Journal of Contemporary Psychotherapy, Vol. 35, No. 2, Summer 2005 ( C 2005) DOI: 10.

1007/s10879-005-2700-5

Therapy at the Cultural Interface: Implications of African Cosmology for Traumatic Stress Intervention
Gillian T. Eagle

The topic of intercultural or multicultural therapy continues to stimulate much debate in the eld of psychotherapy. Intercultural counseling training emphasizes respect for cultural beliefs as a core dimension of appropriate intervention. This paper addresses the limitations of this perspective in guiding therapists when faced with a clinical situation in which the non-challenging of cultural belief systems seems counter-therapeutic. The discussion is focused around critical observations of circumstances in which conventional African wisdom, as understood by clients presenting for trauma counseling, appeared to be counterproductive for their recovery in terms of western intervention principles. In psychotherapy for traumatic stress and traumatic bereavement, such tensions appear to arise particularly strongly because of the inevitable search for meaning in the face of extraordinary life events. Focusing on meaning making, cognitive intervention, schema realignment and reframing within trauma therapy, the paper explores ethical considerations and areas of potential conict with reference to theory and clinical case material. Some strategies for therapeutic engagement are proposed.
KEY WORDS: culture; ethics; psychotherapy; multicultural; traumatic stress.

INTRODUCTION South Africa is a complex place to practice psychotherapy. Therapists are confronted with the legacy of apartheid that contributes to sensitivities in across-race relationships and traditional African beliefs and healing systems are prevalent, existing alongside Western approaches (Airhihenbuwa, 1995; Swartz, 1998). While
Address correspondence to Gillian T. Eagle Discipline of Psychology, School of Human and Community Development, University of the Witwatersrand, Private Bag 3, P.O. Wits, South Africa, 2050; e-mail: eagleg@umthombo.wits.ac.za. 199
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subscription to traditional African beliefs is more common in under-developed areas of the country, many Western-acculturated African people develop hybridized explanatory systems that allow for the incorporation of both Western and traditional premises. These alternatives may exist in harmony, they may make an uneasy truce or they may be compartmentalized in psychological functioning. When clients located within such hybridized cultural milieus present for psychotherapy, practitioners have to intervene delicately so as not to privilege their own standpoints or inadvertently alienate clients (Lago & Thompson, 1996). Essentially one is challenged to nd a principled approach to working at the interface between pre-modern and modernist frameworks and systems of intervention. Although dealing specically with trauma therapy in South Africa, the discussion should have relevance for any psychotherapy with clients who have an allegiance to both Western and alternative, traditional meaning systems. During 20 years of work in traumatic stress as both practitioner and supervisor, the author has encountered many clients whose world-views reect subscription to aspects of traditional African cosmology, despite their engagement with Western healing resources. Traumatized clients commonly search for explanations and meaning in the aftermath of such events. This search often involves a return to tradition and for westernized African clients may require the reconciliation or co-existence of different explanatory systems. Where these are in harmony it may well be that formal therapeutic and indigenous interventions prove complementary (Eagle, 1998). However, there have also been many cases in which substantial tensions have arisen with respect to traditional beliefs and practices. The following case synopses illustrate the kinds of tensions being alluded to. (The third case is more fully elaborated as it provides the basis for a later discussion of intervention.) A mother was told by a traditional healer that her murdered son was still alive and available for contact (upon payment of a substantial sum), reinforcing her difculties in accepting his death. A father of a sexually abused child understood her behavior as bewitchment directed at himself and his family. Against professional advice and his wifes wishes, he withdrew her from play therapy, preferring to counteract the bewitchment by himself consulting a traditional healer. A woman presented for traumatic stress therapy following an attempted rape, disclosing that her response had been exacerbated by a prior rape during high school. She and a female friend had been gang-raped while playing truant. She had managed to escape but her friend was murdered. Severely traumatized, shamed and blaming herself for having abandoned her friend, she did not report the event to anyone at the time. Subsequently she heard that her friends family had instituted a curse, saying that anyone visiting the grave who had undisclosed knowledge of the circumstances of their daughters death would be bewitched and punished. The client had severed all ties with her friends family and had not been to visit her burial site. She had consulted a traditional healer who had prescribed

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the sacrice of a goat, a ritual beyond her means and capabilities. The client experienced nightmares, irritability, loss of concentration, social withdrawal and intrusive recollections of the event. It is apparent that traditional belief systems may sometimes complicate aspects of traumatic stress and bereavement responses, contributing to a lack of resolution of such experiences. When these kinds of cases present at multicultural counseling services it is evident that the clash of wisdoms or explanatory systems warrants further exploration and careful consideration of ethical imperatives. How does one simultaneously respect the autonomy of the client, including their right to hold to alternative cultural meaning systems, whilst at the same time attempting to maximize the benecial impact of Western psychotherapy? In the ensuing discussion, aspects of African cosmology relating to causal attributions for misfortune will be counterpoised with aspects of Western-based psychotherapeutic wisdom with respect to traumatic stress treatment.

