Religion, Ethnicity, and Attitudes Toward Psychotherapy
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- Midlarsky, E., Pirutinsky, S. & Cohen, F. J Relig Health (2012) 51: 498. doi:10.1007/s10943-012-9599-4
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Many presume that White culture supports psychotherapy utilization. However, cultural analyses suggest that many aspects of White culture are antithetical to the values and practices underlying psychotherapy, which appear more congruent with Ashkenazic Jewish attitudes and values. The current research empirically tested this possibility by comparing older Jewish White people, non-Jewish Whites, and Black participants on attitudes relevant to psychotherapy. Results indicated that Jews had greater confidence in a therapist’s ability to help, were more tolerant of stigma, and more open to sharing their feelings and concerns than participants in the other groups. Furthermore, initial differences between Whites and African Americans were lessened when Jewish identity was included in the analysis. Results suggest that Jewish culture is relatively accepting of psychotherapy, and that previous reports of different rates of mental health seeking attitudes and utilization by Whites and Blacks may be due, in part, to the inclusion of Jewish individuals in these samples.
It is increasingly acknowledged that psychotherapy, like any scientific practice, can only be understood within its historical and cultural context (Norcross and Freedheim 1992; Pickering 1992). Many authors ascribe the practice of psychotherapy, and more broadly the science of psychology, to White Eurocentric culture (Grieger and Ponterotto 1995; Jackson 1995; Katz 1985). For example, Katz (1985, p. 619) asserts that “Because counseling theory and practice developed out of the experience of White therapists and researchers working almost exclusively with White client systems, it comes as no surprise that the profession reflects White cultural values.” Similarly, Ivey (1995) underscores the White, middle-class, male, Eurocentric roots of psychotherapy.
However, although it is often considered a truism that psychotherapy is rooted in White cultural values (Langman 1997), many aspects of White culture appear antithetical to psychotherapy. As described by Langman (1997), psychotherapy requires that clients acknowledge that they have a problem, seek help from an expert stranger (the psychotherapist), and freely express their emotions, thoughts, desires, and personal experiences. Each of these activities assumes an attitudinal stance foreign to White Anglo-Saxon Protestant culture. As noted by many (Katz 1985; McGill and Pearce 1982; Zborowski 1969), White culture values the “rugged individualist,” who is self-reliant, independent, autonomous and reluctant to appear helpless, weak, and dependent on others. Such individualism appears to stand in direct contrast to help-seeking for mental health concerns, which requires acknowledgment of the existence of psychological problems, and acceptance of help from a psychotherapist. This discrepancy may underlie the stigmatization of mental health help-seeking reported among many Whites as participation in psychotherapy may signal a diminution of adequacy and of personal control (Hadas and Midlarsky 2000). Furthermore, psychotherapy requires that the client frankly expresses his or her emotions, thoughts, and experiences, an interpersonal openness directly conflicting with the emotionally controlled, objective, and rationalistic communication style characterized by Katz (1985) as a key component of White culture. Thus, the assumption of a White cultural basis for psychotherapy appears inaccurate and incomplete.
Largely ignored is the role of European Ashkenazic Jews and their culture in the development and advancement of psychotherapy (Langman 1997). Psychotherapy has been dominated by Jewish figures (e.g., Sigmund Freud, Alfred Adler, Aaron Beck, Donald Meichenbaum, Albert Ellis, Abraham Maslow, Salvador Minuchin, Kurt Lewin, Fritz Perls, Hans Eysenck, Joseph Wolpe, William Glasser), and many significant similarities between psychotherapy and traditional Jewish attitudes, beliefs, and practices have been noted (e.g., Langman 1997; Schachter-Shalomi 1991; Ostow 1982). As described by Langman (1997) and others (Fischer et al. 1983; Greenley and Mechanic 1976; Lovinger 1984), several key components of Ashkenazic Jewish culture dovetail with psychotherapy’s emphasis on help-seeking, emotional expressivity, and focus on self-knowledge and mastery.
In contrast to White individualism and stoicism in regard to pain and (Zborowski 1969), Jewish culture places a positive value on help-seeking behavior. As noted by Rosen and Weltman (2005), Jews tend to seek and rely on help from experts when they perceive problems, and in the context of medical help-seeking Zborowski (1969, p. 120) quotes one Jewish patient who said, “Of course, when I don’t feel well I go to the doctor. We don’t wait.” The roots of these values may lie in the traditional acceptance of the Rabbi/Rebbe as the communal problem-solver of choice for family issues, workplace difficulties, illness, and depression (Schachter-Shalomi 1991; Zborowski and Herzog 1995). Indeed, Jewish people may sometimes have too great a degree of confidence in professionals, and trust that the helper is a skilled professional engaged in appropriate practice (Zedek 1998).
