. Carkoglu and Toprak (2000) reported that 11.8% of the participants in their survey of religious practices reported that they use amulets. Similar to adak, amulets usually are written by Islamic religious leaders and are assumed to be Islamic in origin. Nonetheless, Islamic scholars argue that such practices are against Islamic rules (Ufuruk ve Muska, 2004). Both giving adak and carrying amulets are used to treat mental illnesses and to alleviate interpersonal problems within the family and marriage (Carkoglu & Toprak; Koptagel-Ilal & Tuncer, 1981). These rituals usually are performed in the presence of friends and family members and combine the healing power of religious beliefs, social support, and sharing. Therefore, these aspects of folkloric practices can serve as therapeutic factors when working with Turkish clients and clients from similar cultural backgrounds across the world. Involving clients' family and friends in counseling and helping them share their concerns with each other might be therapeutic for Turkish clients.

Despite the existence of folkloric approaches to mental health, several Turkish authors point to the nonexistence of more recent and scientifically rooted indigenous approaches to mental health counseling (Kagitcibasi, 1994; Ongel & Smith, 1999). A content analysis of 152 articles from the Turkish Journal of Psychology revealed that there is no tendency toward indigenization of counseling in Turkey. The content analysis also showed that U.S. theories and perspectives are widely used in Turkish mental health counseling (Ongel & Smith).

Turkish mental health counseling has indeed been under the Western influence since its beginnings (Ozoglu, 1982). Dogan (2000) investigated the historical development of counseling in Turkey under five distinct periods. He emphasized the Western influence, especially the U.S. influence, since the initial stages of the counseling movement in 1950. The Western influence is still evident as the counseling approaches of Rogers (1980) and Ellis (1973) are becoming well established among professional counselors (Dogan). Although the past and present of counseling in Turkey has been under the heavy influence of Western approaches, more integration of culturally sensitive, indigenous counseling approaches with Western mental health approaches is needed to better serve the Turkish people.

The Present and Future of Counseling

In addition to socioeconomic, cultural, and religious factors, academic factors and legislative issues also influence mental health counseling. Currently, in Turkish universities, clinical psychology programs usually are located in colleges of sciences and humanities, whereas counseling and guidance programs are located in colleges of education. Psychology departments offer a specialization in clinical psychology. Counseling and guidance departments offer a specialization in school guidance counseling. There are no academic programs or departments similar to the mental health counseling programs and counseling psychology programs in the United States. Additionally, there are gaps in the legal system regarding the level of professional training and qualifications of mental health counselors. There are no formally recognized requirements or certifications for professional counselors (Dogan, 2000). Professional positions such as mental health and guidance counseling do not require an education beyond a bachelor's degree. However, counselors cannot own a private practice and conduct psychotherapy without the collaboration or supervision of psychiatrists. In the midst of such gaps in the legal system, it is only natural that the society is also confused about the qualifications and job descriptions of mental health counselors. As Dogan indicated, "Counseling is still vague and confused with other disciplines such as [clinical] psychology, social work, and even psychiatry" (p. 62).

Despite the lack of economic resources, the legal difficulties, and public confusion, mental health counseling has an optimistic future. Currently, psychology is a popular university major, ranking among the most sought after in social science departments. The popularity of psychology attracts many qualified students to the field of counseling, which leads to establishing new counseling departments that generate more graduates. One of the professional organizations, the Turkish Psychological Association (TPA), has contributed considerably to the mental health field in Turkey. TPA was founded in 1976 (TPA, 2004) and is currently active in lobbying the government to pass a law that defines credentials, educational standards, and job descriptions for mental health practitioners. Other professional organizations that have contributed to the mental health counseling field are the Psychological Counseling and Guidance Association, which was founded in 1989 (Dogan, 2000), and the Foundation for the Advancement of Guidance and Counseling at Higher Education, which was established in 1972 (YORET, 2004).

In summary, demographic characteristics of the Turkish people, the Turkish culture, the academic structure, and the legal system shape the past and present of mental health counseling. Although some of these factors such as economic difficulties and lack of regulations present challenges to mental health counseling in Turkey, hopefully new graduates and professional organizations will develop more culturally sensitive approaches and will shape the future of counseling in Turkey.

MENTAL HEALTH COUNSELING IN INDIA

Similar to Turkey, India is a developing and growing country and exemplifies the characteristics of other developing countries. Mental health services are still in a primitive stage and availability and accessibility are lacking. As India becomes closer to being the most populated nation in the world, there is a growing concern that those who need and want counseling services are not getting services. It is, therefore, necessary for mental health counselors to consider age-old systems of medicine.

One of the oldest systems of medicine, Ayurveda, has its origins in the 6th century B.C. (Rajkumar, 1991). Ayurveda is divided into eight different specialties, one being Bhuta Vidya, which deals with psychiatry (Das, 1987; Rajkumar, 1991; Sethi, Gupta, & Lal, 1977). The importance of mental health can be seen in the classification of Ayurveda into three categories: exogenous, endogenous, and psychic. Traditional systems of medicine such as Ayurveda make up 70% of overall health care as compared to that which is provided by physicians and general practitioners (Taylor, 1976). These traditional systems existed before, during, and after the British rule.

