ETHNOCULTURAL CONSIDERATIONS IN GROUP PSYCHOTHERAPY
John Salvendy
Professor, Department of Psychiatry, University of Toronto and in private practice.
Founding President of the Canadian Group Psychotherapy Association and
Supervisor of group psychotherapy at St. Michael's Hospital, Toronto, Canada 
Email: salvendy@on.aibn.com

Paper originally published in the International Journal of Group Psychotherapy, 49;4, 429-464, 1999, published by Guilford Press.

Over the past few decades the demographic composition of many industrialized countries has changed significantly. More liberal immigration rules in the main recipient countries (US, Canada and Australia) which stopped the past discrimination of potential immigrants of non-Caucasian origin has been a major contributing factor. In addition the existence of long, easily penetrable borders (between the US and Mexico, the US and Canada), the easing of restrictions for entry by most countries of the world and the explosive development of air travel have increased the opportunities for many people to immigrate also illegally from regions stricken by poverty or political unrest. Last but not least the numerous armed conflicts and civil wars have led to repeated mass exodus of refugees and the politically, ethnically or religiously persecuted.

As the traditional European immigration was drying up (due to that continent’s economic recovery after the Second World War) it was replaced in the English speaking immigration countries by arrivals from the developing regions of the world. These migrants are not only visibly different from the local majority population but they bring with them a gamut of disparate cultural properties (language, religion, social attitudes, dress, cuisine and music, among others). The apparent transformation of our societies through this process of infusing different looking and sounding people, which is most visible in the big cities, has left an indelible impact on both the original and the immigrant populations (Salvendy 1983).

Learning and understanding each other’s culture contributes to the process of integration and harmony. However, this process has become much more complex than in the past, due to the diversity of the new minorities. Thus for the longest period, in the United States it was sufficient to understand the difference between the Caucasian and Afro-American cultures. With the influx of Hispanic, Asian, African and Polynesian immigrants that relatively simple equation has changed. This increase in a portion of the population, which appears distinct and dissimilar, poses a significant challenge to (group) therapists. 

Psychotherapy originated in the Judeo-Christian ambience of Central Europe in the early twentieth century and evolved as a white, middle class phenomenon primarily in North America. At a time when immigrants and visible minorities among them in particular, constitute an increasing number of the population (the 1996 Canadian census indicated that half of Toronto’s population were immigrants and 35% represented visible minorities, Globe and Mail, 1998), it is important to contemplate adjustments and modifications to the theories and techniques of group psychotherapy when dealing with non-majority group members. Both my information and available evidence (Burke 1984, Personal Communications 1994) indicate that minority patients are underrepresented in therapy and have higher drop-out rates than Caucasians. The reasons for that are manifold: cultural biases, language barriers, cost and lack of information among others. By learning more about the way of life of these potential psychotherapy patients, by being open to adapt some of our norms and expectations and establish services which are more responsive to ethnic patients, group psychotherapy could become a more attractive, acceptable and effective treatment modality for this segment of society.

EVOLUTION OF CONCEPTS

Race and Ethnicity have been and still are topics that evoke discomfort and anxiety in social and clinical settings and are often treated as a taboo.

Talk about race and ethnicity can arouse powerful feelings related to the problems of difference, wishes for recognition and desires for domination and control (Holmes 1992, Leary 1995).

The sensitivity related to discussions about this topic is due to a history of pervasive prejudice, severe discrimination, exclusion, marginalization and even annihilation on grounds of race and ethnicity in North America and elsewhere. The persecution of the Native Indians of the Americas, of Afro-Americans, of the Jews and Roma (Gypsies) in Europe and the horrors of the latest ethnic cleansing in the Balkans and Africa have all contributed to this sense of uneasiness when the issue of race and ethnicity comes up. The subject is further compounded by widespread prejudices and stereotyping of others.

Therapists have not been immune to the prevailing socio-political views and that partially explains the scarcity of literature dealing with the impact of race and ethnicity on the theories and practice in this field. The other reason for less clinical attention being directed to racial issues is that patients and therapists of non-Caucasian origin are themselves under-represented in the population offering and receiving psychodynamic treatment. As a result, the dynamics of race and ethnicity remain unarticulated because most therapists are unfamiliar with the clinical issues that such patients present (Leary 1995).

