Talking to the Master: intersections of religion, culture, and counseling in Taiwan and Ghana.

Mental health counseling is gaining worldwide popularity. It is, therefore, important to critically examine the appropriateness of direct importation of Western psychological interventions into non-Western countries. This article reviews the state of counseling in Taiwan and Ghana. It highlights the heterogeneous nature of counseling services in the face of cultural similarities. In addition, it demonstrates the importance of considering the interplay of culture and religion in assessment, case conceptualization, and treatment.

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Example 1: Because he had been experiencing nightmares for about a year, a 45-year-old Taiwanese male sought a Buddhist Master's advice. He told the Master that he dreamed about being chased by a man every night. He added that, on occasion, his wife was awakened at night by his heavy breathing during his nightmares. In addition, he told the Master that he was afraid of the dark and slept with lights on. The Master asked him what it felt like for him to have those dreams. The man replied that he suspected that he may have been a murderer in a previous life and that the spirits of his victims came to his dream to get even. The Master advised him to recite sutras and give the merits he gained from reciting sutras to those whom he had hurt in his previous life, which the man followed diligently. Six months later, he no longer has those nightmares and can sleep in the dark.

Example 2: TC, an 11-year-old female, has been living with a foster aunt (Mrs. H) in a suburb of a large city in Ghana for financial reasons after her mother's death. Mrs. H recently observed that TC had been forgetting to do her homework and chores, stealing and drinking alcohol, not eating, spending a lot of time by herself, and refusing to go to church. When confronted, TC said she wanted to live with her father. Mrs. H refused to do this, pointing out that TC's father could not provide for TC financially. An hour later, Mrs. H did not feel well and had to see a doctor the next day. That day, according to Mrs. H, TC appeared happier than she had been all month. In consultation with some relatives and church members, Mrs. H decided that TC's rebellious behavior meant that she was a witch, and she sent TC to a prayer camp. Together, they would talk to the Master and pray for deliverance.

Taiwan and Ghana are two non-Western countries considered to be relatively similar culturally in terms of the importance of collectivism, religion, and gender roles. In both, as the above examples illustrate, the family and religious resources are used to resolve psychological distress. The Taiwanese man's decision to talk to the Master is somewhat similar to counseling-seeking behaviors in the United States (i.e., seeking face-to-face help from a mental health professional for diagnosis and treatment). The Ghanaian case showcases a communal diagnosis that occurred in the absence of the troubled one and a communal intervention of exorcism through religious ritual. Albeit with the same label of Talking to the Master, the above examples, by no means representative of all people in each of these countries, highlight the existence of differences in help-seeking behavior for mental health difficulties. This article explores the influence of cultural practices and religious worldviews on the state of counseling in Ghana and Taiwan and proposes an Ideal Master approach to counseling that integrates cultural values, religious worldviews, and Western psychology theory.

BACKGROUND ON TAIWAN AND GHANA

Taiwan and Ghana have experienced significant socioeconomic change in the past century and increased contact with Western and Eastern countries by means of the media, the entertainment industry, commercial products, business, and education. Both societies strive to preserve their traditions in the face of these changes. Profiles of the two countries are summarized in Table 1.

Strongly influenced by Confucianism, Taiwanese tradition emphasizes filial piety (Lee, 2002), which shapes the family structure, interpersonal relationships, and gender roles. Extended families used to reside together in Taiwan with the oldest son and his wife assuming responsibility for elderly parents. Women were the primary caretakers and stayed at home. In modern Taiwanese households, nuclear families are becoming the norm, a trend that is influencing the attitude toward supporting parents (Hsu, Lew-Ting, & Wu, 2001) such that siblings, not just the oldest, share the responsibilities of caring for the parents. Along with these changes, gender roles are becoming more flexible. The saying that the kitchen is a woman's place is obsolete in modern Taiwanese culture. Taiwanese women can be found in higher education and leadership positions. This change in gender roles is causing significant dissonance for both the older and younger generations.

