Clinical Social Work Journal, Vol. 32, No. 1, Spring 2004 ( 2004)

CROSS-CULTURAL SUPERVISION

Robin Young, Ph.D., B.C.D.1

ABSTRACT: A multicultural perspective is essential in the twenty-first cen-tury. It is projected that by the year 2010 twelve of our most populous states willhave significant minority populations. Thus, the supervision triad of patient, psy-choanalyst, and supervisor will most likely contain persons of differing racial-ethnic backgrounds who are confronting problems and concerns in a diverse socialenvironment. This paper uses examples to illustrate how this diverse triad isplayed out.

KEY WORDS: cross-cultural supervision; multi-cultural supervision.

Supervision is a vital part of psychoanalytic education. It is oneof the major components in preparing psychoanalysts for clinical practice.Supervision imparts knowledge, self-understanding and shifting hierar-chies. One might even say it is the cornerstone of psychoanalytic educa-tion. Supervision serves as a link between the psychoanalyst and thepatient. The major purpose of supervision is to assist the psychoanalystto develop the skills and expertise necessary to ensure that patients re-ceive an optimal level of treatment.

Supervision is taken to be an important and unique enabling process.Although there is a burgeoning literature on supervision (Holloway,E. L., 1995), the actual research literature in supervision is scant. Only30 empirical research articles have been published over the last 25 years(Tsui, 1997). One of the major findings in a critical review of all theempirical research on supervision suggested that there is a pressing needfor researchers to investigate the impact of culture on supervision (Tsui,

1Correspondence should be directed to Robin Young, Ph.D., B.C.D., 175 West 93rdStreet, New York, New York 10025.

39 2004 Human Sciences Press, Inc.

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1997). There is little empirical research on supervision and even less oncross-cultural issues in supervision (McNeill, Hom & Perez, 1995).

For the purpose of this paper I will employ an operational definitionof ‘culture.’ Ward Goodenough (1981) wrote of culture as follows: “Cultureis located in the hearts and minds of men. . . . A society’s culture consistsof whatever it is one has to know or believe in, in order to operate in amanner acceptable to its members.” As Clifford Geertz (1973) has pointedout, this means “the writing out of systematic rules, an ethnographicalgorithm, which if followed, would make it possible to operate so as topass (physical appearance aside), for a native.”

Devereux (1982) has demonstrated that cultural values and socialmores exert a profound influence on psychopathology. “The essence of allresearch that has man as its subject is the scientist’s dogged struggleagainst his own blindness” (p. 137). Following this principle, Devereuxemphasizes the necessity of recognizing and understanding the influenceof one’s irrational cultural and historical biases (as well as individualones) on one’s theories of human experience; ideally, the analyst hasachieved a “cultural neutrality” (corresponding to his/her “emotional neu-trality”) through a dispassionate comprehension of culturally inducedblind spots.

The multicultural perspective is essential in the twenty-first century.It is projected that by the year 2010 twelve of our most populous states,containing about half of the nation’s young people, will have significantminority populations (Hodgkinson, 1992). Thus, the supervision triad ofpatient, psychoanalyst, and supervisor will most likely contain personsof differing racial-ethnic backgrounds who are confronting problems andconcerns in a diverse social environment.

Bernard and Goodyear (1992) advocated that the supervisor is respon-sible for assuring that multicultural issues receive attention in supervi-sion. Generally, whenever the patient is a minority group member, andsometimes when either the supervisee or supervisor is a minority person,supervisors will recognize the relevance of addressing cultural concerns.However, all psychoanalytic and psychoanalytic supervisory contacts havecultural, racial-ethnic aspects which shape core assumptions, attitudes,and values of the persons involved and which may enhance or impede treat-ment effectiveness. Persons of white Anglo-Saxon Protestant backgroundfor example, may have very different cultural norms and patterns thansomeone of Irish background who is Catholic. Socio-economic status alsoinfluences cultural norms. Yet under some circumstances, such as the“American” response to 9/11 these 2 persons of different cultural back-grounds will probably share common cultural attitudes towards theircountry. Cultural differences and sameness are often subtle and multifac-eted, but they must be acknowledged and included in the nuances of think-ing about relationships between therapists and supervisors and patients.

