Psychiatric, Family, and Medical History
Sr. A’s history of unipolar depression and generalized anxiety disorder dated back to age thirty-six. He reported the single hospitalization for suicidal ideation. The only known family member with a psychiatric illness was his brother, who was diagnosed and treated for schizophrenia. Sr. A suffered from hypertension for which he had been prescribed but refused to take medication. Instead, Sr. A treated his hypertension with natural remedies. Sr. A’s mother and father both suffered from heart disease, and his father had died from a myocardial infarction.
Interpersonal Inventory and Cultural Formulation
To better understand how Sr. A’s relationships had evolved during his migration and acculturation to U.S. society, the therapist conducted a cultural formulation in addition to the interpersonal inventory. To track clinical progress and depressive symptoms, the Hamilton Depression Scale 17-item (Ham-D-17) was administered to Sr. A at the beginning, midpoint, and termination of treatment. Upon beginning treatment, the Ham-D score was 27, indicating severe depression. The interpersonal inventory and cultural formulation were introduced as follows:
therapist: Senor A, Id like to take some time to do two interviews that will help me understand the nature of what brings you to treatment and your experience in the context of your cultural background.
Sr. A received this enthusiastically as a perceived sign of respeto and formalismo. The interviews took place over two sessions.
Sr. A was born in a northern South American country and is the second of five children. He reported a pleasant childhood and a secure relationship with his parents and siblings. His father passed away suddenly at age forty-seven of cardiovascular disease, which was the first loss Sr. A experienced in his life. He reported multiple romantic relationships during his adolescence and mid-twenties, stating that he was an “athlete and quite popular when he was younger.” His most significant relationship was with a woman he met while studying naturopathic medicine in another Latin American country. He found this relationship exciting and a source of comfort and security while he was away from his family and friends in his country of origin.
Sr. A had three children with this woman (now ages thirty, twenty-seven, and eighteen) and described many disputes before eventually separating from her and his children because he wanted to move back to his country and she refused to accompany him. He supported his three children throughout the years and remained in contact with them at the time he presented for treatment. As a young adult back in his home country, Sr. A described himself as religious, active, and competitive, spending most of his time in his successful naturopathic medicine practice, attending church, and competing as a player on a national sports team. He recounted this time in his life with nostalgia and pride and reported a shift when the political climate changed in his country. In 1988, Sr. A migrated to the United States “for a better life,” citing political insecurity and abuse as reasons for leaving his country.
He had little family presence in the United States and his social support system mainly comprised his girlfriend and two young children, his church members, pastor, and a few friends he had made since immigrating twenty years earlier. The most important person in his life was his girlfriend, twenty years younger than he, whom he met through the local evangelical church. He described this relationship as supportive, nurturing, and intense. Sr. A and his girlfriend had two infants, nineteen and four months old, at home to care for. Their relationship had become strained as he was the family’s sole provider but was currently unemployed. He did manual labor, managing lift trucks, after immigrating to the United States. In 2000 he was injured on the job when one of the lifts broke and exploded. He sustained injuries to his back, including two herniated lumbar discs. Sr. A viewed the accident as part of his illness, claiming: “My body has many physical problems, and I cannot function in the way I am used to and have relied upon both emotionally and physically.” Prior to his accident, he believed himself an extrovert, outgoing, and someone who experienced very little negative emotion. He felt this way of being had left him unprepared for the “internal world of emotional experience” that he had had to face since the accident. Sr. A now views himself as “weak and incompetent,” both emotionally and physically, but he found this difficult to discuss with his girlfriend and during IPT sessions.
Sr. A described his girlfriend as understanding of his periodic unemployment until recently, and that their religious faith and devotion saved them from worse marital conflicts. He had strong Christian beliefs about his emotional problems, stating that his depression was a “Prueba de Dios [test from God]” and that his devotion and prayer would see him though his depression and anxiety, adding, “Dios me ayuda [God will help me].” Sr. A prefers natural remedies, spiritual help, or vocational rehabilitation to psychiatric help and feared the addictive potential of antidepressant medications.
In his attempts to rehabilitate, Sr. A felt unable to adjust after the accident because of the limited opportunities available to him in the United States. This was reminiscent of the environment just before he left his country. He complained of limited knowledge about vocational rehabilitation and assistance and said that his lack of motivation held him back from pursuing these programs. Sr. A received disability for a time but perceived a “lack of respect and coldness from the disability experience and people I interacted with during this process” This led him to feel angry and hostile towards most people around him; he cited an “opening of his senses to the harsh, cold manner in which human beings with vulnerabilities are treated” When his employer expected him to return to work, Sr. A felt he needed to rediscover his path, yet was frustrated and unmotivated in knowing how to do so.
Although the treatment was delivered by a Spanish-speaking therapist, the therapist, an Indian American psychologist, and Sr. A, of Latin American descent, came from different cultural backgrounds. Sr. A and the therapist communicated effectively in Spanish but faced barriers and gaps in understanding when discussing the role of Christian faith in recovery. They turned these barriers into a therapeutic opportunity, as described below.
Overall, the interpersonal inventory and cultural formulation allowed rapport building and set the stage for the therapeutic relationship in a way that acknowledged the cultural aspects considered key in Sr. As formulation and treatment.