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Plenary symposium

The assimilation of current Western Psychotherapeutic Practice in Asia

The Tao Psychotherapy and Assimilation of Western Psychotherapy in Asia
Kang Suk-Hun, M.D
Prof. Emeritus
Kyungpook National University
Daegu, R. O. Korea
1. Introduction
Although lately, there seems to be growing interests in the subject of
Asian Culture and Western Psychotherapy (Tseng, W.,Chang, S. & Nishizono,
M., 2005), up until 1970s and 1980s the idea has been prevalent that western
Psychotherapy principle, theory and technique can not be applied to Asian
patient. This has been the case in India, Japan and many other countries in
Asia. (Rhee, D,. 1981; Nishizono, M,. 1994; Shamasundar, C., 1994)
In 1972, Eric Wittkower, the faculty of McGill University, during this
preparation of the inauguration speech of president of the American Academy
of Psychoanalysis sent a letter to Prof. Psychoanalysis can not be applied.
Prof Rhee, you are the only person who says Psychoanalysis can be
successful in Asia. Could you elaborate, upon the above matter, so that I can
insert then in my speech? (Prof. Rhee failed to answer in time).
Since the early 1960s, Prof. Rhee, D., the founder of the Tao
Psychotherapy, advocates that the Tao is the ultimate form of Psychotherapy.
Defines the Tao Psychotherapy as the fusion of the essence of Western
psychoanalysis, Psychotherapy and Eastern Tao. (Rhee, D,. 1960; 1968;
1970; 1980; 1984a; 1984b; 1990).
A. Trenkel once expressed, the experience itself could be same in both
Eastern and Western mind, but they tend to diverge after experience.(1994)
with a total agreement with his idea, the present author will have a brief
review on the subject of assimilation of Western Psychotherapy in Asian

countries, with an emphasis on experience and practice. After that, he will

also describe the essence of Prof. Rhees Tao Psychotherapy, with is









2. Assimilation of Western Psychoanalysis and Psychotherapy in Asian

to S. Kakar (1995), G. Bose who stepped in Hindu

philosophy and the Indian cultural tradition, founded the Indian

psychoanalytic society with 15 members in 1922. In the same year, Bose
wrote to Freud in Vienna, which resulted in the birth of the Indian
Psycoanalytic Society with Bose as its first president, a position he was to
hold till his death in 1953. The society became a full-fiedged member of the
international psychoanalytic community.
Without the benefit of training analysis himself, it was Bose who
analyzed the other member in a more or less informal manner and
otherwise endeavoured to keep their enthusiasm for psychoanalysis alive.
The actively didactic stance of the Indian analyst, as he engages in a lively
interaction with the patient, fits more with the model of the guru-disciple than
the doctor-patient relationship.
Kakar (1985) attributed these phenomenon to the absence in the Hindu
philosophical and literary tradition of life-historical introspection so that the
patient may have to be taught the kind of Psychological mindedness needed
for successful Psychoanalysis. Well into the 1940s, the published work of
Indian Psychoanalysis show a persisting concern with the illumination of
Indian cultural phenomena as well as registering the Indian aspects of their
patients mental life.
Here, Kakar (1995) speculates on the reasons for this total divorce of
Indian Psychoanalysis from Indian culture and society. In India, the last forty
years have witnessed an ever-increasing pace of modernization and
industrialization. The country has entered in a big way into the world market,

both economic and intellectual, which is dominated by the first world. If

Psychoanalysis is any kind of illustration for the rest of Indian intellectual
life, then it seems that when Indian entered the world market on a truly big
scale after independence, the Western colonization of the Indian mind
paradoxically became greater than was the case when the country was still a
British colony.
E. Hoch (1984) who stayed in India early 30 years, teaching
Psychotherapy at the B. M. Institute of Mental Health wrote me that My
greatest merit perhaps lies in having tried to be a messenger between East and
She also wrote me as a reaction to the works of Prof. Rhee D. and
Korean Academy of Psychotherapist, in India, nothing very original has
emerged from their activities. In particular, no greats efforts appear to have
been made for integrating traditional Indian elements into Psychotherapeutic
theory and practice.
In a historical overview on Japanese Psychoanalysis, Okonogi (1995)
named Ueno, Yabe and Marui as the forerunners of introducing
Psychoanalytic thoughts to Japan during 1920s.
In 1993, nonetheless, Marui visited Freud in Vienna and received
approval for establishing a Sendai Branch of the IPA.
H. Kosawa, a student of the Tohoku school, left Japan to study at the
Vienna Psychoanalytic Institute from 1932 to 1933. He received training
analysis from Richard Sterba, and individual supervision on Psychotherapy
from Paul Federn. While in Vienna, furthermore, Kosawa visited Freud at his
home at Bergasse 19, and presented him with a paper explaining his theory of
the Ajase complex. Unfortunately, however, Freud does not appear to have
evinced great interest in Kosawas thesis.
According to Nishizono (1995), there are three types of Psychotherapy
in Japan; Psychoanalysis, Morita therapy and behavior and cognitive therapy.
He also described 5 characteristic of dynamic psychotherapy for the Japanese.
Among them, he maintains that Japanese patients are shame-oriented rather

than guilt-oriented. This tendency means that real acceptance in actual life
situation is more important than their intrapsychic perspective for Japanese
patients. Japanese patients tend to have expectation on cognitive intervention
by therapist, e. g. advice, reassurance.
Far earlier than that, in 1984, on the occasion of the meeting of the
pacific Rim college of Psychiatrists in Shanghai; Nishizono also stressed that
during psychoanalytic therapy with Japanese patients, he usually dealt with
the patients external relation rather than his intrapsychic material. To this,
American audience reacted, that couldnt be called psychoanalysis.
Nishizono (1995) also cited opinions of Yamamoto and Eng-Kung Yeh on the
occasion of the symposium, therapy for Americans and Asians, during the
140th APA in 1987. Yamamoto said, insight therapy is difficult for the
Americans of Japanese descent and empathy therapy is what they need. Yeh
of Taiwan reported that dynamic psychotherapy is not of general interest in
After dr. Okonogis presentation on the history of Japanese
psychotherapy, on the occasion of the Kyoto Regional Symposium of WPA in
1984, Prof. Rhee asked a question, I heard that in Japan Dr. T. Doi only can
effectively do psychotherapy, and how is it in recent days? after some
silence of embarrassment, one of them reported, later, we will confer with
outselves and you will have the answer. Since then, Prof. Rhee says he
didnt have any answer from him till now.
According to A. Gerlach (2005), Western medicine was first introduced
into China in the 19th century and its spreading was due primarily to Christian
missionary societies. The first psychiatric clinic was opened in Canton in
1989. There were fewer than 50 trained psychiatrists in the whole of China in
From 1935 until 1939 Dr. Bingham Dai, a psychiatrist of Chinese
origin, worked at Peking Union Medical College; he had received a
psychoanalytically oriented training in psychotherapy from H. S. Sullivan in
New York and from L. Saul in Chicago and passed on his experiences in the