Meaningfully, a good portion of what has been established was contributed by therapists belonging to a particular race or ethnic group (Chen 1995, Maharajh 1984, Silverstein 1995, Sue 1987, 1988, 1998, Tsui & Schultz 1988, White 1994), who are confronted daily with this issue. Much of the earlier views on race and ethnicity were formulated in individual psychodynamic psychotherapy. Generally, race was perceived as a hindrance to the treatment process. Thus a black patient’s race as well as the potentially prejudicial attitude of the white therapist were viewed as obstacles to successful treatment. For example, Kennedy (1952) felt that black patients, from the very beginning, entered treatment fearing and distrusting Caucasian therapists because of specific previous life experience.

Further difficulties arose from the formulation of the role of race in the treatment process. In the early literature the impact of race and ethnicity was often narrowly focused on the inquiry concerning the influence of racism on personality development and interpersonal dynamics (Holmes 1992). This led to a frequent stereotyping of a particular race or ethnic group. As a result, for example, some authors (Kardiner & Ovesey 1951, Karon 1958) described a “negro personality” which developed due to segregation and discrimination and was believed to be characterized by low self esteem, apathy, fears of relatedness, mistrust, problems with the control of aggression and orientation to pleasure in the moment.

The major shortcoming of this approach was that the cultural practices of patients belonging to a non-Caucasian race and their personal experience did not have a meaning of their own apart from reflecting personality defects that were supposedly common to all members of that racial or ethnic group. With the accession of the civil right movement in the United States and widespread integration in the 1960’s the focus has shifted to encourage and acknowledge the patient’s communication about the therapist’s (different) race and not equate racial responses automatically with transference (Curry 1964).

Schachter and Butts (1968) were among the first to point out the major shortcomings of the stereotyped assumption. Rather than see racial differences as limiting they maintained that paying attention to racial and ethnic issues could have a catalytic effect and stimulate the therapeutic process. Later Gardner (1971) argued that in mixed-race therapeutic situations exploring the patient’s and therapist’s expectations about race and ethnicity could enhance the therapeutic process.

Contemporary thinking on mixed-race therapy situations evolved from the above mentioned pioneers. It assumes that attention directed toward the realities and fantasies associated with race or ethnicity may facilitate psychotherapeutic work or even be a precondition for its success.

Some clinicians, primarily of non-Caucasian background have questioned the relevance of a “eruocentric” paradigm developed a century ago to other racial groups (Ivey, Ivey & Simek – Morgan 1993, Sue, 1987). Therefore they have suggested that, for example, Afro-American patients would be better served through the provision of culturally specific psychotherapy, which would be consonant with the cultural practices and beliefs of Afro-Americans.

The risks in this approach (which could apply to other ethnic groups and cultures too) are that it establishes specific norms of behavior for a whole race or ethnic group, that it sets new stereotypes and thus resembles the early psychodynamic writing on race and ethnicity. Furthermore it would likely lead to more separation between the various races and ethnic groups as its premise abrogates the notion that race and ethnicity can be discussed in a social therapeutic setting. This attitude also negates the view that people with a variety of racial or ethnic backgrounds may have different views about themselves and others but can still establish meaningful understanding in ways that maintain the personal integrity of each.

Much of the objection of the above writers relates to older but still influential psychodynamic views. Current theories emphasize the relational nature of therapeutic encounters and the importance of interaction which are both likely to be more conducive to the therapeutic needs of minority patients.

SOCIO-CULTURAL OBSERVATIONS

An explanation of ethno-cultural issues cannot ignore the fact that it is always influenced by the views of the discussant, however enlightened they might be.

While I came from a mainstream culture, my experiences were enriched by having lived for extended periods in five different societies. A common mistake in dealing with other cultures is in stereotyping them. In fact, northern Italian impress their southern countryman as ver (?) Germanic, and there is a world of difference between American and Moroccan Jews living in Israel.

Afro-Americans born in the US differ vastly from their African brethren or from their Caribbean counterparts. In fact, there are distinct differences even among blacks hailing from various islands in the Caribbean. Also the degree of acculturation within the same ethnic groups may differ markedly. Thus second generation Chinese may be quite westernized compared to recent immigrants from China.

Conformity is sanctioned by society, and when a segment is seen as not conforming in appearance, attitude or behavior, prejudice may be the result.

Ethnicity is sometimes correlated with social factors such as poverty and/or single parent families, which contribute to stress, anxiety and a restricted or non-adaptive social life. Each culture also brings with it its own, often disparate perception of power, authority, interpersonal boundaries and family dynamics (Tsui, Schultz & Chen, 1988).

