Psychotherapy in Gaza: Application of psychotherapy in a non-western society

Takk til Sissel Reichelt for verdifulle innspill.

Introduction

This study intends to explore the application of psychotherapy in a non-Western society, through the exploration of the experiences of a group of Palestinian therapists in Gaza, Palestine.

Psychotherapy, traditionally a professional activity representing white, European and European-American cultures, is believed to generally have been most effective on those people whose cultural traditions and social backgrounds have mirrored that culture. The values and beliefs of the West have influenced the actual practice of therapy. Many of the values and characteristics observed in both the goals, as well as the process of therapy, are not shared by Third World individuals (Lee & Richardson, 1991).

Nowadays, psychologists are increasingly challenged in delivering mental health services to clients who do not share their cultural background. Several books have been published concerning the issue of applying psychotherapy to culturally different clients. Some have constructed practical guidelines for meeting these clients (e.g. d’Ardenne & Mahtani, 1989; Tseng & Streltzer, 2001; US department of Health and Human Services, 2001; Vargas & Koss-Chioino, 1992). Others have concentrated on theoretical issues involved in such encounters (e.g. Comas-Diaz & Griffith, 1988; Goldberger & Veroff, 1995; Lo & Fung, 2003; Pedersen et al., 1981). What appears to be common in most publications in this field, is the focus on situations in which white American or European therapists meet minority, non-Western clients. Few have investigated the application of psychotherapy in non-Western cultural contexts where both clients and therapists share the same, non-Western cultural background. This paper examines the experience of a group of psychotherapists with non-Western cultural background encountering non-Western clients in Gaza, Palestine.

Culture and psychology

The discussion about the relationship between culture and psychology is multifold. According to a cultural psychological approach, two opposing positions can be prominent. Universalism: the essential presupposition is the belief in the universality of the theories, and the assumption of the psychic unity of the humankind. Hence, the universalists search for universal laws that govern behaviour and are applicable to any context and culture (Wohl, 1981). Relativism: emphasises the significant impact of cultural factors on individuals’ behaviour and development. According to a relativist view, it is not possible to develop universal laws for human behaviour because humans are not separable from their cultures (Cushman, 1995).

According to Cole (1996), Shweder (1995), and Goldberger and Veroff (1995) psychologists inspired by positivism have traditionally been associated with the search for human commonality rather than using effort to describe cultural differences. These authors criticise mainstream (general) psychology for relegating the study of culture and cultural variables to a secondary position.

Cultural psychology

Shweder (1995) has illuminated the relationship between culture and psychology by pointing out the limitations of general psychology, and in presenting his ideas about cultural psychology: «Cultural psychology is the study of the ways cultural traditions and social practices regulate, express, and transform the human psyche, resulting less in psychic unity for human kind than in ethnic divergences in mind, self, and emotions» (p. 41).

Cultural psychology is concerned with the study of particular cultures and groups and aims to determine the relationship between the structures, values, belief systems, and practices of a culture and the behaviour of persons living in culture. The regularities observed among a group of people (in a lab, or in a natural environment) are interpreted as descriptions of local responses related to context and authority relations rather than as characteristics of a «central processing mechanism».

The approach chosen in this article, to understand the relationship between culture and psychology, is inspired by Shweder’s (1995) notion of cultural psychology. I believe this approach acknowledges the powerful shaping effects of a culture on its members: in their ways of being, ways of knowing, ways of constructing reality, ways of relating, as well as their fundamental assumptions about the world.

Background

The Gaza Strip is a Palestinian territory approximately 360 km² in area, bordered by Egypt to the South and Israel to the North and East. Most of the Gaza strip is governed by the Palestinian National Authority, however, areas of fertile agricultural land are populated by Jewish settlers and administrated by Israel. The population is greater than 1 million (Palestinian Central Bureau of Statistics, 1997). The number of Jewish settlers is approximately 4500, all under the protection of the Israeli military (FAFO, 1993).

The economical base of the Gaza Strip is highly dependent on Israel, where many Gazans find their daily employment. Approximately 35 % of Gaza’s GNP consists of wages earned in Israel. Israel is also a major trading partner and much of Gaza’s agricultural products are exported from Israel as Israeli products. Gaza’s demographic situation is characterised by a high fertility rate: approximately 6.2 children per woman according to the FAFO survey from 1993. 50 % of the total number of inhabitants consist of individuals below the age of 15 (FAFO, 1993).

The Gaza Community Mental Health Programme

The Gaza Community Mental Health Programme (GCMHP) is a Palestinian non-governmental organisation, offering mental health services to the population of the Gaza Strip. It has approximately 200 employees (including the administration staff) working in three outpatient clinics. The mental health staff of the organisation consists of Palestinian psychologists, physicians, psychiatrists, nurses, and social workers.

