Although there is no precise or universally accepted definition of "boundaries," there is general agreement that psychotherapy occurs within a framework created by managing parameters such as time, self-disclosure, physical contact, and confidentiality (1—4). Managing these parameters or boundaries in a manner that benefits and protects patients is a basic skill that every psychiatry resident is expected to learn. However, recent discussions identifying the cultural relativity of boundaries and the effects that a physician’s or patient’s culture has on boundary-keeping practices (1,2,5) show that acquiring this skill is more complex than previously assumed.
A recent literature search conducted by the author of seven psychiatric journals over a 2-year period and the PsychINFO electronic database over a 5-year period produced no articles that discussed the impact of culture on the boundary-keeping practices of psychiatry residents who received their medical education outside of the United States (IMG residents). Recent articles and books that focus specifically on boundary education fail to identify cultural difference as a factor contributing to boundary crossings and violations (6,7). All of this suggests that a lacuna exists in IMG training. This is striking, given that almost one-half (47.4%) of all psychiatry residents are IMGs (8)! Furthermore, a large number of these residents are from Eastern cultures indigenous to India, Pakistan, and Russia and countries that were previously members of the Union of Soviet Socialist Republics (9). According to some experts, these countries are, culturally, the most different from the United States, particularly with respect to the regulation of interpersonal interaction (10).
In this article, I present a study that assesses the affects of culture on the boundary-keeping practices of psychiatry residents in a training program mainly composed of IMG residents from Asian and Eastern European countries. Of the 22 residents enrolled in the residency training program, five received their medical education in the United States. The training program’s standard didactic instruction on boundary theory and practices occurs in PGY2, as part of a seminar that provides residents with a general introduction to psychotherapy. The boundary related instruction focuses on ethics, professionalism, and the management of transference and countertransference. Teaching methods include reading and discussing relevant articles, role play, and presentations by the instructor and residents. In addition to didactic instruction, boundary issues are addressed in clinical supervision as they become evident over the entire period of the residents’ psychotherapy training (PGY2-4).
However, even after receiving the program’s standard instruction on boundaries, a group of IMG residents remained uncomfortable and inconsistent with managing boundaries. This finding was based on the author’s collection of qualitative data recorded in supervisory progress notes and teaching journals over a 3-year period. Data were collected from three types of resident encounters: 1) supervisory contacts with IMG residents in which difficulties with boundary management, such as repeatedly going overtime in therapy sessions and residents’ inability to limit responses to patient requests for personal information, frequently emerged; 2) verbal and nonverbal expressions of discomfort expressed by IMG residents with boundary keeping practices discussed in didactic seminars; and 3) IMG residents’ requests to provide a special seminar addressing their concerns about managing boundaries. These data suggested that cultural differences were factors that negatively influenced their confidence and performance with respect to boundaries.
In order to respond to these concerns, I designed and implemented the following curriculum. The curriculum consisted of eight monthly, 1-hour seminars designed to enable IMG residents to identify how their respective cultures of origin affected their boundary-keeping practices and to develop a level of comfort and confidence with boundary keeping that would enable them to better manage psychotherapeutic boundaries.
Seminars one and two provided the residents with a review of basic boundary concepts and the professional ethics that guide therapist-patient interaction (14). Sessions three and four introduced the work of Gutheil and Gabbard (11) and others (15—17) on the risk factors and causes of boundary violations in psychotherapy (11—13) and presented the hypothesis that cultural difference impacts boundary-keeping practices (1,18—20).
Impact of Cultural Differences on Boundary-Keeping Practices
The innovative focus and content of the curriculum occurred in sessions five through eight. They provided the participants with an analytical framework for identifying important differences between the assumptions of their own cultures, as well as the assumptions of the United States and other Western countries that are reflected in what some consider normative boundary practices. This framework is adapted from the work of cultural psychologist, Henry C. Triandis (10,20), who divides cultures into two basic types: collectivist (basically traditional and Eastern cultures) and individualist (North American and Northern and Western European cultures). For the purpose of this discussion, we will consider Eastern culture to be represented by those indigenous to the countries of the Middle East, East Asia, and Eastern Europe, including Russia. Western culture is represented by those cultures found in the United States, Western and Northern Europe, Australia, and New Zealand.
