I spent five days training counselors in Rwanda in 2008. During each break and after each class, two young men asked me many questions about the pragmatics of counseling in the United States. They seemed especially interested in the length of counseling sessions as we practice them in the United States. I explained a “therapeutic hour” to them several times. Each time they nodded and seemed to understand. Then, at the next break, they would raise the same question again.

Finally, on the last day of training, one of the men respectfully said to me, “Dr. Moffatt, I want to learn from you, but not too much.” I asked him what he meant. He explained that in the Tutsi and Hutu cultures, a 50-minute hour would never work because it would be too rushed. “I might need a whole afternoon with someone,” he said.

Suddenly, I realized why my students in class and my clients outside of class took as much as 30 minutes simply to ask their questions. Relationships are built over time, and trust is acquired by hearing all the details — everything the speaker thinks could be pertinent. For example, my clients might begin asking a question about their marriage by saying, “When I was 5, my father …”

They are not merely providing information or rambling. By patiently listening to their long stories, I confirm for them that I have all the important facts, but more important, I show that I am willing to invest in them. A 50-minute therapy hour would never work in such a context. My Rwandan students taught me that counselors would need to spend a minimum of three hours with clients in their country. That would never work in the United States, but our system would never work in Rwanda. If I had failed to be sensitive to learning from my students, I would have completely missed this critical cultural variance.

Even in the United States, there is amazing diversity, so what we learn in graduate school doesn’t always work very well in real-life practice. For example, I was taught that clients should come to my office, that my office should be arranged a certain way and that everything from lighting to temperature to furniture should be controlled to create the ideal environment for trust and rapport. Generally, these instructions have worked well for me. But the first time I conducted a home visit, I sat in a dimly lit living room on furniture that was less than comfortable. Children were running around, ringing telephones and traffic noise distracted me, and it was nearly impossible for me to maintain a good “listening posture” with my clients, a married couple sitting at opposite ends of the room. Yet I realized I was the most uncomfortable one in the room. Everyone else was fine.

Since that time, I’ve made hundreds of house calls, often with great success. This is especially helpful on the American Indian reservations where I’ve worked for several years. Transportation is often a problem for these clients, but the greater obstacle is that Apache, Hopi and Navajo families are especially leery of counselors, so they would almost never come to a counselor’s office. But even though they remain exceptionally skeptical of Caucasians, these families warmly welcomed me into their homes.

Lessons learned

During the past 20 years, I’ve visited more than 20 countries on four continents. The need for a longer therapeutic hour in Rwanda and the value of home visits are just two of the many lessons I have learned during my expeditions into other cultures. I’d like to share a few other things I’ve learned about how counseling actually works across cultures.

What I was taught: It is ethically questionable to have a counseling session where other people can hear or see your clients.

How it really works: I often counsel in very remote and poor areas. The luxury of having an office that provides total confidentiality is rare. And then there is the culturally questionable behavior of a man and a woman meeting in any kind of private place. In Peru, I sat in the middle of a large open area in a building that served many purposes during the week — as a community center, as a gymnasium for soccer and children’s games, as a classroom and even as a church on Sundays. The couple I was working with seemed unbothered by the fact that the sun was setting and we had almost no light or that people were coming and going just 20 or 30 feet away. In their culture, tight spaces were not unusual and, in general, everyone respected one another’s privacy as much as possible.

Although I would have preferred a more private space, the only other choices were the busy sidewalk or a noisy restaurant. It sometimes worked to meet in homes in Peru, but several generations often lived in the same small space, making confidentiality an even bigger problem. Plus, we then had to contend with noise from children, pets and neighbors.

What I was taught: Counselors don’t give advice. We help people decide for themselves what they want and need.

