To cross or not to cross: Clinical boundary considerations with persons who are refugees

Recent studies suggest that culturally divergent explanatory models of illness and treatment practices, differing physician-patient goals and expectations, and mistrust and misunderstandings between refugee patients and health care professionals are associated with lower health care utilization and outcomes among refugees in Western host countries. In our experience working as psychiatrists with persons who are refugees, we have found that attention to the processes that define and redefine boundary relationships has important implications for therapeutic care, as well as for training residents and others in culturally-responsive care. This article examines the manner and micro-processes by which boundaries are established, maintained, or altered between medical provider and person who is a refugee as a key pathway in the development of working relationships that are culturally sensitive. We work from an expanded concept of boundaries in psychiatry, viewing boundaries as a way of describing interactions that play important and even critical roles in advancing, impeding, and redefining significant aspects of the therapeutic relationship between practitioner and patient. The quality of the interactions occurring minute by minute within treatment sessions provides the foundation from which relationships are defined, parameters of openness or closure of communication are conveyed, and the power structure is laid out. We offer Martin Buber's formulation of the I-Thou relationship as the philosophical grounding of flexible, culturally sensitive boundary behaviors. At its best, boundaries of mutual engagement that are respectful and cognizant of a patient's individuality and cultural history and values are conveyed to the refugee patient.