GCMHP does not follow one psychotherapeutic school or tradition. According to the GCMHP’s 1996–97 annual report, the GCMHP’s strategy is to apply a type of psychotherapy in accordance to the presented complaint of the client: supportive therapy for chronic patients; cognitive therapy for clients with depression; behavioural therapy for clients with obsessive-compulsive disorders and phobia, etc. (GCMHP, 1997).

GCMHP is inspired by the US’s Community Mental Health Movement from the 1960’s. The movement’s characteristics were: the emphasis on the delivery of service or practice to the community (going to where the clients are, rather than a traditional office-based service), and working towards an increase empowerment of the community (Aponte, Rivers & Wohl, 1995). By arranging different workshops and courses, for other professionals and the general public, the health workers at GCMHP aim to put the issue of mental health on the agenda in the Gazan community. GCMHP’s research department has conducted several studies on effect of distress (mainly due to house-demolitions conducted by the Israeli army) on children.

Methodology

This research aimed to study aspects of the adaptation of therapeutic work to a non-Western cultural context. I have chosen to approach the topic of investigation by studying the manner in which the therapists at the Gaza Community Mental Health Programme (GCMHP) work: the therapeutical methods they apply and their experiences in applying these methods. The aim was to explore these general topics and try to uncover the therapists’ meaning perspective and hence gain access to the therapists’ experience and explore the meanings of these experiences. I did not have a fixed hypothesis about the manner of application of psychotherapy at GCMHP during the initial stages of this study. However, I did have a theoretical presumption, inspired by the theories of cultural psychology, about the important role of culture in human behaviour. This theoretical presumption was, more precisely, concerned with the necessity of integrating cultural factors in applying psychotherapy to clients with non-Western cultural backgrounds.

Qualitative research method

Using a qualitative approach, I have focused on GCMHP’s psychiatric clinics as the case study for my research, in which I employed the method of semi-structured interview. Qualitative research methods emphasise the importance of understanding the meaning of the participants’ experience (Richardson, 1996). The focal point in qualitative research methods is actions and events, as interpreted through the eyes of particular participants and researchers.

Collecting data

The data material for this study is based on interviews with a group of therapists at GCMHP, during my time as an intern in 1999 (the data for this study was gathered before the recent Intifada in Gaza and the West bank, autumn 2000. Conflict of this scale has not been seen for the past seven years). One advantage of choosing a particular organisation for the study has been the opportunity to investigate the topic in its context and over time.

The first interview was conducted two months after my arrival in Gaza. The respondents were informed about the goals of the research. The confidentiality of the interview was stressed. The transcription took place immediately after each interview, which gave me the opportunity to use the experience of each interview in the following one. It also enabled me to return to the respondent shortly after the interview in order to obtain clarification when necessary. This latter point was especially relevant due to the interview language being English, which was the second language of both parties.

The interview guide: During the development of the interview guide, I came across a section of a GCMHP annual report (GCMHP, 1997, p. 6) concerning the same issues that this research intended to study:

«While performing classical psychological work, the GCMHP firmly roots its therapy in a culturally sensitive, community based approach, adapting Western approaches to the needs of the Palestinian society.»

The questions of the interview guide were aimed at capturing the concrete experience of the informants in their work. The participants were asked to bring up an individual patient case. The above-mentioned quotation from this GCMHP annual report in the interview guide and was used as a starting point to discuss the adaptation of their therapeutic work. I asked the informants to elaborate on their ideas concerning various aspects of the above-mentioned quotation, e.g. what the informant considered as: the «western approach»; «culturally sensitive approach»; and what the informant considered as resources of the Gazan community relevant to their work.

The participants: The data material consists of interviews with six therapists in two different clinics who voluntarily chose to participate in the study. Each interview had a duration of approximately 1,5 to 2 hours. The subject of the study was presented to all the therapists at GCMHP and the therapists were invited to participate in the study. The main criteria were that the therapist could communicate in English and the therapists’ interest for the topic. The participants were male psychologists with 5 to 10 years of work experience as therapists (There were two female psychologists in the clinics, however due to language difficulties they were not included in the interviews). The participants are graduates from various universities in the Middle East: Egypt; Jordan; and the West Bank. The psychology programs offered in the Middle-Eastern universities follow a similar pattern to the Western universities (Abou-Hatab, 1997). Therefore, it is fair to claim that the therapists’ academic/theoretical backgrounds are similar to those found in Western countries. Apart from this, no informant (and to my knowledge, none of the therapists at GCMHP) had received any specific education for the application of therapeutic models in a non-Western context. Thereby, ensuring that any attempts to apply and adapt the therapeutic models in Gaza are tailor-made. However, there are variations in the informants’ theoretical orientation. Some of the participants have a psychoanalytic orientation, while the majority apply cognitive, behavioural-cognitive, or supportive therapy. The subject of the study was also discussed with the therapists group (both participants and not-participants) in clinics. These discussions provided me with information about the not-participant psychologists’ points of view. It is therefore fair to clam that, except from the informants’ gender, the participants are representative for the therapist group working at GCMHP.