form of teachings, supervisions and training therapies to his colleagues. He

had to give up his work following the occupation of Peking by Japanese
troops and later worked in USA.
Insofar as can be seen in the articles dealing with psychology and







psychotherapeutic methods were tested, such as a combined Short Therapy,










psychotherapeutic conversation, drugs, breathing exercises and shadowboxing.

Since the end of the cultural Revolution, China has undergone rapid
market reform and opened itself to Western influence and ideas, including
those psychotherapeutic theory and practice. (Tseng, W., Chang, S. and
Nishizono, M., 2005). It was within this social and professional setting that
the knowledge and skills of various modern psychotherapists were introduced
into China.
Among many Chinese psychiatrists, there is also an increased concern
with developing psychotherapy suitable for the Chinese. ((Tseng, W., Chang,
S. and Nishizono, M., 2005)
3. Assimilation of Western psychotherapy in Korea
Korean medicine had developed on the same lines as Chinese medicine
since ancient times until the arrival of American missionary doctors and the
Japanese invasion during 1890s. (Rhee, D., 1984a). With the introduction of
Western medicine by American missionary and the Japanese, traditional
psychotherapeutic principles and insight were abolished because Western
medicine was materialistic and elementaristic and did not have any insight
into psychodynamic or psychosomatic principle which is the essence of
Korean and Chinese Medicine (Rhee, D., 1984a).
During the Korean war, Korean Army psychiatrists and American
military psychiatrists joined to train division psychiatrists in the Korean
Army. In 1953 Rhee, D., (1984a) treated a case of psychogenic headache
successfully, without any supervision.

Enthusiasm for dynamic psychiatry and psychoanalysis lasted until

between 1966 to 1969, when many of American-trained psychiatrists started
to find it difficult

to practice psychotherapy in Korean. The cause of

difficulties were enumerated; The financial capacity of Korean patients,

Korean culture and personality were blamed. Korean patients were too
authoritarian, poor in emotional expression and less psychologically minded
than American or Japanese patients.
One American-trained educational counseling professor proposed to
import western counseling philosophy in 1967 at the annual meeting of the
Korean counselors association because he thought there was no such thing in
Korean culture. One professor of psychiatry complained that Korean patients
do not have transference because of the authoritarian character of Korean
culture and personality.
Professor Rhee, D., answered these questions in a paper The
philosophical Ground Laying of Counseling and Psychotherapy in Korea in
1968 and in another subsequent paper Research on Psychotherapy of
Korean Patients in 1970. It was pointed out that Korean therapists difficulty
in treating Korean patients should be attributed to the Korean therapists
themselves rather than Korean patients or culture and personality of Koreans.
Furthermore, Prof. Rhee showed that Korean traditional medicine is based
upon the Tao which is the ultimate form of Psychotherapy and philosophy of
During this period from 1956 to 1970, Prof. Rhee, with his penetrating
insight, superb knowledge and exceptional experiences stated that the
problems encountered in psychotherapy were due to the prevailing cultural
element of defeatism. Also the problems resulted from an incomplete
understanding and digestion of Western psychoanalysis and from the neurotic
phenomenon that culture. Therefore, it was due to the projection of the
terapists own problems into Korean culture and patients. His relentless effort
to delineate these underlying problems seemed to have resolved these issues.

As regards psychotherapy training, one characteristic could be noted

that Seoul Psychoanalytic Study Group with Freudian Orientation, and
Korean Society for Analytic Psychology tend to adhere to their schools
international standards, while Korean Academy of Psychotherapists is under
developmental process of their unique programs integrating the essence of
western psychoanalysis/ psychotherapy and the Eastern Tao.
4. Prof. Rhees Tao Psychotherapy
Prof. Rhee (1984a) repeatedly urged the Korean therapists to study and
understand Korean culture and personality without preconception. The
humanistic, natural communicative character of Korean culture and
personality was pointed out. He also explained that the Tao actually means
self examination, self understanding, self control, self discipline and
purification of oneself. In other words, the Tao means liberation from neurotic
conflict, maturity or mental health. It is also relationship, communication,
harmony, integration. It is reality, perception and practice rather than concept,
conception and theory. It is also commitment, the spirit of Bodhisattva.
It his book, The Subjectivity of Korean and the Tao, Prof. Rhee
(1980), pointed out that the nucleus of Korean culture is the Tao of
Confucianism, Buddhism and Lao-tzu, Chuang-tzu, wit its psychotherapeutic
implication. For example the founding ideology of the nation of Tan-gun
Chosun (old Korea) 5000 years ago was maximum benefit of people and
that of Goguryo (also the name of old Korea) in 37 b.c. was ruling by the
Tao, eternal well-being all over the world.
In 1986, Prof. Rhee maintains that the modern significance of the Tao is
remedy for the neurotic western culture. Since Plato, western civilization
sought to reach the truth by means of intellectual pursuits and they did not
practice catharsis. According to Prof. Rhee (2005), the essence of Tao
psychotherapy is to bring spring to the patient who is shivering in a frozen
land. To achieve this, the therapist must purify his mind. This is non-doing

