addressing the effects of culture on the boundary-keeping practices of psychiatry residents

Academic Psychiatry, 28:1, Spring 2004 47

Addressing the Effects of Culture on the Boundary-Keeping Practices of Psychiatry Residents Educated

Outside of the United States

Gary E. Myers, Ph.D.

Objective: The author sought to develop a curriculum for international medical graduate(IMG) psychiatry residents that addresses their culture-based deviations from normativeboundary-keeping practices common to U.S.-based psychotherapy practices. Methods: Agroup consisting of 12 IMG psychiatry residents and one United States graduate (USG)participated in a curriculum consisting of eight monthly, 1-hour seminars. An eight-item,Likert-type 7-point scale, post-then-pre questionnaire assessed the instructional impact ofthe curriculum. Results: Responses indicated that participation in the curriculum signifi-cantly increased the IMG residents’ levels of confidence with respect to boundary theoryand practice. Conclusion: International medical graduates confidence levels regardingpsychotherapeutic boundaries can be significantly increased through participation in a cur-riculum that addresses cultural differences. (Academic Psychiatry 2004; 28:47–55)

Dr. Myers is Associate Professor in the Departments ofMedical Humanities and Psychiatry at Southern Illinois Univer-sity School of Medicine, Springfield, Illinois. Address correspon-dence to Dr. Myers, Department of Medical Humanities,Southern Illinois University School of Medicine, 913 North Rut-ledge St., Springfield, IL 62794-9603.

Copyright � 2004 Academic Psychiatry.

Although there is no precise or universally ac-cepted definition of “boundaries,” there is gen-

eral agreement that psychotherapy occurs within aframework created by managing parameters such astime, self-disclosure, physical contact, and confiden-tiality (1–4). Managing these parameters or bound-aries in a manner that benefits and protects patientsis a basic skill that every psychiatry resident is ex-pected to learn. However, recent discussions identi-fying the cultural relativity of boundaries and the ef-fects that a physician’s or patient’s culture has onboundary-keeping practices (1,2,5) show that acquir-ing this skill is more complex than previously as-sumed.

A recent literature search conducted by the au-thor of seven psychiatric journals over a 2-year periodand the PsychINFO electronic database over a 5-yearperiod produced no articles that discussed the impactof culture on the boundary-keeping practices of psy-chiatry residents who received their medical educa-tion outside of the United States (IMG residents). Re-cent articles and books that focus specifically onboundary education fail to identify cultural differ-ence as a factor contributing to boundary crossings

and violations (6,7). All of this suggests that a lacunaexists in IMG training. This is striking, given that al-most one-half (47.4%) of all psychiatry residents areIMGs (8)! Furthermore, a large number of these resi-dents are from Eastern cultures indigenous to India,Pakistan, and Russia and countries that were previ-ously members of the Union of Soviet Socialist Re-publics (9). According to some experts, these coun-tries are, culturally, the most different from theUnited States, particularly with respect to the regu-lation of interpersonal interaction (10).

In this article, I present a study that assesses theaffects of culture on the boundary-keeping practicesof psychiatry residents in a training program mainlycomposed of IMG residents from Asian and EasternEuropean countries. Of the 22 residents enrolled in

EFFECT OF CULTURE ON BOUNDARY KEEPING PRACTICES

48 Academic Psychiatry, 28:1, Spring 2004

the residency training program, five received theirmedical education in the United States. The trainingprogram’s standard didactic instruction on boundarytheory and practices occurs in PGY2, as part of a sem-inar that provides residents with a general introduc-tion to psychotherapy. The boundary related instruc-tion focuses on ethics, professionalism, and themanagement of transference and countertransfer-ence. Teaching methods include reading and discuss-ing relevant articles, role play, and presentations bythe instructor and residents. In addition to didacticinstruction, boundary issues are addressed in clinicalsupervision as they become evident over the entireperiod of the residents’ psychotherapy training(PGY2-4).

However, even after receiving the program’sstandard instruction on boundaries, a group of IMGresidents remained uncomfortable and inconsistentwith managing boundaries. This finding was basedon the author’s collection of qualitative data recordedin supervisory progress notes and teaching journalsover a 3-year period. Data were collected from threetypes of resident encounters: 1) supervisory contactswith IMG residents in which difficulties with bound-ary management, such as repeatedly going overtimein therapy sessions and residents’ inability to limitresponses to patient requests for personal informa-tion, frequently emerged; 2) verbal and nonverbal ex-pressions of discomfort expressed by IMG residentswith boundary keeping practices discussed in didac-tic seminars; and 3) IMG residents’ requests to pro-vide a special seminar addressing their concernsabout managing boundaries. These data suggestedthat cultural differences were factors that negativelyinfluenced their confidence and performance with re-spect to boundaries.

