Couples Therapy Around the World

Once considered a purely Western dalliance, psychotherapy now circles the globe. Even before the pandemic upended mental health everywhere, the field had gained momentum not just in its American, European, Australian, and South American strongholds, but within cultures that can diverge dramatically from that of the West: places like rural Pakistan, southern Malawi, Myanmar, and Iran. Trainings of popular Western therapy modalities have proliferated on all continents. At last count, the Beck Institute had trained cognitive behavioral therapy clinicians in more than 130 countries, and the International Psychoanalytic Association had more than 12,000 members, from Ecuador to Armenia to Korea to Senegal. EMDR’s international association’s trainees are not only working in their home countries, but have provided trauma relief on the ground during humanitarian crises in places like Mexico, Southeast Asia, and a dozen African countries.

Emotionally Focused Therapy, first developed by British-Canadian Susan Johnson in the mid-1980s, has also taken root across the globe, providing certification for therapists and conducting clinical research studies on the people it treats through the International Centre for Excellence in Emotionally Focused Therapy. EFT practitioners train and work in Europe, Asia, Australia, the Middle East, Africa, and Central and South America. But with its very Western focus on secure emotional bonds and demonstrative, healthy attachment in individuals and couples, is EFT always a cultural fit?

Therapists and trainers Ting Liu and Kyriaki Polychroni spoke to us about what it’s been like to interpret the core of emotional healing according to EFT where they work, China and Greece, respectively. Both cultures are ancient and collectivist, and wrestling in many ways with modern Western ideas of individualism and gender relations.

Tradition Vs. New Ways of Relating

Ting Liu, born in Taiwan and now both the clinical director of the Philadelphia Center for EFT and director of the Asia Center for EFT, works across Asia as an EFT trainer and family and couples therapist, including in mainland China, Hong Kong, Singapore, Taiwan, Malaysia, and Thailand. When she started, professional therapy was still a rarified experience in the region, and she’s not sure people grasp how complicated introducing Western therapeutic practices to the East has been. “At first, people in China even had a hard time accepting that they needed to pay for counseling, and frankly, they’re still more willing to pay for a fortune teller than a therapist,” Liu says. “But that’s been changing in the past decade or so.”

Given her Western-therapy principles about healthy growth and individuation, she finds a lot of her work involves adjusting therapy for clients who’ve grown up with a different mindset. “When I was pregnant, I remember talking to my American professor and classmates about how my mom was coming to live with me to help care for my daughter, not just for a few weeks or months, but years. Everyone looked at me like I must still be a child to have my mom play that kind of role.

“But in Hong Kong and Taiwan, people often live with their parents after they get married, and even after they start having their own families. This isn’t a sign of poverty or poor boundaries. It doesn’t mean that the adult children in the family aren’t mature enough. It’s just a different way of living. But people who didn’t grow up there often place judgment on that.”

That judgment can go both ways, and Liu notes that some of the therapy we do in the West doesn’t translate for her clients, who may find us independent to the point of selfishness, as well as overly emotional and egoistic. She herself remembers watching a training with EFT’s founder, Susan Johnson, in the late ’90s and being terrified of the raw, emotion-laden language. “I could never imagine myself talking to clients the way she did,” Liu recalls. “It’d be too dramatic for them—just too much. It’d need to be toned down.”

She says, “Perhaps because social norms have historically discouraged the overt expression of affection in China, there’s not a directly translatable word for showing affection in Chinese. Being a good partner, family, and community member hasn’t been about that. People may understand that concept eventually, but as a therapist you’re faced with the question of whether they can really relate to it.”

Liu, who’s a feminist, adds that it isn’t just the touchy-feely nature of Western therapy that gives her pause working in Asia: it’s also squaring the gender expectations of the West with those of the East. “There are parts of China where gender issues are horrible,” she says. “The women are still under great pressure to have male babies. They might not be allowed to eat at a dinner table with their family or put their clothes in the same load of laundry as the men’s clothes. But when I’m working with people with these kinds of gender beliefs, it’s not for me to say, ‘Oh, you have to share the chores.’ I have to help create connection in a different way.”

