7. Educational Enrichment Approach - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
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7. Educational Enrichment Approach

Therapist Resources > Therapy Books > All Relationships MultiCult

All Relationships and Therapy are Multi-Cultural- Family and Cross-Cultural Complications
by Ronald Mah

An education or enrichment approach focuses on information and education being the keys to therapeutic change.  This can mean the therapist educates the individual, couple, or family on communication dynamics, male and female roles, gay and lesbian relationship challenges, parenting and discipline, and so forth.  This also assumes that the therapist would become cross-cultural proficient by learning about a variety of culturally distinct populations.  The therapeutic premise is that the educational enrichment will lead individual, couples, and families to more successful relationships.  Family-of-origin work and cultural investigation may very relevant here.  Individuals may themselves be ignorant or were ignorant of cultural differences.  Joanides, et al (page 380, 2002) note that ethnocentric attitudes tended to create distance and conflict that harmed couples' well-being.  Unrecognized couples' cultural differences may contribute to the couple's or family's problems.  Their research of marriages between Greek Orthodox and non–Greek Orthodox often resulted in the non-Greek Orthodox experiencing different levels of culture shock that were linked to their ignorance of Greek Orthodox religious and familial idiosyncrasies.  They not only found Orthodox liturgical and sacramental traditions unfamiliar but also Greek families to be more enmeshed than their own.  Greater knowledge and understanding of their partners' religion and ethnicity would have served the relationship.  Therapists may proceed by facilitating their clients gaining more knowledge and understanding, but themselves may need more knowledge and understanding to act properly in therapy. Essentially, this is also a knowledge approach to becoming culturally competent therapists.

Having knowledge about the experience of cross-cultural issues and educating the clients can be very valuable.  For example, Ishiyama and Westwood (1992) describe the role of the therapist to facilitate self-validation based on knowledge of cross-cultural challenges.  "…four premises derived from the self-validation model.  First, cross-cultural clients with handicaps in communication and cultural awareness lack opportunities to be socially validated in their new environment.  Second, clients seek relationships that are empowering and validating to them.  Third, the counselor can be an active agent of client validation.  Fourth, better adjustment and self-appreciation result from an increased awareness of deeper feelings and values and the realistic appraisal of the present situation and inner resources."  An education or enrichment approach is often relevant to therapists gaining relevant knowledge about their clients including their experiences and cultural background.  Knowledge directs the therapist's interaction with clients. The therapist who understands the nature of client struggles and validation needs is able to be more sensitive and in promoting client self-expression. For example for immigrants, migrants, or those who have moved into new communities or neighborhoods, "Feelings of uprootedness, loss, and homesickness are common among clients with adjustment difficulties.  They have been removed from their familiar and predictable environment, sometimes suddenly and helplessly... Many young refugees suffer from a painful separation from their family members and friends.  Geographically relocated children are known to go through a symbolic process of death and grief for the old, familiar self and world... It is not difficult to imagine what is experienced by culturally dislocated individuals.  The lack of interpersonal skills and social support can intensify the feelings of insecurity and abandonment" (Ishiyama and Westwood, 1992).  

The knowledge about a specific population such as immigrants or refugees could be of great benefit to the therapist.  The therapist should consider that the same issues or principles of adjustment and so forth could also be applicable to an individual in relationships.  An individual may experience uprootedness, painful separation, grief for the loss of the familiar self in marriage or new relationships as well.  In the earlier excerpt from "Ethnicity and Family Therapy," tremendous knowledge about cultural differences were presented.  Unfortunately, extensive knowledge may serve only to create an extensive body of stereotypes or contribute to more nuanced cultural distinctions so professionals can engage in advanced stereotyping.  For example, Schwab and Schwab (1978) research on Japanese and American couples found that, "all mean differences were smaller among Japanese couples, especially for Japanese husbands.  These findings suggest that Japanese couples are more similar to one another than American couples..." and "the virtue of humility which is equally accepted by males and females" (page161-162).  This is interesting information but is useful only as trivia without a more expansive and nuanced conceptual framework.  With the growing diversity in America and the greater diversity of clients presenting for therapy, a knowledge-based approach to cultural competency can become overwhelming.  Who else is the therapist supposed to know about next!?  Clients may be dependent on the therapist educating them on relevant cultural and cross-cultural issues in the couple.  However, if the therapist does not know or is familiar with the dynamics, experience, values, and so forth, that is cultural background of the individual, or one or both or more of the couple or family (including, perhaps the particular local or media-driven adolescent culture of a teenager), then the therapist would be hard-pressed to educate them within their cultural frameworks.

