The Role of Culture in Psychodynamic Psychotherapy: Parallel Process Resulting From Cultural Similarities Between Patient and Therapist

In July of 2007, I was assigned to be Dr. Rodriguez’s third supervisor for this case. This change was routine; our program assigns new supervisors each year. While potentially disruptive, this procedure provides the therapist with a new pair of supervisory “eyes” each July. To familiarize me with the case, Dr. Rodriguez presented the patient and offered me copies of her previous write-ups. Both presentation and write-up indicated that the patient was intelligent and professionally motivated, with good ego function, psychological mindedness, and the ability to engage in a psychoanalytic psychotherapy. For additional information about the case, I asked Dr. Rodriguez to begin taping the sessions, which she did with the patient’s consent.

As Dr. Rodriguez mentioned, the first videotaped session revealed the patient to be talking in an immature manner and the therapist to be offering suggestions rather than exploring the patient’s thoughts and feelings. The predominant object relationship was of an insecure child with a kind, overtly encouraging mother. I shared this observation with Dr. Rodriguez, and we began to wonder why this was. Was the patient’s ego still quite fragile, despite her evident gains? Was the therapist inhibited in her attempts to undertake a more psychoanalytic psychotherapy? I did not yet have the answer.

Around this time, in an early supervisory session, Dr. Rodriguez told me more about the patient’s early history of deprivation. Noting that patient and therapist both had Hispanic names, I asked Dr. Rodriguez about her own background. In telling me, she emphasized the financial difficulties that her own family had had. As I talked to Dr. Rodriguez about this, I noticed that I was being careful about my pronunciation of Spanish words in particular, that I was rolling my r’s, and I became self-conscious of my non-Hispanic background. Once I realized that I was doing this, I began to wonder why. Was I trying to show my Hispanic supervisee that I understood something about her culture? Did I feel left out of the Hispanic dyad of therapist and patient? Was I having a moment of anxiety that the therapist would have been better off with a Hispanic supervisor? Although I did not yet fully understand my behavior, I did know that I was engaged in a parallel process, which, if understood, would teach us something new about the case, perhaps about the somewhat unexpected object relationship I had observed.

The concept of the parallel process was first described by Harold Searles in 1995 (1) . Searles described the situation in which the therapist unconsciously identifies with something that has been stirred up in the patient and then enacts it in the supervisory relationship. He called the process by which the supervisor understands this the “reflective process,” and he felt that it often illuminated unexplored dynamics in the therapeutic relationship. As with the concepts of transference and countertransference, parallel process has been defined over the years in broader and narrower terms (2) . The narrower view, espoused, for example, by Baudry (3), posits that “true” parallel process only exists when the dynamics of the patient and therapist match. The broader view, which Searles advocated, is that any therapist can identify with any patient with subsequent enactment in supervision. Adopting the broader view enables the supervisor to address the situation focusing on the patient, rather than on the therapist’s personal issues. It also encourages the supervisor to make broad use of his or her feelings during and about the supervision in order to best understand the case, educate the therapist, and help the patient.

Using the “broad” definition of parallel process, it was clear to me that this was operating in the supervision. But what was the parallel process, and how could it help me to understand the dynamics of the case? The therapist was clearly identifying with the patient, in particular, her early deprivation—but she was enacting rather than describing the identification. I, in turn, was trying to demonstrate my knowledge of Hispanic culture to the therapist. We were both trying to be something that we were not and to be close in an ethnicity that we did not actually share. I realized that this was most likely happening in the therapeutic situation as well, that the therapist and her patient were presuming closeness because of their ethnicity rather than exploring the patient’s feelings about their differences. The patient had had a desperately deprived childhood, while the therapist had not; the patient was an academic fledgling, while the therapist had a Ph.D. from one of the finest universities in the country; and the patient was struggling with very disturbed object relations, while the therapist was happily married with a small child. Here was the answer to the therapist’s cheerleading: “You are just like me,” wished the therapist, “so all you need is encouragement.” This avoided the pain on both sides of the therapeutic relationship of acknowledging the marked disparity between the functioning of these two young women and of paving the way for the shame and potential envy that this acknowledgment could spark. The patient and therapist’s denial of the vast differences between them was thus enacted in their presumption of sameness in their ethnicity that we were enacting in the parallel process.

Realizing this helped me to focus the therapist in several important ways. First, I suggested to the therapist that she and the patient were presuming a “sameness” of ethnicity rather than exploring the patient’s unique experience of her cultural background. The therapist illustrates this, for example, in her presumption of the meaning of “Catholic guilt.” Abandoning this assumption allowed the therapist to begin asking the patient much more about her unique cultural background. Second, it allowed the therapist to step back and to realize that her fear of merging with the patient had led to her initial avoidance of cultural issues. Understanding this allowed the therapist to shift discussion of cultural issues from only occurring in supervision to occurring directly with the patient in therapy. Finally, and perhaps most importantly, it allowed the therapist to realize that the patient needed more than just encouragement to overcome her inhibitions, since her early object relationships, unlike those of the therapist, were profoundly disturbed and had produced a pattern of self-destructive object choices that would take time and effort to repair.

