To cross or not to cross: Clinical boundary considerations with persons who are refugees

Introduction

Studies suggest that culturally divergent explanatory models of illness and treatment practices, differing physician-patient goals and expectations, and mistrust and misunderstandings are associated with lower health care utilization and outcomes among refugees in Western host countries (Derr, 2016; Lincoln, Lazarevic, White, & Ellis, 2016; Pavlish, Noor, & Brandt, 2010; Wells et al., 2012). We assume that these impediments to good medical care reflect a problem in part of Western clinicians’ adherence to conventional boundary rules in developing their working relationships with patients who are refugees. Therefore, boundary behavior represents one major area in which practitioners need to think about and do things differently. Underlying this hypothesis is the reciprocal premise that establishing culturally-responsive boundaries serves as a key intermediary in the often implicit negotiations between two strangers from different lands struggling to find a sufficient basis to work on a common task.

Kirmayer (2012), in a pragmatic discussion of achieving cultural competence at the level of the practitioner, postulates that clinicians may: 1) modify their modes of interaction with patients, 2) develop culturally adapted interventions, or 3) offer interventions to patients drawn from their own cultural traditions. Our article seeks to develop Kirmayer’s first suggestion of modifying modes of clinical interaction with patients by inquiring into what the practitioner is expected to do differently.

We analyze the rationale and effects of psychiatric boundaries, and especially what the literature refers to as boundary “crossings,” from the perspective of cross-cultural theory and practice (Savin & Martinez, 2006; Kroll, 1993; Williams, 1997). This involves examining, in clinical terms, what types of practice interactions beyond ordinary politeness, thoughtfulness, and Rogerian positive regard are necessary for culturally-responsive psychiatry. How may boundary behaviors differ when working in cross-cultural psychiatry beyond the general observation that all boundary considerations are context-specific? There is, as yet, little evidence that practicing culturally-responsive psychiatry, which includes shifting our focus from narrowly construed boundary rules to examining how boundary behaviors shape therapeutic relationships, obtains better outcomes. Training and research into cultural sensitivity and competence have been hampered by lack of agreement as to what constitutes cultural sensitivity and competence, how to teach it, and how to develop standardized and validated instruments to assess the effectiveness and impact of culturally-responsive and competent programs (Bernhard et al., 2015; Butler et al., 2016; DelVecchio Good & Hannah, 2015; Doorenbos, Schim, Benkert, & Borse, 2005; Horvat, Horey, Romios, & Kis-Rigo, 2014; S. Sue, Zane, Nagayama Hall, & Berger, 2009).

Boundaries in human relational context

The concept of boundaries, generally speaking, is indispensable when considering relationships and encounters. Boundaries are ubiquitous, coming into existence the “moment” there are two or more entities in some sort of juxtaposition. Boundaries can be fuzzy, or porous, or variable, or rigid—the list is limited only by one’s imagination and richness of vocabulary. They tend to describe and define the limits, obligations, and parameters of a relationship or multiple interdependent relationships. Whether they pertain to national or political borders or to human relationships, boundaries can be clearly articulated or may require metaphorical language to aptly describe them. “Boundary-speak” is a particularly rich and useful way of examining and describing human relationships, with intermingling descriptive, emotional, judgmental, and coercive elements. An examination of the richness of the construct of boundaries makes it apparent that the notion is context- and culture-dependent, and that both informal and formal rules that establish and define boundaries are part of the essential core of a culture itself.

