Cultural Sensitivity and Cognitive Therapy in Thailand.

There has been increased emphasis placed on training counselors to be competent multicultural practitioners (Atkinson, Wampold, Lowe, Mathews, & Ahn, 1998; Arredondo et al., 1996; Kiselica, 1998; Ponterotto, 1998; Ridley, Li, & Hill, 1998; Sue & Sundberg, 1997). In fact, Fischer, Jome, and Atkinson (1998) discussed the etic and emic approaches in multicultural counseling. Etic relates to the belief that counseling is culturally generalizable or universal, while emic approaches are designed to be culturally specific. Specifically, etic refers to a common factor perspective that the curative properties of counseling pertain not to theoretically unique components, but to components common to all counseling approaches (Garfield, 1992). These common factors include the therapeutic relationship, the shared world view between the client and counselor, and client expectations. On the other hand, the emic perspective suggests that counseling strategies unique to the client's culture are needed to effectively meet the needs of ethnic minority, clients and, thus, must be congruent with the cultural characteristics of a particular client group. An example of an emic perspective would be the integration of traditional Native American values and methods of problem solving into a systems-oriented counseling approach (Fischer et al., 1998). Although Fischer et al. stated that there is pressure to incorporate culturally specific treatments in the training of counselors, they indicate that there is significant empirical evidence for the common factor perspective in multicultural counseling. In the same manner, there have been numerous articles which have focused on a global vision of counseling (Barak & Golan, 2000; Leong & Blustein, 2000; Leung, Guo, & Lam, 2000; Marchetti-Mercer & Cleaver, 2000; Poasa, Mallinckrodt, & Suzuki, 2000). For instance, Leong and Blustein (2000) stated this broader vision will provide a global perspective of counseling that recognizes other cultures in other countries. Further, the authors indicated that it is important to develop and maintain a truly multicultural and international perspective of counseling so that we can understand how other cultures describe the major attributes of human behavior. The importance of obtaining this knowledge from different parts the world will broaden the world view of mental health counselors and enhance their sensitivity to clients of diverse cultural backgrounds.

In a prior study, the researchers surveyed two groups of graduate students in India on whether they felt that the cognitive theories of counseling they were taught were consistent with their religious and cultural values (Scorzelli & Scorzelli-Reinke, 1994). Briefly, the sample consisted of 62 graduate students in psychology and special education, with most of the students identifying their religion as Hinduism (80%). Even though the results of the study indicated that the students felt that the cognitive approach to counseling conflicted with their values and beliefs, no common trend was identified. Instead, the reasons provided varied and seemed based more on the students' interpretation of religious or cultural values than any group norm. In order to determine whether this trend could be applied to another distinct cultural group, an exploratory study was conducted with a group of school and rehabilitation agency directors in Thailand on whether the cognitive approaches to counseling conflicted with their religious and cultural beliefs.

In 1998, the primary author received a senior Fulbright award to Thailand. During this time, he gave a 2-day workshop on the roles and functions of the rehabilitation counselor to a group of school and agency directors. Five hours of this workshop were devoted to two cognitive approaches to counseling (reality therapy and rational emotive behavioral therapy), and each participant received a written description of these approaches prior to the presentation. To provide the reader with the social context of this study, some background information about the country's people, history, and system of higher education will be given.

BACKGROUND

Thailand has been independent for 750 years, and until 1932, it was an absolute monarchy called Siam (National Identity Office of the Prime Minister, 1991). A bloodless coup that year changed the political landscape, and the country became a constitutional monarchy--its name was changed to Thailand in 1939. The population of the country is approximately 60 million, with 6 million people living in Bangkok. Forty-seven percent of its citizens live in rural areas, and agriculture is the largest industry. Buddhism is the state religion, which is adhered to by 96% of the population, and Thai is the national language (United Nations, 1997). Thailand has 93 provinces; each has a governor who is appointed, except for the Bangkok governor, who is elected (National Identity Office of the Prime Minister, 1991). The provinces are divided into districts and subdistricts. Similar to all of the countries in Southeast and Southwest Asia, the family is the most important social unit and, for the most part, is patriarchal. Often, this will be an extended family, with several generations living under one roof, or at least under several roofs within the same compound. Thai children learn codes of behavior that will guide them through much of their latter life.