The therapist may also assume his or her understanding of relationship functioning is adequate without cultural adaptation or interpretation.  The therapist would then assert his or her generic or preferred theories hold all the necessary knowledge that the relationship lacks.  This perspective dismisses the respective individuals, couple, or family's background or potential differences as not particularly relevant.  Therefore to such a therapist, Adit's Saudi background, Helena's Ukrainian upbringing, as well as Hannah and Petey's WASP values are unimportant to their relationship and functioning.  The therapist who works extensively and effectively with heterosexual couples may assume that their knowledge, experience, and theoretical conceptualizations are sufficient to work effectively with gay or lesbian couples.  Spitalnick and McNair, Couples Therapy with Gay and Lesbian Clients: An Analysis of Important Clinical Issues, (2005), say that "Twenty-five years ago, it was believed that with the appropriate supportive environment and a well-trained therapist, therapy with same-sex couples would include similar assessment and intervention techniques employed with heterosexual couples."  Their research found that sexual minority clinicians of both genders, as well as heterosexual female clinicians were all rated as more helpful than heterosexual male clinicians.  However, even the two lowest-rated groups (heterosexual male and unidentified male clinicians), a substantial number (30%) were rated as very helpful.  However, they also found therapeutic practices that convey sensitivity to awareness and appreciation of sexual minority issues appear to be more important than sexual orientation or gender of the therapist (page 45).  Green, et al in "Marriage and Family Therapists' Comfort Level Working With Gay and Lesbian Individuals, Couples, and Families," (2009) recommend that straight therapists working with lesbian and gay clients, need to examine their own privileged experiences as heterosexuals to be able to effectively work with gay and lesbian clients (page 160).  Most therapists they surveyed did not learn about gay and lesbian people through their education in graduate school.  95.5 percent reported that they learned about gay and lesbian persons through clinical experience.  Less than 65 percent reported learning in graduate school and only 46 percent learned through supervision during graduate training.  89 percent learned through personal experience from gay and lesbian friends, community involvement, or professional articles (page 164).  Support of legal recognition of civil unions for same-sex couple (73.5 percent) was predictive of comfort working with working with gay and lesbian couples, but not with working with gay and lesbian couples and families.  Green, et al speculate that this comes from a lack of opportunity to work with gay or lesbian couples and families (page 166).  

James M. Ussher in "Couples therapy with gay clients: Issues facing counselors" (1990) touches upon several important aspects of gay relationships that the therapist should know, along with some recommendations for therapy.

a large number of male gay relationships are sexually open--with an acceptance of sexual activity outside the relationship…This can result in relationship difficulties, as one partner may feel less secure in the sexual freedom advocated by gay norms and mores, and issues of jealousy may arise.