A similar trend of social change can be seen in postcolonial Ghana. Modern Ghanaian life is a unique mix of the traditional and the West (Dzokoto & Adams, in press). For example, polygamy, which used to be the norm, is shunned by most Ghanaians but is still practiced by a few. Traditional rulers still occupy an important part in the lives of Ghanaians, despite a transition to governmental rule. The status of women in Ghanaian society has undergone change due to an increase in the perceived importance of female education. Ghanaian women now occupy a diversity of professional roles and contribute significantly to the socioeconomic development of the nation. Motherhood and child-rearing are still highly valued, and as such, balancing demands between professional and domestic expectations has increasingly become a concern given a gradual decline in the availability of extended family support (Ennin, 1999).

RELIGIOUS DIMENSIONS

Taiwanese people are polytheistic and eclectic, with over 57% identified as religious (Government Information Office, 2004); 44% of the population is identified as a mixture of Buddhist, Confucian, and Taoist while 9.4% is identified as "other." It is the norm for different elements from different religions to be integrated to fulfill an individual's spiritual and psychological needs. For instance, people may visit different temples based on the salient characteristics of the figure and their needs at the time. Although these religious practices are viewed as superstitious by some, they provide a sense of peace, comfort, and community and continue to play an important role in modern Taiwan. Religious groups in Taiwan are a major source of support during national crises. For example, during the SARS breakout in 2003, the Buddhist organizations worked to assuage widespread panic by providing medical supplies and delivering Buddhist Masters' messages through media.

In modern Ghanaian culture, 60% of the population identify as Christian, 16% as Muslim, and 20% as adherents of traditional religions (Gifford, 1998). Similar to Taiwan, Ghanaian traditional religion is polytheistic and includes ancestor worship. The importance of religion is manifested in cultural artifacts such as the prevalence of Christian references in first names of individuals as well as in names of businesses and vehicle slogans (Adams, Dzokoto, & Mensah, 2003). Religious institutions in Ghana provide social and financial support to individuals (e.g., the homeless, the terminally ill) and institutions (e.g. hospitals, prison units, refugee camps). Juju (i.e., witchcraft or sorcery) plays an important role in Ghanaian reality, regardless of the person's educational level or religious affiliation. Witches are perceived as being responsible for negative life events such as deaths, illnesses, and infertility. For example, impotence or infertility is assumed to be a result of a witch hiding or eating the penis or womb (Dzokoto & Adams, in press). The wearing of charms from good witch doctors is considered to protect against malevolent forces.

COUNSELING IN TAIWAN AND GHANA

Modern life in both countries is associated with stressors. Major stressors identified in the literature for each country include finances, endemic and epidemic health concerns (e.g., SARS in Taiwan in 2003, HIV in Ghana), unemployment, parenting, marital and relationship issues, family and interpersonal conflict, and sexual violence (Asare, 1999; Bebli, 2003; Dzokoto, 2000; Gadzekpo, 1999; Hsieh, 2004; Luo, 2000; Weinstein, Yamazaki, & Chang, 2004). With all the above stressors, services that will provide mental health preservation and restoration are important.

Definition of Counseling

Spruill and Fong (1990) defined mental health counseling as "an aggregate of the specific educational, scientific, and professional contributions of the disciplines of education, psychology, and counseling" (pp. 20-21). This definition suggests a conceptualization of counseling as services rendered by individuals who have received specialized training in specific scholarly disciplines. Although such a definition may be adequate in the United States, we argue that it does not fully encompass services that are defined as counseling in Taiwan and Ghana. In these countries, we observe that counseling is perceived as what counselors do, regardless of their training background. For this reason, we adopt Seiler and Messina's (1979) definition of mental health counseling, excluding the word interdisciplinary because it implies formal academic training. Thus, the definition of mental health counseling in this article will be a "multifaceted, holistic process of the promotion of healthy life-styles, identification of individual stressors and personal levels of functioning, and preservation or restoration of mental health" (p. 6).

We identify mental health counselors as people involved in all three of the aforementioned processes without their necessarily having formalized academic training in a scholarly discipline to perform these functions. Thus, the words mental health counseling and mental health counselor in this article may sometimes be inconsistent with their definition in the United States. For the purpose of this article, Counseling with a capital C refers to Western-style counseling, and counseling with a small c refers to the broader definition.