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Majority cultural patterns and the culture of psychoanalysis are oftenaccepted by the supervisor and psychoanalyst without thought, what Ber-nard and Goodyear (1992) label the “myth of sameness” (p. 195). Recentwork on white racial identity in counseling psychology (Rowe, Bennett, &Atkinson, 1994) has underscored the need for majority counselors to de-velop an awareness of being White and what that implies in relationto those who do not share White group membership. Thus, regardless ofapparent “sameness,” at some point in all supervision, and preferablyearly in the process, multicultural issues must be explored.

The multicultural supervisory relationship is the “process” of supervi-sion. In this process the supervisor demonstrates knowledge of individualdifferences with respect to gender, race, ethnicity, culture, and age andunderstands the importance of these characteristics in supervisory rela-tionships. The actual work for our purposes will be labeled ‘cross-culturalsupervision.’ Leong and Wagner (in press) have found that race can havea profound influence on the supervisory process, particularly in terms oftrainee’s expectations for supervisor empathy, respect, and congruence.In addition, they have found that cultural differences in worldview andcommunication styles may particularly affect supervisee perceptions ofwhether the supervisor is perceived as supportive and empathic. Theysuggest that early discussion of supervisor and supervisee racial-ethnicbackgrounds and expectations about supervision may help establish abase for the development of trust and empathy.

Another critical dimension of the cross-cultural supervisory relation-ship is the management of power. The supervisor is viewed as havingexpertise and has the responsibility of evaluating the supervisee, both con-tributing to an unavoidable power differential in the relationship. Giventhe United States history of race relations and racial tension, in situationsof a supervisee who is a person of color and a Caucasian supervisor or aCaucasian supervisee and a supervisor who is a person of color, bothparticipants may attribute power to Caucasian or majority group member-ship. These additional perceived power differential and past experienceswith power abuses by Caucasians might make trust formation difficultand result in cautious, guarded communication. This, in turn, may resultin the opposite of the personal self-disclosure and openness to feedbackrequired in supervision. Also at issue here are all the personal prejudicesthat we do not want to admit to even to ourselves that both the supervisorand the supervisee carry.

Underscoring all this is an important point made by Roland (1988),that psychoanalysis has misrepresented itself in claiming to be value-freeand universal; some of its values are intrinsic to the enterprise, such astrying to face painful truths about oneself; other values, often clandes-tinely imported, are not essential. Analysts are constantly engaged inevaluating behavior as pathological or healthy, as infantile or mature,

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and in doing so are liable to apply standards derived from their ownculture, standards which have been built in to the theories without recog-nizing their local character. There are, of course, common threads ofhumanity, and Roland agrees that these threads are captured by thestructure of our theories, but, he argues, the ‘content’ of these categoriesis ‘overwhelmingly Western-centric.’

A classic example is the well-documented “Puerto-Rican syndrome,”in which the patient’s apparent “craziness” is a response to pressures andfears in the family. Often this takes the cultural form of “possession”which can easily be diagnosed by someone who is unaware of this pieceof culturally acceptable behavior as some form of psychosis. This illustra-tion also demonstrates the need to understand the specifics of a culture(Davidson, 1987).

Just before Christmas, I received an emergency phone call from apatient of mine. She is a 25-year-old Latina of Puerto Rican heritage. Sheis an educated young woman currently employed in the field of researchwhile finishing a graduate degree. Her mother who is also an educatedwoman had been hospitalized for a suicide attempt. Her mother had hadan argument with her 22-year-old son about the girl the son was goingout with (of whom she did not approve). The mother’s response was toingest 6 Motrin tablets and then lie prostrate on her bed claiming shewanted to die. When my patient entered the mother’s home and foundher like this she immediately called emergency services. The emergencyservices team that came to the house brought her to the hospital. Atthe hospital she was treated by a very well meaning resident of Indianbackground who had no understanding whatsoever of this woman’s cul-ture and what her behavior was all about. He kept her in the hospitalfor 10 days, met with the children separately and told them they were tonever leave their mother alone again. Someone who was more familiarwith Puerto Rican culture would have immediately gotten this womaninto individual and family therapy. My patients’ mother is torn betweenthe culture she was raised in that says ‘you respect and obey your par-ents’—and the culture she lives in that robs her of her parental powersonce the children are of a certain age. She used the only power she feltshe had, the threat of suicide to coerce her son.

The cross-cultural supervisor also has to keep in mind that the even-tual task will be not just the resolution of the patients discomfort andsymptoms and learning the art of treatment for the therapist but thatthe supervisor, the therapist, and the patient will also in some way haveundergone an experience in supervision and therapy that somewhat re-sembles travel in strange lands with strange customs. Like the journeyto a country whose language and customs are unfamiliar, cross-culturalsupervision begins with a state of unfamiliarity, mistrust, and confusion.

