Transcultural Psychotherapy

New perspectives in clinical application

Enver Cesko

Psychotherapie-Wissenschaft 8 (2) 57–61 2018


Abstract: This article will demonstrate the functionality of Positive and Transcultural Psychotherapy in different transcultural environments. The article will present the psychodynamic, humanistic and integrative approaches to situations in which transcultural questions are the point at issue. The article will show how a psychotherapist, though deeply-rooted in the Oriental, Ottoman culture, can merge the knowledge and experience garnered from this Oriental environment with the scientific advances of the occident to resolve these problems. Works from both of these cultural traditions will be cited and illustrated.

Key-Words: transcultural psychotherapy, positive psychotherapy, psychodynamic, humanistic, integrative, globalization, radicalization, balance, culture, values


What actually is transcultural psychotherapy?

I wish to begin with a story that is often used in psychodynamic and humanistic psychotherapy. The story is from book Oriental Stories as a tools in Psychotherapy, The Merchant and the Parrot (Peseschkian, 1986).

The Merchant and the Parrot

An oriental merchant had a parrot. One day, the bird overturned a bottle of oil. The merchant got angry and hit the parrot with a stick on the back of the head. After this incident, the parrot, that had earlier shown great intelligence, could not speak any more. It lost the feather on the skull and soon became bold-headed. One day, when it was sitting on the almirah of its master shop, a bold-headed customer entered the shop. On seeing this customer, the parrot got very excited. Flapping its wings, it jumped here and there, cawed, and then, to the surprise of all those present, started speaking. «Did you also overturn a bottle of oil and get a blow on the head because you also don’t have hair?»(The Persian poet Rumi, narrated by Peseschkian, 1986, epigraph pp. v.).

During the last few decades’ various terms have been used signifying «transcultural» such as: cultural, cross-cultural, multi-cultural, inter-cultural, ethnic, trans-cultural groups, among others. In some contexts, the function, groups dynamics and even the meaning of the interaction under discussion are affected by the viewpoints of the authors presenting them and their choices among these terms. Indeed, these various terms are based upon different meanings which it is important to recognize so that the concepts put forward by the clients and therapists are not minimized.

Transcultural psychotherapy usually refers to building bridges between the values and attitudes which derive from Eastern and Western cultures and which are the subject of the psychotherapy, regardless of the method being used. The reason is that these familiar values, norms or symbols are ready material which can be used to build the therapeutic relationship between the patient or client and the therapist. We accept these values as they stand in order to present the holistic view of humanistic and psychodynamic psychotherapy.

The psychological and psychotherapeutic methods that have arisen in the late nineteenth century in Europe and America have their roots in the Renaissance. They have brought many social and cultural development emphasizing principles of individualism, democracy, radicalism, globalization and so on. The human being struggles with the concepts relating to the self, such as self-identification and self-realization, core concepts in psychology and psychotherapy.

Concepts such as mental health, psychiatric disorders, emotional destabilizations, stress, trauma and other psychological diseases take on the important characteristic of conceptual relativity in a therapeutic relationship in which a client and therapist are of different ethnicities, cultures, races, genders, socio-economic strata and different educational backgrounds. These concepts which arise from different religions, races, colors and cultures bring multicultural and transcultural approaches into the psychotherapy. Grounded in the theories of psychoanalysis, cognitive and behavioral theory and influences by Erickson’s psychosocial theory and Adlerian social analytics, multicultural and transcultural psychotherapy was developed in the 1970s (Lee & Davis, 2000; Ramirez, 1999).

Practitioners of traditional Mexican medicine undertook a qualitative field study to determine the efficacy of ethnotherapeutic treatment practices of «curanderos» in the treatment of mental illness. The study demonstrated that the «curanderotic» treatment practices of using spirituality, altered states of consciousness, and the bifocality of ritual interventions showed significant remissions of some psychiatric disorders including panic, dependency syndrome and schizophrenia (Zacharias, 2006).

From the perspective of religion, mental health problems are seen as spiritual issues and their remediation as spiritual medicine. However, spiritual medicine cannot be separated completely from physical medicine (al-tibb al-jismani) since man is composed of both the soul and the body (Nurdeen & Mansor, 2006).

Ethnotherapeutic aspects known in treatment of mental health problems, is equal with concepts that is known in positive psychotherapy as cross-cultural psychotherapy.

«The goal of such therapy must not be to renounce cul­tural, group, familiar, and personal distinctions. Rather, what seems important is the realization of indivi­dual characteristics as well as cultural uniqueness, when there exist on the other side possibilities for dealing with conflicts that may arise» (Peseschkian, 1980, pp 39).

