Clinical Social Work Journal

Vol. 29, No. 1, Spring 2001

A RE-CONCEPTUALIZATION OF THE WORKING
ALLIANCE IN CROSS-CULTURAL PRACTICE WITH
NON-WESTERN CLIENTS: INTEGRATING
RELATIONAL PERSPECTIVES AND
MULTICULTURAL THEORIES
Shoshana Shonfeld-Ringel, L.I.C.S.W.
The working alliance has been found to be an important aspect of
clinical treatment and an early and effective indicator of treatment out-
comes (Horvath, 1994; Horvath & Luborsky, 1993; Kokotovic & Tracey,
1990). The working alliance has also been found to demonstrate the inter-
active, relational aspect of the therapeutic process where both client and
therapists personal and cultural characteristics come into play (Bordin,
1979; Mallinckrodt, 1991; Safran & Muran, 1996). However, there seems
to be very little research on the effect of culture on the working alliance
and this particular area of study warrants further exploration. An addi-
53 2001 Human Sciences Press, Inc.
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CLINICAL SOCIAL WORK JOURNAL
tional area of inquiry may be how to understand universal developmental
processes through the lens of local (or relativist) cultural realities, a ques-
tion that could be investigated by focusing on the ways these develop-
mental issues play out in the working alliance with ethnically diverse
clients.
During the past decade, conceptual papers that address the relational,
collaborative aspects of the therapeutic relationship (formerly viewed as
the working alliance) such as mutuality, the therapists subjectivity, and
the dynamics of power and authority have been published by several
relational and intersubjective theorists (Aron, 1996; Mitchell, 1997; Renik,
1996; Hoffman, 1996). These relational dynamics between the client and
the therapist in the working alliance, and their application to cross-cul-
tural framework, is elaborated in the following sections.
COMPONENTS OF THE WORKING ALLIANCE
AND CROSS-CULTURAL IMPLICATIONS
Based on relational theories, the multicultural literature, and current
research findings, the following components illustrate the collaborative,
mutual aspects of the working alliance as well as areas of potential differ-
ences between client and therapist that seem particularly significant in
a cross-cultural treatment relationship. These domains are empathy, mu-
tuality, the dynamics of power and authority, and the use of self and
verbal and non-verbal communication patterns.
Empathy
Animportant aspect of the working alliance that has beenemphasized
is empathy (Ham, 1993; Meissner, 1996). Some research studies found
that the clients perceptionof the therapists empathy and trustworthiness
is an important predictor of a good working alliance and of positive treat-
ment outcomes (Satterfield &Lyddon, 1995). Others found that the thera-
pists perceived personality and empathy are more important than their
clinical experience as a predictor of a strong working alliance (Dunkle &
Friedlander, 1996). Meissner (1996) emphasizes the interactive nature of
the empathic connection between therapist and client in the working
alliance that, in his opinion, facilitates the treatment. These studies seem
to confirm the significance of the therapists empathy (or perceived empa-
thy) for the working alliance.
Ham(1993) has exploredempathy as a culturally constructedconcept.
She differentiates between Western and Asian notions of empathy and
defines empathy as the ability to accept and to be open to multiple perspec-
tives of both personal and cultural realities. According to Ham, empathy
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SHOSHANA SHONFELD-RINGEL
in the West is taught as a skill, or seen as a therapeutic process between
client and therapist. However, in Asian culture empathy is part of tradi-
tional philosophical and religious systems (Confucian, Buddhist, and Tao-
ist) and is considered an essential social structure that reinforces neces-
sary harmony. Ham states that empathy is taught to Asian children
through myths and metaphors. She suggests that, like anthropologists,
therapists need to immerse themselves in the cultural-specific literature,
in observation of individuals and in consultation in order to attain inter-
cultural empathy (p. 55). Like Meissner (1996), Ham views empathy as
an interactive concept, wherein the therapists subjective understanding
of the client leads to specific interactions between them (expressive empa-
thy). Roland (1991) adds that empathy in the working alliance with Asian
clients is expressed by the therapists caring and nurturing, the ability
to empathize with the clients affects through non-verbal communication,
and to provide advice. The significance of specifically intercultural empa-
thy in the working alliance is a concept that requires further exploration.
