“Psychotherapy knowledge gaps may be more challenging to overcome initially due to the need for greater familiarity with the native culture in order to provide a context for fully understanding the patient in psychotherapy” (1, p. 280).
“Preparing International Medical Graduates (IMGs) for Psychiatry Residency: A Multi-Site Needs Assessment” (1) addresses the needs of IMGs entering psychiatry residency training in Canada. On the basis of a survey of five psychiatric residency training programs, the authors report that respondents ranked (in order of importance) understanding the Canadian healthcare system, learning medical documentation, practicing evidence-based medicine, and providing mental health care among the greatest challenges they face in successfully adapting to postgraduate medical training. Language barriers and social isolation were particularly difficult for those residents who did not speak English as their first language. Furthermore, residents who had lived in Canada for 12 months or less reported greater perceived knowledge gaps in psychotherapy.
This commentary will focus on acculturation issues that underlie the survey’s findings, including language difficulties causing social isolation that may affect the psychotherapeutic competence of IMGs. Among the cultural challenges, we will examine how differences between the collectivistic cultures of origin (for the majority of IMGs originating in non-Western countries) and the host country’s individualistic culture (2) can affect an IMG’s performance in psychiatry. After assessing various approaches to acculturation of IMGs, we will explore how training in psychodynamic psychotherapy can serve as an acculturation tool, offering IMGs unique opportunities for letting go of their old cultures and adapting to the new culture in a phase-appropriate manner. In this commentary, we use the term psychotherapy to refer to psychodynamic psychotherapy.
A formal definition of IMGs states that they are physicians who received their basic medical degree or qualification from a medical school located outside the United States and Canada. Trainees of Asian origin constitute 48.5% of all IMGs in all specialties and 27.5% of all trainees in psychiatry (3). In this commentary, the term IMG refers to a foreign-born and foreign-educated IMG (F-IMG), thereby excluding those U.S.-born or naturalized physicians who have attended medical schools outside the United States (USIMG). Studies have identified cultural, linguistic, and communicational shortcomings in the educational background of IMGs (4–8). Some specific deficits reported in IMGs include lack of training in medical interviewing; deficiencies in their knowledge of mental health and psychosocial aspects of medicine; distorted perceptions of U.S. family life, as well as of North American styles of doctor–patient relationships (7, 8); lack of competence in sexual medicine (9); and an increased incidence of professional-boundary infractions (10).
On the other hand, IMGs bring significant assets to their training experience. Studies have demonstrated their ability to handle the stress of residency training better than U.S. medical graduates (USMGs) (8), and their performance on the U.S. Medical Licensing Examination (USMLE) and psychiatry boards is second only to U.S.-born and U.S.-educated physicians (USMGs) (11). Also, a recent study found that IMGs have the lowest patient mortality rates among categories of U.S. physicians, including USMGs and USIMGS, when treating congestive heart failure (12). Therefore, the stress and “inadequacies” found in some IMGs are not due entirely to IMGs’ “inherent” dispositional attributes but perhaps to the process of migration and consequent cultural and linguistic challenges. Differences in pedagogy between the U.S. and foreign medical schools are “simply differences, and are not inherently superior or inferior” (7; p 169).
In psychiatric training, more than in other medical specialties, optimal educational outcomes are intertwined with cultural and linguistic competence. Thus, educational strategies that do not concurrently address acculturation issues faced by IMGs are not likely to be effective. Kramer (13) recommends that educational strategies for IMGs pursuing psychiatric training should focus on interview skills, interdisciplinary collaboration, and teamwork, psychological aspects of the doctor–patient relationship, language training, and the U.S. culture. Although it is beyond the capability of individual training programs to satisfactorily address all the above recommendations, I believe that psychotherapy training in general—and psychodynamic psychotherapy training in particular—can offer a more comprehensive and integrative approach.
IMGs, like any other immigrant group, experience the entire range of emotional reactions described as “culture shock” when they enter the United States (14). These reactions include sadness over leaving behind the culture of origin and anxiety over facing the new—with the attendant identity disturbance (14). According to Akhtar (15), the migration of an individual from one country to another has lasting effects on the individual’s identity, involving drives and affect, psychic space, temporality, and social affiliation. He calls the identity-crisis engendered by migration “the third individuation,” much like the second individuation brought on by adolescence in the separation/individuation process (15). In general, for any immigrant, the ability to work through the trauma of migration depends on one’s psychological resilience in being able to tolerate change and loss, to be alone, and wait. Arguably, these reactions are mostly unconscious and may provide the “background music” to IMGs’ training activities. If properly handled, as with any healthy early developmental challenges in life, these reactions result in better-adapted individuals—translating, in the case of IMGs, into the ability to enjoy their adopted lands fully and find fulfillment in their professional lives.