She gives the case of Joy and Kai, a couple in their early 70s. Joy had been chronically depressed and had attempted suicide three times when their children begged them to go to therapy. They finally agreed, but once in Liu’s office, Kai wouldn’t engage. He thought his involvement should just be to present Joy to the therapist, as if he was taking her to the doctor.

“He was also older than me,” Liu says, “so I needed to spend time showing respect if I wanted an alliance that’d be more than him just watching me work with his wife.” It wasn’t long before she realized that not once in their entire marriage had Kai said thank you to his wife. “He’d never even called her by her real name,” says Liu. “He called her the equivalent of ‘John’s mother.’ So I had to ask myself, how, with a man like this in his 70s, am I going to do couples work? I could tell from the start that I’d have to slice everything he was able to say very thinly to find a bit of positive emotion to offer her. And that’s how we began.”

As she gently pushed him, Kai finally said, “I appreciate her as a mother. And she took care of my parents for 10 years when they had strokes.” She could tell Kai wanted to say the words thank you but couldn’t. When she urged him to do so, his neck turned red, his face purple. Finally, Joy reached out to him, sort of poked his fingertip with hers, and said to him, “That’s okay.”

Liu understands that to Westerners, this exchange reeks of toxic gender inequality. “Maybe I’ve perpetuated their pattern by not challenging it outright,” she says. “But I used that moment. I turned to Joy and said, ‘I saw what you did. When you saw him struggling, you told him it was okay. Here’s another time in your life when you put his needs before your own. Even though being thanked and acknowledged is something you’ve always wanted, you’d rather sacrifice yourself so he didn’t have to be in pain.” Liu then turned back to Kai and asked him what it was like to be loved this way: to have someone who always puts him first. This time he didn’t stonewall: he burst into tears.

“Now maybe that wasn’t a traditional enactment,” Liu says. “He didn’t say or do much else over the course of the session. Despite his tears, he didn’t really risk much by therapy standards. But for me, that was real progress.”

In the next session, Liu says Joy looked happier. She giggled here and there, and her face kept lighting up. When she asked Joy what had happened, she learned that after the last session, Kai had volunteered to do dishes for the first time in 50 years. The two had never talked about the dishes. It had never occurred to Joy that she might want to renegotiate doing them, but she was thrilled.

“It was the best gift she’d ever gotten,” Liu notes. “So I turned back to him and said, ‘Why did you do that?’ He couldn’t tell me. He only said, ‘It’s an easy thing to do. It’s not a big deal.’ I wanted to help them find meaning in this beautiful gift, so I asked Kai, ‘How is it that something that’s ‘not such a big deal’ can bring happiness? How long has it been since you’ve seen her smile?’ I needed him to see that he has the power to do things that will put those smiles on her face.

“Kai helped me see that even with EFT, we may not always be able to ask our clients to articulate their feelings and needs in ways that we assume they should. I always go back to asking what the goal of our work is. Well, we want to help them change. We want to make them happier in their relationship. We want them to get what they need from each other. That’s our job. So if I can get that in any way, as I did when Kai changed in a small but actually quite dramatic way, I’m successful.”

Traumas, Differences, and Love

Liu points out that therapy with older adults in East Asia requires awareness of the collectivity of the culture and how gender roles serve a purpose in maintaining a sense of interrelationship. But therapists need to be cognizant of the traumatizing history of places like mainland China, where the nation’s bloody Cultural Revolution tried to purge capitalism and intellectualism from the population. There’s also the one-child policy. It was amended in 2015 to limit a family to two children, and again last year to three, but the psychological and relational ramifications remain.

“My aunt grew up during the Cultural Revolution, and even after 50 years, all her decisions are driven by fear,” Liu said. “I’ll never forget what she told my cousin on his first day of work: ‘You have to be responsible, so you won’t get fired. But don’t perform too well, so you get people’s attention.’ Our parents had their trauma, and then we were victims of the one-child policy, as was our child. Right there, that’s three generations of trauma.”

She says, “Ultimately, it’s not for me to decide if Chinese families’ ways of showing affection and love are healthy or not. What I look to is the outcome. Did you send a message that you wanted to send? Did the other party receive that? Are you satisfied with what you now have? We want them to get what they need from each other.”