Analysis

The analysis of the data material is basic-ally inspired by Grounded theory, which is a methodological approach developed by Glaser and Strauss (Strauss, 1990). It provides a style of analysing based on a set of inductive strategies for generating theory. A researcher who applies grounded theory method does not follow a theory, as in the theory-driven research designs, but rather allows the key topics to emerge from the data. The researcher aims at generating theory by developing abstract categories from the data material and identifying patterns of relationship within them (Strauss, 1990). In this study I have explored the meanings of the therapists’ experiences, and the reality of their working methods in the clinics. This should be seen as a result of interaction between the informants and the researcher and not as a process of discovering «the truth» or «facts».

Throughout the analysing of the data the following analytic questions were forwarded in order to guide the process:

In order to understand the experiences of the therapists in adapting the therapeutic work in Gaza, it is necessary to become acquainted with their and their clients’ living context.

• What are the cultural characteristics of Gazan society?

The informants were eager to portray the cultural characteristics of Gazan society and their accounts did not differ to any extent.

In order to explore how these cultural characteristics are related to the therapeutic work, the following questions were forwarded:

• How do these cultural characteristics influence the therapeutic work?
• What challenges do the therapists encounter?
• How do the therapists adapt their therapeutic work?

Results

The results of the study is presented as follows: A presentation of two of the main cultural characteristics of Gazan society (The concept of mental illness and the Gazan traditional healing system). A review of how these cultural characteristics influence the work of therapists.

The concept of mental illness

Among Gazans, beliefs concerning the causes of (and dealing with) mental illness range from very traditional and supernatural viewpoints, to naturalistic conceptions influenced by scientific medicine. In both cases, mental illness is regarded as a sign of personal or family weakness, which is a contributing factor to the strong stigmatism associated with mental illness in Gaza. According to traditional beliefs, the origin of emotional and behavioural problems frequently stems from supernatural causes. Traditional beliefs are based on the existence of spiritual beings such as jinnis, angels, and fairies. In this belief system, jinnis are able to take on different forms in different places. They may be overactive, mobile, aggressive and punitive. Mental disturbances are believed to be due to the intrusion of a spirit or spiritual possession whereby a spirit enters into the body of the patient. Indeed, the most popular word used by the Arabs indicating «madness» is the word majnon, which drives from the word Jin, meaning evil spirit. Another explanation may be based on a divine wrath where the illness is caused by God as a punishment for moral transgression,

or violation of taboos. Black magic also serves as a cause of illness. In the latter instance, the problem is caused by a sorcerer’s spell. For example, the phenomenon of the «evil eye» is thought to operate directly through the agency of a wish. It may cause many illnesses, both mental and physical, as well as failures in life. Those who envy prosperity, health, or beauty of others are believed to be able to harm them just by their gaze. Another category of supernatural accountability for an illness is viewing it as a way God examines his creature’s faith. Traditional beliefs may also include the idea that an illness is a disease-entry in itself (a physical-medical explanations), though caused by a supernatural mechanism.

The Gazan traditional healing system

Related to the dominant beliefs surrounding mental illness are a series of traditional healing methods offered in Gaza. These methods can be categorised due to their purposes and the functions that they serve. Some of the healing methods are believed to treat an illness, while another group of methods is used to prevent an occurrence or protect an individual. Yet another type of method is used to predict the future or to find the causes of an illness or a misfortune. The traditional healing process in Gaza is religiously based, in the sense that religious rituals and texts are central elements of the treatment. When a spirit is believed to have invaded body or mind, it must be removed: One practice is the reading aloud of the Koran and other religious texts by the healer. The client may also be asked to pray and read verses aloud from the Koran. Hidjab is another practice in which particular verses of the Koran, religious texts, as well as ritualistic signs and numerical configurations, are used to ward off jinnis. These are inscribed by the healer on pieces of paper, and the client must carry them with them. These are used for the treatment or prevention of mental disorders or other illnesses. Prescribing herbs is another manner of traditional healing. The healer prescribes special herbs to be taken orally. Other prescriptions may involve bathing in a solution of water and herbs. In cases of predicting the outcome of a phenomenon or discovery of causes of an illness some healers read palms and coffee grains. Another type of traditional healing involves the evil spirit being removed from the client’s body during the course of special ceremonies, which often involve the flagellation of the client. Sometimes family members are asked to join the healer in the removing of the spirit by flogging the client.