The importance of empathy incross-cultural treatment is indicated by
a study that cited empathy as the sole significant predictor for counselors
credibility with Asian Americans (Akutsu et al., 1990). Aqualitative study
by Bachelor (1995) also demonstrates that relational aspects of the work-
ing alliance like trust, perceived therapists empathy, and attentive listen-
ing have more impact on the working alliance than insight or collaboration
on therapeutic tasks. In her study, Bachelor used sixty-six descriptive
accounts provided by thirty-four clients (all Caucasians) in a university
setting over three phases of treatment (pre-therapy, initial phase, and
later phase). These findings seemto corroborate other quantitative studies
that found the therapists personal characteristics like empathy and trust-
worthiness to be more important than their clinical experience (Dunkle &
Friedlander, 1996) in determining the strength of the working alliance.
Other clinical accounts by psychodynamic therapists also agree that when
clinicians use empathy, establish trust, and provide culture-specific psy-
cho-education, Asian American clients remain longer in treatment and
eventually are willing to engage in deeper relational explorations (Roland,
1991, Tung, 1991, Tang, 1997). In summary, all these studies support the
notion of empathy as an important component of the working alliance in
cross-cultural treatment.
Mutuality
The concept of mutuality has been chosen as a component of the
working alliance because contemporary definitions include a view of the
working alliance as a collaborative, interactive, and dynamic process be-
tween client and therapist (Henry & Strupp, 1994; Horvath, 1994, Hor-
vath & Luborsky, 1993; Kivlighan & Shaughnessy, 1995). The emphasis
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seems to have moved froma more classical viewof the therapist as having
the power and authority to determine therapeutic tasks (interpretations)
and goals, to a reciprocal process that is negotiated between therapist
and client (Bordin, 1979, 1994; Slavin & Pollock, 1996). This conceptual
evolution is illustrated by Aron (1996), who discusses the concept of mutu-
ality inthe working alliance inclassical theory, where the working alliance
can almost be taken for granted (p. 124), and is narrowly defined as a
shared agreement, contract, or pact (p. 124) between patient and thera-
pist. Aron describes the working alliance in the classical tradition as a
mutual process limited to the actual work of analysis and to the therapeu-
tic pact to do the work. According to Aron, in classical theory neurosis,
transference distortions, and pathology belong only to the patient, and
the patients reciprocal caring, healing, and teaching of the analyst are
not included.
Current relational theories emphasize the interdependence of the
real relationship, the working alliance, and the transference, where the
therapists subjectivity and their real characteristics, rather than their
neutral and objective presence, influences the clients ability to change
old internalized patterns of relating and to form new ones (Aron, 1996;
Slavin & Pollock, 1996). For current relational theorists, questions about
the impact of the therapists subjectivity, authenticity, and the mutuality
of the therapeutic relationship become important queries in the therapeu-
tic process and in the working alliance (Aron, 1996; Mitchell, 1997; Renik,
1996). Relational theories provide a broader definition of the notion of
mutuality in the working alliance, where both patient and therapist par-
ticipate and regulate eachother (Slavin, J. &Pollock, 1996). The mutuality
of the treatment and the therapists personal and cultural characteristics
could have important implications in a cross-cultural treatment, where
therapist and client come from different philosophical and cultural para-
digms and therefore have different relational dynamics and communica-
tion styles. Consequently, what each brings to the treatment and howthey
mutually interact with one another would be important for the working
alliance.
The Dynamics of Power and Authority
Several relational and interpersonal theorists (Aron, 1996; Hoffman,
1996; Renik, 1996) have elaborated on the asymmetry of the therapeutic
relationship. These authors point out that although there are aspects of
mutuality to the therapeutic relationship and to the working alliance
(as previously discussed), there is also the inherent asymmetry of the
therapists power and authority of which the client is acutely aware.