for gay men who are in a one-to-one relationship, 'serial monogamy' is more common than in the heterosexual population.  Gay relationships do last for many years, as long as a more traditional marriage, but the idea of 'till death us do part' is less prevalent.  This may change the emphasis in couples therapy, with gay couples being more prepared to separate if problems cannot be resolved.  It is important for counsellors to acknowledge that the social pressures which cause many heterosexual couples to remain together in unsatisfactory relationships are often working in the opposite direction with gay couples… However, research has suggested that those gay male couples who were in a 'close coupled' stable relationship were the most happy and well-adjusted…

as there is some evidence that couples who adhere to traditional sex role stereotypes are more likely to find themselves in distress…, this is a facet of gay relationships to be facilitated and encouraged.  However, it has been suggested that counsellors often lack an awareness of how gay men perceive gender stereotypes…

for counsellors working with clients experiencing sexual dysfunction, there are a number of important aspects of gay relationships to acknowledge.  Firstly, it has been argued… that gay men have a greater empathy for and understanding of the effects of sexual dysfunction than do heterosexual couples.  This suggests that gay men are more likely to come forward for therapeutic help if it is made accessible to them; a suggestion supported by evidence that gay men are more likely to come for help for particular types of sexual dysfunction, such as premature ejaculation… also argued that a gay relationship is less likely to be 'blamed' for any sexual difficulties, since the difficulties are invariably present outside the relationship also, in other sexual encounters… All of these factors suggest that there is a need for counselling with gay men in the area of sexual dysfunction; particularly so since the advent of AIDS, which has resulted in an exacerbation of the number of sexual problems experienced by gay couples…

before embarking on counselling of sexual problems, the counsellor would need to be aware of the different sexual practices of gay men and their colloquial descriptions such as rimming, fisting, water sports, etc… Gay men are generally less rigid in their sexual attitudes than heterosexual couples, resulting in a wider range of sexual behaviour and an acceptance of more so-called 'deviant' sexual activities… In the light of AIDS, one would need to be conversant with the relative risks of different activities and be able to discuss risk reduction with gay clients, such as the practice of safer sex… Although AIDS might not be an issue with a particular gay couple, a therapist would need to be aware of the psychological factors associated with AIDS and HIV infection and of the ways in which these might affect sex or relationships…

In addition, there are many specific social pressures on gay relationships not experienced by heterosexual couples. These include the difficulties in 'coming out' as a gay couple in a society dominated by traditional values; dealing with parents' ambivalence towards gay sexuality; the absence of a legal ritual, such as marriage, to legitimize the relationships; the difficulties (or impossibility) surrounding childrearing, resulting in a void in many men's lives; the difficulties in housing--either in gaining council housing because of being unmarried, or in getting a mortgage since the advent of AIDS; and difficulties in openly inviting one's partner to functions at work because of prejudices against gay people.  These pressures, and a general lack of support for gay relationships, may lead to couples separating at the onset of any difficulty, rather than seeking counselling, particularly as most therapeutic interventions are geared towards heterosexual couples. There is a strong case for arguing that counselling should be made more available and accessible to gay couples because of the social pressures placed on the relationship."

Spitalnick and McNair had additional points about therapy with gay and lesbian couples.

"therapists working with same-sex couples also serve as a valuable referral resource for community support groups for gays and lesbians, which also can support the couple.  Therefore, as current knowledge related to working with same-sex couples continues to progress and warrants additional investigation, clinicians will continue to provide treatment based on the best information available (page 45).

They found that individuals in heterosexual relationships identified themselves with more stereotypic sex-roles than did individuals in same-sex relationships.  Heterosexual couples also reported more sex-role–differentiated behavior, whereas same-sex couples reported more sex-role–undifferentiated behavior.  This finding may lead researchers and clinicians to conclude that because same-sex couples are more likely to endorse similar sex-role identification relative to heterosexual couples, they may report less conflict with regard to perceived financial, household, child-rearing responsibilities (page 46).

Unlike for heterosexual couples who have multiple role models in their families and in the media, few role models exist for same-sex couples.  Thus, sexual minorities likely develop their own normative relationship dynamics… Heterosexual individuals can more readily obtain advice or validation from other heterosexuals when not sure about current or future relationships.  This is likely to be more difficult for sexual minorities who, because of a lower number of same-sex couples and role models, are limited in their opportunities for relationship feedback.  Thus, sexual minorities might be left with the belief that questions or difficulties that they are experiencing are the result of their sexual orientation rather than mere relationship difficulties… The influence of relationship role models and accessibility to peer feedback on relationship difficulties has not been addressed adequately in the literature and requires further investigation" (page 46-47).