The therapeutic work of the GCMHP

The above mentioned cultural characteristics of the Gazan society influence the work of therapists in various ways. In the following I will present a number of these influences that emerged from the data material. I will concentrate on what the informants perceive as challenges in their work, and the way in which they deal with them by adapting their therapeutic knowledge to the Gazan context.

Faith in traditional healing

The therapists have to take issue with the widespread use of traditional healers by people seeking help in Gaza. According to one of the therapists, most individual and family conceptions of mental illness are often a mixture of two sets of ideas: the supernatural-based and the medical ones. The cause of an illness may be believed to be organic or a disease. The disease or the organic cause may, nonetheless, be in itself originated by a supernatural power, thus explaining why many clients may utilise both a traditional cure for their symptoms, as well as Western psychological and medical treatment.

All the therapists differentiate between the traditional healers and their methods. There is a consensus amongst the informants to appreciate traditional healing methods involving prayer and herbal prescriptions. Simultaneously, they all express their strong concerns about treatments involving physical or sexual abuse of clients. The therapists believe that many of the healers are primarily concerned with economical gain. Their practice is illegal due to its possibly harmful nature, and many reported cases of abuse and injury. Genuine healers are however perceived as men of religion by the population, including the informants.

Some of the informants believe that therapists should take the popularity that the «good» traditional healers enjoy amongst clients into consideration and learn from their experiences. According to these informants, the healers’ «closeness» to the people, the «respect» and «gentleness» they show toward their clients, should be taken up by the therapists.

Somatisation

Clients frequently complain of various body-aches, general fatigue, burning sensations, palpitations, and numbness. The majority of informants relate this to the fact that physical symptoms are more acceptable and less stigmatised than psychological ones, as the inability to cope with a negative event or stressful period is viewed as an inherent weakness and disappointment. Some of the informants mention «lack of tradition» in expressing problems in a psychological way as the reason behind the somatic complaints. Whatever reason may lay behind the clients’ somatic problems, all the informants believe that it would be a mistake to discount these physical complaints. However, all the informants are challenged with the difficulty of «convincing» the clients and their families of the possible psychological causes of the problems. For psychoanalytic oriented therapists, the issue of sharing their psychological interpretations with their clients is experienced as a dilemma because they are in conflict with the cultural beliefs of the client. Despite the fact that these therapists avoid sharing of their interpretations with their clients, they do use these interpretations throughout the treatment process and as a guidance for their understanding of the problems. Also, the informants who mainly apply behavioural or cognitive behavioural therapy stress the difficulty when encountering «somatic patients». However, they believe that offering a psychological explanation/interpretation of the problems to the client is not always necessary. It is the client’s level of education and «openness» to receive a psychological explanation that is taken into consideration. They believe that the most important issue is to encourage the client to continue the therapy process and not to «scare» him/her away from the clinic.

Reluctance towards disclosure

The informants employ various psychotherapeutic approaches. The main reason for choosing a certain therapeutic technique is the assumed «effectiveness of the technique in Gazan context» and its «suitability for each individual case». Nonetheless, most of the informants view the client’s disclosure as an important factor in the therapeutic process. These therapists believe that a client’s «gaining insight» into his/her problem is essential in the treatment process. They are also aware of the difficulties the clients might have in doing so. Besides the fact that some of the clients could have difficulties engaging in emotional issues, the therapists point to cultural factors influencing their clients’ willingness to disclose themselves.

Particularly when using an insight-oriented therapeutic approach, the inconsistency between the therapist’s and the client’s point of views becomes clear. A number of the informants stressed that the process of therapy is an activity foreign to Palestinian culture and is therefore strange to many Palestinians. The majority of clients have no desire to disclose personal or family matters to strangers. They may feel a sense of shame about relating the secrets (conflicts, trauma, and abuses) of the family. They are unwilling to let strangers know their thoughts, feelings, or wants. Because of the general political situation the clients could be suspicious about the therapists’ wish and motives for gaining access to their conflicts, family relationships, thoughts and feelings. One informant stresses that clients are generally «reluctant» to engage in self-disclosure during the therapy, because they don’t believe in «curative-talk». Although the therapists experience different underlying reasons for their clients’ «reluctance» to disclosure, they believe in «building a trustful relationship» as one of the solutions. They also try to normalise the client’s problem during their conversations.