Consequently, the therapist can never be a completely neutral presence
(Renik, 1996). The dynamics of power become even more poignant in
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SHOSHANA SHONFELD-RINGEL
cross-cultural treatment, where the therapist typically belongs to the
dominant majority and the client to a minority group. Littlewood (1988)
addresses the politics of the therapeutic encounter (p. 8), and the power
dynamics of the therapeutic relationship, which is an integral aspect of
the cross-cultural treatment relationship andneeds to be acknowledged by
the therapist. Shapiro (1995), who bases her insights on her ethnographic
study with Russian immigrants in New York City, also addresses the
issue of difference and of subjugated knowledge in the working alliance.
Shapiro writes that the working alliance requires a differentiation of self
and other in cultural terms and an active attempt by the therapist to
validate the special cultural identity or subjugated knowledge of the per-
son seeking help (p. 12). Both Shapiro and Littlewood emphasize the
need for the therapist to validate the minority clients knowledge and
expertise within the dominant culture, and in the cross-cultural working
alliance. Consequently, an awareness of the influence of the therapists
power and authority on the treatment process, both politically and psycho-
logically, would be an important variable in the cross-cultural working
alliance.
The dynamics of power and authority, however, can play out in para-
doxical ways in the cross-cultural working alliance with Asian clients.
While the Caucasian social worker may believe in equalizing the relation-
ship with the minority client, and in basing their practice on principles
collaboration, traditional Asian cultures are more hierarchical, and the
therapist is typically viewed as an authority and as an expert (Sue &
Sue, 1990; Uba, 1994). Consequently, the therapists efforts to encourage
clients to be active collaborators in the treatment may actually clash with
their deeply held norms.
The Use of Self
The use of self, or countertransference, has been presented as a com-
ponent of the working alliance by both relational (Aron, 1996) and more
traditional (Schechter, 1992) psychoanalytic theorists. Schechter proposes
that countertransference may be a particularly useful aspect of the work-
ing alliance with clients whose cultures emphasize non-verbal modes of
communication. According to Schechter, countertransference could be
used as an effective therapeutic tool to help the therapist understand
and formulate the clients unarticulated affect states. Shechter proposes
extending the definition of the working alliance to include cultural differ-
ences and countertransferential issues. She believes that this would con-
stitute a richer, more comprehensive definition of the working alliance.
In cross-cultural treatment, the therapists use of self via their counter-
transference associations could be an important tool in understanding
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the subjective world of the client and in forming a viable working alliance
with them.
Aron (1996) views countertransference as an integral aspect of the
working alliance. He states that Countertransference is not an occasional
lapse that intermittently requires investigation and elimination but
rather is a continual and central element of the investigation. The analyst
as a person and his or her shifting affective experience is both a major
component of the analytic method and a primary variable in what is being
investigated (p. 125). Like Schechter, Aron views countertransference,
or the therapists affective experience, as an important therapeutic tool,
as well as a therapeutic object of investigation. Consequently, counter-
transference appears to be an important aspect of the working alliance,
specifically in cross-cultural treatment.
Communication
An important dimension in the cross-cultural working alliance is
both verbal and non-verbal communication, especially when client and
therapist come from cultures with different patterns of communication
and when English is not the clients first language. Non-verbal signals
can have different meaning in Western and non-Western cultures. For
example, the clients silence may mean a hesitation to disagree with the
therapist out of respect for authority and appreciation for harmony, rather
than because of over-compliance (Root, 1998; D. W. Sue, 1990). Clients
may even leave treatment rather than disagree with therapists or express
their anger directly (Root, 1998). It is clear that the therapists under-
standing and knowledge of culturally unique non-verbal communication
should be included in the definition of cultural sensitivity and in the cross-
cultural working alliance.
Another important aspect of the therapeutic relationship, and a po-
tential source of difficulty, is language. Language may become a treatment
issue because for many Asian Americans English is their second language.
Clinical studies suggest that the use of language is animportant communi-
cation tool between bicultural clients and their therapists. Marcos and
Urcuyo (1979) found that bilingual (Spanish speaking) subjects were able
to gain more access to their affect states in their first language, and that
the use of the second language implied separation of affect and experience.
Perez-Foster (1996) examined the dimension of language in the therapeu-
tic relationship with bilingual clients and found that the bilingual self was
organized around respective languages, and that each language evoked
respective relational experiences, so that the native language could trigger
earlier emotional experiences. The therapists inability to communicate
with Asian clients in their native language may impose limitations on
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SHOSHANA SHONFELD-RINGEL
the treatment process and the working alliance and could imply a greater
emphasis on non-verbal communication.