According to the Psychology Dictionary, transcultural psychotherapy is:

«types of psychodynamic psychotherapy which stress cul­tural awareness and sensitivity, inclusive of socially defined ideals of feelings, psychodynamics, and actions. Within the psychiatric community this terminology is utilized slightly more often in a sense alike to multisocial counseling in clinical psychology» (Nugent, 2009, pp. 425).

Its concept of the unity of mankind provides a holistic acceptance and a better understanding of the meanings among the different values, attitudes, behaviors, thoughts, and concepts.

Many psychodynamic and humanistic psychotherapy approaches, are working in different cultural environments trying to accept and respect their inherent values, norms, behaviors, rules and the treatment process is based on the form of the relationship between client and therapist which emerges with these cultural parameters as framework. In this way we psychotherapists, standing on their different cultural origins, are able to use their own professional experiences, skills and capabilities to approach clients from differing cultural backgrounds and achieve effective treatment. I explain that the focus in the treatment process is not the disease or illness, rather the person as a whole and his/her unique potential. When the therapist emphasizes the patient as a human being full of capacities to be used in the current environment, in the dynamic process of his/her relation with society, and with a belief system as well as a philosophy of life, then the dialogue goes beyond cultural differences and whatever cultural differences may exist between the client and the therapist do not present obstacles to the success of the treatment.


Four Dimension of Transcultural Psychotherapy

Today we are living in environments which are very unpredictable and stressful which do not provide enough safety. Some of us see this as an interesting time in which to live, a time of constant development of science, technology and society, with its extreme materialistic aspirations. A large percentage of people consider themselves as believers who utilize spirituality as an important aspect of their life style. There are often significant differences in the views, concepts, habits and behaviors between clients and therapists about their approaches to deal with problems, difficulties, disorders and diseases. Usually one side does not give enough consideration to the cultural background of the other side.

It is only fair to say that competent treatment must be based on a proper understanding of the patient’s culture – it is impossible to understand the patient correctly without taking into consideration his cultural norms: religious convictions and beliefs, concepts of disease, methods of emotional expression, language, attitudes and social norms (Abu Baker & Dwairy, 2003).

In my psychotherapy practice I use the model of positive psychotherapy and the approach of body psychotherapy. I try to view my clients not as specimens of illnesses but as integrally as whole human beings who have actual capabilities (Peseschkian, 1980). At the time of feeling «sick» they may not be able to raise these capabilities to the levels which they would desire but during the psychotherapeutic process they will work on becoming aware or their own actual capabilities and so solve being «sick».

Therefore, I wish to give some basic information about my model by explaining transcultural psychother­apy.

Positive Psychotherapy is based on a psychodynamic concept with a humanistic conception of man and a transcultural approach. It is a resource-oriented and conflict-centered method where symptoms are viewed as signs of un-solved conflicts derived from the past, usually from the period of childhood. The word «positive» in the context of Positive Psychotherapy is derived from the Latin word «Positum», which means what is factual and given, and allows the therapist to see the client as a whole personality who is able to manage the problems, challenges, disorders and diseases (Peseschkian, 1983). Positive Psychotherapy has an original approach; it uses a set of basic concepts that are phrased in everyday language so that they can be easily understood by different cultures, ethnic groups, and communities, during the therapeutic process in the relationship between therapist and patient. In the transcultural psychotherapy approach, the basic concepts provide a framework for the psychotherapeutic process and can be used to promote communication between different psychotherapeutic models with different cultural entities.

As I am coming from an Eastern, traditional and religious background, having contact, lecturing, presenting and introducing the basic concepts to students or clients, I must respect and accept all existing different cultural norms of western culture.

When I meet a friend from an Eastern culture and he asks: «How are you?», I will disappoint because he is not asking about my family also. This is because, for me, the family is more important then Myself. On the other hand, if I meet a friend from a Western culture and the friend asks: «How are you?», my reaction automatically relict the reply: «Fine, thanks. And you?»

This shows how different cultural values and norms assess different reactions and behaviors of people trying to give importance to different concepts and norms. For one person, how he or she is developing in the career and in the body, physical form will be important (usually for Western cultures), for another person (usually from an Eastern culture) the relationship, contacts and spiritual values will probably be most important. The social changes occur very rapidly in moving from one extreme point to another extreme goal. For this reason, «human consciousness perceives these changes only to a limited degree» (Peseschkian, 1980, pp. 25), that is why people in the society are always in transition from old to new, from east to west, left to right, from high to top, but unfortunately never reach the goal. To keep the balance has been the most stressful engagement during the last twenty years.