A change or shift in boundary rules and observances usually reflects (or perhaps heralds) a change in technology and economic structure, cultural values, and traditions, and in turn may even be the occasion of a pushback to re-establish traditional rules about boundary observances. For example, the sexual freedom accorded to young adults in the last half of the 20th century, occasioned by access to effective birth control methods which gave women control of their fertility, has led to cultural changes in dating and courtship patterns, altered the nature of the boundary rules in relationships between men and women along with a cascade of related social changes, and in turn was a rallying cry for a conservative counterattack against this broadly liberal cultural shift in high-income nations. As a second example that has been described in the literature and that we have observed in our clinical experience, consider the changes in Somali family dynamics. These changes result from economic conditions and public assistance rules in the US, in which women more easily find employment or are designated as “head of household” under government assistance programs and thus become the main financial providers in the family, and have shifted the Somali man from his traditional role as head of household and financial provider. This in turn has led to dramatic changes in customary boundary rules and dynamics between Somali husband and wife (Abdi, 2014, 2015, pp. 180–186). As a third example, traditional practices of corporal punishment and collective child monitoring networks in child discipline - common in many cultural contexts globally - are being altered among West African refugees in New York City, partly as a result of the presence of county child protection agencies. Parents in these largely socially conservative immigrant communities are concerned about the “threats to their children posed by ‘American’ values and neighborhood violence” (Rasmussen, Akinsulure-Smith, Chu, & Keatley, 2012, p. 516). Both the reality and the rumors of 911 (police) calls and ensuing removal of children from their homes by child protective services have resulted in parents feeling disempowered, thereby changing the boundary relationships between parents and children, and changing traditional communal monitoring of pre-teens and teenagers.

Boundaries in psychiatry: The provider–patient therapeutic context

The psychiatrist–patient relationship is a sociocultural construct and, like any relationship, employs explicit and implicit rules that guide this construct. During a psychiatrist’s training, the rules for proper and improper relationships between patient and therapist are often articulated in terms of boundary principles, in particular in terms of therapeutic and risk-management contexts, both of which we will briefly review further below, prior to discussing boundary considerations with a cultural context.

Boundaries in psychiatry refer to a rough consensus over the norms that define the limits, obligations, and parameters of the professional behavior of the medical practitioner—specifically the psychiatrist—towards the patient. The Western basis for this is shaped by the long history of medical ethics, as expressed in the Hippocratic and Maimonidean Oaths. In essence, notions of “Do no harm” and “Do not exploit patients” are central to the traditional notions of boundaries in medicine. Boundaries can also be conceptualized as establishing a foundation for safety and development of trust that allows the therapeutic work to proceed. Gutheil & Gabbard, 1998, who has written extensively about boundaries in psychiatric therapeutic contexts, describes boundaries as the “edge” or limit of appropriate behavior by the psychiatrist in a clinical setting. Gabbard’s fundamental idea about boundaries is that attention to the basic aspects of the professional—as opposed to the personal—nature of the relationship will serve to create an atmosphere of safety and predictability that facilitates the patient’s ability to use the treatment.

Boundary violations and transgressions are those behaviors and interactions that do harm or that involve exploitation of a patient by the medical practitioner. Boundary crossings (a contentious term in itself, with which we are unhappy), in contradistinction to violations, are those actions that encroach upon established medical norms and rules in vogue at the present time and place, and which potentially carry the risk of harm, but that might also represent innovative and helpful techniques that need not be exploitative or harmful. We agree that boundary violations and transgressions must be avoided and are not defensible (Gutheil & Gabbard, 1998; Simon, 1992). In this paper, we describe case-based scenarios and a theoretical framework to support flexibility with certain types of boundary crossings to move the therapeutic relationship along when a Western-trained psychiatrist (non-refugee) is seeing a patient who is a refugee. Crowden (2008) provides a rich discussion of the differences between boundary violations, which are clearly unethical, and boundary crossings, which may be both ethical and useful in moving the therapeutic process forward.

There are currently two ways of conceptualizing and operationalizing boundaries in psychiatry. The first, which predominates in most risk-management articles on the topic, views boundary considerations as a set of rules for avoiding or reducing harmful and non-standard interactions that expose practitioners to potential liability risk. This is a respectable and important contribution to clinical psychiatry.

The language of psychiatric boundary discussions in the US has been influenced by criminal trials and civil torts involving sexual abuse of patients by therapists (Simon, 1999). Such a vocabulary has colored the discussion and analyses of the ways in which boundaries are part and parcel of ordinary therapeutic encounters. The focus on sexual abuse occurring in therapy has, in essence, shifted the more general discussion about boundaries away from examining and defining the evolving relationship between clinician and patient to infrequent but highly dramatic and prurient boundary violations, even lending a hint of illicitness to allowing the development of warm or interactive connections in a therapeutic relationship. In reporting on the conclusions of a New York State Office of Mental Health work group that was assigned the task of addressing overall relationships between staff members and service recipients, Fisher and Goldsmith (1999) commented on the frequency with which discussions of boundaries in the psychiatric literature were narrowly focused on sexual relationships between therapists and patients, and how “many of the general discussions of boundaries are framed around a ‘slippery-slope’ hypothesis that categorizes all boundary violations as potential steps on the road to a sexual relationship between the therapist and the patient” (p. 1448).