Because she was trained in EFT, the push to facilitate powerful emotional connection in session is always present. With the younger generation, the opportunities are more frequent, but even then, Liu has to be patient. She emphasizes that many younger adults never grew up with siblings. To suddenly accommodate a relationship partner is a learning experience. It’s one reason she thinks the divorce rate in China had recently eclipsed even that of the U.S. Last year, in an attempt to lower that rate, China even introduced a “cooling off” period for people filing for divorce.

Addressing extended family tensions has been a mainstay of her couples work. “If a couple I’m seeing has just the one child, there’s often conflict between the in-laws. Who gets to watch the baby? Who gets to live with the children to watch the grandbaby? What’s the spouse’s attitude toward the in-laws? These are not families in big American houses. The couple, the in-laws, and the baby often all live together in a two-bedroom apartment. Just the setting itself is hard.

“I see a couple from a rural area who don’t even have a bedroom door, just a curtain hung above the door frame. The mother-in-law may walk in at any moment, because she’s not expected to knock. On top of that, many of these couples have their kid sleeping in bed with them—sometimes until the kid is eight years old. I’ve asked, ‘How do you have sex?’ Well, the answer is, they don’t!”

Finding the Tenderness

Like couples all over the world, many of Liu’s clients find themselves struggling to locate tenderness in their relationship. Liu is seeing this play out with Qian and Ying. Husband Qian is a police officer with a history of failed relationships, and Ying is a music teacher.

“Qian said to me, ‘The reason all my other girlfriends left me was because I lectured too much. I’m a good man. I’m responsible. I don’t beat my wife. I bring money home. I help with the chores. The problem is my personality.’”

Ying, who’s 10 years younger, has gradually tired of Qian’s lecturing. She’s been responding by withdrawing and keeping her distance. “He pushed her to see me after he’d labeled her with a personality disorder because she shuts down,” Liu says. “After one or two sessions with Ying alone, I knew they needed couples therapy. He happily came, but even in therapy, he lectured at great length.”

Qian told her, “I know there are things I need to change.” But the admission was nearly buried under the way he criticized and labeled Ying. “When I stopped him to say, ‘I hear something that’s really important here. Part of you is agreeing it’s not all her fault. Is that what you’re trying to say?’ He answered, ‘Yeah, nobody’s perfect. But I know what I need to do to be better. She doesn’t.’”

When Liu asked him if he could imagine showing love in a different way than lecturing, he admitted he didn’t know how. Then Ying piped up. “I can teach you,” she said. “I can help.” And she could, Liu says. All Ying’s students loved her; she was wonderful at communicating with them. Finally, here was a chance for her to begin to right the power differential that she’d unhappily accepted in her marriage.

Liu’s experience with Ying and Qian has informed more of her work, as multiple men she sees bury their vulnerability in demands and criticism. “I’ve learned that you’ve really got to trust that the vulnerability is in there,” she says, “instead of turning away from them because they’re so obnoxious. In this way, working in Asia is different, but it’s not that different. I mean, not all Americans are insightful or expressive either! I think it’s just our job to find a way to understand them.”

Proving a Therapist’s Mettle

Taiwan uses American licensure requirements, but China’s requirements have been lax, and the field’s reputation has been muddied by corruption, including grifting providers, subpar training, and ethical concerns. Fortunately, the government recently stopped issuing licenses to people without proper training, but not before it had granted 800,000 of them.

Liu has heard of clients being asked to pay an annual fee up-front, which was higher than the U.S. standard. Or being asked to pay ahead for 50 sessions, at which point the therapist would see them for hours at a time so the money would run out quickly, and then ask them to pay ahead again for another 50 sessions.

“I’ve heard so many horrible stories,” Liu said. “Some therapists would say, ‘If you come to see me for a year, your depression will go away. And then if it didn’t help, they’d blame the client, telling them, ‘You’re so sick that nobody can help you.’”

Part of practicing in this region today, Liu says, is assuring clients that you’re trustworthy and a bona-fide expert. “How I open a session in Asia differs from what I did in Philadelphia,” Liu says. “I’ll chitchat more, and then present myself as a nice person who has expertise. The latter is generally important in the East. You can’t just be warm and nice. Clients want someone to have the competence to help them.”