Psychotherapist as a doctor

The following category (and its sub-categories) deals with the inconsistencies between the informants’ views and what they perceive as their clients’ views of the treatment process. There is noticeable variation amongst different informants’ experiences as to the types of perceived inconsistency, with regard to the way different therapists deal with these inconsistencies. In what follows I present details of such inconsistencies.

Once a client approaches the clinic, he/she perceives it as a visit to a doctor who has more knowledge than themselves and who, in turn, will teach them how best to resolve the situation. It appears that the informants unanimously agree that clients’ understanding of the psychologists’ work and the process of therapy have to be changed.

A number of informants identify what they call «the client’s impatience», as a challenge in the process of treatment. These informants’ solutions are the choice of a therapeutic approach that gives results in a short period of time. For the therapists who are attracted to other therapeutic approaches than behavioural, the challenge is greater. The degree of frustration seems to be higher amongst these therapists.

Several informants stress the issue of the authority of the therapist. The respect for authority in this society has a clear effect on the therapeutic relationship. In some cases it results in the client’s difficulty to express himself/herself freely. Therefore, the client’s «opinions about, anger towards, frustration and dissatisfaction with the therapist» or the therapeutic process cannot be openly discussed. One informant concludes that, «it is not easy to talk about transference and contra-transference in this case».

The issue of the «frankness» of the client toward the therapist and the authority of the therapist is explained differently by another informant: In daily social interaction, Palestinians value what they call «Al Modjamala» being sensitive to other peoples feelings. Accordingly, the client may be over-concerned with the therapist’s feelings: «He is cautious not to disappoint the therapist all the time … and eventually a premature termination of the therapy could follow.»

How does the informant deal with such issues?

«I am acting according to the same norm as him: Certainly, I am careful not to hurt his feelings, this is a part of my job, furthermore, it will take several sessions until he feels relaxed with me. And this is the dilemma: can he carry on with this treatment or does he want some tablets and never come back.»

All informants irrespective of therapeutic approach, stress that clients expect their therapists to be active and concrete, to advice and/or to prescribe medicine, which are believed to influence the client-therapist relationship. The challenge then becomes to «involve the client in the process of treatment». The majority of clients expect their therapist to do the curing and have difficulty understanding their role in the therapeutic process. This opposes the psychoanalytical oriented informants’ expectations of the client reflecting on the problems and the therapist as a passive listener. This results in the rare use of such approaches by the therapists: «The therapist tries to make the patient more involved in the process at the same time (the therapist) take over a more active role.» However, this informant emphasises that this should not be interpreted as a case of «dependency» as in psychoanalytic literature. This type of «dependency» is quite normal in Gazan culture, according to the informant.

The informants who used behavioural or cognitive therapy approaches met similar challenges. It does not seem as an easy task to make the clients do «the necessary homework and exercises». According to several informants, things eventually move forward through the use of fantasy and creativity in finding the right homework. These informants view the principles of behavioural modification as «scientific and less subjected to cultural adaptation».

Arabic time

The issues of therapeutic contract and fixed appointments present a challenge to the majority of the informants. There are several obstacles in establishing a formal contract with clients as expected in the process of psychotherapy. A therapist emphasising «fixed appointments and the rigid framework» of the sessions, would probably be construed as rude and uncompromising by the clients and their families. It would be inappropriate to require punctuality from a client in Gaza because of the cultural conception of punctuality, which is looser than in the Western countries. Besides, the communication system and infrastructure in Gaza is in accordance with the society’s relaxed attitude towards punctuality.

How do the therapists manage? They seem to have a relaxed attitude to the clients in regard to time. According to the informants, the client-therapist relationship should be viewed in accordance with the cultural norms of interpersonal relationships in Gaza. All the informants describe their relationship with their clients as flexible compared to the contract-based, formal therapeutic relationship between the client and the therapist in the West. They try to «teach» the clients the importance of fixed appointments. However, they do understand the difficulties of the clients’ encounter to meet at the exact appointed time, hence the large time margin that the therapists operate within. The psychoanalytic oriented informants are aware that they need to be careful about their theoretical interpretations related to these issues.

The dominant social norms in the collectivist society of Gaza demand that the therapist exercises a high degree of availability and accessibility in relation to the clients. The client may even attempt to seek help at the therapist’s home. All informants view themselves as members of the same society and hence need to comply with some of these demands. Nonetheless, some of the informants view these demands as sources of «burn-out» for the therapists, without having any clear solution for this type of job-pressure. Other informants seem to maintain an idealistic attitude towards their work and try to be as available as possible for their clients.