Not every emotion or expression of affection (positive regard) sends the clinical relationship down the slippery slope toward physical contact and carnal congress (Kroll, 2001). Much more common than sexual abuse of patients by clinicians are the quotidian insensitivities and subtle microaggressions and abuses of power that a clinician may inflict upon persons of color, including refugees, either inadvertently through ignorance of cultural norms, or as a manner of managing discomfort over the unfamiliar ways and beliefs of the patient, or as a way of disguising bafflement over to how to understand and help a patient with an accent and with a different style of dress. Ultimately, boundary control can easily become the method by which clinicians keep patients at a safe distance.

There is a second and equally important way to look at the function of boundaries in psychiatry, which we develop in this paper. We view boundaries as a way of defining and describing interactions that play important and even critical roles in advancing, changing, and redefining significant aspects of the therapeutic relationship or process between practitioner and patient. There is a general sense in this broader view of boundaries that every single interaction can redefine the boundaries (boundary rules, understandings, contested areas)—the processes whereby we work out the flexible rules by which patients and practitioners relate to each other.

However, the scope of this statement (that every interaction redefines the relationship) is unnecessarily broad for our present thesis regarding cross-cultural work. So, we narrow our concept of boundaries somewhat in order to talk about those interactions that strongly perpetuate or reinforce the status quo and stability of the working relationship, as well as those interactions that challenge, question, or redefine the nature of how we (patient and practitioner) relate in a therapeutic context to each other. Our thesis is that this broader concept of boundaries in psychiatry has special salience in cross-cultural work because there is less common ground and mutual assumptions between patient and practitioner, while the power differential between the two is correspondingly much greater. It is with this expanded notion of boundaries in psychiatry that we consider our cases as exemplifying a way to examine productive and non-productive interactions between patient and practitioner. Although our focus is on cross-cultural psychiatry, we do believe that the boundary considerations are applicable (generalizable) to all psychiatric practice.

Boundaries in sociocultural context: The refugee as “other”

It is generally assumed that the boundaries and treatment frame should be informed by the specifics of a patient’s sociocultural background and expectations about a relationship with a healing professional. However, there is legitimate concern that, in accepting too literally the broader cultural rules and patterns of a patient’s ethnicity, the professional is ignoring or insensitive to the hyper-diversity that exists within each sociocultural group, and thus is missing the unique individuality of the specific patient (Block, Riggs, & Haslam, 2013; DelVecchio Good & Hannah, 2015; S. Sue et al., 2009). This approach leads to inadvertent stereotyping, sometimes with roots in implicit or explicitly expressed racism. Thus, we arrive at the crux of our question—when a psychiatrist is working with a patient from a very different cultural background, what guiding principles may help them to determine culturally-responsive boundaries and treatment frame?

To illustrate the type of “boundary bungling” interactions of which we speak, we describe two fairly ordinary vignettes in which simple misunderstandings and oversimplified assumptions about how to provide psychiatric care to our patients quickly complicate the assessment and treatment processes in which our patients corrected us, the “experts.”

Boundaries in cross-cultural context: Intrusion, incompetence, or transgression?

In cross-cultural context, we consider a harmful boundary occurrence as an insensitive interaction or procedure (speech act, behavior, interpersonal occurrence) in which the medical professional proceeds in a manner that ignores, minimizes, or demeans an established custom, cultural norm, or value of a patient. Specifically in this paper we are discussing individuals with an immigration status, “refugee.” We recommend substituting the terms “boundary intrusion” or “boundary incompetence” for the more legalistic or pejorative “transgression” term, recognizing that avoidance of therapeutic engagement with a patient is as much a case of “boundary bungling” as boundary intrusion. But in general, boundary intrusions fall into the general class of interactions that occur between persons of different status and power rankings—what is different here is that the person with lesser power is also a person from a “minority” culture.

