Systematizing cultural awareness: Toward a model for modification of trauma therapy and an application in Turkey

Dimension 1: Relational/individual self

This dimension draws on the work of Çiğdem Kağıtcıbaşı (2005), a Turkish cross-cultural developmental psychologist. She describes relational cultures as supporting the development of a strongly connected conceptualization of self, based on secure attachment and a high value on relationships. The relational self involves the sense that one’s identity is firmly connected to other individuals and that being part of groups is fundamental to selfhood. Family, tribe, and other social groups and affiliations are construed as the fundamental features that define a person. Many cross-cultural psychologists describe this view as a “collectivist” conceptualization of the self (Kim, 1994). Kağıtcıbaşı (2005) emphasizes that a relational self concept can allow for individual autonomy in action and emotion.

An individualistic conceptualization of the self is the contrasting conceptualization of self. Individualism values a highly differentiated and separated concept of self in relation to others. Independence and self-sufficiency are highly valued. The United States and many northern European countries rate very high on measures of individual conceptualization of self (Hofstede, 2003).

For the purposes of our work with abuse survivors, one of the important implications of this dimension is the effect it had on the emotional, interpersonal boundaries of the women with whom we worked. In the aftermath of trauma, the boundaries of a person’s perceived self, field of action, and responsibility are of great importance to the healing process. Researchers have argued that “psychotherapy must address two fundamental aspects of PTSD: the deconditioning of anxiety, and the pervasive effects that trauma has on the way victims view themselves and the world” (van der Kolk et al., 1995, p. 2).

For instance, many of the relatively relationally oriented women in our Ankara survivors groups described themselves as coping with their own distress physiologically and emotionally. Yet many of them said they felt completely overwhelmed when they imagined the impact that knowing about the abuse might have on members of their family. A more individualistically oriented survivor might more easily separate her distress from that of her family members.

Dimension 2: Situationalism/universalism

This dimension is concerned with the way that a person conceptualizes the moral or ethical basis of action. How do we order social life? Is the primary reason for construing one behavior “good” and another “bad” a matter of universal rules and principles, or is it a matter of situations, relationships, and social positioning? Do we act based upon a set of universal principles and rules? Or, do we believe that the most important way to determine right action is based upon the social position a person holds?

The work of Lawrence Kohlberg (1958, 1971) and Carol Gilligan (1982) explores the reasoning processes behind moral decision making. Moral reasoning has a basis in values. The statement, “principled action is the highest form of morality,” represents the universalist pole of this dimension, whereas “rules apply only to the weak” represents the situationalist pole. Trompenaars (1993) discusses something similar to this dimension in his universalism/particularism concept.

This dimension also considers values about quality of life. Is personal achievement valued most highly, or rather an ethic of broader social harmony, altruism, and care? Within the boundaries of a defined group, quality of life tends to be a value for everyone. How broad are the boundaries of the rules of altruism, compassion, and caring for the vulnerable? Is there a universal scope for the rules, or is the focus of concern only the individual, one gender, a family or a tribe? A competitive achievement orientation, or focus on cultivation of personal accomplishment or high social status can be associated with a situationalist ethic. The achievement versus altruism aspect of this dimension is described by Hofstede (2003) as “Masculine versus Feminine” values in a culture. ¹

Kağıtcıbaşı (2005) points out in her concept of the “autonomous relational self” that a person may value relationships and relatedness and at the same time have a high level of interest in achievement and personal accomplishment. She argues that interdependence does not preclude independent action and personal accomplishment. Values of altruism and social cooperation may or may not be fostered by a high value on relatedness. The boundaries of what is considered worthy of concern are most significant.

In these sexual abuse survivors groups in Ankara, the issue of universalism versus situationalism surfaced when the women spoke frequently about their perception (and frustration) that men have license to have sexual relationships outside of marriage but women do not. This is an instance of situationalism, rather than a universal rule about sexual behavior applicable to both genders.

Dimension 3a: High/low power differential

This dimension examines differences in relative social power between people. In low power differential cultures, people have relatively egalitarian social status in relation to one another. High power differential implies a high level of hierarchical difference in social status. Authoritarian and elitist systems are most compatible with a high power differential point of view. Egalitarian social structures support a low level of power difference between individuals and groups. Hofstede (2003) discusses this concept as “Power Distance” and argues that it varies significantly between cultures and has important implications for the functioning of hierarchies and organizational decision making. Theorists interested in the phenomena of social minorities and the experience of oppression explore this issue in great detail. The work of Leticia Nieto in Beyond Inclusion Beyond Empowerment, is an excellent resource on this issue (Nieto, 2010).