For many ethnic populations who are relatively recent immigrants, group therapy is even less acceptable than individual counseling due to the loss of face of having their “weaknesses” witnessed by other non-professionals. Therefore first generation immigrants are even more under-represented in group therapy than in (the) individual (one), and they also tend to be hampered by language barriers (an immigrant may be able to communicate with a health care professional but will often be at a loss to follow a fast flowing group dialogue).

All individuals manifest varying levels of ethnic or racial bias. However, the therapist’s and patient’s awareness of their own prejudices can minimize resistance and promote treatment goals (Addison 1977). Therapists who are knowledgeable about minority cultures and sensitive to their needs may attract members of such communities which otherwise could not be accessible to treatment. Furthermore, in my experience they are likely to encounter a much lower percentage of drop-outs than would be otherwise the case.

SPECIFIC GROUP PHENOMENA IN ETHNICALLY HETEROGENEOUS GROUPS

The group process elicits feelings about one’s own ethnic group with greater intensity than individual therapy. This is due to the individual facing others who are different not just the therapist. All group members experience an intense pressure to conform to the majority view – regardless of how scary or foreign it may appear to them. At the same time white, middle class group norms are generally not receptive to minority values. This often leads to splits among group members due to stereotyping, projection, misinformation and fear. Due to different values, self consciousness and a feeling of representing their whole ethnic group, patients of a different racial or cultural group may often feel ill at ease in therapy groups (Maharaj, 1984). Ethnic and visible minorities experience additional problems relating to the group, due to dissimilar value systems and at times split loyalties. The latter situation arises when the price of the desired change in the group is the alienation or disapproval from one’s own cultural community.

Racial and ethnic differences can significantly affect a person’s diagnosis, assignment to a particular mode of therapy, transference, and the real relationship. Thus a minority group patient may get a more severe diagnostic label and may be referred to a group because the interviewer did not want to see the person in individual therapy. Minority patients may have a strong authority transference to therapists while the latter may respond to such a group member in a negative fashion or over-protectively, depending on their counter-transference.

Attempts to assimilate minority members often cause them anguish, and ultimately they are antitherapeutic (Tsui & Schultz, 1988). At the same time Lieberman, Yalom & Miles (1972) found that patients who (are) assumed a deviant role in a group experienced a lot of anxiety and benefited least.

Ethnic and cultural differences can lead to increased resistance, especially when sensitivities specific to the particular society are overlooked. Thus minimizing the major impact of gossip on a member who belonged to the tightly knit Ismaili community (a Moslem sect of Aga Khan followers among East Indians) has led to her leaving a group after two years of regular attendance.

Distinguishing between cultural and personal distrust and animosity is particularly relevant in ethnically heterogeneous groups. Thus “cultural paranoia” due to persecution and exploitation by white society is not uncommon among Afro-Americans (Ridely 1984) and Canadian Indians. This phenomenon is related to these groups’ shared history, while personal distrust has to be explored in the light of their individual experience.

Many minority members are too inhibited to self disclose, fearing stereotyping and negative implications for their ethnic group (patient stating being of European background rather than specifically Greek, Italian etc.). They perceive themselves in the group not just as individuals but also as representatives of their ethnic group. Therefore, an Afro-American man in an all Caucasian group, who in his individual assessment complained about his mother abandoning him at the age of ten, came to her defense when the event was later discussed in his group.

Self-disclosure for minority members are more difficult unless trust has been established and patients feel that the group will relate primarily to their personal histories. 

The degree of racial harmony or polarization in the community is likely to impact significantly on the group’s composition, dynamics and outcome (Salvendy 1985). It is therefore more feasible to have a racially heterogeneous group set up where members of different ethnic groups having ongoing contact at school, work, and socially than when they exist in parallel societies.

The commonest defense mechanisms in ethnically heterogeneous groups are denial, intellectualization, projection and polarization. The members may not want to discuss their biases and differing views, pretending that all is harmonious, or may construe theories to explain their differences. They may also project their fears and prejudices on each other or focus on real or imaginary differences to keep the group from working. Therapists should also be aware that a minority member may use the reality of racial discrimination in the service of resistance (Kibel 1972). Issues of “common” racism may also mask hidden but unresolved issues (Fenster 1996). Thus parental rejection could be presented in the group as racial discrimination.

It is also likely that more of the therapist’s authentic feelings will be elicited in the group than in individual therapy, as the former resembles real life much more. In the group not all the negative reactions to the therapist are transferential. Some may be in response to insinuations. The racial or ethnic differences between the patients and the therapist are among the most avoided areas in treatment (Addison 1977) – usually with deleterious results for the patient.

