In the Middle

“What brings you in, ma’am?”

“I’m not quite sure.” She was looking down and fidgeting with her hands. After a long pause, she said, “I have been to two other therapists and…I do not know.”

“Tell me about your experiences.”

“The first one, she was an American.” There was notable disdain with this comment. She continued, “The first time I met her, she told me I was too dependent, and that I should take some more driving lessons and then divorce my husband.”

“And what about the other one?”

“Well, I really liked her. She spoke my native language and told me that everything I was experiencing was normal for my cultural background.” She paused again, and then continued, almost reading my mind. “She made me feel as if nothing was my fault, but I was not getting any better.” I nodded, understanding that sometimes what patients need psychologically is not necessarily what they say they want.

“Where are you from?” she asked timidly, as if the question might offend me.

“I was born in India, lived in England for 6 years, and have been in the Midwest since.”

“Well, you do not have an accent.”

Was she simply stating a fact? Or was she reflecting that I, as an “American” therapist, might not be able to understand her? Out of anxiety, I explained that accents are age-dependent phenomena, as if she were not aware of this.

“Mrs. A” was a 55-year-old woman who had grown up in a non-Western country. Despite having lived in the United States for the past 30 years, this was not and never would be her “home.” She had maintained her cultural ties through friends, language, and social customs as well as by excluding “anything American.” She had no previous psychiatric history, although a recent increase in somatic complaints had resulted in a referral from her primary care physician. She described some sadness along with some mild difficulties with eating, sleeping, and concentrating. These symptoms were clearly linked to relationship and phase-of-life issues with a strong cultural overlay. Both her children, whom she described as being “too American,” were doing well. However, she felt like a failure because she and her husband had done everything possible to keep them culturally “pure.” Nonetheless, she did admire her children’s chameleon-like ability to alter their behaviors based on the cultural setting. However, both had married outside her culture, and despite having adjusted to her children’s partners, the thought of possibly living with them—as she traditionally might—produced tremendous angst. She had a degree from her country but never pursued her major and most recently worked filing records. In addition, she and her husband had been emotionally distant for “a long time,” citing communication problems as their major issue. This rift had expanded since their children left home.

Therapeutically, we never strayed far from cultural issues. I supported her feelings regarding being displaced from her country of origin. Based on our examining potential future consequences, she decided to expand her driving capabilities, begin a hobby, and exercise regularly.

We also discussed many cultural distortions that were sources of conflict (1). For example, she vigorously supported the commonly held belief that international families and friends were “closer-knit” than Americans. As we progressed, she was able to appreciate that she defined closeness as spending time together as a family. However, she then conceded that her inability to communicate honestly with those “closest” to her was a source of frustration. We also explored her notion of friendships, which had only been initiated with those of similar backgrounds. Although these connections provided comfort, she expressed sorrow that many of her friends were not trustworthy and did not share many values that she stated as being important. These issues also affected her relationship with her spouse. Unbeknownst to her, prior to therapy, her expectations of her spouse had “Westernized.” As she explained, “No one in my country expects your spouse to be your best friend—that is what you have friends for.” We continued to examine many cultural themes that often reflected subtle but critical aspects of her dissatisfaction up until she unfortunately terminated therapy at the insistence of her husband.

Mrs. A represents those who reluctantly engage in therapy because of concerns that their various cultural, ethnic, or religious practices will be judged or misunderstood. However, the longer they reside outside of a homogenous community, the greater their propensity for change, whether acknowledged or not. Many of these themes are without a doubt, universal, but integrating the cultural nuances can have clinically profound implications. I occasionally wonder if Mrs. A has been able to achieve a sense of peace regarding her multicultural experiences, but I surmise her ever-changing identity will be somewhere “ in the middle .”