When I work with couples in marriage counseling one of the first questions I ask is “what does marriage mean to you?” Marriage therapist Dr. John Gottman focuses on identifying shared life dreams as a glue that can hold marriages together. Both partners need to support each others’ life dreams, and ideally these should be compatible, have some overlap, and be motivational and inspirational for both. Life dreams reflect a shared meaning in life.

But what happens when culture influences a life dream, and both partners are from different cultures? A couple comes to mind, where the husband is from a traditional Eastern mind-set: marriage means being responsible, a care-taker and good provider. To him, these main factors qualify him as a good husband. But his wife was raised in the West, and to her marriage means loving compassion and respect for each other: it’s not what you DO for your partner but how you make them FEEL. And though she’s well provided for, she doesn’t feel the love.

Psychologist Robert Sternberg said loving marriages need friendship, commitment and passion. My multicultural couple can’t relate to this – except for commitment based on the needs of their children, they can’t agree on what friendship and passion even mean. Marriages where there are no shared life dreams, are on shaky ground. When the very definition of marriage holds different meanings, how useful is my therapeutic intervention: “so, what does marriage mean to you?” This vital question needs to be discussed BEFORE getting married. The meaning of marriage in many cases has already been formed through learning from the parental model of marriage, and through the process of enculturation. Doesn’t it make sense to explore these concepts before tying the knot, so a couple can develop a common, mutually agreed upon  life dream – one that forms the foundation for spending their life together meaningfully?

Single women who are over 35 and who have come to me for counseling, regardless of race, religion, nationality, education and status,  all have the same core issue: a “feeling unloved” schema. Each one of these ladies (and I’m talking about more than 10 this year alone), wants to find a guy who will love them. My efforts in helping them re-evaluate their self-worth, or try to re-frame the situation by looking at what’s good in life, or look for meaning in life that’s not dependent upon a partner – are usually futile. I’ve tried helping them identify unhealthy beliefs, socratically questioning them, behavior experiments, problem-solving, self-esteem building, but most of the time they still walk away unable to look inwards for the source of happiness.

The more traditional Eastern female mindset places value on a woman’s role as wife and mother. This value is culturally rooted, and even career-minded, financially independent and successful Eastern ladies do not find fulfillment in their professional lives if they are older. Something crucial  is missing for them – their other half. So they seek help in trying to come to terms with the reality of being unloved. I have listened to how they try to find a mate through community social events, online dating sites, even going to match-makers who do this for a living. But they are disheartened by repeated failed attempts – activating a “failure schema” in addition to the “unlovable schema”. Of course I’m talking only about the women who seek counseling; there are tons of psychologically resilient single older women out there too.

Ditto with my Western female clients who, in contrast,  have been raised valuing independence and self-sufficiency. It seems a bit of a contradiction when Western culture encourages individualism – and yet I see the same issues: low self-esteem, and a lack of fulfillment because of a missing “other half”. They express similar core beliefs and negative automatic thoughts as their Eastern- raised sisters: something crucial is missing in their lives.  Dating or living together haven’t worked, and they are still alone and unhappy, ruminating about their body clocks that are ticking away.

Is it true: are we women psychologically wired to seek a mate and do we feel unworthy, unloved and unfulfilled if we’re alone? Do we really need our other half, to feel whole?

There’s a saying in some cultures that “heaven lies under a mother’s feet” – I think it reflects the sacrifice that mothers make as child bearers. Please dads, don’t feel left out. Recently I’ve witnessed overwhelming paternal love that is so full of heart breaking worry, that it hurts. This type of fatherly feeling has no cultural or geographic boundaries. Six current cases come to mind, three of them of Western ethnicity, and three from Eastern traditions. Even though their world views, languages, and outer appearances vary, these men all share a common internal state: a feeling of desperation and a willingness to do whatever it takes to help cure their emotionally unwell kids (who range in age from 15 to 34).

The parallels are amazing. Each of these cases is very different in terms of family history, life situations and diagnoses. But each of these ethnically diverse dads is brainstorming, searching, and acting in a way that can only be driven by unconditional love. Make no mistake, they are not weak or lacking in resiliency. Each of these men is psychologically hardy in his own way. But the pain shows on their faces, and I can hear it in their shaky voices as they struggle to try to understand what’s happening to their children. For the Western -oriented dads, when their adult “child” has debilitating OCD behaviors, or alcoholism, the cultural ideal of fostering independence and self-sufficiency in one’s off-spring  seems to melt away; when it’s their flesh and blood who may be suicidal or in the downward spiral of depression these dads will do whatever it takes to rescue their kids.

When faced with similar trauma, Eastern dads let go of the stigma and shame linked with DSM Axis 2 personality disorders. I see them side-stepping family and community support typical of collectivist cultures – in an effort to seek the best possible empirically proven treatments. It’s heartbreaking to see a dad’s despair. It’s also a reminder that we are all just human. Sometimes we are stripped of the protective layers that culture surrounds us with, stripped down to bare emotions and vulnerability that is universal. After seeing what these brave, committed dads go through when faced with the possibility of losing their children to mental disease, I’m convinced, heaven must lie under a father’s feet too.

