The role of cultural differences in making and breaking the therapeutic alliance : a qualitative study of immigrant patients' encounters with Norwegian therapists

Abstract

The purpose of this study is to examine the role of culture in therapy when patient and therapist come from different cultures, with a focus on the experiences as reported by the patient. Five non-Western immigrants who had sought therapy in Norway were recruited to be interviewed about their experiences based on concerns raised over cross-cultural therapy in much recent literature, especially the problems deriving from cultural differences between therapist and patient. The interviews were conducted according to a semi-structured interview guide, recorded, and transcribed. The transcriptions were subject to content analysis based on both a priori and emergent categories depending on the information provided by the interview subjects. The results revealed that most of the therapists were unable to bridge the cultural gap: either by conducting therapy without trying to explain the purpose of treatment to their patients who were confused by therapeutic methods as well as the workings of the healthcare system; or by assuming a therapeutic pose that the informants felt created distance; or inability to show the level of empathy expected by their patients. In addition, several attempts to address cultural factors were unsuccessful as they directly offended their patients with stereotypes, while some also reported that cultural concerns and differences were dismissed out of hand when raised. However, successful therapy resulted from the ability to take into account complex individual backgrounds combined with empathy and psychoeducation, and did not necessarily address culture if not directly relevant for the problems under treatment. The reason many therapists were unable to develop a working alliance with their patients seems to derive from the lack of available training combined with the underlying cultural and therapeutic assumptions that result from living in an (until recently) highly homogenous society, where the need to consider subconscious issues ranging from body language to the daunting impact of the therapeutic pose, or explain basic features of healthcare and therapy, is minimal for most Norwegian patients. The recent translation of a manual on cross-cultural interviews included in DSM-V (NAKMI, 2015) is a promising step in the right direction, but will require training and validation of its therapeutic use for Norwegian conditions.