Counseling in Taiwan

In Taiwan, counseling activities and services can be categorized into four groups: Fu Dao, assist and guide; Kai Dao, broaden and guide; Chin Shi, literally "request and show," usually involving a divinity; and Tzy Shang, Western-style Counseling (see Table 2). Great generation differences in the perception of counseling exist in Taiwan: Younger generations are more accepting of Tzy Shang, and the elderly favor the other three. The Internet is utilized by counseling centers and hospitals as a valuable resource in providing and promoting mental health-related information because of the wide use of the Internet among the younger generation.

Counseling in Ghana

It is impossible to consider the state of counseling in Ghana without encountering definitional problems due to the variety of activities subsumed under the label in the local parlance. These activities include public health education, religious mentoring, and Western-style psychotherapy (Dankwa, 1981; Essuman, 1998, U.S. Agency for International Development, 2003). Even though the demand for Western-style psychological services is on the increase, Western-style counseling continues to be the least typical definition of counseling. An informal poll, conducted by one of the authors on working adults who took one or no classes in psychology, suggested that many Ghanaians, irrespective of educational level, are unclear about the role of a psychologist, the value of psychological counseling, situations that warrant referrals to a psychologist, and the difference between a psychologist and a psychiatrist. Psychologists in the public eye are perceived as experts who are able to explain all human behavior and as people who read minds. For a summary of the function of different types of Ghanaian counselors, see Table 3.

Thus far, this review of the state of counseling in Taiwan and Ghana has revealed that, although Counseling as a discipline may be relatively new to people in Taiwan and Ghana, the concept is clearly familiar. Each country has a variety of resources available for the preservation and restoration of mental health, and services provided range from Western-style Counseling practices, which generally exclude religion, to practices solely focusing on religious principles and excluding other factors. In both countries, the idea of seeking Western-style Counseling services is becoming more socially acceptable. In the case of Taiwan, the assumption that Chinese people refrain from talking about personal matters with outsiders (Lee, 2002) is increasingly less valid.

INTEGRATION OF CULTURE, RELIGION, AND COUNSELING

Given that religion is an integral part of Taiwanese and Ghanaian cultural reality, it makes sense to integrate religion into Counseling. Nonetheless, it may not always be beneficial to the client to have a counseling experience that is based entirely on religious principles. In the Taiwanese case example, if the man's sleep disturbances had been due to a preexisting medical condition, then religion-based counseling would be contraindicated. In the Ghanaian case example, if TC is in fact not a witch but clinically depressed or simply homesick, then a religious focus and an exorcism may not be the best intervention for her. It is clear that the conceptualization of these individuals' problems from only the religious perspective could potentially be harmful.

Integration of these two factors is important because ignoring religious themes and tools for intervention may result in improper case conceptualizations and inaccurate diagnoses. In addition, it could leave the client misunderstood and doubtful of the counselor's competence. For example, in treating a Taiwanese woman who suffers from post-abortion depression, it is culturally appropriate for her to report hearing her unborn baby crying. The religious explanation for this symptom is that termination of the pregnancy has prevented the baby from being able to be reincarnated. Discounting of this religious piece of information could result in a misdiagnosis of schizophrenia or a brief psychotic episode on the basis of auditory hallucinations. Similarly, in Ghana, a counselor would consider victims of genital shrinking (see Dzokoto & Adams, in press) delusional or paranoid if he or she ignored or discounted the belief that witches have the power to shrink and steal genitalia of other people with little or no physical contact.

Another advantage of integrating culture and religion into Counseling is that it helps the counselor become more sensitive to the different identities clients may have. For example, a woman in Taiwan may have conflicts with her parents-in-law because she refuses to participate in ancestor worship due to her Christian background. A Ghanaian Christian woman may have different concerns from a Ghanaian woman who believes in a New Age religion, Eckankar, even though they may both have similar educational and ethnic backgrounds. Both examples involve individuals from similar cultural backgrounds with different religious affiliations and highlight religious diversity as predicting different mental health concerns.