«With the increase in world population is spawning other problems: such as food, socioeconomic forces, problems with migrants and refugees, terrorism, nuclear states, etc. These problems of modern urban life are particularly aggravated by the never-before equaled numbers of refugees and migrants on the move toward better lives in cultures different from their own. All this brings new influences upon the division of labor where mankind is moving from differentiation to specialization where the roles are in constant flux. This can be most readily seen in cultures which are still undergoing political and socioeconomic transitions in their quests to attain their true identities. Additionally, many families are experiencing global changes by trying to find new identities by loosening their original family structures. Finally, as: ‹as result of these changes rather than developments, national, ethnic, and cultural groups are beginning to open up to the outside world, i. e., to outside groups. A trend of this kind is accompanied by new possibilities, new transcultural problems›» (Peseschkian, 1980, pp. 36f.).

So, in general, transcultural psychotherapy must deal with two questions, which are important for the maintenance of the harmonious connection between different cultures. One is, what do all people have in common, and second, by what do they differ? This can be better understood if the human beings are aware of and able to accept the similarities where they can meet but not the differences where they are far from each other. Their traditional worlds clash because of their different contents and goal projections and the question always arises as to how well these traditional worlds can harmonize with the new conditions in which the people now find themselves (Peseschkian, 2005).

As one of its tools, positive psychotherapy uses oriental stories. They offer transcultural perspectives in the form of proverbs, myths and fables in which the patient may recognize himself in allegorical terms and thus be able to establish a new form of self-confidence and security. Stories, bits of wisdom and transcultural examples from other cultures are used as respectful mediators between therapist and patient. They encourage using fantasy in conflict resolution, and provide a mnemonic aid for future situations (Peseschkian, 1988). For example: an oriental who comes home relaxes right in the center of noise and chatter of all his family members and neighbors; whereas a westerner rather seeks to relax alone and in a quiet environment.

Psychotherapeutic treatment must be chosen on the basis of the client’s cultural background in order to be able to help the patient with cultural adjustments. Modern psychotherapist’s who are experienced in working with mixed ethnicity and with different cultural backgrounds are necessary for culturally competent psychotherapy. The modern psychotherapist’s needs to develop special qualities such as cultural sensitivity, cultural knowledge, cultural empathy and cultural insight. (Tseng & Streltzer, 2001).


From radicalism to globalism in psychotherapy

Individual life styles and acting patterns in daily life, with their component concepts, habits, behaviors and achievements produce a lot of conflicts, often because of extreme forms of orientation that stem from individual capabilities. If the primary and secondary capabilities are not in harmony, the human being is giving all his attention to only one of these capabilities (work, religion, a familial attachment etc.) and ignoring others, this produces misunderstandings, clashes of ideology, radical decisions, enforced tensions, conflicts, violence, terrorism and war. The peace in the world is shaking and mankind is out of balance with its own self in the workplace, in relationship with society, community, and family, and we worry about the future because of different philosophies of life.

«The ability to achieve (ability to recognize; secondary capabilities) and the ability to be emotional (ability to love; primary capabilities) do not exclude each other, but compliment each other. We can thus conceive of a utopia with social conditions where a person can develop all his capabilities into a harmonious relationship» (Peseschkian, 1980, pp. 109).

Therefor, the transcultural approach is like «a red thread» in the psychotherapy process, «because the transcultural aspect also offers material to understand the individual conflicts» (Peseschkian, 2005, pp. 102), between client and society and with all other significant relationships in life. Above all, this aspect possesses and extraordinary social meaning which we see reflected in problems of immigrants, development aids, difficulties which arise in the environment with members of other cultural systems, problems of transcultural partnerships, prejudices and the abilities to overcome them and with alternative models which originate from other cultures. In this context political topics which result from transcultural situations can also be put on the table (Peseschkian, 2005).


Not for the end – but how to start

The concept of transcultural psychotherapy is challenging and not easy to apply in therapeutic settings because of the complexity of understanding the growth and development of both client and therapist. For this reason, many psychotherapists are not aware of the mistakes and problems that might occur in transcultural psychotherapy. Broude Leonid (2011), in his article «Psychotherapeutic Setting in Non-Western (Arabic) Culture», collected very important research from different authors who explain typical mistakes and difficulties in transcultural psychotherapy:

1. The psychotherapist’s mistakes in understanding the behavior of a patient in a situation where the therapist is not familiar with the cultural characteristics being discussed. The therapist misunderstands the cultural codes of behavior and thus evaluates them as personal properties of the individual or of resistance («pathologising» of cultural features) or – conversely – «overculturization» of real psychological problems.

2. The patient’s mistakes in understanding the behavior of a psychotherapist. Emotional neutrality, avoiding direct intervention in the patient’s life and reluctance to give specific advice to the patient is understood as indifference, coldness and unwillingness to help. The requirement to adhere to time limits and to pay on time is perceived as a lack of interest, greed, and – again – unwillingness to help.