Regarding the roots of mental health problems, Christian theology depicts human beings as creatures born into a state of original sin. In contrast, Judaism makes the humanistic assumption that human beings are fundamentally good, and that problems come from behaviors that are ultimately amenable to change (Zedek 1998). The suppression of pain is viewed as failure to strive for improvement (Rosen and Weltman 2005). Indeed, Jewish culture values the open expression of pain, and it is the denial of difficulties that may be harmful (Langman 1997). As noted by Greenley and Mechanic (1976), Jewish culture encourages introspection and self-knowledge. Based on traditional Jewish notions, self-knowledge is crucial for personal mastery over both one’s identity (Ostow 1982) and over internal destructive impulses (the Yetzer Hara; Encyclopedia Judaica 1974). In light of these parallels with Jewish beliefs and attitudes, it is not surprising that psychotherapy was in many cases pioneered and developed by Jews.
In addition to cultural analyses, these ideas are empirically supported by reports indicating that Jews are disproportionately represented among mental health help-seeking populations (Fink et al. 1970; Greenley and Mechanic 1976; Scheff 1966; Yeung and Greenwald 1992). Loewenthal et al. (2002) found no studies directly contrasting Jewish White Americans, non-Jewish White Americans, and Black Americans using measures of attitudes such as confidence in mental health practitioners, stigma tolerance, and interpersonal openness just to name three. In fact, research examining cultural variations in attitudes toward psychotherapy generally assumes that all White people have the same attitudes, and focuses on comparing attitudes of Whites to non-Whites such as African Americans. Results of these studies indicate that African Americans are generally less likely to seek and employ mental health services than are Whites (Cauce et al. 2002; Kessler et al. 1994). However, much of this research fails to consider the impact of Jewish identity, and thus yields an inaccurate picture of the attitudes and behaviors of Whites in their entirety concerning psychotherapy. Indeed, it is increasingly recognized that cultural formulations should include religious groups, which often have significant impact (Cohen 2009). It is our hypothesis that the apparently greater support for psychotherapy found within White versus African American samples may be partially accounted for by any Jewish individuals who are included within the White samples. Furthermore, it may be the case that it is the differences between the Jewish versus non-Jewish cultures, regardless of ethnicity, which may explain group differences.
The current research aims to examine differences between non-Jewish Whites, Jewish Whites, and African Americans in each of five attitudinal domains: perceived need for help, interpersonal openness (about one’s problems), confidence in mental health practitioners, stigma tolerance, perceived (personal) responsibility for the cause of one’s problems, and perceived responsibility for the cause/solution to one’s problems. Specifically, we hypothesized that (1) Jews would be higher in stigma tolerance associated with mental health help-seeking, and conversely more likely to express confidence in the competence of psychotherapists to provide assistance, as compared to both non-Jewish Whites and African Americans, who may value self-reliance and stigmatize help-seeking to a greater extent (but we had no specific hypothesis regarding differences in perceived need among the three groups). We also hypothesized that (2) Jews would display greater interpersonal openness as compared to White non-Jews, who place a higher value on stoicism and the denial of pain. Reflecting the Jewish emphasis on introspection, self-knowledge, and solution seeking, we hypothesized that (3) Jews would be more likely view themselves as responsible for the solution to their problems than either non-Jewish Whites and African Americans, but not for the causes of their problems. In addition, consistent with our hypothesis that ethnic discrepancies may be enhanced by Jewish versus non-Jewish differences, we hypothesized that (4) introducing Jewish identity would lessen the magnitude of differences between White and African American attitudes toward psychotherapy. In order to explore these questions, we employed data originally collected to examine predictors of attitudes toward psychotherapy by African American and White older adults, who appear to underutilize psychotherapy more than do younger adults (Federal Council on Aging 1995). Older adults reportedly identify with traditional ethnic and religious cultures more than do younger age groups, for reasons probably attributable to the historical and ecological contexts of their age cohorts (Benson and Elkin 1990; Hood et al. 2009). Thus, employment of an older sample allows a stronger empirical test of Langman’s (1997) qualitative analysis, which posits that Jewish culture is more congruent with the theory and practice of psychotherapy than is non-Jewish culture.