Sometimes I really get frustrated! The population I work with is culturally diverse, and I truly value and respect that. But sometimes I have to “sell” the benefits of psychotherapy to parents who can’t understand why their teenagers won’t just talk to them or to other family members about their problems. Some of these parents are so resistant to counselling therapy for their kids, that they sabotage the process from the intake session by openly expressing a lack of confidence in having their teens talk about family problems to a stranger. Some teens have even told me that their parents warn them about psychologists who are only interested in money.  But parents of disturbed kids end up bringing them to therapy anyway because the psychiatrist made scary predictions of suicide risk factors, or the school administration made counselling mandatory in order for the child to remain in school.

Of course the youngsters pick up on the lack of optimism with regards to counselling. This can seriously jeopardize the chance of a good outcome in therapy. However, some kids have been socialized (through school and friends) to be more open to modern psychology, so some of them want therapy even without parental moral support. It’s sad when the parents are the main obstacle to seeking help. Neural plasticity, which enables our brains to change and adapt, helps these youngsters adapt to life situations – I wish it would work for  their parents in the same way!

A basic principle of counselling is that human behavior must be looked at within an environmental context. Why can’t some parents realize that if their teenagers are in a rough, stressful environment, then they may act out or display maladaptive behaviors – regardless of the culture at home. A teenager’s psychological health is tied to his societal system. But some parents are blind to the reality of the psycho-social interaction; they draw the circle of influence around family and home alone.

When cultural taboos prevent psychological treatment, it’s time to adapt. My plea to some parents: please, open your minds………don’t be afraid of losing your culture…….you may lose your kids in the process.

When we think of culture, we usually think about language, food, art, customs and rituals. Culture is the spice of life and generally enriches our lives, right? That’s one way to view culture.

But sometimes teenagers and young adults feel conflicted by the differing demands and expectations of the globalized monoculture versus their own culture. And I’m not just talking about minority cultures – even in communities where the dominant culture is conservative or collectivist, many people are still influenced by the appeal of Western pop-culture. Erik Erikson described the driving force for adolescents as individual identity versus identity confusion. Many of my clients readily identify as coming from traditional, conservative cultures, seemingly comfortable with this view of self. But the reality is that culture is a chronic stressor in their lives. The World Health Organization has described depression as the next global epidemic. I believe culture-based stress is a factor leading to high rates of mental and emotional problems.

In my practice I see teenagers who are taught to respect their parents above all else. Some develop codependency traits as they focus on family needs and neglect their own needs. Their sense of self is  closely tied to heritage – but they are pulled in an opposite direction when seduced by the allure of independence, individualism and fewer boundaries. Tasting the pleasures of forbidden fruits triggers the cycle of excitement, guilt, and shame. Rather than the spice of life, culture becomes a red-hot chili pepper, stinging and burning as they try to make sense of this internal conflict – the tug of war between loyalty to culture, or to self.  This dissonance manifests as anxiety and depression. Their culture is a stressor.

Another group of my clients are depressed single women in their late thirties, stigmatized by their cultural view that a woman’s identity should be linked to being a wife and mother. In counseling these clients present with secure early attachments, no apparent traumas, no other external stressors – aside from cultural expectations which become triggers for low self-worth.

In my view, the evolutionary process of adaptation needs to be applied to culture as well. I’m not endorsing a melting pot – I’m just saying that black and white thinking can lead to stress. So I ask my clients if they can be a bit more flexible with their beautiful cultures, hold onto basic values, but be a bit more accepting of change and different environments. Live life in the grey area……it’s more palatable.

The Western model of counselling encourages us therapists to help our clients explore their issues, develop insight, develop coping mechanisms and tools to make their own decisions. We encourage autonomy, which we believe will empower our clients to find their own solutions. After all, isn’t our goal usually to help our clients achieve self-sufficiency? We’re not supposed to give advice, right?

This model doesn’t always work for all cultures. In the East, collectivist attitudes still prevail over the individualistic mind-set. Problems are solved within the community and family system. A young Omani client who came to see me for marriage counseling told me that back home specialists such as psychologists are few in number, because there is a good support system already in place in the form of extended family members……….who give advice. My knee-jerk reaction was, “does that really help people deal with life problems in the most considered, consistent and constructive way?”. He grinned, and reminded me of the significantly lower rates of depression and anxiety.

A Japanese client who was seeing me for marriage counseling asked me bluntly “what should I do?” This is after she revealed that her spouse had cheated on her. Her expectation was that she had paid money for counseling, and if I don’t give her advice, she may have wasted her money. After -all in the English language, to counsel means to advise.

I work with a very culturally diverse population.  Hence, I need to be diverse in my approaches with them. Symptoms and behaviors may have no cultural boundaries, but clients differ in their needs from therapy. Sometimes open-ended questions leave the client feeling confused, weak and scared. In my view, occasionally giving a client my advice often results in them walking away with a sense of relief, which in turn leads to uplifted mood, reduced anxiety, and strangely, a sense of confidence. Counseling goal achieved! People may wonder if this hinders building long-term psychological resiliency. My conclusion on that is that it’s my job to work within their cultural norms, and if seeking sound advice helps them, then let that be a coping mechanism for them to use now and in the future.

If client beneficence is the framework for counsellor ethics, I believe we need to be very flexible with our theoretical approaches. Self-sufficiency isn’t a goal for everyone. Rogerian- style unconditional positive regard and  person-centered empathic listening can lay the foundation for an emotional support strategy that includes advice-giving – if that’s what the client needs. It’s a no-brainer that when I give advice it has to be through the worldview of my clients. As a counselor I can sometimes model the attitude that makes them feel truly supported – the role of advice-giver.