Group therapy practiced culturally sensitively can help to impart information about and understanding of the other’s way of life. Family structure and dynamics are different in important areas for Orientals, Afro-Americans, South Asians or Middle Easterners than for the white middle class. Social pressures to conform to a particular group’s norms can wield enormous influence upon an individual group member, and if not recognized by the group can lead to injurious results. Thus the intrusiveness of some Italian parents or the major role of in-laws in the (East) Indian culture has to be seen in its perspective. It is also noteworthy that in some societies conflict cannot be directly expressed and is often somatized.

When working with Oriental group members who are first generation immigrants, one may note their acceptance of authority and authoritarianism as norms, and face saving as being of utmost importance. Such group members will be more deferential to their parents and the therapist, more reserved in their emotional expressions and may feel more reluctant to criticize members of their families. They may also have a much more pragmatic view of life and of interpersonal relationships (Tsui & Schultz, 1985). Therefore, some Oriental members may be at times confused and feel anxious about the group’s emphasis on verbalization, confrontation, individuation and autonomy (Tsui & Schultz, 1988).

The therapist’s aim in the group is to improve the ability of minority members to relate to the group and thus increase this treatment’s effectiveness for them. Concomitantly, authenticity and independence should be fostered along with the ability to resist pressure, whenever inappropriate to impose white middle class standards to the detriment of the ethnic group members. Thus a group containing a single, widowed or divorced traditional Moslem or orthodox Jewish woman needs to adjust its expectations and norms to what is acceptable to these minority women when dating or premarital sex is being discussed.

A thoroughly informative preparation of the minority group candidate above and beyond the routine given to others, in order to understand their concerns prior to starting in the group is essential to ensure the settling and thriving of that person in the group. During those preparatory sessions their expectations and goals should be clarified, they should be informed what to expect with respect to their different ethnicity, and how the therapist plans to deal with the many issues arising out of that situation. Such sessions should also touch on the different ethnic backgrounds of the candidate and the therapist, and allow for an open discussion of the feelings and approaches involved. Therefore, therapists who have strong negative reactions to certain or all minority group members should not treat such patients as the results are likely to be less than optimal.

Therapists and their group members are often ignorant about minority cultures or harbor misperceptions that are best attended to early. In ethnically heterogeneous groups the leader aims to establish a broader set of norms which take cultural variables into account. Beyond the simple knowledge of a behavioral variant or belief both the therapist and group members should strive to understand both the manifest and the symbolic meaning of the socio-cultural factors (Tsui & Schultz, 1988). Thus an Oriental group member may view the group as a harmonious family where assertiveness, challenging and confrontation would be misplaced and disapproved of.

Stereotypes, misinformation and projection often result in fear that disconnects people who are different. When therapists and/or group members consider the minority member as a representative of that ethnic group by focusing on stereotypes they risk devaluing that member’s individual life experience and inflict on them a major narcissistic injury. Therapists on the other hand are available as models by containing anxiety and anger, standing firm in the face of perfunctory glossing over, accepting individual differences and by demonstrating a willingness to integrate a variety of cultural experiences.

Effective therapists acknowledge and validate the unique life experience arising out of the relationship between the majority and minority cultures. Leaders and group members should be educated about the norms and life-style of the minority group member in order to discern which behaviors are symptomatic of personal psycho-pathology and which are attributable to cultural influences. Therapists can help the group to move from concrete discussions to those of a transcultural nature, focusing on the universal affective responses to experiences such as physical or emotional deprivation, a variety of losses, separation and family conflict as they are manifested in different cultural contexts (Tsui & Schultz, 1988).

Trust must be fostered not only between the minority member and the therapist but also among all the fellow participants. The successful integration of ethnic members cannot be based solely on the imparting of information, unless accompanied by a “corrective emotional experience” (Alexander and French, 1946), which will make this process truly curative.

A therapeutic focus that includes ethnicity can help individuals resolve identity conflicts. It allows visible minorities and second generation immigrants to integrate enough of the mainstream culture to be functional socially and at work without having to deny the importance and meaning of their own culture to their sense of well being and integrity. What will assist in this endeavor is the acknowledgment in the group of the positive aspects of their particular culture: for example, strong family ties, moral values and well established and organized social, cultural and community activities (Ciordano 1974, Salvendy 1983).

If there is a perceived imbalance of power between majority and minority group members it needs to be addressed for therapy to be effective (Fenster 1996). In some groups it may be a more pronounced problem than in others.