Although there are important cultural differences among countries that we characterize as examples of either Eastern or Western culture, Triandis identifies each cultural type according to their similar views about time, authority, relational style, and the status of the individual with respect to the community. This collectivist and individualist typology provided residents with concepts and a lexicon that enabled them to identify and discuss how cultural differences not only influence their experience of relationships, authority, time, etc., but also impact their attitudes and practices related to boundary-keeping. In addition, this typology provided them with a means for understanding why they have difficulty with managing boundaries in a way that is consistent with the cultural assumptions of individualist cultures that underlie many of the boundary concepts and practices of Western psychotherapy. Finally, the typology helped residents to understand that even though they themselves might have culturally based misgivings about certain boundary keeping practices, which they feared would offend patients, this did not mean that patients from individualist cultures would actually be offended. This insight was crucial because it allowed residents to consider modifying some of their practices that were not a good "cultural fit" for psychotherapy. Resident discussions were guided by the typology and resulted in the construction of a "cultural difference grid," which served as a learning activity in itself and as a kind of conceptual map for guiding subsequent discussions of boundary issues related to culture.
Learning activities involved discussing the cultural theory of Harry C. Triandis (10), with respect to cultural differences and miscommunication; 2) telling personal stories that illustrate how culturally influenced parameters, such as the appropriateness of dual relationships and privacy/confidentiality, shaped interpersonal interactions, both personal and professional, in their cultures of origin; 3) constructing and acting out role plays (5) based on the residents’ experiences of difficulty with boundary keeping; and 4) constructing a grid (t1) that identifies culturally different experiences and interpretations of basic concepts such as, time, relational structure, privacy/confidentiality, autonomy, and relatedness.
Introduction of Cultural Types and Their Characteristics
Cultures are classified by Triandis as being either collectivist or individualistic in their orientation to life. People from collectivist cultures think of themselves as interdependent members of a group and tend to experience life as a fundamentally relational enterprise. As a result, they focus on the relational and contextual dimensions of social interaction. In contrast, most psychotherapies, including their boundary practices, are products of individualist cultures, which tend to view people as autonomous individuals, independent from their groups. Consequently, individualist cultures give priority to personal boundaries and goals and tend to assess social interaction in terms of instrumental rationality.
Stories That Connect Cultural Views With Boundary Keeping
The residents provided personal examples of how they experienced relational parameters, such as, privacy/confidentiality, self-disclosure, and time, influencing social interactions within their respective cultures of origin. These stories were reduced to examples of those parameters and identified as representative of either "collectivist" or "individualist" cultures. They were recorded in the grid under the heading "meaning and function." Next, the residents identified how these various culturally determined experiences of the parameters might affect the psychotherapeutic boundary-keeping practices of a psychotherapist. The results of those discussions are also recorded in the grid under boundary effects.
In collectivist cultures more emphasis is placed on what people hold in common rather than on what distinguishes them as unique individuals. This aspect of collectivist culture affects boundary practices related to dual relationships, privacy and confidentiality, self-disclosure, and the nature of the therapeutic relationship itself.
Residents told a variety of personal stories to illustrate how they experience the dimensions of culture that relate to boundary theory and practice. One resident recalled that in the smaller villages of his country, the physician usually owned one of the few automobiles in the area. Consequently, if a patient needed a ride to the hospital or the pharmacy, it was not uncommon for the physician to provide transportation. If the patient needed to stop at home first or pickup a child from school, the physician might well accommodate these patient needs as well. The distinctions between physician and patient were easily relaxed when patient need highlighted their common bond as neighbors in the same village. This story helped another resident to understand why she agreed to her psychotherapy patient’s request that she attend a school function in which the patient’s child was playing the piano. The resident stated, "It seemed like the natural thing to do, the patient was proud of her daughter’s accomplishment and wanted me to share in it. It would have been difficult for me to refuse." In collectivist cultures, dual relationships honor the complex bonds and interdependency of the members of the community.