It has been argued that biculturalism is the optimal outcome of the acculturation process (2). Failure to reach this outcome might result in psychopathology related to identity issues (identity crisis, identity diffusion, identity dissociation, and identity fragmentation) as described by Akthar (16) and manifested as career and relationship problems, depression, personality disorders, and in extreme cases, suicide. Many IMGs lack formal avenues to help them understand and work through these reactions in a systematic fashion. Although individual psychotherapy can be extraordinarily helpful in this process, it may not be feasible because of lack of finances, or unacceptable because of lack of knowledge or because of the stigma attached to seeking mental health care. Nonetheless, as described later in this commentary, we propose that psychodynamic psychotherapy training may provide opportunities to resolve many of these issues.
IMGs who pursue psychiatric training have been criticized for choosing a specialty in which the language competence may be more critical than in any other (17). Psychoanalytic theorists have posited that separation/individuation issues find expression in the immigrant’s struggles over language. English is not the mother tongue for the majority of IMGs, and, by choosing a specialty in which facility with language is so essential, they may be enacting conflicts over separation. There are two processes involved in learning a language: learning the grammar and syntax, and learning accent and intonation. The first is a cognitive process, and the second is an emotional process having to do with unconscious identification.
In general, IMGs may experience resistance or relative ease with learning or mastering a foreign language (of the host country) with regard to either grammar and usage or accent and intonation depending on the nature of their personalities and associated conflicts. Greenson states that “learning a new language involves introjecting new objects and resistance to giving up the old objects may become obstacles to this process” (18; p 22). If IMGs’ language proficiency in English is viewed in this context, it becomes obvious that taking a purely didactic and cognitive approach to improving IMGs’ language proficiency without addressing emotional conflicts (as is done in psychodynamic psychotherapy) may turn out to be ineffective.
The worldview is “the fundamental cognitive orientation of an individual or society encompassing the entirety of the individual or society’s knowledge and point-of-view” (19). The purpose of describing the worldviews is to highlight the general differences between the cultures, but not to stereotype them. An awareness of these differences will enable the reader to appreciate the challenges faced by many IMGs in learning psychiatry. The native-U.S. physician’s dominant values are individualism (the physician’s ability to do the work himself or herself), mastery over nature (capability to cure the disease), and future-orientation (being focused on the patient’s eventual cure) (20). In contrast, the dominant values of the collectivistic cultures, from which most IMGs originate, are group orientation, coexistence with nature, and focus on the past (21). Such values in IMGs that influence their behavior, marked by high regard for their teachers, their loyalty to their group, and their internal prohibitions against standing out, might be perceived by others as immaturity, passivity, and lack of ambition.
Moreover, many IMGs might be confused by the contradictions in U.S. medical culture: beneath the surface appearance of a seeming lack of hierarchy and a laissez-faire approach, there exists an efficient, purposeful, and highly organized educational/clinical enterprise in Graduate Medical Education, in contrast to the serious and somewhat rigid, hierarchical structures that exist in medical schools abroad. Also, in order to academically excel in the U.S., one has to be self-motivated and disciplined. In contrast, in some IMG home countries, the nature of the teacher–student relationship is different, with the teacher taking on an active instructional role while the student adopts a passive, receptive role. Furthermore, IMGs from Eastern, African, and other traditional cultures may consider Western physicians’ search for evidence in treating a disease as an amateurish pursuit of self-gratification and not as effective as relying on one’s own “clinical sense,” experience, and intuition.
Given the cursory exposure to psychiatry in their undergraduate medical education, many IMGs’ encounters with psychiatry itself can be particularly confusing. For IMGs, especially those from collectivistic cultures, acculturation in the context of psychiatric training involves adapting to North American psychiatry’s cultural attitudes, traditions, regulations, and customs. “Psychiatry is for madmen” (7; p. 166) is a commonly-held Asian belief that has to be replaced by the North American concept that psychiatry is for all and helps people deal with a wide range of psychological difficulties. Also, the doctor–patient relationship in collectivistic cultures tends to be authoritarian and paternalistic, as opposed to the egalitarian and collaborative model that has evolved in the individualistic cultures of the West.