Since, as we argue, boundaries themselves are usually context-specific (as opposed to universal), there is much disagreement about where boundaries lie and what even constitutes boundary crossings. For example, behaviors that are standard practice for CBT therapists, such as riding in a car with a traffic-phobic patient, may well constitute boundary violations for a psychodynamic therapist. In cross-cultural context, boundary bungling often develops not from specific rule breaking, but either from insensitivity or ignorance of “how ethnic minority worldviews may differ from those of the European American majority” (Hall, 2001, p. 505), or from its polar opposite, the universalist generalization that all members of a group fit into the cultural stereotype with no recognition of individuality in development and personality (DelVecchio Good & Hannah, 2015, pp. 208–209).

From a process point of view, every interaction between practitioner and patient can serve to redefine the relationship between the two, of who can speak without fear or concern and who must be cautious and prudent. Interactions near the boundaries or that raise boundary issues are more instrumental or influential in redefining the nature of the relationship between patient and psychiatric practitioner. Our position is that it is not helpful to somewhat arbitrarily define a variety of culturally-responsive interactions between clinician and cross-cultural patient occurring near some “Western-established” boundary as boundary crossings or, more pejoratively, as boundary transgressions. Refraining from automatically assuming that Western standards of proper boundary behaviors can be readily applied to non-Western contexts and persons, much can be gained in improved patient care by recognizing non-Western values and customs of interactions with our patients, and thereby moving toward an I–Thou relationship (Buber, 1958). We discuss Buber’s concept as it applies to psychotherapy later in this article. We suggest that a positive manner of framing transactions at the boundaries is to think of them as opportunities to move treatment forward by a maneuver or pursuit of a topic that leads to increased mutual understanding and trust, rather than negatively, as boundary crossings and transgressions.

Philosophical and ethical basis for boundary considerations: Beneficence, non-malfeasance, and justice

Culturally-responsive psychiatry works to develop a life narrative of the individual and family within a sociocultural context. This clinical process involves storytelling, use of anecdotes, semi-structured and open interviews, family engagement, and the exploration of meaning and values in lived experience. This methodology is often seen as scientifically suspect because it is labor intensive, challenging to quantify, open to clinician bias, and non-replicable. However, both objective scientific and narrative development modalities are necessary to form a full picture of the patient as person.

What philosophical and ethical principles guide culturally-responsive psychiatry? Culturally-responsive psychiatry must rest upon reciprocal philosophical principles of relativism and contextualism of knowledge and behavior, as well as upon a pluralism and, at times, a principled competition between certain goods and values, such as autonomy versus paternalism, or consequentialism versus virtue ethics, or the occasional incompatibility of liberty and social justice. By way of contrast, biomedical psychiatry rests philosophically upon a foundation of logical positivism, empiricism, and verifiability that is codified as the scientific method.

Our sense is that some specialized notions of beneficence, non-malfeasance, justice (equity), and medical humanitarianism are part of the medical ethics informing the practice of culturally-responsive psychiatry, more so than in “regular” psychiatry—by which we mean interactions between provider and patient from similar sociocultural backgrounds. Discrepant cultural values and practices, dismissal of the expertise of persons with “lived experience” (Voronka, 2016), and postcolonial power differentials between medical provider and patients who are refugees have a greater impact on the vulnerable and disadvantaged party in these interpersonal negotiations (Nazroo, 2015; Rentmeester, 2012). The rules and admonitions of “Do good” and “Do no harm” take on special salience in this exceedingly contextual and situation-dependent realm.

In the ethical sphere, Radden (2009, p. 268) argues that the profession of psychiatry, especially in its care of persons with severe mental illness, requires additional moral virtues beyond those basic in other medical fields. This is so because persons with mental illness have compromised autonomy, impaired capacity to communicate their concerns and needs to others, lower social status with, at times of psychotic episodes, exceptional powerlessness and heightened vulnerability, and are often at odds with the psychiatrist about justification and purpose of treatment. These critical factors necessitate that the psychiatric practitioner must have the personality and moral virtues enabling them to enter into an ethical therapeutic relationship that serves as the foundation for whatever healing is to occur (Kroll & Radden, 2017).