A possible alternative to integration of religion in the practice of Counseling in these two countries is referral to or collaboration with a religious leader. This option, although potentially viable, may in some situations be neither useful nor in the client's benefit due to the differences in worldviews. Because a Ghanaian Christian pastor might consider depression to be a white man's illness, or not know about its existence at all, and consider TC to be in fact a witch, collaborating with a pastor, especially if medication and a change of environment are warranted, will prove impossible. In a situation like this, an integrative approach is more useful; the counselor could acknowledge the existence of witchcraft in the culture and yet advocate psychological interventions rather than exorcism.

THE IDEAL MASTER

The previous section highlighted an important point: Paying too much attention to religion may be detrimental, but ignoring religion altogether may have an equally negative impact. A happy medium would be the Ideal Master (IM), a counselor who is knowledgeable of cultural values, religious beliefs, and Western Counseling theories; who is able to assess the importance of culture and religion in the client's worldview; and who is able to integrate all three dimensions in the promotion of clients' mental health. For example, suppose that a 65-year-old Taiwanese female reporting an inability to concentrate, a lack of energy, and constant worrying is brought by her son to see the IM. Being aware that the client is a practicing Christian, the IM can incorporate Bible verses into positive self-talk strategies to combat cognitive distortions and advocate prayer as an additional means of anxiety management. Given his or her knowledge of Taiwanese culture, the IM can assess whether the client is concerned about her living situation with her son and daughter in-law and utilize a systemic approach to facilitate dialogue between the client and her son, if it is needed. Through this process, the IM can incorporate culture and religion into the identification of the client's stressors and levels of functioning, and into the restoration of mental health.

To illustrate the IM approach in working with a Christian Ghanian male victim of genital shrinking, the IM would incorporate Christian principles of prayer and divine protection into the teaching of stress management techniques. In addition, when working with the client, the IM would provide education on koro, an Asian culture-bound syndrome similar to genital shrinking according to the Diagnostic and Statistical Manual of Mental Disorders--IV (American Psychiatric Association, 1994); the cross-cultural base rates in somatization; and information on the sociopolitical precipitants of genital shrinking outbreaks in West Africa.

The proposed IM balancing act may not be easily achieved in practice. Determining when and how to incorporate spiritual and cultural factors for Western-trained counselors working with native clients is not a simple task. We propose a few guidelines. First, counselors may want to be aware of and assess the client's adherence to or deviation from the cultural and spiritual norms within the client's community. Knowledge of these norms would assist the counselor in assessing the presenting problems and formulating conceptualization. It is highly recommended that counselors consult whenever there are gaps in cultural or religious knowledge. Second, it would be helpful to assess how clients adhere to their cultural and spiritual practice. For example, if Taiwanese or Ghanaian clients perceive some of the cultural or spiritual practices in their native culture as superstitious and disregard them, the attempt to integrate a common spiritual or cultural practice when counseling these individuals may not result in a successful intervention.

Third, it is important to consider the different social identities of a client and not assume that one identity defines an individual, because not all individuals who share a religion or cultural identity will be the same. For instance, individual differences in personality and life histories make individuals unique. Furthermore, age, gender, sexual orientation, ability status, and social-economic status form part of an individual's identity and should be considered in assessment and intervention.

IMPLICATIONS FOR COUNSELING IN THE WEST

There has been minimal awareness of religious diversity within cultures in the discipline of Counseling, and the state of counseling in Taiwan and Ghana is a testament to the importance of paying attention to these identities. The Ideal Master approach has several training and clinical implications for Counseling in the West. First, individuals from different countries come to the West, particularly to the United States, for graduate training as mental health counselors. The Ideal Master is a culturally sensitive framework that would help counselor educators provide training that is sensitive and responsive to trainees' native country needs. Second, the multiculturalism movement has made it evident that diversity issues such as race/ethnicity and religion should be taken into consideration when working with clients. However, these dimensions of diversity have largely been considered independently. Given that religious diversity occurs within a cultural group, a therapist should not expect an African American Christian female to have exactly the same concerns as an African American Muslim female. In the same vein, a counselor could find that an Asian American client and a Caucasian American client may share the same concerns because of shared religious beliefs. Thus, it is important to consider the intersection of a client's cultural and religious identities in Counseling in the West.