Curriculum

In order to respond to these concerns, I designed andimplemented the following curriculum. The curricu-lum consisted of eight monthly, 1-hour seminars de-signed to enable IMG residents to identify how theirrespective cultures of origin affected their boundary-keeping practices and to develop a level of comfortand confidence with boundary keeping that wouldenable them to better manage psychotherapeuticboundaries.

Seminars one and two provided the residents

with a review of basic boundary concepts and theprofessional ethics that guide therapist-patient inter-action (14). Sessions three and four introduced thework of Gutheil and Gabbard (11) and others (15–17)on the risk factors and causes of boundary violationsin psychotherapy (11–13) and presented the hypoth-esis that cultural difference impacts boundary-keep-ing practices (1,18–20).

Impact of Cultural Differences on Boundary-Keeping Practices

The innovative focus and content of the curricu-lum occurred in sessions five through eight. Theyprovided the participants with an analytical frame-work for identifying important differences betweenthe assumptions of their own cultures, as well as theassumptions of the United States and other Westerncountries that are reflected in what some considernormative boundary practices. This framework isadapted from the work of cultural psychologist,Henry C. Triandis (10,20), who divides cultures intotwo basic types: collectivist (basically traditional andEastern cultures) and individualist (North Americanand Northern and Western European cultures). Forthe purpose of this discussion, we will consider East-ern culture to be represented by those indigenous tothe countries of the Middle East, East Asia, and East-ern Europe, including Russia. Western culture is rep-resented by those cultures found in the United States,Western and Northern Europe, Australia, and NewZealand.

Although there are important cultural differencesamong countries that we characterize as examples ofeither Eastern or Western culture, Triandis identifieseach cultural type according to their similar viewsabout time, authority, relational style, and the statusof the individual with respect to the community. Thiscollectivist and individualist typology provided res-idents with concepts and a lexicon that enabled themto identify and discuss how cultural differences notonly influence their experience of relationships, au-thority, time, etc., but also impact their attitudes andpractices related to boundary-keeping. In addition,this typology provided them with a means for un-derstanding why they have difficulty with managingboundaries in a way that is consistent with the cul-tural assumptions of individualist cultures that un-derlie many of the boundary concepts and practices

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of Western psychotherapy. Finally, the typologyhelped residents to understand that even though theythemselves might have culturally based misgivingsabout certain boundary keeping practices, which theyfeared would offend patients, this did not mean thatpatients from individualist cultures would actuallybe offended. This insight was crucial because it al-lowed residents to consider modifying some of theirpractices that were not a good “cultural fit” for psy-chotherapy. Resident discussions were guided by thetypology and resulted in the construction of a “cul-tural difference grid,” which served as a learning ac-tivity in itself and as a kind of conceptual map forguiding subsequent discussions of boundary issuesrelated to culture.

Learning Activities Learning activities involved dis-cussing the cultural theory of Harry C. Triandis (10),with respect to cultural differences and miscommu-nication; 2) telling personal stories that illustrate howculturally influenced parameters, such as the appro-priateness of dual relationships and privacy/confi-dentiality, shaped interpersonal interactions, bothpersonal and professional, in their cultures of origin;3) constructing and acting out role plays (5) based onthe residents’ experiences of difficulty with boundarykeeping; and 4) constructing a grid (Table 1) thatidentifies culturally different experiences and inter-pretations of basic concepts such as, time, relationalstructure, privacy/confidentiality, autonomy, and re-latedness.

Introduction of Cultural Types and Their CharacteristicsCultures are classified by Triandis as being either col-lectivist or individualistic in their orientation to life.People from collectivist cultures think of themselvesas interdependent members of a group and tend toexperience life as a fundamentally relational enter-prise. As a result, they focus on the relational andcontextual dimensions of social interaction. In con-trast, most psychotherapies, including their bound-ary practices, are products of individualist cultures,which tend to view people as autonomous individ-uals, independent from their groups. Consequently,individualist cultures give priority to personalboundaries and goals and tend to assess social inter-action in terms of instrumental rationality.