Expectations regarding privacy and confidentiality differ across cultures. Individualist cultures respect the autonomy of the individual by limiting the unauthorized sharing of personal information. However, some residents from collectivist cultures remarked that they experienced both interest and surprise when they first heard the familiar American idiom, "It’s none of your business!" They wondered how it was possible that a person’s life could only be that person’s business? It is typical in collectivist cultures that the individual’s business is also the community’s business. People talk about a person’s "business" in order to keep his or her life connected to the care and common concern of the community. The primacy of connectedness in collectivist cultures mitigates strict notions of privacy and confidentiality. This discussion encouraged one resident to relate that she had once made an error in judgment when she mistakenly invited the girlfriend of an adolescent patient into a therapy session with the patient. The patient’s parents objected to an outsider becoming privy to the family's "private business" without permission. At the time, the resident believed that this was the correct thing to do, given that the girlfriend seemed to be a significant part of her patient’s life.
Even though IMG residents felt uncomfortable answering personal questions that were posed to them by their patients, many found it difficult not to answer. To suggest that they not answer these questions directly, but use such questions as opportunities to explore patients’ concerns or simply indicate to patients that the focus of the hour should remain on the patient and not the therapist, seemed to be impolite and perhaps disrespectful to many residents. In the ensuing discussion, the theme of connectedness once again surfaced. Even though residents were uncomfortable answering patient questions about country of origin, religion, family structure, etc., they often did so as the result of an internalized collectivist cultural expectation that the exchange of personal information strengthens relationships and thereby improves the caring function of the community.
The residents were asked to give personal examples of how concepts of time functioned in the social interactions of the residents’ respective cultures. All but one of the residents was born and raised in collectivist cultures (although three residents self-identified their culture as Western/individualist) and related stories that reflected the collectivist perspective. For instance, one resident said that time was not as important as were the needs of the moment. This comment evoked a number of different personal examples from the residents. Another resident said that if he had an appointment to meet someone at a certain time and he happened to meet a friend or family member while walking to his appointment, he would stop and chat for awhile to reconnect with the person to find out how they were doing. If this made him late for his appointment, it would be acceptable because the person waiting would, presumably, understand and not become upset.
Another, who was a physician in his home country prior to coming to the United States, told the group how his patients would show up in his office according to when they were able to make it. He stated that many things may have required their attention during the day and prevented them from arriving at a specific time. He would see them later in the day if he could; if not, they would return the next day.
Next, the residents were asked to identify the cultural conception of time that was operative in these stories. A variety of comments followed: "time is not imposed on life;" "the life context or the needs of the moment have priority over time;" "time is for relating;" and "time is flexible—not arbitrarily limited."
For the remainder of the discussion, residents were asked to contrast their experience of time in the United States to their experiences in their home cultures and discuss how these contrasting experiences of time would affect boundary keeping. The main points of the discussion were listed in the boundary effects columns.
There were a total of four monthly sessions in which this data gathering and discussion occurred. The discussions produced important personal narratives about the influence of culture on residents’ experiences with relational parameters that figure prominently in boundary-keeping theory and practice, such as acceptance of dual relationships, privacy/confidentiality, self-disclosure, and time. In order to help the residents conceptualize how their cultural assumptions shaped their boundary keeping practices in ways that often differ from those typically practiced in the United States, we created a grid that compared boundary practices based on collectivist and individualist cultural assumptions.
The process of creating the cultural difference grid (t1) was a crucial feature of the curriculum that helped residents to integrate concepts with personal and clinical experiences and identify important learning issues in subsequent role playing. Creation of the grid included the introduction of framework for cultural analysis with respect to boundary issues. It also evoked the cultural experiences of the residents and linked these experiences to their boundary-keeping practices.