AFRICAN COSMOLOGY AND CAUSAL ATTRIBUTIONS FOR MISFORTUNE Despite differences in urbanization, class, tribal afliation, religion and geographical location across the African continent, many authors have nevertheless written of an African cosmology or worldview that reects basic universal themes (Airhihenbuwa, 1995; Buhrmann, 1984; Shutte, 1994). Some key premises underpin the differences in Western and African world-views. A traditional African worldview has many pre-modern characteristics, such as the entertainment of animistic and magical thinking and belief in the power of natural and supernatural forces. Identity is collective rather than individualistic, and the deceased, or ancestors, play a signicant role in maintaining social harmony. Dreams are viewed as important communications and well-dened rituals are prescribed for revering ancestors. The Cartesian mind-body split is eschewed in favor of a holistic model of functioning and physiological and psychological symptoms are experiences as closely interrelated. Some aspects of belief pertain specically to misfortune and hence to trauma intervention. In African society there is little entertainment of notions of chance. If misfortune befalls an individual the search for causality generally excludes the possibility of such an event being random or fortuitous. The unanticipated nature of traumatic events also prompts the search for causality, including why this person has been affected in this particular way at this particular time. Three sets of possible causes for misfortune are entertained: mystical, animistic and magical (Ngubane, 1977). Mystical causation is associated with being in a state of pollution in which a person is understood to be vulnerable to negative forces or

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afictions, applying, for example, to the newly bereaved or menstruating women. Animistic causation is associated with having displeased the ancestors. The search for the origins of ancestor alienation may involve consideration of sins of both commission and omission, for example failing to perform certain expected rituals. Appeasing the ancestors is the mechanism for overcoming misfortune and avoidance of future harm. There are strict rules about the roles, gender and venues for such rituals. Magical causation is associated with witchcraft and the working of curses, spells, bindings or enchantments. The bewitched is under the inuence of some malevolent force, inicted by an ill wisher, motivated by jealousy, envy, rivalry or revenge. Cure entails being unbewitched by a traditional practitioner (Buhrmann, 1984). It should be apparent that within a traditional African worldview there are explanations for the kinds of events that cause traumatic stress and customary practices for the restoration of harmony and balance. The paper addresses clinical cases in which tensions have arisen because of the particular ascription of meaning and causality to certain events and actors and also because of the constraints that prevent the performance of healing or undoing rituals.

COGNITIVE ATTRIBUTIONS AND MEANING-MAKING IN TRAUMATIC STRESS Turning to Western-oriented understandings of traumatic stress, the discussion is focused on cognitive frameworks and aspects of intervention. Such dimensions represent a central framework of understanding within the traumatic stress literature and are relevant to multicultural work. One of the cardinal responses to traumatic events is the search for meaning, usually involving a quest for causal attributions (Herman, 1992; McCann & Pearlman, 1990; Wilson, 1989). In order to heal people need to be able to think about their trauma in a coherent manner and to answer satisfactorily why the event took place and why to them (Kreitler & Kreitler, 1988). In Western logic such reasoning may include notions of chance or randomness. Trauma-related difculties pertain to the intricate manner in which individuals interpret or construct events (Herman, 1992; Kreitler & Kreitler, 1998; McCann & Pearlman, 1990). It is not necessarily the nature of the event which determines vulnerability to symptomology, but its meaning for the individual (Kreitler & Kreitler, 1998, p. 38). Such meaning is inevitably culturally embedded, yet the role of cultural idioms and meaning systems in trauma adjustment is seldom fully explored. A number of universal models of the cognitive impact