The chief complaint is a wonderful red herring, since one could imagine this presenting complaint as coming from a young woman from just about any culture. On the face of it, this therapy could have been conducted in a “culture-blind” manner, focusing on the “universal problems” of dependence and autonomy. Instead, the therapist embarked on a courageous journey exploring the role of culture in the psychotherapeutic process (4 – 13) with the patient that led to both patient and therapist growth.

We assume that similarity in background and language result in better services. Efforts in public health policy are being promoted to make this more possible. Communication can be enhanced and cultural issues may be easier to address. However, little attention has been paid to the pitfalls of such a situation. For example, there are key issues around language of training for the therapist. The therapist may feel less doctorly or even articulate in his or her native language if it is not the language of training. In addition, during training, we learn to listen for both content and process. Process listening, such as is used to identify evasions, defenses, or associations, is likely language-based and may not be easily accessible without specific training in the language in which the therapy is conducted (14) . Difficulties may also arise if the therapist assumes that he or she “knows” what the patient means and expends less effort in exploratory work. This is illustrated in Dr. Rodriguez’s assumption that she knew what “Catholic guilt” meant to the patient. On the other hand, the therapist may assume that the patient will be more open about culture-specific ideas because he or she expects the therapist to understand. However, the patient may nonetheless avoid topics that a clinician would consider superstitious or strange, such as folk beliefs, because the patient anticipates that the therapist may consider the patient “primitive” or “uneducated.”

An illustration of the way in which cultural similarity may actually result in less understanding occurred when Dr. Rodriguez did not notice the patient’s use of words with double meaning. Although the use of double entendre is common in Spanish, women are socialized not to “pick up” on that type of material, allowing them to preserve their “dignity” and not be offended by the “cat-calling” they are subject to on the street. This likely contributed to Dr. Rodriguez’s “not hearing it” at first. In fact, I imagine it would not have happened if the patient were speaking English. There are also times when literal translations from one language to the other can be misleading (14) . Because words can have multiple meanings, culturally specific meanings may be lost.

As therapists, we have no qualms about pressing people to stay on topics that make them uncomfortable. In this case, however, when the patient spoke in Spanish about the flirtatious neighbor, the therapist did not press her to speak more about this. It may be that even this brief use of Spanish shifted the therapist’s stance from that of the probing clinician to that of the polite listener. This may reflect the fact that when therapists who are trained in English shift to their native language they may shift into the cultural mores that they associate with that language.

Of course, knowing the patient’s language can also be useful. The literature suggests that individuals have access to different memories in different languages. At the same time, as Dr. Rodriguez and her patient experienced, speaking the mother tongue can be extremely anxiety producing. In fact, the use of English, the non-native language, may allow the patient to “regroup” and to temporarily restore higher-level defenses. Our work in psychodynamic therapies is to allow patients to explore fantasies and primitive wishes, which often induces regression. In this case, the patient’s use of Spanish-induced anxiety in the patient, which Dr. Rodriguez experienced via projective identification when she felt like the floor was “falling out.” Recognizing this, Dr. Rodriguez and her supervisor appropriately took a step back and redirected the therapy toward a more supportive approach. This interaction between Dr. Rodriguez and her patient was an excellent example of access to different feelings depending on language.

The struggle between closeness and “appropriate therapeutic distance” was also illustrated in the conundrum about the hug after Dr. Rodriguez had her baby. As Dr. Rodriguez points out, in Hispanic culture it would be cold to not hug someone who had just had a baby. Negotiating these transactions is tricky and warrants examination for each individual patient.

Dr. Rodriguez realized that because of their cultural similarities, she was colluding with Ms. B in not addressing the negative maternal transference. As Dr. Rodriguez focused on the male-centered Hispanic culture, she enacted the familiar role of the “women sticking together.” Although this “maternal enactment” may have been supportive, it is also important to note that in many Hispanic cultures the young girl often gets mixed messages from the mother, who may be loving yet insistent that the woman’s role is to serve the men. I think that Dr. Rodriguez was trying not to be this type of Hispanic mother.

It is likely that the issue regarding Dr. Rodriguez’s countertransference of “wanting to be Spanish enough or poor enough” in order to better understand her patient was picked up because of her supervisor’s sensitivity to cultural issues and knowledge of Spanish and Hispanic culture. We use parallel process often in understanding dynamics, but it requires awareness on the part of the supervisor. In learning how to construct cultural formulations, residents should have an opportunity to work with supervisors who are tuned in to these issues and interested in discovering cultural aspects of presentation and treatment with the resident so that they can develop these skills.