Culture Issues in Therapy Not Always Predictable

Residents must be aware of the many ways that a patient’s cultural background can influence the therapeutic alliance and, above all, not impose their views on patients, according to Lisa Mellman, M.D. She explored issues such as immigration, gender, and religion with training directors as part of a session on cultural competence at the annual meeting of the American Association of Directors of Psychiatric Residency Training in Long Beach, Calif., in March.

Mellman, who is vice chair of APA’s Task Force on Competency in Graduate Education and associate director of psychiatry residency training at Columbia University, grew up with firsthand knowledge of cultural diversity.

“My grandparents were originally from Eastern Europe and emigrated to Guatemala just before the Holocaust,” said Mellman. “My mother was born and raised in Guatemala, and when I was quite young, my grandparents moved to Brazil, where I then spent several summers in childhood.” Her grandparents moved to Israel when Mellman was a teenager, and she spent a couple of summers there during adolescence.

“My family background helped me to develop an early interest in cultural issues and cultural differences,” said Mellman.

Due to requirements set forth by the Residency Review Committee (RRC) in Psychiatry of the Accreditation Council for Graduate Medical Education that went into effect in January 2001, residents must be trained in sociocultural aspects of patient care. RRCs in other specialties established similar requirements.

“Many sociocultural issues can affect the therapeutic alliance,” said Mellman, including the gender, ethnicity, skin color, class, religion, and language of both residents and patients.

Residents should be aware that sometimes patients—when given a choice—ask to be treated by a clinician from the same cultural background.

“Implicit in this request,” said Mellman, “is an expectation on the patient’s part that the therapist will automatically understand [the patient’s] experience.” Conversely, patients from a cultural background different from a resident’s can be more hesitant to trust the resident.

Mellman told training directors that sociocultural issues can arise not just in the dialogue that occurs in psychotherapy sessions, but around the structure of the sessions themselves. “In our American culture,” she said, “things have concrete starting and stopping times, but in other cultures, beginnings and endings are more fluid.”

For example, non-American patients are especially vulnerable to feelings of rejection or resentment about time limits in therapy sessions. “Some patients may question why their therapist is so rigid,” Mellman pointed out. Also, residents need to be aware that patients from certain cultures may value their families more than they do their individuality. In America autonomy is upheld as a virtue, and American therapists may consciously or unconsciously expect patients to strive to be autonomous.

Sometimes residents who are unaware of certain cultural norms may misinterpret a patient’s adherence to those norms as an aspect of the patient’s personality. “In some patients,” Mellman said, “being deferent to authority figures such as the psychiatrist can be mistaken by the psychiatrist as passivity, when in fact this is just the patient respecting the hierarchical structure established in his or her culture.”

Countertransference issues can arise when the resident consciously or unconsciously imposes his or her views on the patient. Expectations on the therapist’s part about premarital sex, arranged marriage, and abortion, for instance, can and do enter therapy when they shouldn’t, Mellman said.

She also addressed some of the unique issues that arise for first- and second-generation immigrants in psychotherapy. “There are so many losses that first-generation immigrants must cope with—loss of home, family, and language, for example.”

For the children of immigrants, balancing and integrating two different cultures can be emotionally taxing. They must assimilate into American culture at school during the day and then enter a different world at night “where they must change their identities when they come home so that they can blend in with their families,” she observed.

The children of immigrants can be found in emergency rooms and other settings translating for their non–English speaking parents, Mellman said. Children are overburdened with responsibility and exposed to information that can be potentially upsetting to them. ▪