In our trauma treatment groups in Ankara one example of the high power differential context was members’ frequent comments on class differences between the group members. In many groups, members discussed their desires to set class differences aside and find solidarity instead as survivors and women: “We’re all women, no matter what our backgrounds are.”

Dimension 3b: High/low gender differentiation

This dimension may be conceptualized best as a subcategory of high and low power differential. Hofstede’s “Masculine and Feminine” conceptualization of cultural values (1998) suggests that gender differentiation may increase with power differentiation. However, the issue warrants further research. As Hofstede himself suggests (1998), gender differences are complex and controversial. Cultures vary significantly in the degree to which they expect differences between males and females. Gender roles, gender expressions, and gender identities are more or less differentiated in various cultural groupings. The expectation of highly differentiated genders is discussed in some gender theories as a binary concept of gender (Nestle, Howell, & Wilchins, 2002). Low gender differentiation expectations may make people comfortable with more androgynous appearances and less distinct and defined gender roles. For a more thorough discussion of gender expression and the performative nature of gender, see the work of Judith Butler (1999, 2004) and Riki Wilchins and colleagues (Nestle et al., 2002).

The differences between men and women are a common topic of conversation in women’s sexual abuse or family violence therapy groups. It was common in our Ankara survivor groups to hear women say they believed too much was made of the differences between the genders and for them to connect high gender differential with their abuse: “So what if I am a woman, does that mean I can’t just live my life!”

Dimension 4: Internal/external control

This dimension draws upon the social psychological literature around “locus of control” first developed by Rotter (1966). The focus here is on how a person conceptualizes the motivation or impetus for action. Do people view themselves as having a large degree of control over their own behavior and experience, that is, internal control, or do they believe that they are largely controlled by other people, random chance, or situations outside of themselves, that is, external control? Does autonomous choice form the most important basis of experience or is a person’s behavior contingent upon outside direction, external choices, and circumstances? Are avoidance of uncertainty, direct communication, and a high expectation of personal control preferred, as in internal control? (In Hofstede’s model this concept is linked with “Uncertainty Avoidance” [2003]). Or, as expressed by some members of our groups in some contexts, can a person enjoy the spontaneous and unpredictable experiences that may accompany acceptance of uncertainty, indirect communication, and an expectation of control by factors external to the self?

As therapists, one of the important questions we consider with this dimension is the degree to which a person believes that he or she is able to exercise a high degree of control or choice in their own lives and to what extent they believe they are ruled or directed by other people or by external factors like chance. This issue is especially relevant in trauma therapy. The women in our Ankara groups frequently described themselves as controlled or strongly affected by other people and external factors, especially in the first stages of the therapy work: “What could I do? Everyone expected me to be like this.”

Dimension 5: Emotional expressivity/containment

This dimension focuses on the degree to which a culture values or allows outward expression of emotions. Emotions are conceived of in some cultures as experiences or feelings that are best contained internally so that others are less aware of or affected by them. Emotions can also be conceived of as experiences and feelings that can or should be shared and expressed so that others are aware of them. This issue is discussed in Trompenaars’ schema in terms of “Neutral vs. Emotional” stances (1993).

Another aspect of this dimension relates to tolerance of affect or emotion in self and others. The position valuing expressivity perceives benefits that stem from externalizing and sharing emotions. Emotional containment may reflect a greater focus on the importance of self-control and the risks of affecting others through one’s emotional expressions. Tolerance of affect involves both the degree to which a person can tolerate his or her own experience of affect and the degree to which she or he can tolerate the expression of affect by others. Tolerance of affect in self and others may vary independently, but both are linked to expression of affect.

This dimension has significant implications for psychotherapy. In trauma therapy, the degree to which affect can be tolerated and expressed has important implications for the client’s ability to manage and integrate emotions associated with traumatic experience. For instance, borderline personality disorder, a diagnosis common among abuse trauma survivors, is a psychiatric diagnostic category in the DSM defined in part by a very low level of ability to tolerate and manage emotional experience and expression (American Psychiatric Association, 2000). We discuss more observations related to this dimension as noted in our Ankara groups in a later section.

Dimension 6: Short/long-term time orientation

This dimension is drawn directly from Trompenaars’s work (1993) and is not discussed in detail in this analysis. It has been argued that some cultural groups, including many North American indigenous peoples, tend to view events in the frame of a very long time span. This long-term orientation towards time is exemplified by concepts such as the need to consider the potential effects of present actions on the seventh generation in the future.