Stories That Connect Cultural Views With BoundaryKeeping The residents provided personal examplesof how they experienced relational parameters, suchas, privacy/confidentiality, self-disclosure, and time,influencing social interactions within their respectivecultures of origin. These stories were reduced to ex-amples of those parameters and identified as repre-sentative of either “collectivist” or “individualist”cultures. They were recorded in the grid under theheading “meaning and function.” Next, the residentsidentified how these various culturally determinedexperiences of the parameters might affect the psy-chotherapeutic boundary-keeping practices of a psy-chotherapist. The results of those discussions are alsorecorded in the grid under boundary effects.

Relational Boundaries

In collectivist cultures more emphasis is placedon what people hold in common rather than on whatdistinguishes them as unique individuals. This aspectof collectivist culture affects boundary practices re-lated to dual relationships, privacy and confidenti-ality, self-disclosure, and the nature of the therapeuticrelationship itself.

Dual Relationships Residents told a variety of per-sonal stories to illustrate how they experience the di-mensions of culture that relate to boundary theoryand practice. One resident recalled that in the smallervillages of his country, the physician usually ownedone of the few automobiles in the area. Consequently,if a patient needed a ride to the hospital or the phar-macy, it was not uncommon for the physician to pro-vide transportation. If the patient needed to stop athome first or pickup a child from school, the physi-cian might well accommodate these patient needs aswell. The distinctions between physician and patientwere easily relaxed when patient need highlightedtheir common bond as neighbors in the same village.This story helped another resident to understandwhy she agreed to her psychotherapy patient’s re-quest that she attend a school function in which thepatient’s child was playing the piano. The residentstated, “It seemed like the natural thing to do, thepatient was proud of her daughter’s accomplishmentand wanted me to share in it. It would have beendifficult for me to refuse.” In collectivist cultures, dual



TABLE 1. The Effects of Culture Differences on the Conception and Implementation of Boundaries

Collectivist Cultures Individualistic Cultures

BoundaryParameter Meaning and Function

EffectiveInterpretations of

Boundaries Meaning and Function

EffectiveInterpretations of

Boundaries

Relationalboundaries

Permeable boundariesand dual functionrelationships reflectcomplex socialrelations

Commonality valuedover uniqueness

Flexible or diffuseboundaries strengthencommunity

Boundaries betweensocial andprofessionalrelationships aremore difficult todefine

Extratherapeuticcontacts moredifficult to control

Single functionrelationships reflectclear separation ofsocial andprofessionalrelationships

Uniqueness valued overcommonality

Firm clear boundariesfavor autonomy andindividuality andprevent exploitation

Boundaries between socialand professional easilydefined in most cases;Boundaries enabletherapist and patient tofulfill their respectiveroles

Extratherapeutic contactmore easily controlled

Clear relational boundariesencourage patients todevelop their ownpersonal resources,which strengthsautonomy andindividuality

Privacy/confidentiality

Open flow of personalinformation improvesconnectedness,prevents isolation

Connectednessstrengthenscommunity, whichimproves care of itsmembers

Personal informationmay be shared morefreely in order toenhance family andcommunity resourcesthat can improvepatient care

Confidentiality practicesplace more emphasison mobilizing familyand communityresources than on thepatient’s individualresources

Privacy andconfidentiality protectand strengthenindividualboundaries, whichenhance personalagency and theintegrity of self

Strict boundaries withrespect to privacy andconfidentiality that arerelaxed in cases wherethere is a clear andimmediate danger to selfor others

Self-Disclosure Similar to privacy andconfidentiality (above)

More likely to sharepersonal informationin order to build atrusting relationshipwith the patient

Similar to privacy andconfidentiality(above)

Relatively little self-disclosure, althoughsome believe that whendone judicially it can betherapeutic

Focus remains on thepatient and theprofessional nature ofthe relationship

Time FluidNon-linear

Always enough time

Time supportsrelationships

Context determines theuse of time

Flexible time based onthe needs of thepatient or situation

Session begins whenthe patient arrives,ends when thepatient is finished

LinearSegmented

Scarce commodity

InstrumentalLimit of reality

Time is valuable and istherefore tightlycontrolled

‘‘Giving time away’’ is notprofessional andtherefore suggestspersonal interest or lackof self-control

Patient must learn toaccept limits

relationships honor the complex bonds and interde-pendency of the members of the community.