Spitalnick and McNair also have present issues relevant to lesbian couples.

"Lesbian bed death" was first documented in 1983, when Blumenstein and Schwartz reported that lesbians in long-term relationships have significantly less sex than gay men or women in heterosexual relationships.  Despite the fact that the 1990s saw lesbian sexuality change when lesbian sex clubs and parties emerged and dildo sales increased, lesbians still seemed to be engaging in less sex that other men and women… In one of only a few studies that has investigated the decrease in sexual behavior in lesbian relationships (page 48).

Two theories have been proposed to explain the phenomenon of decreased sexual behavior over the first few years of the relationships: a decrease in sexual desire and internalized homophobia.  Recently, researchers have found that low sexual desire, secondary type, is experienced more frequently among lesbian than gay or heterosexual couples… Secondary type, as opposed to primary type, is often specified as lesbian couples typically report strong sexual desire and high levels of sexual behavior during the beginning of the relationship but then a decline in sexual activity and desire after the first few years of the relationship… cites several factors that may contribute to a low frequency of sexual behavior, including the cultural socialization that teaches women to be less sexually assertive, leaving lesbian couples without a "trained initiator," and the extreme degree of connectedness between lesbian partners that develop, known as fusion.  The second issue, internalized homophobia, may also explain the decrease in sexual behavior in lesbian relationships over time. Internalized homophobia has been described as the process by which one who is a member of a stigmatized group internalizes negative stereotypes and expectations held by the majority… Internalized homophobia can impact lesbians in profound ways and lead to guilt, self-hatred, self-doubting, and negative outlooks regarding the possibility of maintaining a long-term relationship… (page 48).

Researchers have suggested that, for lesbians, a major outcome of gender and female socialization is relationship "fusion"… Fusion has been conceptualized as the process by which the boundaries and emotional distance between each partner become blurred to the point where there tends to be an extreme form of emotional closeness… problems develop when neither partner establishes an autonomous identity in the relationship…. one possible explanation for the development of this relational closeness in lesbian couples is that the couple begins to bond and support one another in reaction to the social and political pressures, stigmatizations, and negative stereotypes that typically undermine the relationship (page 49)

For fused lesbians, introducing exercises that establish some distance and differentiation between the partners while supporting and validating them would allow for each partner to maintain the emotional and intimate connection while also developing a greater sense of autonomy. This kind of therapy ultimately aims to establish a secure and appropriate level of attachment…"(page 49).

The three articles referenced introduce issues and concepts but should not be assumed to be comprehensive about working with gay and lesbian individuals or couples.  The quality and quantity of educational information may be very good about any population such as just briefly presented about gay and lesbian couples.  However, essentially the facts of the statistics or tendencies are still stereotypes about a group of people and not definitive about the group.  And, especially not definitive about an individual, a particular couple, or a specific family.  In working with a lesbian couple, therapists should be aware of the possibility of a fused relationship and/or "lesbian bed death" but not assume these stereotypes occur in the couple.  Non-lesbian couples, that is gay couples or heterosexual couples can also have fused relationships and/or have their version of "bed death" or lack of sexual intimacy.  Therapists should take an investigative approach, and evoke from the couple information about their process from both their cultural backgrounds and their family of origin and other life experiences.  

"View cultural differences as one explanation of conflicts.  Therapists may use knowledge of cultural differences to recognize patterns when present, but should not assume the presence of a pattern until it is evident… However, making assumptions based on stereotypical cultural patterns can cause problems as well.  There are frequent intragroup differences that can easily be overlooked if therapists assume that they are familiar with clients' cultural groups… For example, a Mexican American couple…did not identify cultural differences as contributing to their marital difficulties.  However, the interview revealed that the husband was a fourth generation, middle-class, Catholic, Mexican-American.  He strongly identified with the Mexican-American community.  The wife was a second generation, wealthy, Jewish, Mexican-American.  Her religious beliefs were far more influential than the nationality of her parents.  Religious and social class differences permeated this couple's difficulties, yet could have been overlooked in therapy had the therapists assumed that similarity on one cultural dimension meant similarities on all dimensions" (Biever et al, 1998).