Establishing boundaries is one major process by which each party negotiates their expectations and goals in this unequal therapeutic relationship. An expanded concept of boundaries moves beyond a customary list of discouraged and prohibited behaviors, such as warnings against extending the length of the treatment session, maintaining neutrality, seeing patients only in the setting of office, clinic, or hospital, minimal self-disclosure, and avoidance of physical contact and comforting (Gabbard & Crisp-Han, 2010; Walker & Clark, 1999) and includes the development of positive understandings of how the two parties can work respectfully together. The power differential strongly favors clinicians over patients who are refugees, more so than in the case of culturally homogeneous and more proximate socioeconomic doctor–patient pairings. There is considerable risk that misunderstandings in the observance of correct boundaries due to lack of shared assumptions, and inadvertent damage from the use of clumsy and insensitive words and expressions, may cause feelings of rejection and disrespect, leading to a cascade of increasing breakdowns in communications and a failure of therapeutic intent and action. Svenberg, Skott, and Lepp (2011) identified the comment, “It’s really nothing” (p. 696), used by many Swedish doctors in response to Somali patients’ pain complaints, as conveying rejection and disinterest by the physician.

It is difficult for the psychiatrist to avoid harm and injustice when there is little understanding of the cultural values, sensitivities, and vulnerabilities of the other party. Issues of vulnerability go well beyond a fear of insensitivity or ridicule, bad as those might be. Many patients who are refugees often fear that they may be blocked from obtaining citizenship if they inadvertently say the wrong thing. This is universally the case for those with compromised immigration status, such as asylees and those without papers, who feel boundlessly vulnerable to incarceration and deportation and must be mistrustful of us, or the clinic or an interpreter, and yet they also need to trust someone with some information, but never know what and how much is safe to reveal (Goo, 2015). The possibilities for betrayal, whether unintentional or purposeful, give refugees, asylees, and illegal immigrants reason to be cautious and even to withhold or alter parts of their stories. This may be in combination with or separate from the effects of traumatic stress on memory retrieval and being able to tell a coherent, linear narrative. Sandhu et al. (2013) speak to these issues in their report on the difficulties experienced by mental health practitioners from 16 European countries in working with these different immigration status categories of refugees who are seeking or have been referred to mental health services.

Philosophical and ethical basis for boundary considerations: “I–thou” attitudes

Expanding the search for specific foundational principles for cross-cultural psychiatry beyond those of beneficence, non-malfeasance, and justice, Martin Buber’s differentiation of two basic attitudes of “I and Thou” and “I and It” in the structure of human relationships (Buber, 1958; Zank & Braiterman, 2014) provides a key connection to the importance of boundaries with persons who are refugees. In the dialogue between two persons, the inquirer who treats the second person as a subject with his/her unique perspective enters into an I–Thou relationship, in which mutual sharing of each perspective occurs. I–Thou is characterized by openness, reciprocity, and a deep sense of personal engagement. The I approaches its Thou not as a thing to be studied, measured, or manipulated, but as a unique moral agent that responds to the I in its individuality. The relationship is dialogical, between subject and subject, as each party encounters and shapes the other. According to Buber, there can be no I without a Thou.

I–It is characterized by the tendency to treat something as an impersonal object consisting of its component parts without a unifying center, merely governed by causal, social, or economic forces (Seeskin, 1995, p. 90). The I can study and measure pieces and mechanisms of the It with great accuracy, but without regard to the It as a unity. In an I–It relationship, an inquirer engages in an asymmetric relationship, in which little is shared beyond that which the inquirer observes (Habermas, 2013, p. 124). The attitude of the I–It relationship defines the “It” as a thing about which objective knowledge but not understanding is obtained, and perspectives are not shared. The I, in studying the It, places a barrier that interferes with the development of an I–Thou relationship, just as restrictive boundary rules and formatted questionnaires and instruments interfere with a freer exchange and transfer of critical biographical and personal information between the clinician and the patient who is a refugee. Within limits, a good working relationship with a patient who is a refugee requires an acceptance of each other as a person within the scope of I–Thou. In Jaspers’ juxtaposition of knowledge and understanding, the I–It relationship generates Erklaren, which is knowledge or explanation derived from the perception of causal (scientific) connections. The I–Thou relationship generates Verstehen, which is understanding derived from the perception of meaning (Jaspers, 1963, p. 27; p. 302 ff.).