(wu-wei) of Laotzu, emptying mind (sunyata) of Buddhism, no projection

(counter transference) of psychoanalysis.
Prof. Rhee continues, Tao psychotherapy is the fusion of Tao with
western psichoanalysis and psychotherapies (Daseinsanalysis, existential
analysis, client-centered therapy, transpersonal psychotherapy and spiritual
theological psychotherapy). These Western psychotherapies are the result of
the influence of the Tao and they are healing to wards Tao.
Nuclear feelings, purification of mind (elimination of nuclear feelings)
and compassion (empathy) are 3 key words of Tao psychotherapy.
Prof. Rhee (1970) founds the parallels among nuclear felling and
meaning of the ox in the Tan ox-herding pictures and the something stuck in
your chest described by Tahui, the great Suhn master of song Dynasti in
China 12th century. While the central issues, nuclear dynamic, major
motivation, and nuclear emotional constellation described by western
therapists are objective description, Prof. Rhees term, nuclear felling is
subjectively felt emotion.
Curative factors in psychotherapy are personality of the therapist,
concern, love (Freud), therapeutic Eros (Seguin), desire to help (J. Frank),
change by feeling, Sorge (care) of Heidegger and empathy. All these converge
on compassion. Rhee, D., 2005) therefore, in the book of Wun-Hyos
Commentary on the Awakening of Faith [Mahayana-Sraddohotpad Shatra]
(translat. By Eun J.H., 2003), The future Bodhisattva during his training and
practice, in some cases he becomes a parent, a relative or a family member [to
the client he wants to salvate] in another case he serves as a servant, in the
still other cases he becomes a friend, or even a foe, to save them with the
limitless compassion.
While Kohut (1984) expressed his limitation of empathy to severely
disturbed (borderline state and psychosis) because he should deal with
prepsychological chaos, Prof. Rhee had different idea and experiences that

in Taopsychotherapy, one can empathized not only with psychotics but also
with everything in the world as evidenced by the Chinese character for Sage.
Lastly, we have many reactions of western psychotherapists, to the
audio-visual- demonstrations of Prof. Rhees therapy. C. Brenner (1994)
wrote me, he is very quick to the essential issue of the schizophrenic
patient. G. Taylor (1997), remarked, Prof. Rhee asks patients feeling, what
were your feelings (not, what did you think about it). there is also
laughter between the patient and the therapist. Prof. Rhee employs a
number of techniques and intervention which seem, from a western
perspective, to be based on an integration of cognitive-behavioral therapy,
learning theory, and psychodynamic understanding,
G. Rodin (1997) remarked, overall, the clinical material demonstrates
a seamless interview., this in an excellent example of what might be termed
sustained empathic inquiry. Etc. some patients who had therapy experiences
with Prof. Rhee would tell, Dr. Rhee does neither want to give (any), nor not
to give. He also neither take nor not take. other patient expressed, Dr. Rhee,
when I am with you, if you do not say a word, I am good.
It is very remarkable when Prof. Rhee says, my question to patient is
not for what I want to know. I let them to say what they want to say.and he
predicts in the future the word interpretation will disappear. Only directly
pointing at the human mind/heart, with live word will be mutatively
effective for the patient.
5. Conclusion
In this paper, the author had an anecdotal, sketchy overview on the
assimilation of western psychotherapy and psychoanalysis in some Asian
countries, with an emphasis on practice and experience.

Its seems that in Asia countries, the western psychotherapy did not take
firm roots in their cultural soil up until 1970s or1980s. of this phenomenon,
this aouthor thinks, we need futher study and discussion.
Finally, the Tao Psychotherapy of Prof. Rhee is beyond concepts so that
we should have similar experiences of him self in the realm of Tao practice
and psychotherapy. Only then, we will fully understand what he advocates in
the Tao Psychotherapy.

The Assimilation of Current Western Psychotherapeutic Practice in

Sylvia D. Elvira
Department of Psychiatry faculty of Medicine University of Indonesia / Dr.
Cipto Mangunkusumo National General Hospital, Jakarta Indonesia
As individuals, psychiatrists, psychotherapists, counselors are members of an
emergent profession evolving historically from the traditional disciplines of
medicine, psychology, education and social service. The members of this
emergent profession generally organize themselves, across disciplinary lines, in
term of their theoretical orientations, seeking like-minded groups of colleagues
whether in orthodox schools or societies of eclectic practitioners. These
theoretical orientations are essentially subcultures within the broader professional
community. But psychiatrists, especially who are also psychotherapists, viewed as
individuals, who are also many other things, prominent among which is being
natives of the particular country where they were born and raised, and a
representative of is culture.
Conceptions of the good helping relationship are generally implicit in the
culture of every country. It also form an important part of the psychiatrist and
psychotherapists professional orientation, where they are usually explicitiy
defined by clinical theory. For instance, therapists of psychodynamic or
psychoanalytic orientation will tend to see the helping relationship as requiring
great personal reserve of them, therefore their patiens association and
transferences can develop frealy. On the other hand, humanistic oriented therapist
emphasize genuine personal involvement with the patient as an important quality
of the helping relationship, while cognitive-behavioral therapists tend to take a
more active and directive part in the helping process.

When examining therapists of various theoretical orientations in different

countries, it would involve the interactions between the culture of the country and
the professional subculture represented by the therapists theoretical orientation.
With respect to the theme of listening to the heart of the east, it would be
interesting to discuss how therapists in western countries in doing their
psychotherapeutic practice.
Two sets of psychotherapeutic assumptions
The Asian psychotherapist is aware of the conflict between two sets of
psychotherapeutic assumptions. The western assumption stemming from an
individualist model of man and crucial in the formation of the therapists
professional identity are epitomize in classical psychoanalysis. The other sets of
assumption, which the Asian therapist has absorbed from his culture from early
childhood, stresses that surrender to powers greater than the self is better than
individual effort that the source of human strength lies in a unselfconsciously, of
the communitys life in cherishing the communitys gods and traditions.
How do these differences in the two models of man and theoretical orientation
or professional subculture interact with the apparently more pervasive influence of
national cultures on therapeutic relationship ?fortunately for the Asian
psychotherapist and his patients, the conflict between the two models of man is
not ii practice a simple dichotomy. Both visions of human experience are
expense of the other. Relational values, witch were submerged during the 19th and
first half of 20th century in the west, now increasingly inform many modes of
western psychotherapy. Equally individualism has not been completely absent
from the history of Asian societies.
All western therapies talk, in some fashion or other, about the growth,
development, and actualization of the individual. They talk of increasing the
individuals environmental mastery, positive attitude toward him self, and his
sense of autonomy. Psychological individuality, is Recognition that one is
possessed of a mind in all its complexity. It is the acknowledgment, however

vague, unwilling or conflicted, of a subjectivity that fates one to episodic suffering