In my experience the risk also exists that majority members overcompensate and invest the minority member with special powers not available to anyone else. Thus in a newly constituted out-patient group the only Afro-American woman kept coming considerably late to several early sessions, giving rather flimsy explanations for her tardiness. The rest of the group ignored these occurrences until the therapist confronted them with it several sessions later – and only when they perceived his approval, the late-coming patient was finally challenged.

Due to the intense nature of the group proceedings all parties are prone to misinterpretation, and therefore the clarification of communication in ethnically heterogeneous groups is particularly important. This is even more imperative if some members of the group are immigrants and may not have a full command of the language or are difficult to understand due to their accents.

It has been my experience that having minority patients first in individual therapy, where trust, rapport and credibility are established, and then transferring them to a group with the same therapist (often keeping the option of some parallel individual sessions open) will facilitate their adjustment and cause them less anxiety.

One should also be aware that the minority members’ adjustment to the majority’s cultural norms may be neither ego-syntonic nor serve them well in their own communities (Maharaj, 1964). The group leader has to gauge how much change in a particular direction is adaptive outside the group for minority members who may spend most of their time within their own communities.

Therapists are not immune to biases towards minorities, and being alert to their own stereotypes will allow them to have less counter-transference feelings and may obviate itself in a number of forms. To compensate for feelings of guilt related to their own prejudices, minority patients may not be confronted or may be granted special privileges. At the other extreme, due to their feelings of hostility therapists may exhibit aggression and be too confrontational. If the therapist is overly curious regarding the minority member’s culture it may impede therapeutic work in the group as the patient’s personal dynamics are likely to get lost.

Therapists should watch for signs of negative transference and mistrust by a group member of a different racial background. As ethnicity and race are emotionally loaded issues therapists may repress their own personal stereotypes (i.e. due to political correctness) and fall short of working through them. When clues in either of the above are discernible they are best addressed early before the therapeutic alliance suffers. At the same time therapists should be able to perceive to what extent the minority members behavior or attitude is deviant or conforming not just to white middle class standards but also to the values of their own ethnic group (Spiegel 1976).

CONCLUSION

Group therapy conducted with the knowledge and acceptance of other ethnic groups and cultures and sensitive to their values enables visible and ethnic minorities to relate better to others, improve their own self esteem and retain a sense of self respect and autonomy. As psychotherapy has an inherent change-oriented focus, when setting individual goals for patients, their particular view of the world has to be appreciated so that they can safeguard their principles (Silverstein 1995). Therefore, different cultural, social and religious imperatives have to be assessed in their proper context and should not be overridden by a white, secular, Judeo-Christian middle class ‘gold standard.’

When a group member’s cultural-religious beliefs are very different and dogmatic they are best treated in homogeneous groups (Silverstein 1995). Thus all adherents of fundamentalist religious populations and politically or nationalistically fanatic groups and sects will be more effectively treated in homogeneous groups.

The cohesiveness and effectiveness of multi-ethnic groups can be measured by the degree that its members feel free to discuss their feelings about the group and its members including people’s tendency to stereotype. Another gauge is to what extent members feel free to express criticism or caring for each other.

There is increasing evidence that interracial and/or interethnic group therapy can be effective if the minority members satisfy themselves that the therapist is sensitive to their socio-cultural and personal situation (Jenkins 1990). These types of ethnically heterogeneous groups operate successfully when the therapist manages to create a common bond for the participants despite diversity. 

The above observations and considerations highlight the pivotal role assumed by therapists who work with ethnically heterogeneous patients. It is therefore crucial that therapists dealing with such a clientele educate and sensitize themselves to the particular cultures they are dealing with.

It may not be possible for a single therapist to master a whole gamut of different cultures (cultural competence) but specialize is some and be known for it.

As no therapist is likely to be completely free of bias, one should be able to recognize this and watch out for its manifestations.

Medical schools, residency programs and other graduate school curriculi need to establish a much more comprehensive trans-cultural awareness reflecting the changing demographic realities. When therapists manage to treat minority members more competently through modifications of attitude and technique it helps to lessen social tensions and increase racial harmony.