Her clients want to know Liu’s educational background, how long she’s been working, and how many couples she’s seen. “They’ll interrogate me in a polite way,” she says. “Before I end each session, I’ll highlight all the key points we’ve covered, the change we made, or the new discoveries, and I’ll give them a preview of what we’ll do next time to assure them that I have a plan.”

“Ultimately, between working in the U.S. and China, there are always going to be different pressures on therapists, and I’ve found you can never know enough about any culture you work with, even if it’s your own. The work is about being respectful and curious. That’s really what’s most important, because when I lose my curiosity, I lose my ability to empathize.”

Regulating in the Group

Kyriaki Polychroni, founding member and past president of the European Family Therapy Association, lives in Greece, seven thousand kilometers away from Liu, but it’s easy to imagine the two lingering together at an EFT conference dinner table late into the night.

Polychroni is a trainer, psychologist-psychotherapist, and member of the Scientific Council at the Athenian Institute of Anthropos, the first center to practice family therapy in Europe.

Through its longstanding research on couple and family relationship patterns in more traditional cultures, the center’s shown that in countries such as Greece, where families may have had minimal resources and a basic goal of survival, couples’ relationships were long characterized by a clear division of roles and analogous normative behaviors.

“Within this context,” she says, “Greek grandmothers will traditionally tell their daughters and granddaughters, ‘When you get married, the husband should know you from the waist down.’ That means that you don’t express how you think and feel—your heart and head being above the waist. If you talked from your heart and complained to your husband, there’d be a greater chance the marriage would have difficulties. And the marriage working was very important because one couldn’t survive outside the family.

“Fortunately, women always had an in-group of other women who were there for each other from the waist up. For example, in a traditional community, when a woman had troubles with her husband, she’d go next door to her women friends. One woman would validate her frustration, another would normalize her feelings by saying ‘all men are like that,’ while another would point out ways in which he was a good partner. In short, the woman regulated her emotions, her dissatisfaction, and her loneliness through connecting with other women.”

But today, Polychroni says, “There’s no such community support in our modern and postmodern society, with its emphasis on the individual. Now we ask women as well as men to be able to have this ‘community dialogue’ within themselves. So they now need to develop inner-dialogue skills and be able to share thoughts and feelings with their partner to engage in coregulation.

“This can be very be confusing, and is further complicated by the reality that such traditional inner voices still exist in Greek women today, even younger ones. These come down through the generations by way of stories, proverbs, and old movies that are very popular in our culture. So although you’re a modern woman, even a postmodern woman, these more traditional voices influence you.”

“Men, on the other hand, have traditionally been expected to be ‘strong providers,’” Polychroni says. “So when their partner—or a therapist for that matter—asks them to express more vulnerability, they might be scared and confused. In traditional cultures undergoing transition today, men can be seen as being in an extremely difficult position. One where their sense of worth is threatened.”

In the transition away from traditional aspects of the culture, Polychroni has seen many mothers and sons now creating triangulation in their families. “Once the support system of the community is lost, a woman might naturally turn to her children for support—which often creates parentified children with resulting mental health symptoms. Also, in a marriage, instead of partners turning toward each other for support, they often turn toward parents, who then get involved and amplify the conflict, because it comes out like a competitive attachment to the couple.”

At the Athenian Institute, Polychroni will focus on empowering couples to create a flexible boundary around their relationship. This boundary can firm up when they need to be a couple, rather than give primacy to their in-laws’ desires.

Take a couple from Athens in their early 40s, recently referred to her by their separate therapists. Nikos is a history professor and Elena a member of a university art department.

In Greece, tradition dictates that the first son is named after the father’s father, and the second son may be named for the mother’s father. So 12 years ago, when they had their son, Nikos felt he was stepping up to the plate as a modern man by resisting parental and cultural pressure and telling his mother they were going to break with tradition. She said, “Don’t worry. Give him the name of your wife’s father.” Nikos was proud to have done this deal for his wife. But Elena wasn’t interested in giving her father’s name to their son. She’d wanted an entirely different name.

Since then, Nikos has felt like he’s tried to satisfy Elena with little acknowledgement. He sees her lack of response to this gift of a name as indicative of her general feeling that he doesn’t do enough.