After the family, the next larger unit is the village, consisting of about 150 homes and 500 people. Each village elects a president and has a board of governance. A characteristic of the village, based on Buddhist teachings, is the Thais' sincere consideration of others, which is embodied in namchai or water of the heart. This sense of goodwill for friends or strangers encompasses spontaneous warmth and compassion that allows families to make anonymous sacrifices for friends and to extend hospitality to strangers. For instance, a stranger visiting a village will rarely be seen as an intruder, but more likely will be taken in, fed, offered a bed, and treated as a friend. Buddhism also lies behind such common expressions as mai pen rai or never mind. Literally, this expression means that it doesn't matter when something unfortunate happens and reflects on the feeling that one must gracefully submit to external forces beyond one's control. Further, outward expressions of anger are regarded as dangerous to social harmony and as being signs of ignorance, crudity, and immaturity (National Identity Office of the Prime Minister, 1991).

According to the National Identity Office of the Prime Minister (1991), Buddhism--founded by the Indian, Prince Siddartha Gautama, 600 years before the birth of Christ--first appeared in Thailand during the Third Century B.C. Briefly, Buddhism teaches that one's life does not begin with birth and end with death but is a link in a chain of lives, each conditioned by volitional acts (karma) committed in previous existences. The concept of karma, the law of cause and effect, suggests that selfishness and craving result in suffering. Conversely, compassion and love bring happiness and well being. Therefore, only by eliminating desire can one find peace of mind. The ideal Buddhist aspiration is to attain perfection through Nirvana. Nirvana is an indescribable, immutable state unconditioned by desire, suffering, or further rebirth, in which a person simply is, yet is completely one with his or her surroundings. Fundamentally, Buddhism is an empirical way of life. It is free of dogma, it is a flexible, oral, ethical, and philosophical framework within which people find room to fashion their own salvation. Buddhism is the primary and state religion of Thailand, in that the Thai constitution stipulates that the Thai king must be a Buddhist. Yet, Thais have always subscribed to the ideal of religious freedom, and all monarchs have had the title Upholder of All Religions, and the government, through the Religious Affairs Department, annually allocates funds to finance religious education and to construct and maintain monasteries, mosques, and churches. Throughout the centuries, Buddhism has been the main driving force in the cultural development of Thailand. Much of the classical Thai art, particularly architecture, sculpture, painting, and early literature has been influenced by the religion (National Identity Office of the Prime Minister, 1991).

Higher education in Thailand consists of 16 state universities and 26 privately operated universities and colleges (Ministry of University Affairs, 1996). Admission to state-run universities is through a competitive national university entrance examination. The language of instruction in these institutions is Thai, but some courses (economics and medicine) are conducted in English. Education beyond the bachelor's degree is limited except in the areas of business administration and technology. There is only one Ph.D. program in educational psychology, and 13 master's degree programs in applied psychological fields (counseling psychology, guidance and counseling, educational psychology, and rehabilitation counseling). Except for a master's degree program in counseling psychology, all of these graduate programs are offered by the public universities. Furthermore, there are no professional associations for counselors in Thailand, and the government does not recognize the job title of "counselor."

In trying to compare the counseling strategies in the United States and Thailand, a major difference is that giving advice is equated with counseling in Thailand, and there is a broad group of professionals in the country who conduct counseling as part of their job duties. These professionals can include school teachers and governmental workers. In addition, mental illness is still misunderstood, with individuals often being sheltered by their families and not receiving services. However, due to the 1991 landmark legislation, The Rehabilitation of Disabled Persons Act, these attitudes are changing. This act defined rehabilitation as the "improvement of the potentials and capacities of disabled persons through medical, educational, social methods, and vocational training to provide them opportunity to work or lead their lives to that of the non disabled" (United Nations, 1997, p. 507). Included in this act, are services for persons with mental illness and behavioral disabilities.