Experiential Learning: Role Play
We anticipated that addressing the cultural basis of boundary keeping difficulties would require the curriculum to have a significant experiential component (5,21). This was essential because supervisory and other discussions indicated that the residents’ conceptual understanding of boundary theory and practices, although adequate, did not determine their actual practices in clinical encounters with patients. In these interactions, the IMG residents typically relied on their respective cultural interpretations of clinical interactions to guide their boundary-keeping practices.
Role playing is an especially effective way to teach learners to look beyond immediate assumptions and expectations and to incorporate new learning into professional practice (22,23). Accordingly, residents role played a number of boundary difficulties that they encountered, such as time management issues. Following the brief role playing scenario, they described the nature of their discomfort with ending the session on time. Then the resident group discussed the cultural basis of this discomfort with the presenting resident and suggested ways the resident could end the session on time. In doing so, the peer group would attempt to respectfully and therapeutically respond to the patient’s displeasure (should it occur) with the boundary. Finally, the residents repeated the role play experimenting with different methods of managing the time boundary. Sharing personal stories, role playing, and lively open discussion about cultural differences composed the crucial experiential elements of the curriculum.
The curriculum was required for all residents in the training program, with the exception of three medicine-psychiatry residents and four PGY1 residents who were in medical rotation and unable to participate. Two additional residents were unable to attend for unspecified reasons. As a result, a total of 13 residents (12 IMG and I USG), ranging from PGY2-4, participated in this curriculum designed to address the distinctive learning issues of IMG residents regarding boundary management in the practice of psychotherapy.
The curriculum director is a member of the Department of Medical Humanities faculty at the Southern Illinois University School of Medicine, cross-appointed to the Department of Psychiatry. He is a white male, born and raised in Chicago, and a partner in a bicultural marriage. He has substantial experience in providing cross-cultural psychotherapy and psychotherapy supervision.
In order to assess the boundary related concerns of the residents, they were asked, prior to the initial seminar, to respond anonymously to the following question: "What are your main concerns regarding boundaries in the practice of psychotherapy?" Representative responses to this question are listed in the results.
The effectiveness of the seminar was evaluated through the administration of an eight-question, Likert-type 7-point scale (1=No confidence, 7=Total confidence), post-then-pre-assessment instrument (24—26) in the final seminar. A post-then-pre assessment differs from the traditional pre-then-post assessment in that it asks the participants to answer two questions at the completion of the curriculum. It first asks about the participants’ levels of confidence as a result of the curriculum, which is the posttest question. Next, it asks the participants to report what they recollect their levels of confidence to have been prior to their participation in the curriculum, which is the pretest question. This approach precludes the tendency of pretest-posttest comparisons to yield inaccurate assessments of the instructional impact due to the risk that participants’ limited knowledge and experience at the beginning of the curriculum may prevent them from accurately assessing their baseline levels of knowledge or ability.
For purposes of analysis and comparison, the residents were instructed to indicate on the assessment instrument which cultural group, Western, Eastern, or Other, most closely matched the one with which they identified.
Statistical analyses of the eight-scale items were performed, separately, with a paired t test on the change scores. Statistical significance was set at the 5% level. The questionnaire was administered and collected anonymously and reported here in the aggregate. The institutional review board (IRB) determined that this study met all criteria for an educational instructional exemption from full IRB review pursuant to 45CFR46.101(b) and (2).
At the first curriculum session, residents were asked to respond to the following question: What are your main concerns regarding boundaries in the practice of psychiatry? Residents’ concerns included doing favors for favorite patients, patients asking personal questions, being on the "slippery slope" without being aware of it, and allowing patients to contact them outside of working hours.
Of the 15 residents that were available for the curriculum, 13 attended regularly. The two infrequent attendees had conflicts with the schedule that were unrelated to the theme and content of the curriculum. Two curriculum evaluations were not returned, producing a total of 11 returned evaluations.