The following vignette will be used to illustrate howthese dimensions
of the working alliance play out in cross-cultural treatment. The names
andidentifying informationof bothclient andtherapist have beenchanged
to protect their confidentiality.
VIGNETTE
Jen was a 19-year-old Taiwanese student who came with her brother to attend
college in the United States. When she came to the university counseling center,
Jen was already a sophomore, experiencing depression and frequent suicidal
ideation. After an initial assessment it became clear that Jens depression was
related to missing her family and to her difficulties in adjusting to the newculture.
Jen was referred for treatment to Donna, an outgoing and loquacious young social
work intern. Initially, Jen sat huddled in her coat, her eyes lowered and saying
very little. She never contradicted her therapist or initiated the conversation and
she always seemed to agree with everything her therapist said, never voicing her
own needs. Donna wasnt sure whether Jen really wanted to come or whether
the treatment was of any use to her. However, Jen continued to come punctually
every week, never missing a session.
Finally, when Donna was about to leave for spring vacation, Jen admitted
after some coaxing that she wanted to schedule an extra session with her. For
Donna, this was a significant turning point in the treatment as Jen had finally
asked for something she wanted. Jen seemed to need more time to formulate and
articulate her thoughts and feelings, perhaps, Donna thought, because of language
constraints or because of her different cultural communication system. Therefore,
Donna realized that although she found it difficult, she had to be very patient
with Jen and to give her lots of space and time (at times spending long periods
of time in silence) so as to allow Jen to formulate and articulate her experience.
She wanted very much to help Jen find her own voice and express her own needs,
and gradually Jen became more comfortable with her therapist and started to
share her difficulties.
Jen felt torn between her own desire to pursue her studies in Taiwan and
her loyalty to her father, who wished her to come to the UnitedStates to accompany
and to care for her brother who chose to study here. Jens dilemma of whether
to follow her own individual wishes and desires or instead to abide by her familial
and cultural mores became the central theme of the treatment. Jens cultural
traditions advocated the importance of familial over individual needs and empha-
sized a model of interdependence and harmony between individual and family.
This viewof self was very different than the independent, outspoken, and competi-
tive personae that Jen noticed all around her among her American peers. Donna,
who strongly believed in feminist values, felt that their therapeutic task was to
help Jen find her own voice, learn to stand up for herself and become more
independent. For example, she encouraged Jen to express her resentment and
frustration at her fathers controlling attitude and at her American friends lack
of consideration for her.
As their relationship deepened Jen started to share her feelings of alienation
and estrangement in the American culture, her difficulties in adjusting, and her
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experience of difference because of her Asian features and her foreign accent.
Donna experienced a deep sense of empathy and identification with Jen, both as
a Jew, another cultural minority, but especially as a large woman who frequently
felt stared at, marginalized, and out of place. Donna was herself not far off from
her own adolescence and she identified with Jens difficulties in finding her own
sense of identity. While it was clear that Donna had an impact on Jen, Donna
also found herself modulating her outgoing and expressive style to match Jens
quiet and formal behavior. Donna learned to check carefully and re-check with
Jen to find out exactly what she meant, as subtle affective nuances could easily
be lost in the translation.
As the treatment progressed, Donna found herself feeling frustrated and
angry with Jens continuing need for her familys approval, her compliance with
her brothers and friends wishes and especially with Jens difficulty in making
her own decisions. Donna felt that Jen was bending over backward to please her
friends and family. At times, she wanted to shake Jen and to tell her to stand up
for herself and to be more assertive. However, in supervision she started to reflect
onher own countertransference reactions, whichhelped her to beginto understand
the source of her frustration. Eventually, Donna recognized that her reactions
stemmed from conflicting cultural values and expectations between her and Jen,
and that her preference for egalitarianrelationships, autonomy, and independence
was foreign to Jens Taiwanese culture. She started to realize that she needed to
learn to viewJens behavior in a different way. Reflecting on her reactions thereby
allowed Donna to become more open and attentive to their cultural differences.
