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The learning acquired through conventional U.S. clinical psychology graduate training often is unsuitable when working with individuals who have survived torture, war or ethnic cleansing. Culture is an important factor influencing a clinician's work within this population. Because clients come from non-Western cultures, it is important to modify and adapt Western-based models of psychotherapy, to redefine the role of therapist and to adjust ethical principles in order to be therapeutically effective.

Prevalent in Western psychotherapeutic practice is the premise that the therapist should be non-directive. Conventionally, the client decides on the content of a session, and the therapist responds to this. Clients who come from non-Western cultures may not be socialized or acculturated to the Western concept and practice of psychotherapy. Hence, the process may be equated with seeing a medical doctor-someone who is an expert and, therefore, directive and prescriptive.

Conventional American psychotherapy models demand that the therapist remain neutral. Neutrality is important in terms of respecting the client's autonomy and, therefore, in refraining from directing the client's life decisions or taking sides in the client's inner conflicts. However, when working with survivors, a stance of neutrality, in certain situations, may be countertherapeutic and result in either a failure to establish rapport or in an empathic break. The client may perceive the therapist's neutrality as punitive and non-validating, and as a negation of his experience.

When working with survivors, the therapist must have a committed moral stance and be willing to express it in order to affirm the injustice that the client has experienced, which can be thought of as "verbal non-neutrality." Also there is an "emotional non-neutrality" that involves the therapist's emotional response to the client's experience, such as a show of sadness. These non-verbal responses from the therapist echo the client's own suffering and therefore can be experienced as validating. Both verbal and emotional non-neutrality can be means of demonstrating solidarity with the survivor, can enhance the therapeutic relationship and can provide for the beginning of a reparative connection with others.

Finally, in the context of being ethical practitioners, psychology trainees are taught an American code of ethics, which emphasizes the importance of maintaining appropriate boundaries within the therapeutic relationship. However, when working with survivors from non-Western cultures, it is important to remain flexible around the issue of what constitutes a therapeutically appropriate boundary. One such boundary is that of physical contact. Stringent rules exist discouraging physical contact between client and therapist, ensuring client safety. However, when working with survivors, appropriate touch may indicate that a positive rapport incorporating trust and safety has been established.

For survivors, and particularly for those who have been physically brutalized and/or sexually violated, the ability to be tactile is an indication of their healing. For these reasons, rejecting such a gesture initiated by the client, based on ethical grounds, would be countertherapeutic. Moreover, an individual's inclination to engage in physical contact is influenced by the person's culture. In a number of cultures, touch is a way of demonstrating affection, the formation of a connection and positive feeling toward another person. Therefore, the client's gesture also is a manifestation of culturally appropriate behavior and must be understood in this context. It is important to specify, however, that client-therapist physical contact should be non-sexual, that the therapist be vigilant and avoid transgressing boundaries under the guise of being therapeutic, and that careful consideration be given before engaging in even "benign" forms of tactile contact with a client (e.g., a hug) regarding the intent and consequences of such action.

Thus, as briefly described, an understanding of the survivor's culture of origin and trauma experience and its impact are crucial and must guide the formulation of the required modifications to Western-based psychotherapeutic practice.

Sonali Gupta is serving a clinical psychology internship at Cambridge Hospital/ Harvard Medical School. She trained for two years at The Marjorie Kovler Center for Treatment of Survivors of Torture and Refugee/Bosnian Mental Health.