Privacy/Confidentiality Expectations regarding pri-vacy and confidentiality differ across cultures. Indi-

vidualist cultures respect the autonomy of the indi-vidual by limiting the unauthorized sharing ofpersonal information. However, some residents fromcollectivist cultures remarked that they experiencedboth interest and surprise when they first heard the

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familiar American idiom, “It’s none of your busi-ness!” They wondered how it was possible that a per-son’s life could only be that person’s business? It istypical in collectivist cultures that the individual’sbusiness is also the community’s business. Peopletalk about a person’s “business” in order to keep hisor her life connected to the care and common concernof the community. The primacy of connectedness incollectivist cultures mitigates strict notions of privacyand confidentiality. This discussion encouraged oneresident to relate that she had once made an error injudgment when she mistakenly invited the girlfriendof an adolescent patient into a therapy session withthe patient. The patient’s parents objected to an out-sider becoming privy to the family’s “private busi-ness” without permission. At the time, the residentbelieved that this was the correct thing to do, giventhat the girlfriend seemed to be a significant part ofher patient’s life.

Self-disclosure Even though IMG residents felt un-comfortable answering personal questions that wereposed to them by their patients, many found it diffi-cult not to answer. To suggest that they not answerthese questions directly, but use such questions as op-portunities to explore patients’ concerns or simply in-dicate to patients that the focus of the hour shouldremain on the patient and not the therapist, seemedto be impolite and perhaps disrespectful to many res-idents. In the ensuing discussion, the theme of con-nectedness once again surfaced. Even though resi-dents were uncomfortable answering patientquestions about country of origin, religion, familystructure, etc., they often did so as the result of aninternalized collectivist cultural expectation that theexchange of personal information strengthens rela-tionships and thereby improves the caring functionof the community.

Time The residents were asked to give personal ex-amples of how concepts of time functioned in the so-cial interactions of the residents’ respective cultures.All but one of the residents was born and raised incollectivist cultures (although three residents self-identified their culture as Western/individualist) andrelated stories that reflected the collectivist perspec-tive. For instance, one resident said that time was notas important as were the needs of the moment. Thiscomment evoked a number of different personal ex-

amples from the residents. Another resident said thatif he had an appointment to meet someone at a cer-tain time and he happened to meet a friend or familymember while walking to his appointment, he wouldstop and chat for awhile to reconnect with the personto find out how they were doing. If this made himlate for his appointment, it would be acceptable be-cause the person waiting would, presumably, under-stand and not become upset.

Another, who was a physician in his home coun-try prior to coming to the United States, told thegroup how his patients would show up in his officeaccording to when they were able to make it. Hestated that many things may have required their at-tention during the day and prevented them from ar-riving at a specific time. He would see them later inthe day if he could; if not, they would return the nextday.

Next, the residents were asked to identify the cul-tural conception of time that was operative in thesestories. A variety of comments followed: “time is notimposed on life;” “the life context or the needs of themoment have priority over time;” “time is for relat-ing;” and “time is flexible—not arbitrarily limited.”

For the remainder of the discussion, residentswere asked to contrast their experience of time in theUnited States to their experiences in their home cul-tures and discuss how these contrasting experiencesof time would affect boundary keeping. The mainpoints of the discussion were listed in the boundaryeffects columns.

There were a total of four monthly sessions inwhich this data gathering and discussion occurred.The discussions produced important personal nar-ratives about the influence of culture on residents’experiences with relational parameters that figureprominently in boundary-keeping theory and prac-tice, such as acceptance of dual relationships, pri-vacy/confidentiality, self-disclosure, and time. In or-der to help the residents conceptualize how theircultural assumptions shaped their boundary keepingpractices in ways that often differ from those typicallypracticed in the United States, we created a grid thatcompared boundary practices based on collectivistand individualist cultural assumptions.

Cultural Difference Grid

The process of creating the cultural differencegrid (Table 1) was a crucial feature of the curriculum



that helped residents to integrate concepts with per-sonal and clinical experiences and identify importantlearning issues in subsequent role playing. Creationof the grid included the introduction of frameworkfor cultural analysis with respect to boundary issues.It also evoked the cultural experiences of the resi-dents and linked these experiences to their boundary-keeping practices.

Experiential Learning: Role Play

We anticipated that addressing the cultural basisof boundary keeping difficulties would require thecurriculum to have a significant experiential compo-nent (5,21). This was essential because supervisoryand other discussions indicated that the residents’conceptual understanding of boundary theory andpractices, although adequate, did not determine theiractual practices in clinical encounters with patients.In these interactions, the IMG residents typically re-lied on their respective cultural interpretations ofclinical interactions to guide their boundary-keepingpractices.