Buber acknowledges that an I–Thou relationship between humans cannot always be reciprocal, but is subject to the limitations of the human condition (1958, p. 131). Mutual and reciprocal relationships are delicate and fragile, difficult to forge and maintain, while also being easily damaged or destroyed through a change in attitude, or careless remarks, glances, or self-protective and thereby distancing behaviors. Chester Pierce coined the term “microaggressions” in the 1970s for many such subtle behaviors that reflect underlying disdain, distrust, and social status differentials toward persons of other races and ethnicities. Pierce, referring specifically to race relations in the US, described microaggressions and their effects in these terms: “These subtle, minor, stunning, automatic assaults are a major offense mechanism by which Whites stress Blacks unremittingly and keep them on the defensive, as well as in a psychologically reduced condition” (Pierce, 1989, p. 308).

Pierce’s insights and formulation of microaggressions also have broad applicability to the range of interactions experienced by persons who are immigrants and refugees in their host countries. In parsing out this concept, D. W. Sue et al. (2007) distinguished three forms of microaggressions: microassaults (explicit racial derogation meant to hurt the target; we feel these are “macro,” not micro, but are reporting Sue et al.’s formulation here), microinsults (communication that conveys rudeness and insensitivity, demeaning the target), and microinvalidations (communication that excludes, negates, or nullifies the target).

In Buber’s framework, I–Thou takes constant nurturance and protection. Psychiatric practitioners may inadvertently or intentionally convert an I–Thou into an I–It relationship by treating the corresponding Thou as an object whose parts are to be studied, analyzed, measured, and who is to be held at a distance. The object then is no longer a unity, but a mere thing, a part of the world of objects to be studied and its pieces analyzed (and perhaps exploited) along with other objects within the world. Scott (2006) describes the I–It as a relationship of separateness and detachment.

In working with persons who are refugees in a psychiatric setting, adherence to inelastic boundaries, role stereotypes, and power differentials inevitably leads to a shift from I–Thou to I–It encounters, relinquishing the development of trust for the virtues of efficiency. In recognizing that the two basic attitudes that human beings adopt toward the world (I–Thou and I–It) are abstractions, Buber is forced to acknowledge that, in the world of real relationships, given context or contingency, persons may shift in how steadfastly they can maintain the purity of exclusive I–Thou relationships.

Although we can say that the clinician ought always to treat a patient from an I–Thou perspective, the reasons why this cannot be so range from limitations on the human capacity for empathy to disagreements about the inherent value of the I–Thou perspective when an important task must be accomplished under tight time and resource limitations. We (Western-trained psychiatrists) are used to this atomization of tasks and we greatly benefit from scientific progress in many facets in our life; it may not seem like a strange or off-putting way of obtaining or using knowledge. From this perspective, when scales and other diagnostic instruments are used to generate Western psychiatric diagnoses with persons who are refugees, it is important to make space for the I–Thou relationship, as this forms the basis of a productive partnership.

Conclusion

We have presented a discussion of boundaries as a critically important process in establishing culturally-responsive working relationships with patients who are refugees and who seek or need psychiatric care.

We hypothesize in this article that rigid and clumsy boundary behaviors on the part of psychiatric practitioners are related to lower rates of health care utilization and therapeutic engagement among persons who are refugees. We posit that the path to culturally-responsive psychiatry traverses the territory of boundary behaviors, in which attention is paid both to the gross outlines and to the minute-by-minute interactions between clinician and patient as the two parties define and redefine how they engage each other. We presented two cases (out of dozens or even hundreds from which we could have chosen) of seemingly ordinary interactions with patients at our clinic, in which clearly different cultural values and customs challenged our ways of interacting with patients and threatened an impasse until they were resolved by examining the boundary processes that were at play on the spot. Failure to modify traditional Western psychiatric boundary rules to accommodate differences in cultural norms between Western practitioners and non-Western persons who are refugees can lead to mistrust and misunderstanding; whereas modification of a boundary, such as a clinician permitting herself to make a self-disclosure or serve in the role of advocate of the patient, can at times substantially advance the therapeutic relationship. These examples are not meant to be understood rigidly as new boundary rules for every patient who is a refugee, but rather as examples of how flexibility, humility, and the I–Thou attitude towards our patients can allow for the emergence of a non-textbook clinical process rooted in permission to soften or redefine a boundary rule; ultimately, with the potential to be best for the person whom we are privileged to care for.