through some of its ideas and feelings, simultaneously with the knowledge, at
some level of awareness, that the mind can help in containing and processing
disturbed thoughts.
By contrast, in Asian countries, for example in India, Chinese and Japan, the
patients have in their minds what might be called a relational model of the self.
The person derives hi nature of character interpersonally. He is constituted of
relationships. His distresses are disorders of relationship not only within his
human, but also his natural and cosmic orders. The need for attachment,
connection, and integration with others and with his natural and supernatural
world represents the pre-eminent motivational trust of the person, rather than the
press or expression of any biological individuality.
In Indonesia, the situation is more relatively complex because there are so
many different cultures (as there are thousands of ethnics) which affecting the
patients and therapists daily life. Beside culture, religion are also influence their
daily activities, the communitys life and in valuing the communitys traditions.
Furthermore, its often happens that the therapist culture and religion is different
with the patients culture and religion; therefore as therapists, psychiatrists and
psychologists, have to study at the least consider the cultural background and
the religion of their patients in order to have the capacity for empathy with their
Other factors influencing the psychotherapeutic approach
To understand the differences between therapists in different countries is to
view those differences in the context of other factors that influence therapists
description of their relationships. These factors include the therapists professional
background, experience level, and the theoretical orientation. In Indonesia, like in
many other countries, psychotherapy is done by psychotherapist and psychologist.
The theoretical orientations of the psychiatrists and psychologist, are in variety of






cognitive-behavioral and some are mentioned themselves as being spiritual or

religious therapists.
Eunsun et al had done an international study on evaluation of the
psychotherapeutics relationship in six different countries (Korea, Belgium,
France, Germany, Israel and USA). Their study focused on the cultural influences
shaping therapists experiences of the therapeutic relationship with their patients.
According to their study, for the professional background, there was no significant
differences in relational style between medically trained and psychologically
trained psychotherapists. Unfortunately, we havent had any study for proving this
evidence in Indonesia. They also found that the therapists level of experience had
an influence on style of relating with respect to being warmly involved, and on the
other hand, with respect to being formal with patients (they categorized the
psychotherapists style in relating to patients as five category; warmly involved,
care-taking, active-directive, critical demanding and formal).
The culture in psychotherapeutic approach
The conflicting demands of Asian culture and of western psychotherapy,
however, are not always so easy to reconcile. The reconciliation becomes much
more difficult if the therapist and the patient do not share fundamental cultural
assumptions about human nature, human experience and the fulfilled human life.
The Asian therapist has absorbed from early childhood, stresses that surrender
to powers greater than the self is better than individual effort that source of human
strength lies in harmonious integration with ones group, in entering into the
living stream, naturally and unselfconsciously, of the communitys life and in
cherishing the communitys gods and traditions.
In Indonesia, although the people consist of so many ethnics, fortunately,
people are inherited and born of almost the same ancestral. The ancestral of most
Indonesian people who lived thousands years ago were animist. The cultural that
constructed by the ancestral were affecting peoples daily life and activities.

Next thousands years after that era, most Indonesian people were deeply
complied with what was mentioned in their belief system which was from Hindu
and Buddha in their personal and the communitys life and in valuing the
communitys traditions. The tendency to look at a person in transpersonal or
relational terms in reflected in all aspects of the culture. But some of them in east
Indonesia, such as Maluku, Papua, Celebes, and also in Java, are Christians. The
cultural which inherited from their ancestral were mixed with what they belief in
those religions, therefore, for instance, the Hindu in Bali, is different from Hindu
in India, for the reason that is also affected by the culture beside its rules and
pattern in the religion.
After Islam entering Indonesia (It was around the year of 1500), people
thoughts, behavior and activities were affected by Moslem belief. It transpired in
around 90% of Indonesian people. The cultural standard of moral and ethnics had
not been totally changed, except their belief system that the communitys gods
that previously plural, then it becoming single; they only believed in one God. A
Muslim is one who resigns himself to God and thereby professes the faith of alIslam. In order to be a true Muslim there things are necessary: faith, action
according to that faith and the realization of ones relation to God as result of
action and obedience. Most of that Moslem people than seemed to obey and
follow the rules. The communitys traditions afterward were gradually following
the belief system too, although it seemed that it had not totally changed, but it
becoming mixed with the previous one.
According to this condition, some of psychotherapists, specifically
psychiatrists, were tend to blend their approaches dealing with their patients,
between what they have learned from training which based on Western theories
with what they face and experiences in the field with their eastern patient. For
instance, with depressed patient, theories mentioned that we usually do not allow
to give advice or reassurance if the patient is still in his or her rage or very
depressed condition; but in fact, the patient usually asked the therapist to give
advices, because according to what they have been raised by culture and religion,

that surrender to the powers or the all mighty is greater than the self, and it is
better than individual effort. To response to this situation, many of therapists were
not able to stick on the psychotherapeutic principles, and they afterwards give
their advices. Fortunately, the patient responded well, he or she then seemed to be
in a better condition than before.
The current situation in Indonesia
In doing psychotherapy in our area, as well as in other country, is necessary to
consider the cultural standard of moral and ethics and social role of the patient.
As the amount of psychiatrists are too few compare to the total population, the
helping action towards mentally unstable and disturbed persons had been done
also by psychologist, counselors (who mostly have based training on educations),
udstadz (Islamic teacher who give lessons in guiding Islamic principles in life and
also teaching in reading Quran), priests (for Christians, Buddha, Khong Hu Chu,
and Hindu), and paranormals (who usually named as dukun or orang pinter).
Fortunately among those professions there looked as if not any conflict happened,
as if each of them had known their position, portion, and responsibilities. The
psychiatrics, Psychologist and counselors doing their job based on their so-called
Westernized knowledge and skill, where udstadz and priest worked based on rules
written and mentioned in the religion, on the other hand, paranormals do their
work based on traditional cultural belief systems which inherited form the
As trained in Westernized resources and medical sciences, psychiatrics in
Indonesia are in a dilemma, because beside bond to the technical principles of the
psychotherapeutic approaches, they also have to adjust the mind, thoughts,
perception to those in the patients, which affected also by the cultural and religion
belief system. They are not only have the virtue of not questioning that because
the patients are usually basically want to ask advice, but they themselves as
therapists also have to distancing themselves from what they have been given and
raised as Eastern persons. Therefore in practice, they have difficulties applying

therapeutics techniques in their training on that eastern patient population. There