Role playing is an especially effective way toteach learners to look beyond immediate assump-tions and expectations and to incorporate new learn-ing into professional practice (22,23). Accordingly,residents role played a number of boundary difficul-ties that they encountered, such as time managementissues. Following the brief role playing scenario, theydescribed the nature of their discomfort with endingthe session on time. Then the resident group dis-cussed the cultural basis of this discomfort with thepresenting resident and suggested ways the residentcould end the session on time. In doing so, the peergroup would attempt to respectfully and therapeu-tically respond to the patient’s displeasure (should itoccur) with the boundary. Finally, the residents re-peated the role play experimenting with differentmethods of managing the time boundary. Sharingpersonal stories, role playing, and lively open discus-sion about cultural differences composed the crucialexperiential elements of the curriculum.

METHOD

The curriculum was required for all residents in thetraining program, with the exception of three medi-cine-psychiatry residents and four PGY1 residents

who were in medical rotation and unable to partici-pate. Two additional residents were unable to attendfor unspecified reasons. As a result, a total of 13 res-idents (12 IMG and I USG), ranging from PGY2-4,participated in this curriculum designed to addressthe distinctive learning issues of IMG residents re-garding boundary management in the practice ofpsychotherapy.

The curriculum director is a member of the De-partment of Medical Humanities faculty at theSouthern Illinois University School of Medicine,cross-appointed to the Department of Psychiatry. Heis a white male, born and raised in Chicago, and apartner in a bicultural marriage. He has substantialexperience in providing cross-cultural psychotherapyand psychotherapy supervision.

In order to assess the boundary related concernsof the residents, they were asked, prior to the initialseminar, to respond anonymously to the followingquestion: “What are your main concerns regardingboundaries in the practice of psychotherapy?” Rep-resentative responses to this question are listed in theresults.

The effectiveness of the seminar was evaluatedthrough the administration of an eight- question, Lik-ert-type 7-point scale (1�No confidence, 7�Totalconfidence), post-then-pre-assessment instrument(24–26) in the final seminar. A post-then-pre assess-ment differs from the traditional pre-then-post as-sessment in that it asks the participants to answer twoquestions at the completion of the curriculum. It firstasks about the participants’ levels of confidence as aresult of the curriculum, which is the posttest ques-tion. Next, it asks the participants to report what theyrecollect their levels of confidence to have been priorto their participation in the curriculum, which is thepretest question. This approach precludes the ten-dency of pretest-posttest comparisons to yield inac-curate assessments of the instructional impact due tothe risk that participants’ limited knowledge and ex-perience at the beginning of the curriculum may pre-vent them from accurately assessing their baselinelevels of knowledge or ability.

For purposes of analysis and comparison, the res-idents were instructed to indicate on the assessmentinstrument which cultural group, Western, Eastern,or Other, most closely matched the one with whichthey identified.

Statistical analyses of the eight-scale items were

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performed, separately, with a paired t test on thechange scores. Statistical significance was set at the 5%level. The questionnaire was administered and col-lected anonymously and reported here in the aggre-gate. The institutional review board (IRB) determinedthat this study met all criteria for an educational in-structional exemption from full IRB review pursuantto 45CFR46.101(b) and (2).

RESULTS

At the first curriculum session, residents were askedto respond to the following question: What are yourmain concerns regarding boundaries in the practiceof psychiatry? Residents’ concerns included doing fa-vors for favorite patients, patients asking personalquestions, being on the “slippery slope” without be-ing aware of it, and allowing patients to contact themoutside of working hours.

Of the 15 residents that were available for the cur-riculum, 13 attended regularly. The two infrequentattendees had conflicts with the schedule that wereunrelated to the theme and content of the curriculum.Two curriculum evaluations were not returned, pro-ducing a total of 11 returned evaluations.

Figure 1 presents the responses of 11 residents toa 7-point scale Likert-type post-then-pre evaluationinstrument that measured the mean change of theirself-reported levels of confidence, with respect totheir knowledge of boundaries, and ability to identifyboundary violations.

Subtracting the pre-curriculum from the post-curriculum levels of confidence revealed meanchanges of confidence levels regarding from 1.9 to 2.8(on a 7-point scale) for the areas assessed. Confidencelevels with respect to residents’ abilities to identifyfactors that increase the risk of committing boundaryviolations showed the greatest increase (2.8 points ona 7-point scale), while knowing how to care for selfand patient when feeling vulnerable to commitboundary violation indicated the smallest increase(1.9 points on a 7-point scale). The post-then-pre as-sessment instrument produced a statistically signifi-cant result (p�0.001) for all variables.