METHOD

Procedure

A workshop, taught by the principle investigator, was given to 58 managers and program directors of the country's public and private facilities, which provide services to children and adults with disabling conditions. The workshop was conducted at Ratachasuda College, Mahidol University in Salaya, Thailand. The purpose of the workshop was to introduce the profession of rehabilitation counseling to a group of prominent human service providers. During the time of the workshop, Ratachasuda College had the only rehabilitation counseling program in the country. The first day of the workshop involved an overview of the philosophy of rehabilitation and the psycho-social implications of disability. The second day consisted of 5 hours of training in reality therapy and rational emotive behavioral therapy. Prior to the training, the participants had an opportunity to read a description of both approaches from a booklet given to them on the first day of the workshop. The format used in training consisted of a brief lecture, followed by case examples and structured group exercises. The source of the materials used were the lecture notes of the principal instructor that he utilized in teaching an introduction-to-counseling course at his university. Further, examples of specific techniques and case presentations were taken from the text by Ivey, Ivey, and Simek-Morgan (1993), Counseling and Psychotherapy: A Multicultural Perspective, and Glasser's 1984 book, Control Theory. The major components covered included the role of emotions in behavior, the identification of irrational thoughts, and methods of changing automatic thoughts. In order to facilitate the instruction and avoid any misinterpretation due to language barriers, the instructor was provided with three translators. After the training, the participants were surveyed on whether they felt that the cognitive theories they were taught were consistent with their religious beliefs and cultural values. This involved a "yes" or "no" response. They were also asked to write down the reasons for their response. To avoid biasing their responses, the interpretation of what constituted religious or cultural values was left up to the participants. The responses were tabulated, and a content analysis of the reasons given for a "yes" or "no" response was conducted by an administrative assistant of the college.

Participants

The participants were a convenience sample of 58 program directors and managers of public and private facilities in Thailand that provide services to children and adults with disabling conditions. The sample participated in a 2-day workshop conducted by the principle author. Of this group, 2 were medical doctors and 15 were headmasters of special schools. The remainder of the group were either directors or associate directors of rehabilitation facilities. Although their education varied, all had some knowledge of counseling. In a survey of their knowledge of counseling theories and techniques during the first day of the workshop, the participants only identified person-centered therapy and/or behaviorism.

RESULTS

Fifty-four (93.1%) of the participants felt that the two cognitive approaches to counseling did not conflict with their values and beliefs. In a content analysis of the reasons given that provided for this consistency was their belief in Buddhism. That is, the participants stated that Buddhism emphasized the present and focused on an awareness of one's identify and behavior. Furthermore, most of the participants stated that the mind is the major cause of suffering. Other responses included it is "real life," and "not many steps to learn technique." The reasons given by the four (6.9%) persons who felt that the cognitive approach to counseling was inconsistent with their religious or cultural values were as follows: "Thais lacked education," "The family decides for them," Thais can't accept themselves," and "are very shy."

DISCUSSION

Although there are similarities with respect to the importance placed on the family and the belief in karma, of the two groups of participants in both studies conducted by the authors, their perceptions of cognitive therapy were quite different. The participants in the India study felt that the cognitive approach to counseling conflicted with their values and beliefs (Scorzelli & Reinke-Scorzelli, 1994), while the Thai group felt that cognitive therapy was consistent with their religious and cultural beliefs. Furthermore, although there was no trend identified in the reasons given by the students in India, the participants in Thailand indicated that their belief in Buddhism was the major reason that cognitive therapy was consistent with their culture. Specifically, they stated that Buddhism emphasizes the present, and that one's thinking can cause a person to suffer. Even though it would appear that the belief in karma would conflict with the tenets of cognitive therapy, the participants in Thailand did not include it in their reference to Buddhism.

Although it is felt that the differences in the perceptions of cognitive therapy by the samples in India and Thailand emphasized the diversity within cultural groups and the difficulty of trying to incorporate counseling strategies unique to a client's culture, it could also relate to the background of the participants. All the participants in the India study were graduate students, with little or no experience in counseling. In contrast, the Thai group were all professionals and had counseling experience. Therefore, this difference among the groups with respect to their knowledge and practice of counseling theory and techniques may have affected their responses.

Because of the internal validity problems of this study and the fact that the participants may not have been representative of counselors in Thailand, readers should be caution not to generalize the results. However, even though this was an informal survey, a major implication of this study is the importance of understanding a person's world view rather then generalizing characteristics based on cultural or religious stereotypes. Although reference was made to Buddhism by most of the respondents, they selectively made reference to certain tenets in the religion, while leaving others out, (i.e., karma). Therefore, similar to the study in India, it appeared that the reasons given by the Thai sample were based on their interpretation of religious doctrine rather than on any group norms.

In summary, although it is important for the counselor to have knowledge of the norms, values, and attitudes of minority clients, he or she should be aware that there are individual differences among members of these groups and be cautious about trying to tailor the counseling intervention to presumed group differences.

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James F. Scorzelli, Ph.D., is a professor, Department of Counseling and Applied Educational Psychology, Northeastern University, Boston, MA. Mary Reinke-Scorzelli, Ph.D., is a consultant in developmental and pediatric psychology, Newton, MA.