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Most professional mental health associations in the developed world now have policies and procedures aimed at not only applying affirmative action in the recruitment of minorities, but also of encouraging all therapists to develop at least minimal level of multicultural competence.  In the United States, not unlike other developed countries, 31 percent of the population is made up of ethnic minorities, yet 90 percent of the social workers, psychologists, and family therapists are white (Psychotherapy Networker, Sept/Oct 2003).  Recruitment and retention of minority therapists is not keeping pace with the growth of minority populations, and hence the need for all therapists to become more skilled in working multiculturally.  The high no show rates found by some white provider agencies with minority clients can be addressed in part, say those responsible for ethnic minority training, by inviting mental health professionals to question their positions of privilege and embrace their "not knowing".

 Judith Mishne's book Multiculturalism and the Therapeutic Process (2002), is then a welcome addition to this endeavour.  Well-written, with in-depth case examples, it extends intersubjectivity theory and Kohut's self psychology from the object-relations approach, into the cross-cultural arena.  Central to this is the empathy that follows from recognising the self in the other, which evokes a human echo in both client and therapist, as a reciprocal and mutually influential system of exchange arises.  As the therapist remains transparent and in recognition of their own biases and cultural/ethnic ignorance of the client's reality dyadic learning is facilitated in the crucible or context of our mutually recognised common humanity and fallibility.  Within this context of a shared recognition of our commonalities and fallibilities, Mishne shows us how to integrate the use of feminist, empowerment, family, narrative, and strength theories.

 The book consists of four sections.  Part 1 provides an overview of the history of cross-cultural therapy from an object-relations view, and highlights the need to become more responsive in the 21^st century.  Earlier views in psychoanalytic theory, as many have suggested, reeked of "colonialism" and at times, a racist assumption that ethnic minorities were not suitable for 'insight therapies'.  The position of power and authority adopted by earlier therapists in the therapeutic relationship are rejected by Mishne in favour of a more humble position where the therapist explores their own biases and prejudices through a willingness to learn about the client's worldview.  Amongst other things this requires setting aside our pet theories about psychopathology in order to avoid premature clinical decisions.

 Parts 2, 3, & 4 cover the beginning, middle, and end phases of the therapeutic encounter.  Each phase contains some delightful case illustrations of the processes involved.  The first phase, that of obtaining the referral, engaging and developing the therapeutic alliance as the assessment and treatment plan are formulated, is best done as a collaborative endeavour.  This is achieved through a warm relationship generating "optimal responsiveness" rather than classic objectivism, characterised by professional detachment, that generates "optimal frustration" (and undoubtedly accounts for some of the drop-out rates earlier researchers found).  Mishne has the courage to reflect on one of her less than successful cases in this section.  She also highlights the "provisional credibility" some clients (especially from ethnic minorities) extend to therapists in the early phase, and which can be so easily undermined by lack of humility and respect of differences.

 In the section on the middle phase of treatment (where the transference and countertransference aspects of the therapeutic relationship are central), Mishne brings her wealth of knowledge of the newer analytic paradigms which stress the use of empathy, warmth and the self of the therapist, rather than the traditional therapeutic neutrality which has given analysis such bad press in a postmodern world.  Mishne has the therapist recognize and acknowledge his/her contribution to the transference dance, thus allowing both client and therapist to get more 'real' with each other.  Here such factors as gender and/or cultural power disparities have to be raised in the therapeutic conversation.  This may include deference on the client's part to the cultural position occupied by the therapist; or cultural hostility expressed by either the therapist or the client.  Culturally different styles of communicating, both verbally and non-verbally may also become fodder for the conversation.  The exchange of gifts, usually so taboo in therapy, is another topic Mishne brings to the discussion, as it has differing cultural meanings.

The fourth phase is the end phase of therapy, where Mishne relates to Kohut's notion of cure being when the patient is seeking out appropriate selfobjects and fruition or flowering of the creative potential has occurred.  In this section Mishne takes a well-deserved swipe at managed care and the limits it has placed on the development of lasting change.  In the cross-cultural context, "working through" or a "cure" has occurred when patient and therapist are no longer "ethnic strangers".  Using her own cultural identity as a white, Jewish American woman Mishne shows in this section, via more case illustrations, her own "working through" of cultural responsivity. 

 Throughout the book she shows us that cultural responsivity is not always easily acquired, as much as for any reason because of our own counter-transferences.  However, persevered with, it brings its own rewards to us as therapists in this global village, as it does in turn to our clients.  This is a thought-provoking book, which is rich in its coverage of psychodynamic therapy and multiculturalism, and contains a strong invitation to all therapists to broaden their relational responsibility.

 © 2003 Nick Drury

Nick Drury, Kaimatai Hinengaro (N.Z. Maori Psychologist)

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