We initially contacted 321 community-dwelling older adults, all of whom were English-speaking, lived in the New York metropolitan area, and were perceived by a mental health professional to have psychological problems. Of these individuals, the preponderance (96 %) agreed to participate. Excluded from the study were individuals who had received mental health treatment within the past 5 years, resided in an institution of any kind (including a nursing home), or suffered from an organic brain syndrome or psychosis precluding informed consent. Analyses were conducted solely on data from participants who reported an ethnicity of White or African American. The final sample consisted of 307 individuals ranging in age from 65 to 94 years (M = 74.01, SD = 6.95). Of these, 64.5 % were women, and 35.5 % were men. About half of the subjects (52.8 %) were Black and 47.2 % were White. About half (52.4 %) of the group of Whites were non-Jewish, and the remaining 47.6 % were Jewish. Regarding marital status, 47.2 % were widowed, 29.6 % married, 13 % divorced, and 10.2 % were separated or never married. No demographic differences were found between the study participants and the 4 % of those originally contacted who declined participation. Ethnoreligious groups did not differ in terms of gender (χ2(2, N = 307) = .64, NS); however, the African Americans were younger (F(2,304) = 26.37, p < .001), and more likely to be divorced (χ2(8, N = 307) = 27.82, p < .001) than both the non-Jewish Whites and the Jews.
Attitudes Toward Psychotherapy
Participant attitudes toward psychotherapy were assessed using the Fischer-Turner Attitude Toward Seeking Professional Psychological Help Scale (ATSPPH; Fischer and Turner 1970). This scale consists of 29 Likert-type items, which are scored on a 4-point scale ranging from “agree” to “disagree.” This instrument yielded four divergent subscales measuring specific attitudinal domains, each of which was internally consistent in our sample. These were Recognition of Need (a = .75), Stigma Tolerance (a = .73), Interpersonal Openness (a = .66), and Confidence in Mental Health Practitioners (a = .75). The ATSPPH has previously demonstrated test–retest reliability and low correlations with social desirability (Fischer and Cohen 1972), the ability to discriminate between those who have utilized psychological services and those who have not (Price and McNeill 1992), and has been widely used with a variety of populations (e.g., Brody 1994; Kaminetsky and Stricker 2000; Joyce et al. 2009).
Perceptions of Responsibility for Cause and Solution
Perceptions of responsibility for cause and for solution were measured by a scale developed by Midlarsky and Kahana (1994) that has been used in several investigations of personal control orientations among older adults (Hadas and Midlarsky 2000; Nemeroff and Midlarsky 2000). Perceptions of personal responsibility for cause were assessed using eight Likert-like items such as “My attitudes tend to cause a lot of my problems”; “The troubles I face were caused by events outside my control.” Responses to these items were averaged to form an internally consistent “personal responsibility for cause” score (α = .85). A second group of eight items assessed the extent to which respondents regarded themselves as responsible for solutions, and included such items as “I play an important role in solving my problems,” and “I need to rely on others to do what needs to be done for me.” Responses were again averaged to form an internally consistent “personal responsibility for solution” score (α = .76). Higher scores indicated that individuals viewed themselves as responsible for either cause or solution, while lower scores denoted that external forces were viewed as responsible. These scales have previously demonstrated both convergent and discriminant validity (Hadas and Midlarsky 2000).
Potential respondents were informed about the study by referring professionals, and then received a letter describing the general framework of the study. An appointment for an individual interview to take place in their home was scheduled for each respondent who agreed to participate, and demographic data were collected both from participants and from those declining to participate. Prior to the interview, participants signed a consent form informing them that the study was a survey about their health, social relationships, and current life situation and that the goal was “to learn more about how older adults feel about the counseling services available in their community.” They were also assured about the confidentiality and anonymity of the data. All interviewers were individuals with masters or doctoral degrees in psychology, sociology, or social work, and were trained to interview older people experiencing psychological distress. Interviewers read each question to participants, who responded orally. The protocol and procedures used in this investigation were approved by the Institutional Review Board of Teachers College, Columbia University.
