Category Archives: Cultural Issues

Cultural Factors in Diagnosis

new1I just had my first session with a 20-year-old woman who meets the DSM criteria for borderline personality disorder.  Her emotions are very labile, her relationship with her boyfriend is unstable and she was fired from her job as a nanny recently because she was often late and had frequent crying spells.  I think DBT would be a good treatment for her, but she immigrated from Thailand three months ago and I don’t know whether DBT has been used with Thai Americans.

It’s important to be aware of the importance of culture in choosing a treatment modality, but before addressing that question let’s look at the issue of culture related to diagnosis.  This young woman’s recent immigration is the context for her symptoms, which makes an initial diagnosis of adjustment disorder more appropriate than borderline personality disorder.  If she came alone to take a job as a nanny, the drastic change in cultures would be exacerbated by a loss of social support and the network of relationships she left behind.  If she came with her boyfriend, that relationship would be under tremendous strain as they both adjust to U.S culture.  In one session, you don’t have time to gather information about her history and background to know whether these symptoms have been longstanding, as required for a personality disorder diagnosis, or whether they developed around the time of her immigration.

Regarding the question of treatment modality, it is possible she would benefit from learning some of the skills that are part of Dialectical Behavior Therapy (DBT).  However, if you begin with a diagnosis of adjustment disorder, the initial focus of treatment will be on learning more about the circumstances of her immigration and her life in Thailand as well as her three months in the U.S.  You will also want to learn more about her previous strategies for coping with distress, her interpersonal relationships including the boyfriend, and her educational and work achievements.  It would also be advisable to learn more about resources appropriate for recent Thai immigrants as well as to research available mental health providers who are fluent in her native language.  It will be important to take a collaborative approach with the client, asking what she feels would be helpful and what steps she wants to take, as you talk with  her about different treatment options with you or other providers and social supports that are relevant to her circumstances.  Consulting with your supervisor, teachers and colleagues who have knowledge and expertise in clinical issues related to immigration and Thai-American culture will also be valuable.

If the client decides to continue in treatment with you, you can then move to the question of specific treatment goals and interventions.  Your consultation and supervision may give you information about interventions shown to be effective with Thai American immigrants, but your client’s responses and preferences about treatment are the best source of guidance.  You should be prepared to adapt interventions, like DBT, that were developed for a different cultural group and to pay close attention to the subtleties of the therapeutic relationship to gauge the impact of your interactions.

I hope you find these suggestions helpful in working with an individual or family who has recently immigrated from another country and culture.  Please email me with comments, questions or suggestions for future blog topics.

Cross-Cultural Mental Health Treatment

I have just been assigned to see a client who is from a culture that is completely unfamiliar to me.  She immigrated to the U.S. three years ago and speaks English, but I’m concerned about being able to do psychotherapy with her.  How can I make sure I don’t over diagnose symptoms that may have a different cultural meaning for her than for my other clients?


It’s good that you’re aware of the importance of your client’s culture in your diagnosis and psychotherapy.  When working with a client whose culture is unfamiliar to you, I recommend doing some research into the culture to learn some basic facts about her country of origin.  If you haven’t worked with other individuals who are recent immigrants, doing research into this area will also be valuable.  However, also remember that your client is the best person to educate you about herself.  She is presenting for behavioral health treatment because she is in distress and wants help with some issues that are troubling her.  The skills you use in the first session with any client will serve you well in this situation.  In addition, you may want to ask her how her family members or friends in her country of origin would understand or interpret her symptoms to provide some cultural context for her concerns.

One way to keep the cultural context in mind when using the DSM for diagnostic purposes is to ask about events leading up to the client’s immigration and conditions since she arrived in the U.S.  It is possible that an adjustment disorder or posttraumatic stress disorder diagnosis may be appropriate.  If her symptoms don’t fit either of these diagnoses, you can use an initial “not otherwise specified” or provisional diagnosis, which will note your lack of sufficient information to make a full diagnosis.  This can be changed as you learn more about her history and current life circumstances.

Another way to use the DSM as a resource for assessment is to incorporate the cultural formulation found in Appendix I of the DSM-IV and in Section III of the DSM-5.  The outline for cultural formulation includes cultural identity, cultural conceptualization of distress, psychosocial stressors and supports, and cross-cultural features of the treatment relationship.  The DSM-5 also includes a set of interview questions that can be used in assessing the cultural context of the client’s clinical presentation.

A final issue to consider in your initial assessment and ongoing psychotherapy is the cultural context of your role as a professional in the therapeutic relationship.  If you are still in training, you may not think of yourself as an expert, and many of your U.S. born clients may treat you as a peer or make comments about your status as an intern or trainee.  Many other cultures hold a value of deference to authority, however, and this may make your client reluctant to disagree with you or to express her preferences about the treatment.  In addition, recent immigrants and other cultural groups often have experiences of discrimination and misunderstanding by officials, administrators and service providers.  It can be helpful to directly express your interest in the client’s ideas, to ask open-ended rather than closed questions, and to acknowledge the extent and limitations of your knowledge.  Even so, it may take more time to develop a therapeutic alliance with this client than with clients who are from cultural backgrounds similar to yours.

I hope you find this blog helpful in working cross-culturally.  Please email me with comments, questions or suggestions for future blog topics.