are differences in patient response to their techniques. Therapists are often left to
their own devices to build therapeutic rapport with their patient and resort to a
paternalistic kind of counseling (i.e. the Experimentally Supported Therapy) often
with a religious tinge, or outright religious or else resort or pharmacotherapy,
perhaps with some non specific reassurance gestures. As the consequences it built
resistances in psychotherapy, both in patients, and also in the therapists. Some of
them are aware of these resistances, but on the other hand the others are not.
Fortunately, again, the patient achieved better condition after therapy. This
possibly because of the good Therapeutic alliance in doctor-patient relationships,
and could also be the transference cured condition, beside the effect of
pharmacologic agents that often have been given too.
Assimilation of Western psychotherapeutic practice in Indonesia is not an easy
work, because of several factors that influences the condition, such as different
principles and approach between Westernized psychotherapeutic principles and
the Eastern approach which based on culture and religion belief system, also the
Indonesian therapists themselves as Easter person that had to adjust to what they
have trained.
As trained in Western resources and medical sciences, psychiatrists in
Indonesia are in dilemma in applying therapeutic techniques in their training on an
eastern patient population, because beside bond to the technical principles of the
psychotherapeutic approaches, they also have to adjust the mind, thoughts,
perception to those in the patients, which affected also by the cultural and religion
belief system. They are not only have the virtue of not questioning that because
the patients are usually basically want to ask advice, but they themselves as
therapists also have to distancing themselves from what they have been given and
raised as Eastern persons. Therefore in practice, they often left to their own
devices to build therapeutic rapport with their patient and resort to a paternalistic

kind of counseling often with a religious tinge, or outright religious or else resort
or pharmacotherapy, perhaps with some non specific reassurance gestures. As the
consequences it built resistances in psychotherapy, both in patients, and also in the
therapists. Fortunately, the patient changed to a better condition after therapy, its
possibly because of the good therapeutic alliance, and could also be the
transference cured condition, beside the effect of pharmacologic agents as well.

Assimilation of Current Western Psychotherapy Practice in Asia

T. Maniam
University Kebangsaan Malaysia, Kuala Lumpur
Psychotherapy in its many form seeks changes in the individual. Whether it is
psychoanalytically oriented therapy with the objective of giving insight into
unconscious conflict, or behavioral therapy seeking to modify behavior or
cognitions trying to inculcate different ways of thinking, they, to a greater or
lesser extent seek to produce significant changes in the person. Each of these areas
carries profound meaning for personhood. Physiotherapeutic intervention, more
then any other form of intervention, touches the person in deep ways involving
sense of self-understanding, self-esteem, self-fulfillment, goals and values. Many
factor interact in producing changes in patients are not inert objects upon whom
techniques are administered (or) dependent variables upon whom
independent variables operate. (1) They are active agents seeking change in
ways that are consonant with their worldview.
In this paper I would like to discuss there areas that I believe are of particular
interest to the Asian practitioner.

The philosophical assumptions of western psychotherapies

The concept of therapeutic boundaries as appllied in western


psychotherapeutic practice
The need for a distinctively Asian psychotherapy

Much of what I have to say would touch on the ethics of therapheutic practice
as well. This is unavoidable as the reader would appreciate. I would like to begin
with a note of caution when we talk of diverse cultural and religious groups.
There is a tendency to lump a people who belong to a subgroup together as if
they are homogenous. This often arises because we tend to at the modal
characteristics of the group, that is, when we take a summary statistic (the
average value for that group) of a particular variable (2). This ignores individual
variability and gives rise to stereotyping ( all Asians, or al Westerners, are like
that). The truth is there is considerable variability between individuals belonging

to the same cultural subgroup. This, I have observed, is a particular problem when
the therapist and the patient belong to the same subgroup. In such a situation the
patients expectation of the therapist is not met and the therapeutic relationship
becomes a problem. Conversely a therapist who is very religious may impose his
values and approach on to a patient who is not quite ready for it. There are many
things that divide Asians. Their religious belief is a case in point. Asians who are
Hindus and Buddhist may hold very different approaches to life when compared
to Asian Christians and Muslims. Needless to say, within these groups too, there
are enormous differences. It must also be noted that sometimes the social class
differences between the patient and the therapist could be very significant. It
might even be the case that an upper class Asian might be closer to an upper class
European than to his lower class Asian neighbors. This of course, is not peculiar
to the Asian setting.

Now I shall address some of the philosophical assumptions of Western

psychotherapies and how these may present challenges to the practice of
psychotherapy in the Eastern setting. Our understanding of who and what we are
as persons is to the great extent by our cultural and religious backgrounds. Our
practice of psychotherapy of any modality may bring us into conflict with the
patients own value system.
The assumptions of the major schools of psychotherapy an the West were heavily
influenced by the rise of modernism and humanism since the Renaissance, and
more recently by post modernistic ideas. As modernism abounded in confidence
in the tenets of science to discover and describe reality, its adherents largely
disparaged the spiritual/religious approach to the understanding of man and
consequantly to healing. Philosophical humanism makes man the measures of all
things and belief in God is either considered unnecessary or is actively opposed.
Such attitudes are reflected in the writings of Freud among others. McLemore (3)
says, Some therapist regard therapy/counseling primarily as a means to giving
people new philosophies of life. Cognitive therapist like Ellis Would actively
challenge patients religious belief if, in their opinion, these were considered
unhelpful to patients recovery. Changing peoples philosophy of life changing

their worldview would make deep inroads into how a person develops priorities
in life. If I may use an example from the Cristian perspective, conservative
Cristians would agree that their Faith set three basic priorities the priority of
seeking God, the priority of caring for others an of sharing theirs faith. Other
religious system might have somewhat similar ideas too. This would be, quite
early antithetical to the humanistic approach to life. The Secular Humanist
Manifesto, for example, has religious skepticism as one of its 10 main points.
Therefore a therapeutic approach that seeks to apply western forms of therapy
without an appreciation of the religious/cultural milieu of the patient would not be
in the latters best interest.
Since the late 1950as an early 60s the rises of postmodernism has dented
the influence of modernism somewhat but healing practices continue to be based
largely on the theories of its founders. In contrast religious/spiritual ideas heavily
influence the Eastern way of life and thought. Orthodox Asian religious adherents,
including those of the revealed religions. Take their religious belief very
seriously indeed, so much so their identity and their way of life are to a great
extent inseparable from their religion. An insult to their emphasis on individual
rights and freedom and, perhaps a different postmodern view of truth. [Some of
the so-called civilizational clashes we have seen, over issues of free speech and so
on, are partly do this completely different ways of thinking.]
Western approaches place great emphasis on the individual. I do appreciate
that not all Westerners are individualistic, and it is just as true that there are large
numbers of Easterners who are highly individualistic. The attainment of
individual goals, the idea of becoming independent from ones parents by late
adolescence, and other aspect of personal autonomy are almost sacrosanct for
many western oriented people. Their self-image and self-esteem are often tied to
it. Much of are anathema to the Eastern mind where interdependence is highly
valued. It is not uncommon for community is highly valued. I remember a
western-trained therapist being roundly criticized by colleagues for describing a
Malaysian male patient as being overly dependent on his parents on the grounds
that he was still living with them. The extended family system, however, is not