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The supervisor, the therapist, and the patient are an enigma to each otherat the outset. They must of necessity become participant-observers andethnographers of each other’s culture. For the supervisor this means care-ful questioning of the therapist whenever an unfamiliar piece of data orbehavior surfaces and making notation of any cultural significance. Thisin turn becomes a model for the therapist with his patient. It is oftenuseful to ask the supervisee at the beginning of supervision to tell abouthis culture and to admit ignorance when necessary.

In cross-cultural supervision it is a critical role for the supervisor topromote cultural awareness, identify cultural influences on patient be-havior, identify cultural influences on psychoanalyst-patient interactionsand identify it in the supervisory relationship and provide culture sensi-tive support and challenge to the supervisee as an ongoing process.

As one struggles with providing psychoanalytic treatment to a sociallydiverse population authors have been suggesting a change in psychoana-lytic models. Altman (1996) argues that the one-person model in psycho-analysis derived from Freudian drive theory is limited in its capacity toaccommodate cultural differences in the psychoanalytic dyad. He arguesthat a two-person or three-person, relational model is necessary for takingaccount of the community or clinic context in which psychoanalytic workwith a diverse clientele often takes place.

As a supervisor in such a situation I am not in agreement. A synthesisof models is necessary. In today’s world of varying psychoanalytic models,political camps have risen. The psychoanalytic clinician may in theirprivate professional life be a member of any of these political parties, butmost psychoanalysts in their actual clinical work require a variety ofperspectives to understand and treat patients (Pine, 1990). Just as wework cross-culturally with our patients and supervisees a multi-perspec-tive approach underlies the way many analysts in fact work with theirpatients today. For the American psychoanalyst these perspectives in-clude: drive, ego, object, relational, and self. As a psychoanalytic supervi-sor working cross-culturally I have added an additional psychoanalyticperspective to my work. That is the perspective of Lacan. The writingsof Lacan have greatly influenced not only the French psychoanalytic worldbut also the South American world, especially Argentina. I have been super-vising psychoanalysts and psychoanalytic psychotherapists from SouthAmerica for the last 10 years.

For the past 17 years I have been a supervisor of psychotherapistsand students of psychoanalysis and psychoanalytically oriented trainingat the Metropolitan Center for Mental Health (MCMH). MCMH is a com-munity based mental health clinic serving the upper west side of Manhat-tan. Approximately 10 years ago a new division was founded withinMCMH to serve the large Spanish speaking community in the immediate

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vicinity of MCMH. It is called Hispanic Family Services (HFS). Today,HFS is a viable division of MCMH that provides mental health servicesfor this under serviced population.

I am an individual and a group supervisor for HFS. It is here that Ibecame more acutely aware of the notion of cross-cultural supervisionbecause that was indeed what I was doing. What is so very interestingabout the HFS program is that most of the therapists are from SouthAmerica. Most are from Argentina, the next group are from Columbiaand a few from Brazil, Venezuela, and Chile. The population HFS servesis almost always Caribbean. The therapists often have a fairly good back-ground in the rudiments of treatment (their primary education is oftenpsychoanalytic) and almost always assume if the clients speaks Spanishas their first language (and often only language) they will have no problemunderstanding and communicating with their clients. As a psychoanalystand a woman who grew up in a multicultural setting I was and am fullyaware that there is more to communicating than a common academiclanguage. There are three cultures in the room, when I supervise: thereis the client from the Caribbean, whose culture is dependent upon exactlywhich island in the Caribbean, either urban or rural and which socio-economic status; then there is the therapist whose culture is markedlydependent on exactly which country in South America they are from (Ionce supervised a Brazilian woman whose family were Syrian Jewswho had migrated to Brazil. Her cultural perspectives were very differentthan a male colleague of hers, also from Brazil, whose family had beenin Brazil for many generations); the third culture in the room is mine,the white American supervisor of eastern European heritage from NewYork City. This work has provided for a fascinating mix and unlimitedchallenges.