REFERENCES

ADDISSON, R. (1997) : The racially different patient in individual and group psychotherapy. Journal of Contemporary Psychotherapy, 9,1, 39-40.
ALEXANDER, F. , FRENCH, T. (1946) : Pschoanalytic therapy: Principles and applications. New York, Ronald Press.
ALLPORT, G.W. (1954) : The nature of prejudice. Cambridge, MA: Addison-Wesley Publishing Company.
BURKE, A. (1984) : The multi-racial small group on race : theoretical issues and practical considerations. International Journal of Psychiatry, 30, 89-101.
CHEN, C.P. (1995) : Group counseling in a different cultural context; several primary issues dealing with Chinese clients. Group, 19, 1,45-55.
CURRY, A. (1996) : Group therapy as an effective treatment modality for people of color. International Journal of Group Psychotherapy, 46, 399-416.
GARDNER, E. (1971) : Psychotherapy and counseling with black clients. In P. Pederson (Ed.) Handbook of cross-cultural counseling and therapy (pp.173-179). Westport, CT : Greenwood.
GIORDANO, J. (1974) : Ethnics and minorities; a review of the literature. Clinical Social Work Journal, 2, 200-207.
GLOBE AND MAIL (1998) : p.A8, February 18, Toronto.
HOLMES, D.E. (1992) : Race and transference in psychoanalysis and psychotherapy. International Journal of Psychoanalysis 73, 1,1-11.
IVEY, A. IVEY, M. and SIMEK-MORGAN, L. (1993) : Counseling and psychotherapy. A multicultural perspective. Boston : Allyn&Bacon.
JENKINS, A. (1990) : Dynamics of the relationship in clinical work with African-Amerian clients. Group, 14, 1 36-43.
KARDINER, A. , OVERSY, L. (1951) : The mark of oppression. New York : World.
KARON, A.B. (1958) : The negro personality : A rigorous investigation of the effects of culture. New York : Springer.
KENNEDY, J. (1952) : Problems posed in the analysis of Negro Patients. Psychiatry, 15, 313-327.
KIBEL, H.D. (1972) : International conflicts as resistance in group psychotherapy. American Journal of Psychotherapy, 26, 555-562.
LEARY, K. (1995) : "Interpreting in the dark." Race and ethnicity in psychoanalytic psychotherapy. Psychoanalytic Psychology, 12,1 127-140.
LIEBERMANN, M. , YALOM, I. , MILES, M., (1972) : Encounter Groups : first facts. New York; Basic Books.
MAHARAJH, J. (1984) : Alice in Wonderland : the multi-racial small group in clinical practice. International Journal of Social Psychiatry, 30, 1-2, 85-88.
PERSONAL COMMUNICATION (1994) : Conference of the German Association of Group Psychotherapy and Group Dynamics. Bad Wildungen, May 13-15.
RIDELY, C.R. (1984) : Clinical treatment of the non-disclosing black client. American Psychologist, 39, 1234-1244.
SALVENDY, J.T. (1983) : The mental health of immigrants : a reassessment of concepts. Canada's Mental Health, 31, 1 9-16.
SALVENDY, J.T. (1985) : Training, leadership and group composition : A review of the crucial variables. Group Analysis, 18, 2, 132 -141.
SALVENDY, J.T. (1999A) : The dynamics of prejudice in Central Europe. International Journal of Psychotherapy 4:2, 145-159.
SALVENDY, J.T. (1999B) : Ethnocultural Considerations in Group Psychotherapy. Internat. J. Group Psychotherapy 49:4, 429-464.
SCHACTER, J; BUTTS, H. (1968) : Transference and counter-transference. Journal of the American Psychoanalytic Association, 166, 792-808.
SILVERSTEIN, R. (1995) : Bending the conventional rules when treating the ultra-orthodox in group setting. International Journal of Group Psychotherapy., 45,2, 237-249.
SPIEGEL, J.P. (1976) : Cultural aspects of transference and countertransference revisited. Journal of the American Academy of Psychoanalysis, 4, 447-467.
SUE, S. ZANE, N. (1987) : The role of culture and cultural techniques in psychotherapy. American Psychologists, 42, 37-45.
SUE, S. (1998) : Psychotherapeutic services fo ethnic minority groups. Some optimism, some pessimism. American Psychologist, 43, 301-308.
SUE, S. (1998): In search of cultural competence in pyschotherapy and counseling. American Psychologist, 53,4,440-448.
TSUI, P. , SCHULTZ, G. (1985) : Failure of rapport; why psychotherapeutic engagement fails in the treatment of Asian clients. American Journal of Othopsychiatry, 55, 561-569.
TSUI, P. , SCHULTZ, G. (1988) : Ethnic factors in group process : Cultural dynamics in multi-ethnic groups. American Journal of Othopsychiatry, 58, 1 142.
WHITE, J.C. (1994) : The impact of race and ethnicity on transference and counter-tranference in combined individual-group therapy. Group, 18, 2,89-99.