The British rule led to the development of the early mental hospitals, which were actually established to cater to the needs of European patients in India (Rajkumar, 1991; Wig, 1990). After India gained independence in 1947, psychiatric departments began to be incorporated in the general hospitals, instead of more mental hospitals being established. This movement resulted in a shift toward decreased stigma associated with the mentally ill. This movement also led to the Indian government formulating policies to provide reduced-cost health care to the masses (Rajkumar). In spite of these advances, there are still numerous limitations with respect to the current state of mental health services provided to the people of India.

In India, there are only 37 governmentally run mental hospitals, 3,500 psychiatrists, 1,000 psychiatric social workers, and 1,000 clinical psychologists to serve a population of more than one billion (Archarya, 2001). Data on mental health counselors could not be obtained even though India has master's and doctoral programs in counseling psychology. According to Blanche Barnes, president of the Bombay Psychological Association, most psychology programs in India are not accredited, and there are no procedures for licensing (Clay, 2002). This lack of accreditation could explain why there is no statistical information available on practicing counselors, mental health care is not covered by insurance, and most facilities focus specifically on mental retardation, suicide prevention, drug addiction, and psychogenic care rather than on broader mental health care (Rajkumar, 1991). It is estimated that about 20 million people need mental health services in India, but only 25,000 of them can be serviced in the existing system (Rajkumar). In spite of these problems, indigenous models continue to be a source of help to Indians. These indigenous models include, for instance, shamans, astrologists, palmists, and priests who guide individuals and families toward healing. Use of such indigenous models, however, necessitates mental health counselors' cultural sensitivity.

Culture and Counseling

Cultural sensitivity requires the mental health counselor to be aware of clients' worldview and to use clients' perspective in interpreting the world (Wrenn, 1962). This understanding is imperative in a society that is a fusion of several subcultures within the dominant Indian culture. Although the Indian culture traditionally has been considered collectivistic, research has indicated that the Indian society is rapidly transforming into a coexistence of both collectivism and individualism (Sinha, Sinha, Sinha, & Sinha, 2001; Sinha, Vohra, Singhal, Sinha, & Ushashree, 2002). Each one of the many cultural groups in India may differ significantly on a number of areas that range from acceptance of mental illness to help-seeking behaviors. With respect to culture-specific factors that influence help-seeking behaviors, some experts have argued the importance of cultural epidemiology. Cultural epidemiology is an integrative approach that examines the social and cultural features of a community from an epidemiological and anthropological framework (Chowdhury, Chakraborty, & Weiss, 2001). One such feature is the presence of stigma among Indians with respect to mental health counseling, which makes it difficult for those who need help to seek it (James et al., 2002). Other features include apathy on the part of the mental health professionals who are not motivated to work with individuals with severe mental illness for a long period of time (Nagaswami, 1990). Such apathy extends to family members and others who have direct contact with those who are mentally ill. Thus, stigma about mental health counseling among the general population and professional apathy on the part of mental health counselors help to highlight certain unique cultural factors.

A study conducted by Chowdhury et al. (2001) in West Bengal, India, for example, sought to identify the particular mental health concerns of the people of the region and to characterize how they experienced their problems. Results of this study indicated that causative factors included stress in the community, the presence of alcoholism and adultery, the presence of corruption and nepotism within the local village administration, and the general conditions that arose as a result of poverty. When asked about their understanding of mental health, most of the respondents equated mental illness with seriously disruptive behaviors. Individuals with such illnesses often were termed as pagal or pagla (i.e., mad) and were teased. With respect to causes of such mental illness, the respondents pointed to several different factors such as diet, possession, traumatic shock, and smoking cannabis. Treatment in early stages usually was characterized by visiting a healer such as a shaman or an alternative medicine practitioner. However, if the condition was not lifted, then families were known to abandon such people as a result of hopelessness (Chowdhury et al.). Thus, even though people in West Bengal, India, understood the concept of mental illness, the manner in which they distinguished among emotional distress, mental health problems, mental illness, and psychiatric disorders was entrenched in the context and setting in which the illness occurred (Chowdhury et al.).

It is here that an ethnographic perspective can contribute to the development of local programs that focus on the need for specialized mental health services. One implication of an ethnographic perspective is the inclusion of mental health in the area of primary care. A second implication includes establishing awareness of such mental health concerns and focusing on cultural and social components of illness. Also, interactions with the community, health workers, local leaders, village administrative systems, and nongovernmental organizations can help to mobilize resources for optimum health care (Chowdhury et al., 2001). Finally, with respect to treatments for mental health disorders in general, it is strongly believed that preventive measures, such as strengthening protective factors in local communities, call for government initiatives to this end rather than spending on medical treatments that may cripple an already depleting economy (Archarya, 2001). In keeping such cultural factors in mind, Indian mental health counselors are learning to adapt their Western training to the Indian milieu.