One of the major issues provoked by the work of supervising thesetherapists was my need to explore as fully as possible all my identifica-tions. I realized I take my identity from many different groups. My genderidentity is first and most absolute, and that is female. The rest is not asabsolute for me. I am Caucasian but not completely identified with beinga White American. I am a second generation American yet still identifyvery strongly with the values and attitudes of my east European Jewishgrandparents who saw themselves as a persecuted minority. Prior to Sep-tember 11, 2001, I did not identify with being persecuted at the moment,but like many Jews throughout the world I lived in anticipation that itcould happen at any time. Although this piece was originally writtenbefore September 11th, the aftermath of that day confirmed the fears Iinherited from my grandparents. In a recent article in the magazinesection of the New York Times, Rosen (2001) spoke of the state of Israelas being demonized in the European press, and Jews are being demonized

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in the Arab press. In recent months I have been reminded, in ways toplentiful to ignore, that anti-Semitism is alive and well.

Now if I may get back to the major theme of this paper after thisurgently felt digression. In addition, my identity includes the fact that Iwas born and raised in New York City and identify with a politically liberalurban intellectual group peculiar to New York City. When I supervise Ibring a particular mix that is my own culture.

In this country people of color identify themselves as, black, brown,red, or yellow. I have come to understand the subtlety in one particularethnic color identification, brown. Usually the identification of brown forpeople of color means Hispanic. What are seldom elaborated on are thevast differences in peoples who identify themselves as Hispanic. At HFSthe therapists from different countries in South America have some cul-tural issues in common. The histories of all these countries differ greatlyand consequently so do the cultural values. This is also true of theirclients, who come from many different countries in the Caribbean. The“myth of sameness” is just that, a myth. Even the language is notcompletely the same. Words are used differently and in unique ways indifferent countries even though the language maybe the same. The maintool of treatment is language. Language is a culturally sensitive instru-ment. As a consequence even the very instrument the therapist, the pa-tients, and the supervisor use must be sensitively tuned into culturalnuances.

When I first started to supervise at HFS, a new therapist from Argen-tina was one of my first supervisees. He was a young man who hadfinished his baccalaureate approximately two years before coming to theUnited States and starting to work at HFS. He was very bright, knowl-edgeable in basic psychoanalytic theory and eager to get to work. Hewas conducting the initial interviews with a woman from the DominicanRepublic in Spanish. She was able to elaborate in detail about her symp-toms, even her thoughts as to what the stresses were in her life that mayhave triggered them. Then he began to ask about her life situation athome. She reported that she was divorced and had two children living athome with her. He casually asked in Spanish what the sexes of the childrenwere. She replied in Spanish that one was el nino meaning male andthe other was la hembra. My supervisee from Argentina was aghast. InArgentina, the answer to such a question as to what the sexes are of yourchildren are, el nino and la nina. The adjective la hembra, is reservedfor the description of animals (i.e., la elefante hembra is a female elephant).He understood that she was degrading her female child by using an ad-jective reserved for animals. He immediately brought this into supervi-sion. The two of us started speculating on her degraded view of her daugh-ter, the projections that must be involved. We even considered that there

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would be a need to bring this child into treatment if she had grown upwith a mother who could speak about her in such a way.

I conferred on this case with a colleague who had been born andraised in the Dominican Republic. She explained to me that this indeedwas ‘normal usage’ to describe a feminine person as la hembra. The patientwas not denigrating her daughter by describing her as la hembra. Thisis a good example of the ‘myth of sameness.’ The patient and the superviseespeak the same language; yet use words differently because they learnedtheir language under different cultural settings in different countries.

As the above illustrates, language is a culturally sensitive instrument,but it is also the main tool of treatment. As a consequence, even the veryinstrument the analyst and the supervisor use must be sensitively tunedinto cultural nuances. As psychoanalysts, the words of our patients haveprofound meaning. They are our main routes to the unconscious alongwith dreams. We are always looking at the chosen words a patient usesas connections to an unconscious conflict, relationship, self state, and soon. Because each patient’s psyche is different, his or her choice of wordsis unique, but we all learn language within a socio-cultural context. Soas psychoanalysts and supervisors we must first learn to read the culturallanguage if we are to be able to read the personal language.

The terrorist attack of the United States on September 11, 2001, andthe methods of coping can be used as an illustration of cross-culturalissues that appear in supervision.

While all of America was deeply shocked, frightened, and woundedby the event, the methods used to cope, by those of us who were herein New York City at the time of the attack clearly underscore culturaldifferences and raise the issue of how much does one impose their culturalstyles on another.

In the Caribbean community in NYC an important component of lifeinvolves daily interactions with neighbors. People chat on the street, infront of their buildings on the stoops, on the benches, and most importantin the neighborhood bodegas. It is here that this marginalized communityreceives not only the emotional support and actual sustenance necessaryfor life but also tips and information on how to negotiate the myriad stateand city agencies urban life demands and also the news from the broaderworld outside their everyday existence.

