Culture, Diversity, and the Therapeutic Alliance: How Can Psychiatrists Contribute to the Discussion?

Michelle Riba, MD, MS

The recent American Psychiatric Association (APA) annual conference included a powerful debate about the Goldwater Rule. As you may remember, in 1964 Fact magazine published an article that provided details of a poll of psychiatrists about whether Senator Goldwater was fit to be President. The Editor of the magazine was sued successfully for libel. The APA’s Principles of Medical Ethics, Section 7, was subsequently added in 1973, stating that it is unethical for psychiatrists to give a professional opinion about public figures whom they have not examined in person, and from whom they have not obtained informed consent to discuss their mental health in public statements.

The current political climate and rhetoric of certain world leaders was one of the fundamental issues that instigated this crowded session. Could psychiatrists be more helpful to the public and media if the Goldwater Rule was modified or even abolished?

The Goldwater Rule is a provocative topic and certainly has gotten a lot of buzz. It’s of special interest to psychiatrists because we naturally think about using our expertise to understand the world around us. But the bigger issue of how we as psychiatrists can be helpful, worldwide, is not in the assessment of the mental state of one or more political leaders, but rather how world events are affecting our patients who come from diverse cultures, countries, religions, nationalities, and sexual orientations; and, how these differences are affecting the therapeutic alliance and therapeutic effectiveness. This is indeed a key issue for us as clinicians-and something we need to collectively talk about.

We are a country of immigrants, so it is no surprise that so many of the patients I see in my practice at the University of Michigan were not born in the US. Similarly, our trainees-medical students, residents, and fellows-are also often first- or second-generation Americans or are here on various visas. Throughout the world, we are witnessing the largest mass migration in history of people to different countries. Also of great importance, but not discussed nearly as much, are the internal dislocations where people are in the same country but have had to leave their homes and cities, even regions, to survive. This is part of the fabric of our work in medicine and psychiatric education, worldwide, and should be of the highest level of importance because it is of the highest level of consequence.

There are daily reports of walls that are potentially going to be built to keep out our neighbors; executive orders for detentions of people who have entered our country; reports of fathers and mothers who have been in the country for years but who are now facing deportation; terror attacks around the world; possible intrusions and meddling by countries into other countries’ elections. The daily morning newscasts are no doubt having an impact on how we think about our safety and security and our relationships with others. Do you remember the old TV game show, “Who Do You Trust?” That’s what it sometimes feels like.

As psychiatrists, how do we listen to and help our patients and trainees understand and deal with these issues as we, ourselves, try to determine the manifest and latent impact of these daily assaults on our psyche? How do we weave the ongoing traumatic events occurring throughout the world . . . by realizing that no one is really safe? Do I worry every time a patient tells me he or she is going to get on an airplane, is going into a skyscraper, is going to a concert, or is planning to run a marathon?

How do we help or problem-solve? How do we address the variances between our patients who are from a different cultural background or religion than ourselves, and how do we help them? Or do we not even address these issues? What can we do to help our trainees who are not settled in their careers because they don’t know what the immigration policies will be? What do we say when they tell us that their relatives will not be able to attend their graduation because of worries that they would not be able to return home?

These are some of the issues that are important to us and to our patients and their families. These are the issues that our students, residents, and fellows are worried about. And they are critical as we try to help understand and seek to evaluate and determine how much of our patients’ problems are medical, societal, political, or economic, and how each of these factors will affect their mental and physical health.

Clearly, these are complex issues. But we are not alone, organizations such as the World Psychiatric Association, the APA, and allied groups of the APA that represent psychiatrists throughout the world can help us better understand the difficulties of people from other countries trying to study, learn, work, and be in loving relationships in this country. Our colleagues from psychiatric societies throughout the world can help educate us and guide us as we determine how to help patients integrate into a different society, without losing themselves.

We must listen and learn from psychiatric colleagues who are perhaps more experienced and knowledgeable about these issues and how these feelings can affect the therapeutic alliance. Being humble and realizing that there are colleagues who can help us is, in my mind, the first step. Asking for advice-both informal as well as formal-is key. Setting up grand rounds, case conferences, and discussions about these topics . . . these are formative steps. Trainees and faculty stepping forward to talk about how these issues may have already had an adverse or a positive impact on patient care would be instructive.

We cannot solve the political problems of the world, but we can help those who are affected by them. We must work together at every level, individually, academically, organizationally, both within our own countries and across national boundaries.

I have had the honor and privilege of serving as an officer of the World Psychiatric Association, Past President of the APA, past Board Member of the Pacific Rim College of Psychiatrists, past Chair of the APA Council on Global Psychiatry, and a faculty member and mentor in the University of Michigan Medical School Global Health and Diversity Track. I know firsthand from these experiences that there is a major organizational level, in addition to the individual and academic levels discussed above, where important contributions to address these issues can occur.

As psychiatrists, these are some of the multitude of questions we must be asking and collectively debating and answering. The Goldwater Rule helped us formulate some ethical boundaries about what psychiatrists could and could not do. Certainly, there is currently a call for us to step up and help determine what is important now and the positive role that we can have with the issues we are facing as we try to optimize the therapeutic alliance and therapeutic effectiveness.