The psychotherapist as a part of the community

The therapist cannot simply disregard his/her position as member of a certain family and a certain kinship. That is why the therapist should be sensitive about the role and the potential influences such a kinship relationship may have on the treatment process. In this regard, several informants describe a formal professional relation with the clients and their family, as it is understood in textbooks, as difficult to maintain. These therapists deal with the issue by reducing the «formality» of the relationship and dismiss some of «the textbook demands». One method that the informants use to cope with these obstacles include ensuring the client that «the therapist is from the same culture» and acting as «familiar» as possible according to the culture. Indeed, this informant defines the concept of respect for the client, which is «crucial in therapy», as having little distance from the client’s general cultural beliefs and behaviour. Another informant stresses that the clue is the use of cultural elements, for instance the intimacy of the relationship, in the process of treatment. He has little difficulty to use his potential position (as a member of certain kinship) in the therapy as a resource.

Educating people

«Educating people» is a strategy that informants view as a method of engaging with many of the challenges met during the course of their work. The informants all agree that «educating people» about mental illness and the course of treatment is an integrated part of their work. However, the informants have several interpretations of the term «educating people». As a part of their job description, all therapists are involved in arranging lectures and courses in the wider community. These informative courses aim to increase the population’s general knowledge about issues of mental health and the GCMHP’s work. Some therapists view these «public meetings» and similar courses as identical with the idea of «educating people».

Some of the cognitive therapists emphasise the use of a psycho-educative approach in the majority of their cases. These therapists believe that without «educating» the client and the client’s family in what the therapists believes as the best way of combating the problems, the treatment would be useless. The psychoanalytic oriented therapists, on the other hand, seem to be careful not to contradict the cultural sensitive beliefs among their clients. Believing in the psychoanalytic interpretations as being universal, the therapists use these interpretations to understand their clients. However, they are cautious not to share these interpretations with their clients. In sum, both cognitive and psychoanalytic oriented therapists, take over an expert role toward their clients. Nonetheless, they differ in their sharing of their ideas with the clients.

The therapists appear to have different attitudes toward their clients and the general public when contemplating the issue of «educative work». While some informants use terms such as «ignorance» to describe the unfamiliarity of their clients with mental health issues, a minority of the informants use more neutral terms to characterise what they perceived as a differing perspective to the issues of mental health.

Discussion

The findings indicate that the clients’ unfamiliarity with the notion of psychotherapy poses a major challenge for the therapists in Gaza. This is an indication of differences between the worldviews clients’ and therapists’, which is rooted in their different conceptions of mental illness. These differences have an impact on the client-therapist relationship, as well as the process of therapy. Differences between the therapist’s and client’s beliefs about the causes, nature, and solutions of psychological problems also affect the outcome of psychotherapy (Krause, 1998).

Sue and Sue (1990, p. 30) refer to psychotherapy as «a process of interpersonal interaction and communication» and emphasise that each participant in this process «must be able to send and receive both verbal and non-verbal messages accurately and appropriately». I assume that the therapists in Gaza with their background in the same community and mastering the same patterns of communication as their clients have little problems in communicating with the clients. In this respect communication should not present the challenge. Nonetheless, psychotherapy is more than a form of communication. It is also a helping relationship; a rather «dynamic encounter between two distinct views of the world» (Toukmanian & Brouwers, 1998, p. 117).

The themes identified in the analysis of the data highlight that the clients’ unfamiliarity with the notion of psychotherapy is manifested in several areas in the encounter between the informants and their clients. The clients’ somatic complaints and the notion of insight are two such areas.

Somatisation and psychological-mindedness

The informants use the term «somatisation» to refer to the phenomenon implying that there is an underlying process being somatised. The term somatisation is construed as the antithesis of psychologisation (psychological-mindedness), which is considered the appropriate mode for the manifestation of emotional distress.

In agreement with the therapists in Gaza, several authors point out that a higher level of somatisation is found in the non-Western world (for instance: Al Issa, 1995; Dahl, 1989). This can be seen in contrast to western middle-class clients who are reported to «psychologise» their distress (Al-Issa, 1995; Lee & Richardson, 1991).

Several interpretations have been proposed to explain the higher level of somatic complaints among non-Western clients: Somatisation in non-Western cultures has been explained in terms of the inability of some people to express emotional distress psychologically. Such an explanation rests on traditional views of somatisation, which suggest that somatising clients express psychological distress through physical channels. Somatisation is believed to serve defensive functions. Some people may fear psychological illness so much that they fixate on the somatic aspects of their suffering, thereby avoiding confrontation with their own emotional conflicts. The above perspective represents a universalistic approach to human psychology that presumes that the notion of somatisation is a universal defence mechanism.