Indigenous Models of Counseling

According to Clay (2002), there is a trend toward incorporating Indian traditions into Western approaches to counseling in India. Yoga and meditation have been integrated into mental health counseling. For instance, Aruna Broota (Clay), a U.S.-educated Indian therapist, developed a relaxation technique that combines four yogic postures and the repetition of a religious word such as shanty (i.e., peace). According to Broota, this process helps clients be more aware of their thoughts and, therefore, increases the effectiveness of cognitive behavioral interventions. Broota also maintained that her counseling approach has been effective in relieving symptoms of depression, panic disorder, and stress. Similarly, Sangram Singh Nathawat, a professor of psychology and editor of the Indian Journal of Clinical Psychology, recommends that his clients go to meditation and yoga camps before entering mental health counseling (Clay). This recommendation is based on the assumption that yoga and meditation will increase positive emotions and decrease negative symptoms.

Besides yoga and meditation, visiting religious centers is commonly used for healing purposes in India (Raguram, Venkateswaran, Ramakrishna, & Weiss, 2002). Raguram et al. investigated the effectiveness of a "healing temple" in South India. Persons identified by family members as mentally ill were brought to this temple where they lived for an unspecified period of time free of charge (Raguram et al.). No specific healing rituals took place in the temple, but persons seeking these services took part in the daily activities of the temple, such as cleaning the courtyard and watering plants in the temple's garden. Results of the study revealed that 22 of 31 clients who were initially diagnosed with paranoid schizophrenia, delusional disorder, and bipolar disorder had less severe psychopathology following their stay at the temple. The authors believed that, in addition to specific healing powers of the temple, clients' improved mental health stemmed from the temple's supportive, non-threatening, and reassuring environment (Raguram et al.).

Indians also may seek help from indigenous healers when residing outside of India. For example, Dein and Sembhi (2001) found that Indian psychiatric patients in the United Kingdom often visited hakims or mullahs, who are religious healers, for treatment. These religious healers prescribed herbal preparation and included the patient's entire family in the consultation. This practice differs from the one usually followed by general practitioners who prescribe only biomedical drugs and meet with the patient alone.

In summary, incorporating indigenous methods of healing has a therapeutic value for Indians. Thus, mental health counselors working with Indian clientele need to incorporate traditional modes of healing into their counseling practices (e.g., referral) to increase counseling effectiveness and to ensure client satisfaction. Also, integrating mental health care with primary care in India will increase awareness and reduce stigma about mental illness, and it will result in the availability of good, low-cost, effective treatment because mental health care will no longer be an elusive treatment available only to rich people (James et al., 2002).

CONCLUSION

Turkey and India share several characteristics. Both countries have low levels of income and low levels of education, and both countries lack laws regulating the delivery of mental health counseling. Also, both Turkey and India lack the economic and educational resources needed for the advancement of mental health counseling. Despite their many similarities, the unique cultures of Turkey and India require culturally sensitive approaches to counseling. Both countries have been greatly influenced by Western mental health approaches.

Because of cultural differences between Eastern and Western countries, a direct application of Western approaches to persons of Eastern descent may have negative consequences. For example, direct application of Western approaches to people of these cultures can alienate people from mental health counseling, cause deterioration of clients' conditions, and waste counselors' resources (Azuma, 1984). In addition, applying Western approaches to people of Eastern cultures imposes the Western values of independence and self-sufficiency on people who value interdependence and harmony (Mocan-Aydm, 2000).

In light of the cultural differences between Eastern and Western countries, rather than imposing Western values and counseling approaches on clientele from Eastern countries, a more useful approach is to integrate Eastern philosophies and indigenous approaches into mental health delivery. Turkish and Indian mental health counselors may want to include clients' family and friends in counseling and incorporate the healing power of religious interventions (Raguram et al., 2002). Similarly, mental health counselors could refer their clients to indigenous healers so that both indigenous healing methods and Western counseling approaches can be used simultaneously (Hohmann et al., 1990).

An integration of culturally sensitive, indigenous methods with the Western approaches to mental health can be useful not only for Turkish and Indian clients but also for U.S. minority clients of similar cultural backgrounds. Including family and friends in counseling may be beneficial, as is encouraging and supporting clients' religious practices. Both Western and indigenous approaches to mental health have scientific and heuristic value and should be utilized in conjunction. Rather than using either approach in isolation, integration of Western and indigenous counseling approaches will be more effective for Indian and Turkish clients.

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Shonali Raney, M.A., and Deniz Canel Cinarbas, M.A., are international students with the Department of Counseling and Guidance Services, Ball State University, Muncie, IN. Raney is from India and Cinarbas is from Turkey. E-mail: [e-mail]

Part of this article was presented at the symposium "A Trip Around the World: A Counseling Psychology Travelogue!" conducted at the Annual Meeting of the Great Lakes Conference on Counseling Psychology, Kalamazoo, MI, April 2003.