IPT appeared culturally congruent in the case of Sr. A. Focusing on relationship issues is consistent with Hispanic cultures, and IPT was flexibly adaptable to the cultural tensions that arose. Cultural adaptations that were implemented focused on incorporating cultural experiences—spirituality, acculturation, familism—into IPT in order to help Sr. A understand interpersonal problem areas, and gradual, modeled expression of emotion while preserving equanimity. The therapist had to subtly alter the IPT model in this case. De-emphasizing the medical model for this naturopath, who held distinct beliefs about health, and integrating his religious beliefs in the treatment were important in orienting Sr. A to therapy and facilitating expression and communication of distress. His gender role expectations, which ranged from personal virility to more extreme masculinity, crucially influenced the role transition and dispute contributing to the depression. IPT engaged these expectations by exploring culturally syntonic ways to develop a more desirable gender-based sense of self within cultural bounds. Based on the psychotherapy adaptation literature, some general principles applied in the care of Sr. A might generalize to other minority cultures in other parts of the world, including orientation to therapy, using cultural bridges and metaphors, understanding culturally influenced models of illness, framing treatment concepts within cultural beliefs, and treatment in the patient’s native language (e.g., Domenech-Rodriguez & Wieling, 2004; Griner & Smith, 2006; Hwang, 2006; Ying, 2001).
In our general supervision of cases, several salient issues arose when working with depressed Hispanic patients, including time-limited treatment and deference to therapists for guidance and needed resources (Markowitz et al., 2009). Patients at times construed time-limited treatment as potential abandonment. Coming from intensely social cultures, patients saw therapy as a relationship they did not expect to end. Therapists provided an orientation to therapy by educating patients about time- limited psychotherapy at the outset and acknowledging that it differed from the usual handling of problems in their social network. Therapists reassured: “As we work together, I’ll check in with you to see how you feel about the process and how our work fits with your world outside the office." Nonetheless, termination was sometimes difficult and IPT was sometimes extended beyond the initial time frame.
Many depressed patients desperately needed concrete resources and related their distress to lack of housing and other needs. They saw their therapists as more successful, better integrated into mainstream culture, and better positioned than them to acquire these goods. (See also Chapter 17 for work with low-income patients.) Patients therefore often appeared passively resigned, expecting therapists to resolve their claims or to direct them, rather than having to act themselves. They often seemed unable to navigate English-language-based procedures for obtaining needed benefits. Depression magnifies such passivity. The precariousness of patients’ environments furthered some therapists’ wishes to make suggestions or referrals for concrete services.
Obtaining needed services might indeed relieve environmental stress, yet psychotherapy typically arms patients to achieve such goals themselves. Thus therapists, without rejecting patients’ requests, focused on the patient’s role in IPT. Although occasionally offering concrete advice, therapists predominantly asked what patients had already tried, and what options remained to try, in order to meet their needs. Role-playing viable options then prepared patients for attempting them, as in the case of Sr. A.
In any clinical encounter, therapists need to be aware of their own feelings and prejudices as well as patients’ diagnoses, character, and cultural and socioeconomic backgrounds. These factors have differing impacts in different cases, requiring therapists to respond sensitively and flexibly, and complicating generalization about what “works” with a particular cultural group. Every adaptation of IPT has required determining the salient issues of the treatment population, which vary among depressed adolescents, depressed geriatric patients, and depressed HIV-positive patients, for example. Similarly, IPT with Spanish-speaking immigrants in New York City likely differs slightly from IPT with, say, Scandinavian or Ugandan patients (Bolton et al., 2003; Griner & Smitth, 2006). IPT appears sufficiently flexible to maintain its general structure, with some adjustment, with varied patients.