Al-Issa (1995) suggests that the experience and reporting of distress is influenced by the cultural variation of illness models. Western versus non-Western differences in somatisation may be related to cultural differences in the causal attribution of distress. Non-Western clients may tend to attribute distress to somatic or social events rather than to intra-psychic emotional experiences. Accordingly, physical complaints could have an adaptive social function. Illness can be seen as a social affair because it affects the person’s immediate group, and treatment involves the members of that group. In this regard, somatisation can be the outcome of culturally regulated pattern of ill behaviour. Indeed, they might not «mask» social problems, but serve as devices to draw attention to them. That is, physical symptoms may form a link between the individual, the social, and the political spheres.

According to Kirmayer and Robbins (1991) demonstrating that a symptom is psychogenic is rarely possible and is ambiguous in most cases. Thus, the clinician’s insistence on a somatising interpretation must be understood with regard to the ultimate clinical goal. The clinical goal ought to be to help the client. Hence, we should ask whether the labelling of a problem as somatisation leads to an intervention that will ultimately benefit the client.

Insight

Historically, impaired insight has been at the core of the many conceptions about the nature of psychopathology and treatment. Sackeim (1998) argues that many forms of psychotherapy are based on the assumption that failure of insight causes the generation of psychological illness and that the restoration of insight is curative. Other formulations view the lack of insight as a breakdown in some aspects of information processing, a motivational-neutral process (Kirmayer & Corin, 1998). Impaired insight does not only refer to cases in which the patient is unaware of the nature of the symptoms but also to instances in which the patients make «inappropriate» attribution for the sources of the symptoms.

Clients in Gaza tend to attribute their discomfort to supernatural phenomena or they expect the therapist to find out about the physiological reasons of the symptoms.

Insight traditionally refers to the ability of the client to re-label unusual mental events as pathological. It is synonymous with the acceptance of the therapist’s interpretation and compliance with treatment (Kirmayer & Corin, 1998). The cultural constructive/relativist view of insight is at odds with the clinical perspective that measures a patient’s insight against the clinician’s judgement as a standard. A relativist explanation suggests that the client’s interpretation of his/her experiClients in Gaza tend to attribute their discomfort to supernatural phenomena or they expect the therapist to find out about the physiological reasons of the symptoms.

Insight traditionally refers to the ability of the client to re-label unusual mental events as pathological. It is synonymous with the acceptance of the therapist’s interpretation and compliance with treatment (Kirmayer & Corin, 1998). The cultural constructive/relativist view of insight is at odds with the clinical perspective that measures a patient’s insight against the clinician’s judgement as a standard. A relativist explanation suggests that the client’s interpretation of his/her experience reflects an alternative construction of reality, rather than being a deficit in information processing or a purely defensive function. The clients’ responses do not occur in isolation; they are part of a more extended network of meaning. Insight can be seen as the culturally constructed version of experience to which the client subscribes by virtue of its appropriateness to his/her social world. In the instance of Gazan clients, this would involve consulting intimate members of the family, seeking advice and treatment from a traditional healer, performing certain rituals, and seeking help from a physician.

Western cultures consider insight into, and understanding of, the self as a desirable and an indication of a state of good mental health. By approaching all aspects of the self and one’s experience, including the negative, one can gain a comprehensive understanding of personal attitudes, beliefs, and behaviours (Kazarian & Evans, 1998). The clients in Gaza do not necessarily share this cultural valuing of insight. Insight does not automatically have any value and is not a state to which individuals aspire. Instead, a state of good mental health may be defined as successfully exercising one’s will power, avoiding unpleasant thoughts, and addressing pleasant thoughts. Thus, inhibition of negative or distressing thoughts is seen as a healthy, rather than unhealthy, goal. For instance, within some Islamic teaching, individuals are encouraged to control their unacceptable desires by not focusing on them.

The nature and the degree of insight is context-dependent and must be understood by clinicians as a response to the cultural meaning of a mental disturbance. Taking this into consideration, the appreciation of insight-oriented therapy as a universally applicable model of therapy should be re-examined. A presupposition of insight-oriented psychotherapy is the client’s disclosure. That is, the client’s willingness to let the therapist know his/her thoughts, feelings, or wants. Disclosure of psychological distress requires an individual to focus on negative thoughts and emotions that are central to the self. Thus, Western cultures that encourage insight-orientation, including insight into unpleasant and negative features, would support strategies such as disclosure to facilitate this process. In contrast, disclosure is avoided in some non-Western cultures, where such endeavours are discouraged.