The Turkish and U.S. groups considered in this research did not show a clear difference in the way that they considered the time frame of actions or behaviors. Generally, the time orientation of both groups appeared to be relatively short, focused on the present and near future and immediate relatives and friends. Thus, our data do not allow for an anecdotal illustration of psychotherapeutic differences between the Turkish and the U.S. cultural groups we considered with regard to this dimension.

Cohesion/relational skill

Related to Dimension 1 (relational/individual self) in our model, the speed and readiness with which our group members connected with each other and the degree to which they developed group cohesion was remarkable compared to experiences with comparable groups in the US. With some exceptions, women joined the conversation early (within the first two group sessions) and offered significant information about themselves, their backgrounds, and their abuse, without frequent prompting from the therapists. Group members also offered interactive feedback and supported one another. Overall, group participants seemed particularly eager to join, trust, and offer one another caring. Many women spoke about how isolated they felt in the wider society because of their abuse experiences, and how valuable it was to have a social situation in which the issue of sexual abuse was not a source of stigma for them. Group participants rated group cohesion as one of the top three therapeutic factors in their group experiences on a postgroup test, Yalom’s Group Therapeutic Factors Questionnaire (Sayın et al., 2013).

Many participants quickly made strong bonds with one another, and some members of all five therapy groups continued to meet after the therapists concluded the 12-session process. However, not every group member was firmly drawn into the cohesion. In each group, one or two members stayed outside the strong cohesion, generally leaving the group early. Of our 15 dropouts, seven occurred after the screening appointment but before attending a first group session, three were asked to leave the group because of irregular attendance (after more than three absences), and five never responded to phone calls, so we do not know their reasons for dropping out. Members who stayed peripheral to the group process most often left the group altogether. It was unusual for a group member to stay and accept a position mostly separate from the group cohesion. It is possible that the style of cohesion in these groups (interacting with a relational construction of a sense of self) was related to the pattern of dropouts.

The group cohesion was sufficient to tolerate expressions of difference and conflict, but the level of difference or conflict tolerated may have been limited. The high value on politeness in Turkish social interaction also may have limited conflict expression. Closer examination of this issue is warranted. Strong group cohesion coupled with a tendency for some members to leave the group, perhaps indicative of a low tolerance for remaining separate, can be related to the relational self/individual self dimension in our model. This pattern might reflect a strong relational quality in the values and identity patterns of Turkish families (Kağıtcıbaş ı, 1996).

Expression and tolerance of emotion

Another significant theme can be related to Dimension 5 (emotional expressivity/containment) along with tolerance of affect in self and others. The level of distress expressed by these Turkish group participants, voicing pain, fear, anger, hurt, sadness, anxiety, and other emotions, was marked. It is not surprising that participants would express intense emotion in a trauma treatment group. This is an essential part of the process of trauma therapy. However, relative to the first author’s prior experiences in the U.S., this group displayed a high level of tolerance for their own emotions. In other words, although pain, difficulty, distress, and dismay about these feelings were commonly expressed in the group, participants rarely expressed a perceived inability to cope, a feeling that the emotion was wholly unmanageable, or a sense that suicide or dying would be better than the feelings that were being experienced.

The Turkish groups displayed high levels of both expressed emotional intensity and affect tolerance. The affect tolerance appeared to operate both for each member’s own emotions and for the emotions of others. In this case, “tolerance” does not imply that the women were comfortable or fully accepting of the emotions they were feeling and describing. Rather, we use the concept of tolerance in this context to indicate that the women coped with the emotions they and others expressed with a relatively low level of “acting out” and “acting in” (Yoder, 2005). Although one woman made a suicide gesture after a period of attending group, there were few self-harm behaviors among participants, and relatively little alcohol and drug abuse that the therapists were able to observe. There were also very few occasions in group when women were verbally aggressively toward one another as a means of defending against the expressed emotions of others.

This contrasts with the norms of many groups of survivors in the United States observed by Welkin. In her U.S. groups, expressions of distress and fear at the intensity of experienced emotions were frequent in trauma therapy. For example, it was common for survivors in the United States to say “I think this pain may kill me,” or “I would rather die than feel this way.” Such expressions of an inability to tolerate fear, sadness, pain, or other strong emotions were not noted in our Turkish groups. This could be because such direct expressions of distress were curbed to spare the feelings of others, or it could be that expectations of emotional intensity were different in this cultural context.