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of trauma have been proposed and have gained considerable credibility in the eld. Such understandings provide the backdrop against which Western-trained therapists formulate their interventions. Janoff-Bulmans (1989, 1992) work on the rupturing of what she terms basic assumptions offers a widely cited and respected framework for traumatic stress psychotherapy. Most human beings develop and hold three core assumptions about the operation of the world and about themselves: i) The world is benign; ii) The world is meaningful (implying notions of controllability, predictability and justice); and iii) The self is worthy. These assumptions are based on a largely rationalist worldview. The idea of a benign world assumes that others are generally trustworthy and that the world is not controlled by destructive forces. A meaningful world is predicated upon beliefs that outcomes are predictable and generally fair as exemplied in Just World premises (Lerner, 1980). Self-worth is tied to humanist ideas about the intrinsic value of human beings and is primarily based upon early experiences of good caretaking (Janoff-Bulman, 1992). Whilst it seems possible to marry this conceptual framework with much of the African world-view described previously, it is apparent that the substance of these premises may be rather different in alternative cosmologies. For example, the sense of a benign world may be signicantly predicated upon ancestral intercession, self-worth may be inextricable from communal worth and meaningfulness may incorporate understandings of supernatural forces and more holistic sets of relations. Such reinterpretations of basic assumptions need to be fully appreciated in multicultural work. Exposure to a traumatic event involves rupture to one or more of these basic assumptions. A core dimension of psychotherapy is to assist the individual to restore these assumptions, to heal or repair the rupture, often entailing modication of the basic assumptions. Extending Janoff-Bulmans framework somewhat, McCann and Pearlman (1990) propose that seven cardinal schematic representations are impacted upon by trauma, those for safety, trust, independence, power, self-esteem, intimacy and frame of reference, the last-mentioned referring largely to existential beliefs such as the entertainment of hope and locus-of control. They also view psychotherapy as entailing examination of how these schemas have been affected by the individuals traumatic experience and assisting clients in the reconstruction of a schematic system that will allow them to live satisfying and engaged lives. An interrogation of these schemas also reveals some Western bias in the formulation of the impact of traumatic stressors, for example an emphasis on self-judgment as opposed to social disconnection. One of the cardinal dimensions of traumatization is the experience of loss of control or disempowerment (Herman, 1992, p. 55). There is a general assumption in the treatment literature that the restoration or instantiation of a sense of personal control over life events, particularly future events, is an important goal of psychotherapy. Therapists are not tasked with helping their clients to accommodate

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to the whims of fortune, but rather with instilling a sense of personal efcacy that it is believed will also generate a greater sense of optimism and meaning. The traumatic event may have been outside of ones control, but as a client one is invited to reframe ones behavior as a form of adaptation (Eagle, 2000; Hoyt in Scott & Palmer, 2000) and also to embrace an expectation that future outcomes will be largely within ones control and life therefore worth living. Such expectations have intrinsic therapeutic appeal. However, the reframing of traumatic experiences and support of more optimistic future orientations tends to reect largely unquestioned notions of value in individual achievement, an internal locus-of-control and selfefcacy. These goals may not always be compatible with cultural belief systems that emphasize surrender to forces beyond oneself, dependence on a greater social fabric, or the interpretation of negative events as important communications or learning experiences. In the rebuilding of assumptions and adaptive cognitive schemas there are many premises, or even presumptions, about what constitutes good mental health and adjustment, premises which it is suggested may sometimes run counter to fundamental elements of traditional belief systems. How does a responsible therapist value their own clinical sense of what is in the interest of the client, whilst simultaneously empathically engaging with the clients frame of reference and assisting them to reconcile with their culturally-embedded sense of what cure entails? Such observations about the hegemony of enlightenment-based rationalist and modernist Western value systems in psychotherapy are not new (Lago & Thompson, 1996), nor are they limited to treatment of traumatic stress cases. However, clashes in value systems are signicant in this arena for two reasons. Traumatic stress exposure precipitates a degree of regression, including in the area of cognitive functioning. This means rstly, that clients are particularly open to suggestion and often very dependent on therapists for their interpretation of events, including any reframing. Secondly, under such duress, many clients revert to prior, less sophisticated frameworks of understanding, characteristic of earlier stages of maturation (Lebowitz & Roth, 1994), including adopting more magical and stereotypic thinking. What Freeman (in Datillio & Freeman, 1992) terms dormant or inactive schemas and Lebowitz and Roth (1994) refer to as latent or sub-dominant schemas may re-emerge in the wake of traumatic events. In a hybrid cultural environment in which Western values have often been absorbed at a slightly later stage of development, it is quite plausible that fundamental values may re-emerge as signicant in attempting to deal with unfathomable situations. The surfacing of latent schemas in the aftermath of trauma is not limited to particular cultural groups. Many people draw on magical, non-rational, religious or spiritual beliefs, sometimes long abandoned, in attempting to draw meaning from trauma. Whilst recognizing the integrity and complexity of metaphysical belief systems and the benecial role they may play in coming to terms with

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traumatic stress, it is also important to acknowledge that traumatic stress exposure may invite more reductionistic framing of events, for example that ones assault is a punishment by a higher being for some wrongdoing. In light of such observations about traumatized clients, it behooves the therapist to tread extremely carefully in engaging with alternative belief systems.