F1 presents the responses of 11 residents to a 7-point scale Likert-type post-then-pre evaluation instrument that measured the mean change of their self-reported levels of confidence, with respect to their knowledge of boundaries, and ability to identify boundary violations.
Subtracting the pre-curriculum from the post-curriculum levels of confidence revealed mean changes of confidence levels regarding from 1.9 to 2.8 (on a 7-point scale) for the areas assessed. Confidence levels with respect to residents’ abilities to identify factors that increase the risk of committing boundary violations showed the greatest increase (2.8 points on a 7-point scale), while knowing how to care for self and patient when feeling vulnerable to commit boundary violation indicated the smallest increase (1.9 points on a 7-point scale). The post-then-pre assessment instrument produced a statistically significant result (p<0.001) for all variables.
The primary goal of this curriculum was to improve the boundary-keeping practices of IMG psychiatry residents by helping them to identify how their respective cultures of origin caused their boundary-keeping practices to diverge from what is generally considered normative practice in the United States. The types of boundary management issues that concerned IMG residents and provided focus for the development of the curriculum were illustrated by the residents’ responses to the question: What are your main concerns regarding boundaries in the practice of psychiatry? These concerns included boundary issues related to special treatment for some patients, time management, self-disclosure, the ability to recognize violations when they occur, extra-therapeutic contacts, and dual relationships.
Cultural distance is a function of the degree of dissimilarity between language, social structure, religion, and standard of living. Since Eastern and Western cultures are the most distant, it is likely that residents from Eastern cultures felt less confident with boundary practices that reflected Western norms than residents who identified with Western cultures. Therefore, residents from the East were likely to experience greater impact from a curriculum that addressed the effects of cultural differences.
Contrary to expectations, however, there was a significant increase in confidence for all cultural groups. There are two possible explanations for this finding. First, residents were asked to place themselves in what they considered to be the most fitting cultural group. Since all residents, with the exception of one who is a United States graduate, are from countries that Triandis identifies as having a collectivist or Eastern culture, it is possible that residents who self-identified as being Western are not aware of the degree to which their native Eastern cultures continue to exert influence on their boundary practices. This could explain why there is no significant difference in the increases of confidence levels between cultures.
Second, it is possible that residents who placed themselves in the Western cultural category initially had low levels of confidence due to factors other than cultural difference, such as insufficient general knowledge or the lack of opportunity to practice boundary-keeping skills addressed by the curriculum.
The results of the post-then-pre assessment instrument indicate that the instructional impact of the curriculum resulted in significant increases in the confidence levels of residents, with respect to the knowledge base necessary to understand the nature and function of boundaries and the ability to identify the risks and actual occurrences of boundary violations.
One important and unexpected effect of the curriculum was the obvious enthusiasm that residents expressed for the curriculum. This enthusiasm seemed to be related to the opportunity to talk about how their cultures impacted their learning and practice of psychotherapy. The author believes that by making cultural difference the focus of the curriculum, residents were able to openly acknowledge the distinctiveness of their cultures, identify the points of tension that exist between their cultures and U.S. culture, and to cooperatively develop strategies for coming to terms with cultural differences in their learning and practice of psychotherapy. A retrospective analysis of this enthusiasm suggests that critical features of this curriculum included its valuing of the cultural perspectives of the residents, the experiential character of their learning, and the creation of a safe, inviting, and affirming environment.
This study has validated the hypothesis that cultural difference is a factor that affects the boundary practices of this group of IMG residents. In addition, it has demonstrated that the confidence levels of IMG residents, with respect to their knowledge and ability to identify risk factors and boundary violations, can be significantly increased through participation in a curriculum designed for this purpose.
The primary limitations to these findings are the small number of subjects (N=11) and need for multiple reiterations of the curriculum to determine the repeatability of these findings. Thus, the results of this study may need to be more widely tested before they can be considered conclusive.
Another limitation is the need for a follow-up assessment of clinical performance to determine the degree to which increased levels of confidence, with respect to boundary keeping, results in improved boundary-keeping practices.