CONCLUSION

As mental health counseling continues to cross political and cultural borders in the 21st century, comprehensive conceptualization and effective treatment must be ensured. To this end, the importance of considering the cultural values and religious beliefs in the client's native country cannot be overemphasized. It is also important to consider the religious diversity within a culture, cultural diversity within a religion, and individual differences in degrees of adherence to cultural values and religious beliefs. In addition, given the multiple identities individuals possess, we advocate for mental health counselors to consider each identity and its interaction with others in the Counseling process in the hope that the holistic view, rather than the simplistic, will further enrich the Counseling experience and its appeal to regions all over the world.

Table 1
Country Profiles

                   Taiwan                      Ghana

Location           Southeast Asia.             West Africa.

Colonial history   First documented in 230     Former British colony,
                   AD, officially became       also German and Dutch
                   part of China around        colonial influences.
                   1400, colonized by the      First African country
                   Netherlands and Japan.      to gain independence
                   Two major waves of          (1957).
                   immigration in 1662 and
                   1949. Descendants of the
                   1662 immigration wave are
                   locally referred to as
                   Taiwanese and those of
                   the 1949 wave are
                   referred to as Chinese
                   Mainlanders.
                   Internationally, the term
                   Taiwanese generally
                   refers to people from
                   Taiwan, combining both
                   groups, which is the
                   definition adopted in
                   this article.

Ethnicity          84% Taiwanese (local        Typically classified
                   definition), 14% Chinese    under five major
                   Mainlanders, and 2%         groupings: Akan, Ewe,
                   aborigines.                 Ga-Adangbe, Guan, and
                                               Mole-Dagbane.

Population         22,603,000                  20,000,000

Area               Island, 14,054 square       92,100 square miles
                   miles (35,980 square km).   (238,533 square km).

Government         Transitioned from a         Troubled political past
                   mono-party system to a      that included coup
                   multiparty democratic       d'etats and military
                   regime in the late 1980s.   rule. Currently
                                               democratic (multi-party
                                               system) with a
                                               relatively stable
                                               political climate.

Languages          Mandarin (the official      English (official
                   language), Taiwanese,       language), Akan, Ewe,
                   Hakkanese, Kantonese, and   Ga-Adangbe, Guan, and
                   aboriginal languages.       Mole-Dagbane languages
                                               and dialects.

Migration          Increased rate of           Emigration to different
                   immigration from other      parts of the world,
                   South Asian countries       particularly the West
                   over the past decade.       for economic reasons.

Economic change    From agriculture to         Some attempts to shift
                   labor-intensive             from an agro-economy.
                   industries to a
                   technology focus.

Economic status    Major investor in China     Classified as a Highly
                   and countries in South      Indebted Poor Country by
                   Asia.                       the World Bank.

Table 2
Summary of Counseling Professionals in Taiwan

Counselor   Examples             Role                 Training

Fu Dao      Guidance             Help children with   Teacher training
            counselors           emotional problems   colleges,
                                 B.A., M.A., and
                                 Ph.D. degrees in
                                 psychology

Kai Dao     Parents, older       Advice giving,       Informal
            siblings, older      mentoring,
            relatives,           guidance
            influential
            people, teachers

Chin Shi    Feng shui masters,   Consulting           Varies
            religious leaders,   oracles,
            fortune tellers      divination, advice   Varies
                                 giving

Tzy Shang   Psychologists in     Western-style        Graduate programs
            college counseling   counseling           in counseling;
            centers                                   licensure
                                                      regulations
                                                      implemented
                                                      in 2003

Counselor   Cost

Fu Dao      Free in
            school
            system

Kai Dao     Free

Chin Shi    Varies;
            recipients
            usually offer
            cash gifts

Tzy Shang   Free in
            university
            settings;
            fee-based in
            private
            practices

Table 3
Summary of Counseling Professionals in Ghana

Personnel              Training             Role

Hospital health        Formal medical       Preventive education
educators              training (e.g.,      (e.g., sexually
                       doctors, nurses)     transmitted diseases,
                                            HIV, prenatal and
                                            postnatal care)

Psychiatrists and      Formal medical       Diagnosis and
psychiatric nurses     training             medication
                                            management of severe
                                            psychopathology

Religious counselors   Varies from none     Interpersonal conflict
                       to bible school or   management, couples
                       pastoral training    and premarital
                                            counseling, seminars,
                                            advice-giving