Polychroni says, “Right in their first session, they started in on the difficulty around their son’s name. ‘I did it for you and for your parents, and you don’t even acknowledge it.’ Nikos said. Elena came back with, ‘My parents didn’t need that. And why do you want me to acknowledge something that I didn’t even ask you for?!’”

When Polychroni spent time validating how difficult it must’ve been for Nikos to go against an important tradition in an effort to please her, Elena started to cry. She hadn’t really empathized with him before, nor had she seen the underlying intention of his act. “That moment was a turning point for them,” Polychroni says. As they worked on their relationship after having resolved this issue, Elena was able to see Nikos’ love for her more clearly, even as it revealed how much more there was to learn about one another.

Philitimo!

No matter how much Greek culture shifts and morphs in these modern times, Polychroni says it’ll always maintain a relational value at its core, a concept called philitimo.

“Philitimo is the love of honor,” Polychroni says. “I believe only Hebrew has a similar term. It’s not easily translatable to English, but it loosely means that we need to self-sacrifice, be caring, be honest, and be respectful with each other. All these virtues are contained in that one word, and it’s reflected in how we relate to each other in a community.”

Despite a devastating economic decade preceding COVID, Greece’s suicide rates remain 10 points below those of surrounding countries and among the lowest in the world. Could philitimo be part of the reason?

An American visitor to Greece unfamiliar with philitimo once told Polychroni, “I went into this corner store and saw an older woman behind the counter. I wanted to be polite and said, ‘Hello, how are you?’ expecting her to answer, ‘Fine thank you.’ But she said, ‘Oh, how can I be fine, my son? My knees are hurting from my arthritis, and I haven’t heard from my daughter for two days.’ All this from a woman I just came to get milk from!”

Polychroni explained, “The older woman was essentially inviting him to connect, to be philitimos and show concern by responding, ‘Oh, I’m so sorry to hear that. It must be difficult.’ It’s important to understand this exchange in the light of our cultural expectation, which is, ‘I’m telling you my concerns and difficulties so that I can explore if you’re there for me.’

“Clearly, our culture has something to teach the postmodern cultures, where independence is overrated, about the crucial importance of relationships. No person is able to live alone. It’s the same with couples. With the value of philitimo, you show concern and develop interdependence in relationships.”

Polychroni says this often comes up in therapy when siblings or other family members haven’t shown enough concern for a couple or a couple’s parents. At her institute, she and her fellow therapists make it a point to create a social support system that mirrors core Greek values of taking care of community members.

“Our therapeutic approach focuses on utilizing our knowledge of our culture. Along with couples and family therapy, we run systemic therapy groups where members voice their fears, concerns, and grief. For example, we’ll create groups that offer women the context to share the difficulties they have relating to their partners. Or we’ll have men’s groups that can help participants feel safe to open up more emotionally. Eventually, we’ll feed what family members have done in group therapy back into the couple and family to foster change.”

They call this multifocal, multilevel psychotherapy, and Polychroni says the institute offers this way of working in Greece and in nearby countries that are also traditionally group-oriented. Anywhere where modern urban culture has decreased the availability and power of family and community relations, she says, “we revive it through integrating therapy on these multiple modality levels: the couple, the family, and the group.”

Much like Liu’s efforts, Polychroni’s blending of therapeutic insight, emotional support, and a healthy respect for tradition and the group shows us how a good therapy model can be malleable. Perhaps the worldwide popularity of EFT, with its foundation in attachment, comes down to the ease with which it adapts to cultures where interdependence has long been valued.

And yet, critiques that too much globalization and Westernization will soon dictate what constitutes healthy relationships in cultures that have their own time-tested notions of love and commitment, still give wary global citizens and therapists pause. But in Greece and China, at least, traditional community bases are eroding to some extent, with or without the help of therapy.

When stepping in to offer a path to healing outside the cultural norm, maybe the trick that Liu and Polychroni seem to be mastering is to go slowly and respectfully, whether it be with large groups or elderly couples or frightened singles leaving the countryside for their big break.

Their respect and sensitivity to the client and the culture create a path not to subvert tradition, nor to dismantle old ways of creating strong healthy relationships, but to enhance what’s already been working.