3. Difficulties with the intention of the treatment: The main instrument (and the intermediate goal) of dynamic psychotherapy is understanding the unconscious impulses and behavioral correction. Eastern society punishes the expression of sexual desires (e. g., a married woman’s awareness of her affection for another man), or anger at parents – an awareness of these unconscious desires is unlikely to lead the patient to happiness. Moreover, the awareness of internal conflicts and their enactment usually does not resolve the conflict and could complicate them even more (Broude, 2011).


What can be done then to prevent typical mistakes and problems? From my personal experience of working in different countries with clients from different cultures, I have learned how to build trustful relationships between the client and the therapist. Every psychotherapist must consider four aspects of this relationship in order to avoid these mistakes.

The first aspect is the acceptance of the whole personality of the client, regardless of gender orientation, race, nationality, sex, believes and traditional values. This aspect includes how the personality structure was growth and developed from the early child till adult period.

The second aspect is the acceptance of the contents that the client brings to the session. Discussions of sensitive subjects during the session often disorientate the process of treatment by their strong impact on one or another side. The maturity and professional growth of the therapist is very important to prevent disorientation of the treatment process, so that it does not become stuck or the psychotherapeutic alliance is not damaged. Transference and counter-transference very often occur with this type of content and can consciously or subconsciously become one of the problems that disorientate the therapeutic alliance.

The third aspect is the client’s perspective and the therapist’s interpretation of the social and family structure. Family background developed from different ideological believe concepts (traditionalism, patriarchies, contemporary, rural, or urban, new style of living etc.) may influence the existing and already rigid concepts held by the therapist and this might stress the doubts of the successful result of the treatment process. Sometimes the therapists are not aware of their being «blind» in their actual rigid concepts as a consequence of strongly-rooted influences of social and family environment.

The last, fourth aspect is the humanistic concept of mankind. In order to understand and follow the believe systems, philosophies of life, different concepts in society and in family system, therapist must understand the patient’s view of the world and his/her place in the cultural continuum. This means that the therapist must develop, correct and improve his own quality of psychological care without overestimated any unconscious prejudices by constantly searching for any possible mistakes.



The influence of culture on psychotherapy is primarily understood from practical and theoretical perspectives which are determined by the differences in cultural background which may exist between client and therapist. In the psychotherapeutic process the role of psychotherapist is to be aware of existing differences between client and therapist: «when there is a need to help the patient evaluate the meaning of life, the implications of solving problems in life, and the direction the patient undertakes in life» (Tseng & Streltzer, 2001, pp. 34).

Today more and more psychotherapists consider themselves «open-minded» and apply eclectic approaches to therapy that will best fit the patient’s cultural background, values, concepts and personality. The language differences very often present obstacles in the therapeutic process. Additionally, religious beliefs can be a key to the reason for the breakdown of communication in the Ethnopsychotherapy relationship where psychological intervention and the necessity for cultural knowledge and dialog are very important for the successful treatment (White, 1999). Some therapists who are working within a larger society are applying an eclectic approach to some clients, taking into consideration that every client has his/her own unique culture. Also, some therapists apply specific methods and principles within different minority backgrounds (Aponte et al., 1995), different social classes (Foster et al., 1996), different sexual orientations (Greene, 1997), or with physical handicaps. Such patients may be so different from the therapist in their life experiences and views of the world that empathy across this barrier of «difference» is needed (Tseng & Streltzer, 2001).

Transcultural psychotherapy also becomes an integrative and holistic approach when the crises, problems and many difficulties become matters of interest not only to psychotherapists but also to the individuals in society, politicians in government, and religious leaders, who must unite to deal with these subjects by finding the common ideas with which to solve the problem. To quote a saying of a wise man: «small actions change the world, if you are not patient with small things, you cannot do big things (Peseschkian, 2005, p. 18).



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The Author

Mr. Sci. Enver Cesko, Licensed Clinical Psychologist and certified body psychotherapist and positive transcultural psychotherapist, international trainer and supervisor. President and founder of the Kosovo Association for Psychotherapy. He is a Board Member of European Association for Psychotherapy (EAP); a Board Member of World Association of Positive Psychotherapy (WAPP); a Board Member of World Council of Psychotherapy (ECP); a Council Member of the European Association for Body Psychotherapy (EABP); and a holder of the ECP, WCP and is also an accredited therapist from Mind-Body Medicine, Washington DC. He used to be a former university lecturer, currently he is working in his own private practice in Pristina, Kosovo, and conducting international training workshops on positive and body psychotherapy, as well as coaching, stress management, leadership and team building. He presented his workshops and lectures, in more than 20 World and European Congresses for psychotherapy. He published more than 150 different kind articles in professional and weekly journals.



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