Traditional healers    Varies from none     Diagnosis and herbal
                       to long              medication
                       apprenticeships      management of severe
                                            psychopathology

School counselors      B.A., M.A., or       Provide support for
                       Ph.D. in             students with academic
                       psychology           and emotional difficulties

Family elders          None                 Interpersonal conflict
                                            management

Nongovernmental        Varies               Support for women
organizations          Varies               and children victims
                                            of violence and sexual
                                            abuse

Psychologists          M.A. or Ph.D. in     University counseling
                       psychology           center work,
                                            counseling services to
                                            general public, teaching,
                                            research, agency
                                            consultation

Personnel               Cost        Consumer Information

Hospital health         Free        Built into health-care
educators                           system

Psychiatrists and       Fee-based   Both inpatient and
psychiatric nurses                  outpatient services
                                    available; insufficient
                                    manpower

Religious counselors    Free        Most popular
                                    nationwide; currently
                                    most numerous
                                    resource; varying
                                    degree of competence
                                    and regulation

Traditional healers     Varies      Most popular in
                                    rural areas

School counselors       Free        Mostly in schools
                                    serving diplomatic
                                    community

Family elders           Free        Most popular
                                    nationwide

Nongovernmental         Free        Relatively new
organizations                       resource

Psychologists           Free and    Awareness and
                        fee-based   demand increasing
                        services    in some urban
                                    sectors of
                                    population

REFERENCES

Adams, G., Dzokoto, V. A., & Mensah, K. O. (2003). Christian identity in African spaces: Public representations in Ghana. Unpublished document, University of Kansas, Lawrence.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders--IV. Washington, DC: Author.

Asare, J. B. (1999, March 15). Psychological violence against women. The Ghanaian Chronicle, 61, 2.

Bebli, B. (2003, October 15). Doc warns on mental health delivery. The Ghanaian Chronicle, p. 1.

Dankwa, D. O. K. (1981). Guidance and counseling in the Ghana education service: History and policy. Unpublished document, University of Cape Coast, Ghana.

Dzokoto, V. (2000). Predictors of psychological well-being in Ghanaian adult workers. Unpublished master's thesis, University of Illinois at Urbana-Champaign.

Dzokoto, V., & Adams, G. (in press). Koro, juju, or mass hysteria: Genital shrinking epidemics in West Africa from 1997-2003. Culture, Medicine, and Psychiatry.

Ennin, B. A. (1999). Gendering work and economy domestic work. Unpublished manuscript, Ghana National Commission on Women and Democracy. Retrieved January 29, 2004, from http://www.skk.uit.no/WW99/papers/Adunyame_Betty_Ennin.pdf

Essuman, J. K. (1998). The history of guidance and counseling in Ghana (1950-1998). Unpublished manuscript, Eastern Washington University.

Gadzekpo, A. (1999). Societal attitudes to violence against women and children. In D. A. Coker & K. Cusack (Eds.), Breaking the silence and challenging the myths of violence against women and children in Ghana (pp. 120-137). Accra, Ghana: Yamens Press.

Gifford, P. (1998). African Christianity: Its public role. Bloomington, IN: Indiana University Press.

Government Information Office. (2004). Taiwan Yearbook 2004. Retrieved January 19, 2005, from http://www.gio.gov.tw/taiwan-website/5-gp/yearbook/P351.htm

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Luo, T. Y. (2000). "Marrying my rapist?!": The cultural trauma among Chinese rape survivors. Gender & Society, 14(4), 581-597.

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U.S. Agency for International Development. (2003). Country profile--HIV/AIDS: Ghana. Retrieved January 29, 2004, from www.synergyaids.com/Summaries_PDF/Ghana_profile_2003.pdf

Weinstein, M., Yamazaki, A., & Chang, M. C. (2004). The role of intergenerational relations in the association between life stressors and depressive symptoms. Research on Aging, 26(5), 511-530.

Hsiao-Wen Lo, Ph.D., is with Counseling and Psychological Services, Colgate University, Hamilton, NY. Vivian Dzokoto is with the Department of Psychology, Fayetteville State University, NC. E-mail: [e-mail]