without problems and there are many couples in my practice who suffer because
of interfering in-laws.
I think long before the rise of postmodernism in the West, some sections of
Eastern society has always, to the certain extent, been post modernistic. The
Eastern mind is more comfortable with contradictions. What the Western trained
person would consider to be mutually contradictory may not necessarily be so the
Easterner. This may partly explain the enormous popularity of many traditional
treatments. It might even be an expression of refusal to face or outright denial of
the real problems. Much of this popularity is due to the closeness of the traditional
healers approach to the worldview of the patient, whereas the Western-trained
therapists approach is seen as somewhat alien. However, let me say at this point
that this Eastern practices are not always helpful. The Asian patient is sometimes
better helped by a ood dose of rational, thesis versus antithesis, type of thinking. A
short case vignette will illustrate this.
A young couple, both university graduates, sought marital therapy because
of frequent disagreements leading to the wife experiencing depression. They
found the task of working out their differences tough-going. In between therapy
sessions they sought the help of a religious-based traditional healer (a bomoh)
who, by rolling an egg on the torso of the wife, divined thet she had been
charmed. She was given holy water to drink and lime juice to bathe in. for the
next three days she felt very well but all her difficulties gradually resurfaced after
that. However they continued to hold firmly to the belief in the validity of the
traditional healers diagnosis, when in actual fact he might have only postponed
their facing the truth about the causes for their frequent disagreements. In that
sense their visit to the bomoh, while heaving a placebo effect, was actually
To help the Asian, one must understand her worldview and take into
account her concerns about God, spirit sin, and forgiveness. Western
psychotherapy might doff its hat in this direction but has, in my experience, little
pace for seriously addressing these concerns. We Asian therapists must seriously
consider this to make therapy more acceptable.


A second areas of interest is the concept of therapeutic boundary. In Western

practice therapeutic

boundaries are more rigidly drawn, no doubt for good

reasons. Boundary violations adversely affect the course of therapy and may harm
patients in very serious ways and may even permanently scar them. So there are
very cogent reasons to be circumspect about therapeutic boundary. But in the East
patients tend to see the doctor/therapist as more than a fee-for-service practitioner.
The therapist, like the traditional healer, is part of the community, and the is seen
as being equally accessible. Her presence is sought at community functions such
as weddings of patients children; her advice is sought on areas outside of the
immediate concerns of therapy. She is plied with gift during festivals, and
declining to receive them is deemed to be insulting. Some patients of course,
might abuse this, and use the friendship of the therapist as a reason to avoid
bringing up difficult issues, or to seek favors that might impinge on the therapists
time ets. So the Asian therapist needs to walk a tight time protecting patients from
harmful boundary violations.
How then shall we protect our patients, maintain reasonable boundaries and
still manage not to appear stand-offish? The therapist must wisely decline to
advice patients on areas that are beyond their expertise, even when such advice is
sought. We must refuse the seduction of the inherent flattery when our advice is
sought on subject far and wide. Patients must be redirected to relevant experts. We
must also anticipate situations that may lead to the crossing of proper boundaries.
There are Ethical Codes in each country. Those who belong to the medical
profession are subject to the Code of Conduct of the profession which is legally
enforceable. In many countries counselor and non-medical psychotherapists have
governing bodies to provide and enforce guidelines. Therapist who work with
government agencies are subject to the rules and regulations of service. We note,
of course, that rules and regulations not with standing, abuse of patients, trust
does take place. I have a patient now who, while staying overseas in a developed
country where the psychiatry is highly regulated, was abused by a senior therapist,

who is a recognized leader in his field

I do not think we need to develop a uniquely Eastern therapy, but any Eastern
therapy approach should incorporate the many valuable contributions of Western

therapy rather than see the latter as inimical to our practice situation. We may
benefit from both the techniques of therapy and the increasingly scientific
approach to testing their efficacy/effectiveness; while we may ignore. Some antireligious bias in them. Some Asian therapists claim to have formulated
specifically Asian therapies. Some of them are based on specific religious beliefs
which do not appeal to followers of other religions. Even Yoga, as widely
practiced as it is, is not acceptable to all religious groups. Furthermore any truly
new system of therapy should provide a comprehensive formulation of human
personality and psychopathology, not merely consisting of a series of techniques. I
do not see this at yet, though I stand to be corrected.
Psychotherapy is a much sought after treatment modality in many Asian countries.
Recently a Malaysian consumer association urged that Malaysia psychiatrists
should provide more therapy for depressed patients rather than prescribe
antidepressants (4). To meet this need we need to make therapy more acceptable,
more in line with the worldview of the patient and make adjustments in the way
we practice.
1. Bergin AE, Garfield SL (1994) Overview, Trends and Future Issues, In:
Bergin AE, Garfield SL (Eds.) Handbook of Psychotherapy and Behavior
Change; 4th edition,
2. Inkeles A, Levinson SJ (1969) National character: The study of modal
personality and social cultural systems. In G. Lindzey & E. Aronson
(Eds.), The Handbook of Social Psychology. Reading, MA; AddisonWesley.
3. McLemore CW (1987) Counseling and Psychotherapy: An Overview. In:
David G Benner (ed.) Psychotherapy in Christian Perspective. Michigan,
Baker Book House.
4. New Straits Times (March 17, 2008) Use only in serious cases. Letter
to the Editor.