How it really works: Almost nothing I learned in graduate school is more Western in thought than this concept. When I’m in a foreign country, I’m only there for a few days or a few weeks. I don’t have the luxury of session after session of brainstorming, homework and therapeutic ideals. In many countries (India, the Philippines and some parts of Mexico to name a few), they expect something from their visit. They do not want to hear, “What do you think?”
Imagine calling a plumber because your faucet is leaking. He arrives, tools in hand, and all he can say is, “So, what I’m hearing you say is you are distressed about the leak in your bathroom. How do you feel about that?” We expect him to fix the leak. When clients in many cultures risk coming to see me — and it is a risk for them because, in some cultures, counselors are viewed less honorably than witchdoctors or palm readers — they want answers. This doesn’t mean that I do all the work. After all, I’m not a guru or a village elder. However, the way I practice in the United States doesn’t necessarily work elsewhere. In many countries, I have to be much more directive or I would never gain respect from my clients, just as your plumber would fail to gain your confidence if he didn’t get busy fixing your leak.

What I was taught: Paraphrasing is a way to make sure you understand your clients. If you misunderstood something, they will usually tell you.

How it really works: This approach works well in the United States but not in cultures such as India and Panama. Among the natives of interior Panama as well as in India, saying “no” is the highest form of insult — especially to someone “superior” to you. In both countries, I eventually realized my clients never contradicted or corrected me. Even in the United States, I don’t get it right every time, so I knew something was wrong. One gentleman in Panama finally explained that they would rather be misunderstood than to insult me because I’m a “doctor” — a person of higher status.

During one trip to India, I became aware that clients wouldn’t ask me questions. I found out that asking questions, even in an academic setting, is considered insulting. To them it implies that the teacher didn’t teach well enough. So I repeatedly asked my clients to ask questions if they had them. It took hours of interaction with them before they realized I meant it. In both cultures, I’ve had to learn other ways to confirm what I think clients are saying. I rely heavily on congruence of the narrative. As with my Rwandan clients, this takes far longer than it would in the United States.

What I was taught about other cultures: Nothing. When I was in graduate school, there was no course work on cultural diversity.

How it really works: For more than 20 years, I’ve taught a course on diversity at both the undergraduate and the graduate levels. As an introductory course, I teach my students about “American Indian” culture, “Latino” culture and “African American” culture. But lumping all Latinos together as one culture is like lumping all Europeans together as one culture. Do Germans really have anything much in common with the Portuguese?

There are immense variations in food, religious beliefs, language, clothing, customs and expectations even within cultures. For example, I speak Spanish, but I function much better in Spanish in Chile, where I spend several weeks each year, than in any other Latin culture. The language nuances of Mexico, Peru, Colombia and Argentina are quite different. Likewise, in southwestern India, almost all men wear a type of clothing called a lungi, while almost all women wear a sari or a chudidhar. Nearly all marriages in that part of the country are arranged by parents. But in Bangalor or Chennai, almost nobody wears chudidhars, saris or lungis, and many young people court and choose their own mates in a similar fashion to people in the United States. The stereotypical turban is worn in some parts of India, such as Delhi, but almost never seen in other parts of the country.

St. Vincent and the Grenadines, a small series of islands in the Caribbean, is the most diverse place I have ever been. At one time, these islands were a crossroads between the European mainland and the Americas. Every single client who came through my office space in St. Vincent was from a different country — and none of them was from St. Vincent.
Cultural variation within a people group can be determined by rural versus urban, type of religion, socioeconomic status, caste, language, education or a variety of other measures. Recognizing these variations is critical to building rapport.

Conclusion

My education was important, and the things I learned in graduate school formed the foundation on which my practice has been built. I still practice many of the things I was taught, both in the United States and in other cultures, but I am exceptionally careful not to assume there is only one way to practice. The ideal situations I learned about in my textbooks rarely match what I am faced with in real-life practice, whether in a sweltering grass hut in the Philippines, the frigid winters in Chile where I counsel wearing mittens and I can see my breath, or even instances in which I use Skype or some other electronic medium to help clients face the demons that possess them.

I have never abandoned my training or ethics. However, my hope is that my flexibility brings healing to individuals, marriages and children from varied backgrounds. At the same time, they are teaching me how to move beyond my books and become a more effective therapist.

Letters to the editor: ct@counseling.org