With time, Jens depression lifted. She started to speak up and to express
her needs with her American college friends. Eventually, she even told her father
that she did not want to continue her studies in the United States and insisted
that she wanted to go back to Taiwan. Jens father refused to speak to her for
weeks, but finally he did call to tell her that she could do whatever she chose.
Yet Jen remained indecisive and suddenly felt that she did not know what she
really wanted. She ultimately decided that she was going to stay in the United
States as she couldnt tolerate disappointing her family. However, for the first
time she realized that she did have an impact and that her voice could be heard.
She started to adjust and began to go out on dates and to enjoy new activities.
During the subsequent sessions, Donna noticed that Jenseemed more comfortable,
taking off her coat, taking up more space, and expressing her feelings more openly.
Donna was pleased that she had helped Jen change her subservient behavior
and develop a new sense of her own identity. At the same time she also recognized
that these changes presented a new dilemma for Jen. Jens new independence
and autonomy were inherently in conflict with her cultural traditions and values
and Donna realized that these new achievements would ultimately result in
serious familial conflicts when Jen returned to Taiwan. She was not sure whether
Jen, despite their hard work together, would be able to maintain her new gains.
DISCUSSION
This vignette illustrates important cultural dimensions that need to
be recognized as integral components of the working alliance in cross-
cultural treatment. One important aspect of the working alliance is the
ability to form an empathic connection with culturally different clients
through the process of associative identification (Schechter, 1992).
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Donna, for example, was able to empathize with Jen through her own
experience of difference and marginalization. The working alliance also
includes a process of mutuality and reciprocity, whereby both therapist
and client impact each other in multiple ways, as well as the mutual
accommodations that they inevitably make for each other over time. In
this vignette, both Jen and Donna clearly accommodated to each others
style of behavior and communication. The underlying dynamics of power
and authority may become a subtle issue in the working alliance with
clients who come from non-Western, hierarchical, and authoritarian cul-
tures. Even when Western therapists advocate a collaborative, egalitarian
model of treatment they may unconsciously use their power to encourage
clients to acculturate and become more Westernized. Donna, for example,
plainly used her position as Jens therapist (perhaps inadvertently) to
encourage her to acculturate to Western standards. This vignette also
suggests that the use of self is an important component of the working
alliance in that it can be utilized to develop a better understanding of
cultural differences and the relational dynamics between therapist and
client. The reflection on countertransference reactions such as anger and
frustration, as shown in Donnas case, can help therapists gain insight
into their own cultural biases. Finally, this vignette also illustrates the
significance of understanding cultural differences in verbal and non-ver-
bal communication systems, for example, the different meaning of silence
in Asian and Western cultures.
There are several other important issues that were raised in this
vignette but due to the limited scope of this paper, they will need further
elaboration elsewhere. One of these is the need to adapt Western treat-
ment goals of individuation and autonomy, as these may not be appro-
priate for clients who come from cultural contexts that emphasis interde-
pendence with family and community. Additionally, psychodynamic
treatment that emphasizes conflict, affective exploration, and emotional
expression may need to be modified with clients whose cultures are based
on maintaining social and familial harmony at all costs. Finally, the
process of acculturation and adjustment to a new culture may cause
serious psychological symptoms that need to be considered as integral
part of the diagnostic criteria.
CONCLUSION
Based on current views of the working alliance as a collaborative
bond betweenthe client and the therapist whichfacilitates the therapeutic
work, cross-cultural issues in the treatment need to be examined in order
to learn how they may shape the working alliance in particular ways.
These culturally specific issues can be investigated by looking at discrete
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relational components in the working alliance, which include mutuality,
empathy, the dynamics of power, and the use of self and communication.
The clients ethnic identity and cultural characteristics, and the thera-
pists subjectivity and cultural sensitivity are important variables in shap-
ing these components. Additional areas that seem relevant to the cross-
cultural working alliance are the therapists potential biases, such as
expecting their clients to achieve typical western treatment goals (individ-
uation and autonomy, for example) or using a framework of traditional
Western psychodynamic theories without modifying themto fit non-West-
ern clients.
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Shoshana Shonfeld-Ringel, L.I.C.S.W.
Assistant Professor
School of Social Work
University of Western Michigan
Kalamazoo, MI 49008