Educating people

An important strategy encountering the challenges rooted in the different worldviews between clients and therapists is education. Participants in this study emphasise that general education focused on the issues of mental health, and especially the education of clients and their families in this area. Education is the main strategy pursued to narrow the conceptual gap that exists between them and their clients. In common with most of the non-Western world, institutions of mental health care are recent phenomena in Gaza. As the participants described, the practice of traditional healing exists side by side with «modern» psychological and medical beliefs, and mental health care. It is fair to assume that the contrast between traditional and modern ideas, as to the causes and nature of mental illness, is part of contemporary Gazan culture. On one hand, there is the traditional way of thinking about traditional healing procedures, while on the other hand there is a fashionable belief in modern science, especially medicine.

Through their work, the participants are engaged in the introduction of new conceptions of mental illness. However, these have possible consequences for the already existing cultural system: The traditional conception of dysfunctionality could be replaced by psychiatric nosologies, psychological explanations and standards of normality. Furthermore, certain social values, life styles, and child rearing practices may be judged as pathological. Recent occurrences suggest a possible increase in the official disapproval of traditional healing, which could create a vacuum in psychological care since contemporary mental health systems maintain only token resources and still suffer the stigma of rejection by the community.

It can be argued that changes in the conception of mental illness/health in Gazan society, are inevitable. Indeed, the work of GCMHP is an indicator of such cultural change. However, if it is not integrated with the basic socio-cultural elements, the practice of the institution will impose social change. Change without the participation of those affected is not only unethical but also undesirable. Imposition of influential yet incongruent institutions may hasten socio-cultural disintegration.

Conclusion

Despite the fact that the Gazan therapists share their clients’ cultural background, the Norwegian reader may recognise the challenges Gazan therapists cope with. The ethnic match between therapist and client, and thereby, therapist’s cultural specific knowledge about the client’s background, are the salient differences which emerge by comparing the informants’ and the Norwegian context. Ethnic match between client and therapist is reported to associate with continuing in treatment and improving in client functioning (Sue et al., 1991) (however, not all studies support these findings e.g. Ying and Hu (1994)). Among the factors that makes ethnic match influential is the therapist’s cultural specific knowledge about the client’s background. This type of knowledge seems necessary but not sufficient. It may provide a better position for the therapist in his/her assessment, understanding, and facilitating change in the client. However it does not automatically bring about the desired changes.

It becomes apparent that the experiences of the therapists from Gaza congregates on dealing with their clients’ unfamiliarity with the notion of psychotherapy, and the role/position of the therapist in the process of therapy; a challenge familiar to the Norwegian therapists. According to Wohl (1989, p. 347) psychotherapy contains particular sets of assumptions, rules, myths, and rituals. These can be viewed as the «psychology and psychotherapy cultural baggage» that «we tote around as creatures of our professional culture». Based on Triandis’ (1996) definition of culture, the psychotherapy culture consists of shared elements that establish standards for perceiving, believing, evaluating, and communicating. The informants, having studied at Middle-Eastern universities, underwent socialisation in the field of psychology/psychotherapy: an academic domain strongly rooted in, and dominated by the Western philosophical and scientific traditions. They carry the psychology cultural baggage and face similar challenges to their Norwegian colleagues when encountering «culturally different» clients. That is, those clients who do not share the «cultural of psychotherapy» with them.

Moreover, in many non-Western societies, the culture of psychotherapy and its assumptions, are viewed as a part of the modernist idea of development and progress. The modernist idea of development and progress continue to appeal to the educated population of Gaza, which is also one possible reason for the incorporation of the informants into the culture of psychotherapy. However, the culture of psychotherapy is dynamic. Recent concerns amongst therapists about the role of culture and the criticisms of applicability of Western methods of therapy to populations other than Western, can be assumed to be parts of the contemporary culture of psychotherapy.

According to a cultural psychologists approach (Shweder, 1995), culture and behaviour are regarded as inseparable rather than considering culture as an external factor that influences individual’s behaviour. In encountering a culturally different client, this type of cultural consciousness on the therapist’s side would probably reduce the importance of having extensive cultural specific knowledge about the clients’ background as the presupposition in treating with these group of clients. Rather, when encountering a culturally different client, the therapist recognises that clients may not share his/her notion of mental illness and investigates the ways this effects the functioning and behaviour of the clients during the psychotherapy process. He/she should also be able to be open to the client’s worldviews as equally legitimate, albeit not identical. The therapist should establish credibility in the eyes of the client, and most importantly, the therapist should be willing to negotiate the content and the goal of the treatment.

Having assured the above set of conditions, regardless of the amount of specific knowledge on the client’s cultural background, one can argue that the therapist would be in a better position to incorporate culture into the therapy process.