For the U.S. trained therapist, there were times when the intensity of emotion expressed in the group evoked concern. Welkin expected much more suicidal acting out and was surprised that the groups could sustain and tolerate such high levels of affect without displaying defensive stances and conflict. In the literature, there is clear evidence of cross-cultural differences in levels of emotional expressivity (Lu & Wang, 2012), but there has been no extensive study of differences in emotional expressivity between Turkish and U.S. populations. Expectations about levels of emotional expression could influence both group process and leader–member interactions. Given that one of the primary goals of trauma therapy is to bring emotions into awareness and integrate them with the narrative and sensations of the traumatic experience, this tolerance of emotional intensity was likely therapeutic for group members.

Issues of power differential

Related to Dimensions 3 (high/low power differential) and 4 (internal/external locus of control), the adult women participating in our groups described experiences of abuse that were most often perpetrated by family members, close associates, and people they expected to trust in positions of authority over them. Most of the instances of abuse happened when the women were children or very young adults. The perpetrators of the abuse were people in positions of authority over the women and victims felt an obligation to submit and to be obedient to their abusers (Sayın et al., 2013). This is the typical pattern in abusive relationships according to research in the U.S. and Europe as well (Finkelhor, 1994). Abuse consistently involves the misuse of positions of power and authority.

Mocan-Aydin (2000) identified submisiveness to authority and high power differential as significant cultural differences between Turkish and American or European groups as observed in counseling situations. A habit of submission to authority and expectations in this context that women should be obedient made Turkish women more vulnerable to abuse. In other words, a high power differential, as observed in the Turkish cultural context, may increase vulnerability to abuse. On the other hand, a habit of obedience to others, or a tendency to respect authority, may also increase the strength of the therapeutic suggestions of therapists. A well-trained therapist may have enhanced influence in a cultural context with high power differential. But of course this means that a therapist without adequate training and preparation, who is not appropriately respectful of the needs and integrity of the client, may also be very influential, with potentially negative consequences.

Challenging and questioning of therapists’ authority in our Turkish groups was muted and most often indirect. Group members deferentially called the therapists “hocam” (“my teacher”), a term of respect. They asked for advice often and rarely questioned or disagreed openly with the opinions or interventions of the therapists. In the U.S., questioning and challenging of group leaders’ power and authority is an expected part of the group therapy process (Yalom, 2005). As a therapist in the U.S., Welkin had become accustomed to much more frequent and open challenges of her authority. There were times when the respect and idealization by group members in Turkey became uncomfortable for her.

The level of power commonly afforded to therapists, especially in the context of trauma therapy, must be used with great care and caution. A cultural context of high power differential may significantly increase the potential for secondary trauma resulting from therapy experiences. Therapists must be particularly conscious of the power they hold in their position of authority in cultures with a high power differential.

Mocan-Aydin (2000) also identified a cultural difference in the tendency to adopt an internal or external locus of control. In the U.S., therapists are trained to support an internal locus of control for clients, as described in Dimension 4 (Mocan-Aydin, 2000). The common American cultural ideal is a very high level of internal locus of control which may be linked to other cultural factors within the U.S. (Berry, Poortinga, Segall, & Dasen, 1992). There is also evidence of variation according to racialized identity and social class in U.S. society; some groups tend to be less convinced of the value of an internal locus of control (Berry et al., 1992). High power differential coupled with an external locus of control expectation in our Turkish groups challenged our U.S. trained therapist’s expectations and assumptions.

Shame and namus

One of the issues that clearly distinguishes a Turkish point of view on sexual abuse from dominant attitudes in the U.S. is “namus.” The word namus is most often translated as “honor” and is often described as an Islamic concept, though in fact the values and the traditions of namus and honor clearly predate the advent of Islam. Similar values of honor have been described among groups from the Mediterranean to Central Asia, including Muslims, Christians, Jews, and other groups (Ahmed, 1992; Bağlı & Özensel, 2011; King, 2008).

Namus is involved with the integrity of family honor and social standing. The virginity of unmarried girls and the sexual virtue of women in a family are among its most important determinants. Thus, girls and women are in many ways the primary holders of family integrity and honor. Traditionally, women should protect the virtue of the family, and the standing of all the men and women in it, by maintaining flawless, unquestionable morality and purity in the eyes of the community (Cindoğlu, 2000; Delaney, 1991; Kağıtçıbaşı, 1982; King, 2008).