IMPLICATIONS FOR THERAPEUTIC INTERVENTION AND PRACTICES Traumatic stress therapies addressing cognitions, schemas and/or beliefs have been informed by information processing theory, by cognitive-behavioral understandings and by psychodynamic and constructionist perspectives. However, as is the case with many other anxiety disorders, cognitive-behavior therapy is often viewed as the treatment of choice, supported by most empirical evidence (Foa, Rothbaum, Riggs, & Murdock, 1991; Richards & Lovell in Yule, 1999). Cognitive-behavior therapy (CBT) for posttraumatic stress consists of three major components: exposure techniques, anxiety management techniques and cognitive reframing and restructuring. Cognitive therapy is broadly aimed at training clients to critically examine their beliefs for errors in logic and to challenge and modify maladaptive patterns so as to adopt more constructive ways of thinking (Richards & Lovell, in Yule, 1999). The therapist plays an active role in training the client to scrutinize and evaluate their beliefs. Particular ways of thinking are identied as more or less positive or negative, for example arbitrary inferences or over-generalization. Although a collaborative endeavor, the psycho-educational orientation of the therapy necessarily implies that there is a degree of leading or direction taking place (Beck, 1976; Ellis, 1962, 1980; Scott, Stradling, & Dryden, 1995). In traumatic stress therapy, the examination of possible cognitive distortions is often targeted at attributional processesthe questions of why, why me and what does this mean for my sense of self, my relationships, my engagement with the world, the cosmos and my future? In Resick and Schnickes (1992) Cognitive Processing Therapy (CPT), the focus is on identifying and modifying stuck points (p. 750), signicant points of conict between existing schemas and new information associated with the trauma. They employ a comprehensive treatment model encompassing psycho-education, exposure and cognitive therapy. The cognitive component, involving examination of thoughts and affect, draws upon Janoff-Bulman (1992) and McCann and Pearlmans (1990) theoretical conceptualizations. Other cognitive therapeutic approaches include elements of cognitive restructuring and self-dialogue (Foa et al., 1991), designed to lead to more adaptive appraisal and coping. Cognitive reframing, relabelling and reattribution are central in the re-evaluation of behavior, symptoms, responsibility and blame.

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Freeman (in Freeman & Datillio, 1992) notes that in conceptualizing any cognitive therapeutic intervention, change may be recommended on a continuum, involving schematic reinterpretation, modication or reconstruction, the latter entailing the most dramatic alterations to schemas. Traumatic stress treatment often entails schematic reconstruction, emphasizing the signicant ethical demands on the therapist to remain aware of respecting the autonomy of the client. Although therapists may recognize the limitations of universal models and the important role of culture in schematic constructions, few have explicitly interrogated how cultural awareness should be incorporated into traumatic stress therapy. THERAPEUTIC STANCE AND STRATEGIES Returning to the initial question posed in this paper, i.e., how to engage with traumatized clients whose cultural beliefs appear to be hampering rather than aiding in recovery, an overarching framework for intervention is proposed as well as a number of strategies that have been helpful in clinical practice. A constructivist orientation to cognitive psychotherapy, as opposed to a rationalist style of intervention, is recommended (Hoyt in Scott & Palmer, 2000). Without a therapeutic model that can encompass subjectivity, alternative logics and content that the therapist might consider to be non-rational or irrational, it would be impossible to fully engage with African clients holding to traditional worldviews. A conservative reading and application of either Ellis (1962, 1980) or Becks (1976) cognitive-behavioral approaches is unlikely to be effective in such cases. Meichenbaums constructivist narrative approach (Meichenbaum & Fitzpatrick in Goldberger & Breznitz, 1993; Hoyt in Scott & Palmer, 2000) offers a useful model for multicultural traumatic stress psychotherapy, encompassing elements of both CBT and narrative therapy, with an emphasis on collaborative narrative repair. Meichenbaum and Fitzpatrick emphasize the authority of the client in the therapeutic process, arguing that the scientic validity of any healing theory is less signicant than whether it is credible and plausible for the client. They also emphasize that the reconstruction and reframing of events into a therapeutic narrative has to be a collaborative, non-instructional endeavor, in which if anything, the client has greater agency. This framework or stance would seem to hold considerable promise for engaging with the kind of cases illustrated at the outset of the paper. It allows for alternative systems of explanation in the necessary re-authoring and integration of traumatic material. Adopting the constructivist narrative perspective as the broad basis for intervention the following pointers illustrate the manner in which multicultural tensions have been negotiated in psychotherapy with such clients and are further exemplied in the concluding case discussion. The therapist should: Engage in open dialogue about points of discrepancy between their own frameworks and those of the client and the possible implications of