Another important contrast is that, in collectivistic cultures, the “primacy of (interpersonal) connectedness takes precedence over notions of privacy and confidentiality” (10; p 51). In India, for example, patients use self-disclosure as a tool in establishing a deeper sense of connection with a physician, whereas, in the West, it is seen as an important prerequisite for accurate history-taking during a physical exam, without any interpersonal connotation. The Western style of reflective introspection, termed psychological-mindedness, in which “the definitions of self and identity become contingent upon an active process of examining, sorting out, and scrutinizing the ‘events’ and ‘adventures’ of one’s own life” (22; p 7), is by-and-large unfamiliar to many Asian cultures. In many Eastern meditative practices, introspective activity focuses on a self “uncontaminated by time and space, and, thus, without the life-historical dimension [which] is the focus of psychoanalysis” (22; p 8). Finally, while the Asian mystical and religious orders emphasize the freedom and potential one has in the pursuit of an inner differentiation while keeping the outer world constant (22; p 272), the Western notion of freedom refers to having an enlarging sphere of choices outside while keeping the inner state constant to that of a rational, waking consciousness (22; p 272).
Each culture’s worldviews influence the ebb and flow of interpersonal relationships. According to Alan Roland (23), interpersonal relationships in India and Japan are characterized by a strong sense of “family self;” that is, identification with the esteem and reputation of the family and inhibition of physical and psychological separation from it. In contrast, the predominant self in the United States is an “individual self,” with well-defined self–object boundaries, that values autonomous functioning and inhibition of dependency needs. In North America, modes of communication are highly verbal and self-expressive, and cognitive themes are strongly oriented toward rationalism, self-reflection, efficiency, mobility, and adaptability to extra-family relationships (23). In contrast, the “family self” that is still predominant in Asian cultures exhibits a mode of communication that is highly contextual and oriented toward symbolization and metaphorical expressions (23).
Cultures differ in how they handle legal and ethical considerations regarding the protection of sick and needy patients. For example, such patient safety protocols as involuntary admission, restraints and seclusion, informed consent, testamentary capacity, and medicating against the patient’s choice are all of immense concern in North America, because of the high regard given to the patient’s autonomy. In contrast, patient autonomy may not be highly regarded in collectivistic cultures (24). Consequently, confidentiality and privacy are not traditionally maintained in these cultures, where principles of duty and loyalty replace the principles of autonomy and fidelity espoused by the West (24).
In Asia, religious and spiritual values predominantly influence the ethical principles that guide one’s life. Karma, defined as “the force generated by a person’s actions held in Hinduism and Buddhism to perpetuate transmigration, and in its ethical consequences to determine his destiny in his next existence” (25; p 630), and Dharma, which is the concept of right action (26), often influence day-to-day actions of both physicians and patients in South Asia more powerfully than any other ethical principle discussed thus far.
Impact of Worldviews on Training
How do these worldviews affect psychiatric training and practice? Psychiatrists are taught to identify and monitor their reactions, to ensure that their personal conflicts do not impinge on the care of their patients. Furthermore, when psychiatrists are not able to resolve such conflicts on their own, they are also taught to seek external resources such as consultation, supervision, and/or personal therapy. These actions might not be possible for a physician with serious psychological blind spots. Some IMGs may decide not to share their personal reactions or conflicts, or, because of the unconscious nature of these conflicts, they may not even be aware that these conflicts can influence their behavior. Some among them may even fear standing out; they may feel discomfort about becoming an object of anthropological curiosity among their colleagues; and they may experience internal cultural prohibitions and embarrassment about revealing “family secrets” to strangers concerning cultural customs such as food practices and interpersonal relationships. An IMG’s guilt over leaving home might manifest in fantasies of being punished through deportation, dismissal, or other punitive measures by the authorities. Consequently, countertransferential reactions, academic underachievement, boundary violations, and other unfortunate outcomes may ensue. The crucial step to avoid these outcomes is to create a safe environment for IMG residents to confide their ethical conflicts to their supervisors.
Mohl et al (27) elucidated the benefits that psychiatric residents derive from psychotherapy training, but, to-date, the idea of psychodynamic psychotherapy training as an acculturative experience has not been examined in IMG literature. Psychiatric educators have tried various acculturation approaches, such as mentorship; “buddy system;” film clubs; ethnic, cultural, and food festivals; language and cultural-psychiatric courses; or a combination of these (28). These methods have all depended on the enthusiasm and commitment of individual faculty members to succeed and have not taken root as a universal practice. The emphasis of these methods is on social engagement, social networking, accent-reduction, enhancing language skills, and increasing familiarity with cultural traditions and practices. Although these activities may foster acculturation, their gains tend to be short-lived.
Mentorship has the potential to offer opportunities for genuine acculturation, but, more often than not, many IMGs have been frustrated by their inability to find or nurture a successful U.S. mentoring relationship. Too few faculty members have the time, the cultural familiarity, or the motivation to engage in non-remunerative activities of mentorship with mentees from unfamiliar cultural backgrounds.