DISCUSSION

The primary goal of this curriculum was to improvethe boundary-keeping practices of IMG psychiatry

residents by helping them to identify how their re-spective cultures of origin caused their boundary-keeping practices to diverge from what is generallyconsidered normative practice in the United States.The types of boundary management issues that con-cerned IMG residents and provided focus for the de-velopment of the curriculum were illustrated by theresidents’ responses to the question: What are yourmain concerns regarding boundaries in the practiceof psychiatry? These concerns included boundary is-sues related to special treatment for some patients,time management, self-disclosure, the ability to rec-ognize violations when they occur, extra-therapeuticcontacts, and dual relationships.

Cultural distance is a function of the degree ofdissimilarity between language, social structure, re-ligion, and standard of living. Since Eastern andWestern cultures are the most distant, it is likely thatresidents from Eastern cultures felt less confidentwith boundary practices that reflectedWestern normsthan residents who identified with Western cultures.Therefore, residents from the East were likely to ex-perience greater impact from a curriculum that ad-dressed the effects of cultural differences.

Contrary to expectations, however, there was asignificant increase in confidence for all culturalgroups. There are two possible explanations for thisfinding. First, residents were asked to place them-selves in what they considered to be the most fittingcultural group. Since all residents, with the exceptionof one who is a United States graduate, are fromcountries that Triandis identifies as having a collec-tivist or Eastern culture, it is possible that residentswho self-identified as being Western are not aware ofthe degree to which their native Eastern cultures con-tinue to exert influence on their boundary practices.This could explain why there is no significant differ-ence in the increases of confidence levels between cul-tures.

Second, it is possible that residents who placedthemselves in the Western cultural category initiallyhad low levels of confidence due to factors other thancultural difference, such as insufficient generalknowledge or the lack of opportunity to practiceboundary-keeping skills addressed by the curricu-lum.

The results of the post-then-pre assessment in-strument indicate that the instructional impact of thecurriculum resulted in significant increases in the



FIGURE 1. Change in Levels of Confidence by Question

0.0 0.5 1.0 1.5 2.0 2.5 3.0

1. Knowledge of the role of boundariesin psychotherapy

2. Ability to identify boundary violatonsas they occur

3. Ability to identify factors that increasethe risk of committing boundary violations

4. Ability to identify how culturaldifferences between patient and therapistcan affect boundary keeping

5. Knowlegde of legal implications ofboundary violations

6. Knowledge of professional/ethicalimplications of boundary violations

7. Understanding the impact of boundaryviolations on the patient

8. How to care for yourself and your patientwhen you feel at risk of committing aboundary violation

Mean Change on a 1–7 Likert-type Scale

Ques

tions

confidence levels of residents, with respect to theknowledge base necessary to understand the natureand function of boundaries and the ability to iden-tify the risks and actual occurrences of boundary vi-olations.

One important and unexpected effect of the cur-riculum was the obvious enthusiasm that residentsexpressed for the curriculum. This enthusiasmseemed to be related to the opportunity to talk abouthow their cultures impacted their learning and prac-tice of psychotherapy. The author believes that bymaking cultural difference the focus of the curricu-lum, residents were able to openly acknowledge thedistinctiveness of their cultures, identify the points oftension that exist between their cultures and U.S. cul-ture, and to cooperatively develop strategies for com-ing to terms with cultural differences in their learningand practice of psychotherapy. A retrospective anal-ysis of this enthusiasm suggests that critical featuresof this curriculum included its valuing of the culturalperspectives of the residents, the experiential char-acter of their learning, and the creation of a safe, in-viting, and affirming environment.

Conclusion

This study has validated the hypothesis that culturaldifference is a factor that affects the boundary prac-tices of this group of IMG residents. In addition, ithas demonstrated that the confidence levels of IMGresidents, with respect to their knowledge and abilityto identify risk factors and boundary violations, canbe significantly increased through participation in acurriculum designed for this purpose.

The primary limitations to these findings are thesmall number of subjects (N�11) and need for mul-tiple reiterations of the curriculum to determine therepeatability of these findings. Thus, the results ofthis study may need to be more widely tested beforethey can be considered conclusive.

Another limitation is the need for a follow-up as-sessment of clinical performance to determine the de-gree to which increased levels of confidence, with re-spect to boundary keeping, results in improvedboundary-keeping practices.

The author thanks Steven J. Verhulst, Ph.D., for pro-viding support for the statistical analysis of this study.

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addressing the effects of culture on the boundary-keeping practices of psychiatry residents

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