The therapist cannot be fully knowledgeable about every individual, couple or family that presents for therapy no matter how conscientious they may be to be culturally competent.  The diversity of modern American society, the nuances within the diversity, and the interplay among differences create an exponentially massive total of possible relationship combinations and presentations.  The therapist that realizes he or she cannot understand individuals or relationships from prior knowledge alone can facilitate personal/professional education within and during the therapeutic process by taking an inquisitive approach.  The therapist should inquire about Adit's Saudi culture and Helena's Ukrainian heritage as it affects her behavior.  Inquiry of Hannah and Petey's dynamics may similarly elicit their versions of WASP cultures as manifested in their respective families for the therapist to evaluate.  Such an approach has value for individuals in the relationship as well.  Often when responding to the therapist's questions, clients discover their own truths that they may have not been fully cognizant of.  For example, Adit may not have realized how much he anticipated having a relationship with Helena similar to what his mother and father had.  Or in responding, Helena came to realize that she had internalized more liberal American feminine values and adapted the Ukrainian values she had grown up at home.  An investigative approach can be formal or informal, but should be a comprehensive process that seeks broad assessment.  

Bhugra and De Silva suggest the following set of questions for assessing couple therapy across cultures, along with offering a second table for assessing advantages and disadvantages of intercultural marriage that can be used to assess for strengths and weaknesses in the relationships (page188-89, 2000).  

TABLE I. Assessment in couple therapy across cultures
Normative age for marriage

Why that age?

Do men have to achieve certain things before getting married?

When are men/women considered eligible?

How much free will do they have?

History of arranged marriage?
Definition of arranged marriage
Whose responsibility?

Do these patterns continue with migration?
Other basis for mate selection
If so, how different?

How is it accepted by the culture?

Role of common interest, mutual attraction, love or lust

Expected duties of husband/wife

Gender roles


Division of responsibilities

Power, alteration of power equation

Role of families of origin

Conception of sexual relations

Do' s and don'ts in interactions with outsider

TABLE II. Intercultural marriages: some advantages and disadvantages
More thorough preparation for marriage

Greater degree of commitment

Greater degree of self-other

Broader opportunities for learning and growth

Greater opportunities for children

More accepting of differences

Less common ground in relationship

Differences causing doubts

Sense of loss of self

Learning and growth interfered with by conflicting backgrounds.

Social stigma and non-acceptance

Institutional racism

From information gained from therapeutic investigation, the therapist may be able to properly interpret and "educate" individuals regarding the relationship's effective and ineffective dynamics.  Advantages that have developed may be targeted for extension and amplification.  Attention would be directed to minimize or eliminate disadvantages that have developed.  However, sometimes knowledge by itself will not suffice.  In fact, sometimes the individual, couple, or family totally understands their toxic dynamic and the reasons why, yet may remain stuck.  This is extremely frustrating for everyone involved.  The implication of an unsophisticated education approach that is ineffective in facilitating therapeutic change would be that the individual, couple, or family is not educable.  This becomes an unfortunate implicit insult to the intelligence of the individual, or members of the couple or family.  More or less, it may be a repeat of negative dynamics already existing in the relationship- "I told you!" "How many times do I need to tell you!?"  "What's wrong with you?  You know I don't like that!"  The therapist may show frustration and impatience toward individuals, the couple, or the family that inadvertently pathologizes them possibly insulting them for their ignorance or their inability to activate knowledge into change.  The effect would be to cause greater hopelessness.

3056 Castro Valley Blvd., #82
Castro Valley, CA 94546
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
office: (510) 582-5788
fax: (510) 889-6553
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