In most residency programs, didactic instruction on cultural psychiatry traditionally focuses on a few ethnic minority groups, whereas many IMGs need guidance in dealing with the cultural majority, as well. Also, whereas training in the skills of cultural competence has, for all practical purposes, become an orphan topic in psychiatric curricula, psychodynamic psychotherapy training continues to be a vibrant and required component of most residency curricula. In addition, most psychiatric residents view psychodynamic psychotherapy as integral to their professional identities and future practice plans, and consequently, the potential for psychotherapy training to serve as an acculturation tool merits consideration.
Gunderson and Gabbard (29) define psychodynamic psychotherapy as “therapy that involves careful attention to the therapist–patient interaction with carefully timed interpretation of transference and resistance embedded in a sophisticated appreciation of the therapist’s contribution to the two-person field” (p 685). Training in such a modality includes coursework, supervision, and, in many cases, the strong suggestion that trainees engage in personal psychotherapy. Personal therapy, in my opinion, offers the IMG opportunities to increase awareness of unconscious processes, transference and countertransference reactions, empathic failures, and the IMG’s own cultural blind spots. I believe psychodynamic psychotherapy also provides an in-vivo model for the doctor–patient relationship and a safe environment needed to work through migration-related issues. It is essential that IMGs have opportunities to undergo individual psychotherapy or to participate in a Balint-like group, which helps physicians become aware of their countertransference reactions to their challenging patients (30). Although many facets of supervised psychotherapy may resemble phenomena occurring in individual psychotherapy, the individual therapy clearly is a lot more personal. Also, in this context, the therapist does not evaluate the resident for purposes of professional competence or administrative advancement, is not answerable to the training program, and is paid for his or her services by the resident.
Aside from the benefits of personal therapy, psychodynamic psychotherapy training and supervision can allow most of the IMGs to vicariously relive the intrapsychic, interpersonal, and developmental aspects of the patient’s life, and to thereby appreciate the broader cultural and contextual underpinnings of the clinical phenomena. This process, thus, provides a model of acculturation to the resident. For example, the stereotypical views about serial monogamy, teenage dating, premarital sex, divorce, and parent–child relationships that were reported by Searight (7) can be more successfully challenged within a setting of supervised psychotherapy, in which the patient’s life in all its richness, intimacy, and immediacy unfolds before the eyes of the resident and the supervisor. When residents discuss such cultural phenomena in the setting of supervised psychotherapy, it is more likely that they will confront their own stereotypes. Under the watchful eyes of a supportive supervisor/therapist, residents can compare, imitate, and identify with the cultural patterns of behavior, thus paving the way for their own successful acculturation.
The dynamics of the one-to-one relationships offer residents valuable opportunities to learn about and manage interpersonal boundaries, as well as other aspects of professionalism and ethics. The therapeutic alliance, so vital for the success of psychotherapy, can be experienced firsthand through the efforts of both supervisors and residents to understand each other through the parallel process that occurs in supervised psychodynamic psychotherapy (31). Active listening, reporting of data to one’s supervisors, and learning how to interpret core elements in psychotherapy training will likely enhance the IMG’s communication and language skills. The nature of the supervisor–resident relationship and the nuanced manner in which the power differential inherent in the therapeutic relationship is handled in supervised psychodynamic psychotherapy will offer the IMGs opportunities to observe and master the workings of a more collegial, less authoritarian model of the doctor–patient relationship than they might have previously encountered in their home countries or other clinical settings.
Each psychotherapy session offers further opportunity to refine the IMG resident’s core psychiatric interviewing skills of engaging, observing, assessing, and communicating—areas deemed to be deficient in IMG education. Under supervision, an IMG can learn how to observe himself or herself and manage countertransference. If the supervisory relationship is sensitively handled, the IMG may feel encouraged to explore private thoughts and feelings engendered by immigration and by acculturative stress.
Ultimately, a patient’s healing process in psychotherapy can be likened to the IMG’s own acculturation process. A patient in therapy grieves the loss of old objects, behavioral patterns, coping activities, attitudes and worldviews—even if they have caused suffering—as he or she learns to supplant them with more adaptive alternatives. Likewise, the acculturation process for an IMG entails mourning the loss of the culture of origin as he or she learns to accept and eventually value the host culture. By mindfully accompanying patients in the psychotherapeutic process of healing, and by examining their own acculturation process in individual psychotherapy and supervised psychotherapy, most IMGs will successfully acculturate.