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this for psychotherapy, without assuming superior validity of either system. Expand the sophistication and subtlety of reconceptualization, reframing and relabelling to incorporate examination of traditional as well as western explanatory frameworks. Work with more individually problematic self-attributions initially, in the expectation that the client will then become better able to challenge detrimental communal/traditional attributions from his/her own base. Understand the particular respects in which the client is vulnerable to suggestion and attempt to address the origins of this susceptibility. Examine the parameters within which restitution of balance or performance of rituals is prescribed, the intention behind them, and possible alternatives for expression that are acceptable to the client (individually and socially). Encourage clients to seek input from other powerful interpreters of events who may allow for some contestation of rigid explanations and provide alternative versions, for example older relatives. Under duress, challenge the detrimental explanatory frameworks put forward by others in terms of questioning motives such as self-gain or the possibility of malpractice. Acknowledge the importance of cultural embeddedness and cultural reconciliation, whilst afrming that culture is something that transforms with time and is open to variable interpretations. BRIEF ILLUSTRATIVE CASE DISCUSSION

In the case of D, the rape survivor described at the outset of the paper, the application of these kinds of principles of intervention took the following form. In order to establish a good multicultural working alliance the therapist engaged in an open-minded way with Ds interpretation of her symptoms and their origins. She did not question the sangomas recommendations but assumed that D had placed some modicum of trust in Western psychotherapy by seeking her assistance. She concentrated upon assisting D to reconstruct the traumatic experience and by means of reection and judicious questioning enabled her to identify her self-blame and guilt as particularly salient elements of her traumatic response. By means of reframing, involving Socratic questioning and hypothetical role reversal, Ds judgments of her own behavior shifted in psychotherapy. Psycho-education about posttraumatic stress symptoms also assisted D to interpret her responses differently. D gained insight into the links between her self-recrimination, her survivor guilt and her view of herself as deserving of punishment; and her entertainment of the belief that she had been cursed and that her symptoms and the attempted rape were forms of retribution being visited upon her. She was able to appreciate her own levels of traumatization, as validated by the therapist,

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and shifted from viewing her nightmares as a communication from her deceased friend to understanding them as a form of intrusive reliving of an overwhelming experience. This reconstruction of events and reframing of her suffering were experienced as a profound revelation and her recovery following this insight was remarkable. Her traumatic stress symptoms abated almost immediately and she displayed sufcient self-value and interpersonal trust to speak about the attack for the rst time to a friend. Following the cognitive shifts, the afrmation of her distress and the nonjudgmental responses of therapist and friend, D resolved to approach her friends family. Her disclosure of the events surrounding her friends death and her own anxieties, elicited a forgiving and joining response from them. Her friends mother accepted her as a daughter, evidencing the kind of communally embracing philosophy of African culture. They agreed to visit the grave to dispel any vestiges of the curse and to mourn appropriately together. It is apparent that the success of this intervention was predicated upon resisting any impulse to directly challenge the validity of the clients culturally laden interpretation of events or of the authority of the traditional healer. Rather, by relying on the co-construction of an alternative version, based in a validating therapeutic relationship, the judicious employment of cognitive therapy techniques enabled the client to spontaneously reconcile with an alternative explanation that proved liberating for her. In Ds case her embracing of a more modernist framework of understanding proved benecial, however, for other clients reconciliation and healing may take a different form. Therapists need to be exible in entertaining the possibility of different outcomes.

CONCLUSION The respectful stance of the therapist and her willingness to engage sincerely with the felt impact of Ds interpretation of traditional beliefs and practices, created the therapeutic space for D to reconceptualize and rewrite her own narrative. D was able to develop a meaningful and acceptable (Meichenbaum & Fitzpatrick in Goldberger & Breznitz, 1993, p. 711) interpretation of her traumatic life experiences, free of personal guilt, social approbation and malevolent forces. If therapists keep these principles in mind, seeking to co-construct with clients narrative versions that are both meaningful and acceptable in all senses, then they are likely to be able to negotiate the complex pathways of multicultural psychotherapy with integrity.

ACKNOWLEDGMENT This article appeared in Psychology in Society (2004) 30, 122.

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