Men’s honor is more often identified with the term şeref. According to tradition, the protection of the honor of women in the family and the cultivation of high social standing in the community, şeref, are essential duties and obligations of Turkish men (Delaney, 1991). Male honor is not exclusively tied to sexuality. However, a man’s şeref may be damaged by a female family member’s loss of namus. As all of our group participants were female, the concept of şeref was not raised in these groups.

Honor killing is the most extreme custom associated with the protection of family namus. According to King, “Most cultures in which honor killings occur are Muslim-majority, however, examples of honor killings occurring among non-Muslims are easy enough to find that a compelling case cannot be made for a direct linkage between Islam and honor killing” (2008, p. 336). King (2008) argues convincingly that the common denominator of societies in which honor killings are practiced is not Islam but rather patrilineage, or the idea that the male lineage is the sole source of procreation (King, 2008). A longer discussion of namus, şeref, and some implications for survivors of sexual abuse in societies that hold these values is beyond the scope of this article.

In our research groups, discussion of utanç, or shame, was common. Again, this is a natural and necessary part of trauma therapy for sexual abuse. Self-blame, a sense of being “flawed,” “unclean,” “broken,” or “unworthy,” as expressed in these Ankara groups, are routinely expressed by sexual abuse survivors in the United States as well (Herman, 1997). The difference between the cultural contexts was subtle: in the Turkish context, shame was usually discussed in terms of the social stigma that a woman felt as a result of abuse. Frequently, survivors in these Turkish groups described feeling that they had to protect their families from knowing about or having to experience the embarrassment and shame of the abuse. Many survivors in our groups reported they had never told anyone about the experience, which is not unusual across contexts. However, given that family members are among Turkish women’s most frequent confidantes, it was notable that group members would often say that they had not discussed the abuse even with their closest family members. They often expressed fear that others would be harmed by their emotions or experiences: “I can’t tell my family what happened, it would upset them too much.”

Our urban, relatively educated, and less traditional sample of women in one of Turkey’s most Europeanized cities did not describe being afraid of being murdered in traditional “honor killings.” However, levels of self-blame, and the perception of self as flawed, unclean, bad, or immoral, were marked. These women reported feelings of separateness and difference and deeply feared being excluded from participation in normal social life. In a U.S. context Judith Herman (1997) has described survivors’ sense of separateness and difference as characteristic of complex posttraumatic distress.

Many women had never had boyfriends or had not married. The majority of the women who had married had been divorced and many described themselves as having chosen or been forced into poor marriages due to their own or their families’ shame about the abuse. Many said they did not think they deserved to have relationships with decent, good men: “No good man would have me.” These women were markedly different from other women in their social groups in this way, and they said that they feared this difference.

Using the model we have described, these women’s experience of shame and namus can be related to at least three dimensions of culture: Dimensions 1 (individual/relational self), 2 (situationalism/universalism), and 3 (high/low power differential, with high/low gender differential). Women’s experience of namus is focused on their identity and sense of responsibility for others. Namus is based on a relational sense of identity. In societies that encourage such a relational identity, a person’s construction of his/her sense of self is not based upon his/her individual qualities, as it is in individualistic societies. Instead, sense of self is based on relationships or affiliations with others and groups (Kağıtcıbaşı, 1985). Family, tribe, religious group, ethnic identity, and national identity are some of the many kinds of groups that may be very important in the construction of the sense of self (Kim, 1994). In Turkey, family is the group that forms the basis of most people’s idea of who they are and what is important about them (Kağıtcıbaşı, 1996). To some extent, it can be said that a person is nothing without his or her family. Because abuse so often occurs within families and is damaging to family relationships, it may be especially damaging in this cultural context.

The other key element in the construction of the concept of namus is a social structure that places public power and control over families, women, and children in the hands of men (Kağıtcıbaşı, 1982). This can be related to the high gender differential and high power differential dimensions of culture, it also reflects Dimension 2, situationalism/universalism, in that rules about sexual purity apply to women but not to men. In effect, women and men are understood to be very different from one another in this society (Olson, 1982). The qualities ascribed to males and females, and the duties and behaviors expected of them are different. Men are assigned superior position of power and must demonstrate control of their family and subordinates in public. They are also allowed great sexual freedom. Women are assigned responsibility and given power in separate and more private spheres, family, and home life (Bağlı & Özensel, 2011; Olson, 1982). The interaction of the values of relational self, situationalism, high power differential, and high gender differential that plays out in the cultural phenomena of namus contributes to the complexity of the consequences of sexual abuse for women in this Turkish cultural setting.