Comparison of Jewish, non-Jewish White, and Black attitudes toward psychotherapy
Confidence in psychotherapists
Responsibility for cause
Responsibility for solution
Results of the ANOVAS indicated no significant differences in the degree to which Jewish and non-Jewish Whites perceived a need for psychotherapy, whereas African Americans expressed lower perceived need than both groups. Consistent with our hypotheses, Jews and other Whites differed on several other variables. Jews expressed greater confidence in psychotherapists’ ability to help them, greater willingness to express their thoughts and feelings to a psychotherapist (interpersonal openness), and were more tolerant of any stigma associated with the need for psychotherapy than either non-Jewish Whites or Blacks. These results parallel Langman’s (1997) cultural analysis, which asserts that Jews tend to have greater confidence in professional helpers, and contrasts the interpersonal openness and generally positive attitudes by Jews about mental health help-seeking with the values placed on self-reliance and stoicism by non-Jewish Whites. Furthermore, consistent with the theoretical perspectives of Greenley and Mechanic (1976) and Ostow (1982), Jews accepted less personal responsibility for causing their problems, and greater personal responsibility for solving their problems, than the other study groups. These findings are in accord with previous descriptions of Ashkenazic Jewish Culture as one that promotes introspection, and wherein self-knowledge is considered to be crucial for mastery over one’s problems.
Ethnicity and Jewish identity as predictors of attitudes toward psychotherapy
Confidence in psychotherapists
Responsibility for cause
Responsibility for solution
Although White culture is generally presumed to provide a seminal basis for psychotherapy, many aspects of White culture appear antithetical to the values and practices underlying psychotherapy (Langman 1997). For example, White culture places a high value on the self-reliant and fully autonomous “rugged individualist” (Katz 1985; McGill and Pearce 1982; Zborowski 1969), while psychotherapy requires seeking the help of another, such as the therapist, for personal problems. Furthermore, White culture values an emotionally controlled, objective, and rationalistic communication style (Katz 1985), while psychotherapy requires an open acknowledgment and expression of emotions, thoughts, and desires. In fact, as described by many (Langman 1997; Fischer et al. 1983; Greenley and Mechanic 1976; Lovinger 1984), the key attitudes and values underlying psychotherapy appear more consistent with European Ashkenazic Jewish culture than with American non-Jewish White culture. The current research supports these assertions by demonstrating that older Jewish participants express attitudes more consistent with psychotherapy than do White participants.
In particular, when compared to non-Jewish Whites, the Jewish people in our study were more confident in a therapist’s ability to be of help, more tolerant of any stigma associated with mental health help-seeking, and were higher on interpersonal openness (cf, Ross and Mirowsky 1989). Furthermore, Jewish participants were not likely to perceive themselves as responsible for the cause of their problems, but were significantly more likely to perceive themselves as responsible for solutions when compared to both non-Jewish Whites and Blacks.
In fact, the intriguing dichotomy between perceptions of cause versus solution has been previously reported in a study comparing the reactions by older Jewish and non-Jewish mothers to the death of a child. In that study, Jewish mothers expressed greater external locus of control, despite seeing their loss as preventable or as a punishment for their own shortcomings (Goodman et al. 1991). This intriguing dichotomy may be a function of personal and intergenerational traumatization through pervasive European anti-Semitism culminating in the near annihilation of European Ashkenazi Jews in the Holocaust (Brustein and King 2004). Since socio-political trauma has been generally unavoidable and victimization almost normative under certain circumstances, it was realistic to take little or no responsibility for causes of one’s problems (i.e., to have an external locus of control for the causes of one’s problems) (Maercker and Herrle 2003; Solomon et al. 1988; Landau and Litwin 2000). On the other hand, the Jewish cultural and religious lens places a strong value on the self in the solution for problems (Greenley and Mechanic 1976; Ostow 1982). Thus, although they were more likely to perceive external forces as responsible for the causes of their problems, Jewish people took personal responsibility for the solutions to their problems. Seeking help from mental health professionals is an important way in which internal control for solutions can be manifested (Hadas and Midlarsky 2000).
Furthermore, it was our expectation that differences between Whites and African Americans would be lessened by the inclusion of people with Jewish identities. Consistent with this possibility, we found that the inclusion of Jewish identity attenuated differences between Whites and African Americans and revealed the other differences described above. However, some differences between attitudes of Whites and Blacks (i.e., perceived need, confidence in psychotherapists, and stigma tolerance) were still significant, even after controlling for Jewish identity, while other attitudes were not. These results suggest that although some of the previously reported differences between Whites and African Americans can be explained by the inclusion of Jews in the White sample, others cannot. In conclusion, our results suggest that Jewish culture is most compatible with the values and methods of psychotherapy and that the relatively greater willingness of Whites to engage in psychotherapy, when compared to Blacks, may be due, at least in part, to the inclusion of Jewish individuals in those samples.