The Assimilation of Western Psychotherapeutic Practices in the Phillipines

Alma L. Jimenez
Department of Psychiatry and Behavioral Medicine, College of Medicine
University of the Philippines
My task is to describe the assimilation of Western psychotherapeutic
practices in the Philippines. I have decided to focus on boundary setting in clinical
practice since I believe that this concept embodies Western psychotherapeutic
Following Western psychotherapeutic practices, a therapist has to
conduct session in therapists office which is private. Soundproofed, arranged for
maximum interaction, with accessories that do not betray personal circumstances
of the therapist; within an appointed period of time with clear arrangements for
payment schedules and confidentiality,
In the Philippines, psychotherapy follows this format in private urban
medical centers. But in public rural hospitals, psychiatrists have had to conduct
psychotherapy session in crowded, noisy rooms, unlocked unappointed with n
discussion of fee schedules.
Regardless of setting; urban or rural; private or public; sanitized or
disorderly, Filipino psychiatrists in 7100 islands of the Philippines conduct
psychotherapy with a distinct Filipino flavor. Trained to think in Western
approach, Filipino psychiatrists still feel and behave in the Filipino way. Thus,
boundary setting practices are inconsistently applied. This hodge podge of
techniques; principles, values and meanings conglomerate into psychotherapy,
Filipino style.
My main message is that in the Philippines, western psychotherapeutic
practices, exemplified by boundary setting in clinical practice have been

influenced by cultural forces. Thus, in clinical practice, psychodynamic tenets coexist 2ith Filipino values and have evolved into a distinct perspective.
For next 30 minutes, I will develop this message using the following
1. Pattern of boundary setting in Filipino psychiatrists clinical practice
2. Influence of culture on the application of boundary setting practice
3. Integrating psychotherapy within Filipino culture
Pattern of Boundary Setting in Filipino psychiatrists clinical practice
In 2003, I conducted among 56 Filipino psychiatrists from all over the
Philippines to ascertain the pattern of boundary setting in clinical practice. From
this survey, I gathered that Filipino psychiatrists apply particular boundary setting
practices in their clinics in varying degrees or consistency. Moreover, I learned
that the practices were applied consistently if they jibed with cultural rooms. If
certain practices contradicted cultural factors, then, they were not applied or at
best, inconsistently applied.
1. Particular boundary setting practices are consistently applied. These are:
Giving advance notice of anticipated absences.
Enforcing a time limit to session.
Outlining the benefits, risks and alternatives for proposed treatment
approaches to patients.
No sexual activity with the patient.
2. However, some boundary setting practices are inconsistently applied.
These are:
Non-disclosure of personal problems to patients
Removing all possible sources of personal information from the
Not taking repeated phone calls from patients
Confronting an exploitative patient
No barter of patients service for therapy
3. A number of boundary setting practices are not applied. These are:
No complementary treatment for colleagues, religious, friends and

Refusing gifts from patients

Non-treatment of own relatives and friends

Not testifying as forensic witness for current psychotherapeutic

So you can see that Filipino psychiatrists apply boundary setting in their
clinical practices varying degrees of consistency.
Most of the respondents opinions on boundary setting match the
Western norm. However, their opinion on six practices diverge from the Western
Filipino psychiatrists opinions converged with the Western norms on the
following practices:
1. Not engaging in sexual activity with the patient
2. Outlining the benefits, risks and alternatives for proposed treatment
3. Giving advance notice of anticipated absences and enforcing a time limit
to session
4. Not discussing the patient with his own family and friends
5. Not disclosing their personal problems to patients
6. Not taking repeated phone calls from patients
Filipino psychiatrists opinions diverges from the Western norm on the following

Not bartering patients service for therapy

Removing all possible sources of personal information from the office
Confronting an exploitative patient
Giving complementary service to colleagues, members of the religious

friends and family

5. Not accepting gifts from their patients
6. Testifying as forensic witness for current psychotherapeutic patiens
So you see that Filipino psychiatrists boundary setting practices
converge with the Western norm in same situations, while they diverge from the
Western standard in others.
The Influence of Culture on the Application of Boundary Setting Practices

A review of these two patterns of boundary setting yields some

interesting observation about the role of culture in the application of boundary
setting practices.
Firstly, the practices that are consistently applied jibe with culturally
held values.
Secondly, the practices that contradict culturally held values and mores
are not applied inconsistently so, at best.
Medical Culture
Some practices are applied because they are part of medical culture. For
example, the practices of giving advance notice of anticipated absences and
enforcing a time limit to session are consistently applied. Psychodynamically
speaking, they reinforce the boundary issue of stability whereby these these
behaviors promote a stable and consistent treatment setting analogous to the
holding environment provided by parents in early childhood. However, for most
Filipino clinicians, they are applied because of practical considerations and Good
Clinical Practice.
The same holds true for the practice of outlining the benefits, risks, and
alternatives for proposed treatment approaches to patients. It reinforces the
boundary issue of neutrality and promotes the autonomy of the patient. However,
in clinical practice in the Philippines it is applied because it is a tenet of Good
Clinical Practice
Non-discussion of patients with own family and friends is also
consistently applied. It promotes the boundary issue of confidentiality. In
contemporary psychodynamic psychotherapy, patients alone have the right to
release information about them in the therapeutic relationship. The Filipino
psychiatrists generally adhere to this rule on the basis of professional ethical
standards rather than psychodynamic values.

Not taking repeated phone calls from patients reinforces the boundary
issue on self-protection and self-respect. This principle is necessary to protect
clinicians from abusive patient as well as to model fairness in relationships to the
patient. Filipino psychiatrists appreciate the psychodynamic underpinnings of
these practices. However, it is inconsistently applied because more respondents
put more weight on the impracticality of taking repeated patient phone calls
because these calls are time-consuming.
Abstinence from direct forms of pleasure such as touching or sexuality
in the course of their interactions with the patients is consistently applied. In
psychodynamics, when the therapist has sexual relations with the patient, he
appears to violate the patients trust in him as the parent who is more interested in
his patients health rather than his gratifications. The respondents unanimously
adhere to the boundary practice on sexual abstinence. This psychodynamic
interpretation not with standing, the moral dictum against engaging in sex outside
of marriage may very well have determined this value.
Filipino Culture
Filipino psychiatrists are aware that the function of non-disclosure of
personal problems to patients and removing all possible sources of personal
information from the office reinforce the boundary issue on anonymity to prevent
role reversal and seducing the patient. But they refrain from divulging their
problems or remove all sources of personal information from their offices because
they are wary of the Filipinos culturally determined tendency to personalize
relationships (Jocano, 2001). And because culture is the driving force behind their
behavior, they tend to apply it inconsistently. Because they are

Filipinos, they

also tend personalize relationships. Accordingly, he feels that self-disclosure to the

patient is part part and parcel of relating to his patient in a real context.
The practice that diverge from the Western norm are either inconsistently
applied or not applied for all.

The admonition to confront an exploitative patient merits further

discussion because in clinical, practice in the Philippines, about 25% of the
respondents will not confront a patient who exploits by his lateness in paying.
This divergence from the Western norm bears a distinct Filipino flavor. In the
surveyed literature, (Epstein; Gabbard) practitioners who allow themselves to be
tormented by certain highly demanding patients are interpreted as having an
impaired ability to cope with their own aggressive feelings, resulting in their in
their feeling that it wpuld be sadistic to set limits on their patients. In the Filipino
context, non-confrontational behavior is a cultural norm, termed hiya. Faced with
an exploitative patient, a Filipino psychiatrist will not confront the patient because
doing so would cause the patient to lose face. Between the therapist and the
patient, the result is sama ng loob (hurt feelings) which can strain future relations.
The boundary setting practices of not giving complementary
service to colleagues, religious, friends and relatives for professional services; not
bartering patients service for therapy and not accepting gifts from patients
reinforce the boundary issue of compensation. In the psychodynamic context,
therapists should be paid for services rendered and monetary compensation should
be the Behavior as a result of his own internal attributes, independent of his social
context. Conversely, collectivist cultures view the individuals behavior as
interdependent on the social context.
Thus, it follows that psychotherapy differs in the two cultures
Psychodynamic psychotherapy frame a personal problem as an
individuals failure to come to term with unresolved unconscious issues in the
past. On the other hand, helping traditions and customs in the collectivist cultures
frame personal problems in a social context, mostly in the here and now.
Consequently, the foci for listening differ in the two interventions. In
psychodynamic psychotherapy, one listens to facilitate exploration of unconscious
processes (Ivey,1997) while in traditional collectivist helping interventions, one
listens to facilitate exploration of family and contextual clues that affectthe

persons expression of self. Furthermore, there is greater emphasis on feedback

and self-disclosure to build a more egalitarian relationship. Finally, interpretation
is usually the extent of intervention in psychodynamic psychotherapy whereas in
the collectivist setting, the reframing of a problem in terms of familial or cultural
issues marks the start of interventions directed at the family or social group.
To a large extent, the characteristics of this collective culture have been
articulated in Philippine sociology, anthropology and psychology.
For example, the Filipino concept of self is that of self in relation to the
other. In Filipino psychology, this concept is termed kapwa. This term refers to
the until of the self and others and hinges on recognition of a shared identity.
(Enriquez,1978). agreeableness in the Filipino is a behavioral manifestation of
the cultural emphasis on smooth interpersonal relations, or getting along with
people (Chruch,1985; Guthrie and Bennet). Hiya (Shame), is one of important
norms governing good manners and right conduct (Jocano).
Filipino helping behavior in a collectivist context has been describe by
Decenteceo (1997) and Jocano (1998). In the pagdadala model. Decenteseo
posits that the Filipino is seen to gain meaning mot only from fulfilling
accountability but also from a sense of belonging to a community of co-burden
bearers that in return gives meaning to acts of burden bearing. F. Landa Jocano,
inhis book, Filipino social organization describes providing assistance to the
immediate kinship group as well as the wider kinship sphere as a dominant
postulate operative in Filipino culture.
Thus, it may not be farfetched to think that in the Filipino setting, the
helping relationship may be viewed as an interaction between two persons, keenly
aware of their connection to the society at large. As a result, boundary setting may
not be as sallent to the Filipino helping tradition as in the west. As early as twenty
years ago, Filipino psychologists had pointed out that the goal of privacy is rarely
achived in a Manila survey due to such conditions as the large number of people

per household, small number of rooms, and cultural factors related to privacy
(Church, 1985).
So you see that boundary setting is a set of techniques for an individually
oriented intervention. Is it any wonder that it is inconsistently applied in a

Filipino psychiatrists apply boundary setting in their clinical practice in

varying degrees of consistency.

Filipino psychiatrists boundary setting practices converge with the western
norm in some situations while they diverge from the western standanrd in

Culture, along with psychodynamic consideration strongly influence
boundary setting practices. In situation where the western practice

contradicts Filipino culture, the dictates if culture prevail.

The juxtaposition of boundary setting, a set of techniques for an
individually oriented intervention, in a collectivist culture leads to its
inconsistent application.

Action Steps
The question of the applicability of western concepts in psychotherapy to
Philippine culture has long been playing in the minds of Filipino academics in
psychology. The clamor for the modification of western psychological models to
suit the Filipino culture Church, 1990; Salazar-Clemena, 1998) was sparked bay
Virgilio Enriquez, whose work serve as the foundation of Filipino psychology.
The literature has accounts of indigenous Filipino psychotherapies
(Bulatao, 1999; Jagmis- Socrates, 1998); as well as forms of psychotherapy that
are considered applicable to Filipinos (tanalega, 1998). How ever, the search for
the culturally relevant form of psychotherapy continues.

Tailoring psychotherapy to suit individualist and collectivist cultures has

been proposed but found wanting. Although Oyserman et al have recognized that
the individualist-collectivist construct is helpful in describing particular ways in
which cultures differ systematically, it should not replace the study of culture.
Rather, they proposed a framework for understanding the influence of culture on
psychological phenomena by analyzing construals of social situation. Since these
construals are viewed from the individual to the social to the institutional levels,
the cultural variables are as exclusively individualist or collectivist. Instead, they
are viewed as an integration of both (Oysserman et al, 2002 cited by Della,
I end mw lecture with the thought that culture trumps theory in
psychotherapy. Boundary setting necessarily takes on the colors of the therapeutic
dyads everyday cultural space. In that way, they serve as a backdrop against
which the therapist discerns deviations.
Thus, Filipino psychiatrists face the challenge of promoting culturally
relevant psychotherapy by incorporating the best of the East and the West. This is
a tremendous challenge, given this caricature of Filipino help-seeking behavior
should the Filipino get sick, lie is cured physically with drugs and
medical aid but socio-psycologically with fruits beside him which he may not
even eat. More importantly, he has people: friend and relatives. Even a room in
supposedly modern hospital which says strictly no visitors as you enter proves
to be crowded with people (Enriquez, 1977).
Now try setting boundaries in this situation.