The terrorist attack first shocked then terrified the city and the na-tion. Americans across the country sat glued to their televisions to getthe latest information. New Yorkers, who were not downtown immediatelytelephoned friends and loved ones to see if they were “accounted for.” Asthe days and weeks went on one could keep abreast of information throughthe media. It is true that information came in that was anything butreassuring but somehow or another with all the ‘experts’ called in one couldget a larger perspective on it. In a marginalized community such as the

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Caribbean one where people gets the bulk of their information about theworld through the various community forums, little frightening pieces ofnews traveled in an incendiary fashion. Neighbors would further infecteach other with these terrifying pieces of information. Patients would runto their therapists asking if the rumors they heard were true. Was thewater safe? Can they shower? Can they drink the water? Do you thinkwe are safe? Do you think they came to the United States? Do you thinkthey have invaded us in the United States? Their conception was thattwo countries were at war. They seemed to imagine that planes, bombs,and soldiers had invaded the U.S. The therapist had to explain that it isa war between the United States and terrorists groups.

One of the therapists I was supervising at the time is a gentlemanfrom Argentina who migrated to the United States a year ago. He grewup and came of age under a totalitarian regime. He has memories ofpeople who “disappeared.” He has a very distinct memory as a child ofhis mother becoming very upset and burning the books in his father’slibrary for fear they would be persecuted for the literature he was reading.The September 11th atrocity was very disturbing to him, but not in thesame way as it was for his patients and his supervisor. His patients andhis supervisor (myself) had never lived through such a threat to ourexistence. The therapist had an inner experience of being able to survivein a world where men with some power could arbitrarily destroy yourworld. It is akin to the experience of someone who has lost their parentsduring their childhood. It is a devastating experience for the child butover time the child learns to accommodate to this monumental loss al-though the child is irrevocably changed from that day forward.

As a student of psychology in Argentina the therapists’ orientationin psychoanalysis is Lacanian. His understandings of patients are under-scored by this Lacanian orientation. I will attempt to illustrate how thetherapist understood his patient through a Lacanian perspective thatwas then translated into the American psychoanalytic perspective of thesupervisor. I would like to use a disclaimer at this point in underscoringthat I am not a Lacanian scholar.

I return to the illustration of the Caribbean patients who were run-ning to their therapist to confirm all the rumors they were hearing afterthe September 11th atrocity. This Argentinean therapist through hisLacanian perspective felt that his patients’ saw him as ‘complete’ or ‘whole’not lacking anything. He had all the answers because he was the authorityfigure or phallic mother that had it all. For a Lacanian, the therapistallows this appearance of being ‘whole.’ Even though, in the Lacaniansense to be “whole” or have ‘all the answers’ is a psychotic position (Gure-wich & Fairfield, 1998). He would tell his patients that it is true thesituation is very difficult but we must continue with our normal lives.We must listen to the president and continue to function in our normal

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lives but be attuned and attentive. He discouraged them from gettinginformation from their usual network. He advised them to stop watchingtelevision and talking to neighbors about it, and so on.

With other patients that he felt had a better grasp between theimaginary and the real he would pose the question “yes, it is true thesituation is terrible but what can we do? Do you think we can’t takeshowers anymore?” In an ego psychological sense he lent his own ego andstrengthened their ego defenses. In an object relations sense he becamethe voice of the good father to introject. Like a good father he helpedstrengthen their egos reminding them of the power of the ultimate father,the United States, and impressed upon them to go back to their usualactivities. What is interesting is that, whether your lens is Lacanian orAmerican psychoanalytic, the intervention would be the same. You areeither becoming the ‘whole’ father for the patient or as an ego psychologistlending your stronger ego to the patient when their ego is faltering.

This same therapist was working with an 8-year-old boy whose fatherhad died a year and a half before. The child had been in treatment for afew months but could never speak of his father. After September 11th hebegan to speak of his dead father through talking about the terrorist attackof September 11th. As a Lacanian, the therapist explained it as the childnever having a signifier to symbolize the event (Gurewich & Tort, 1996).The child required something symbolic to stand for the monumental eventof the loss of his father. The events of September 11th served as a signifierallowing the symbolization of the father’s death for the child.

As an American psychoanalyst I understood the child being ablefinally to speak about his father somewhat differently. Using the lens ofobject relations theory the child is seen as having begun truly to internal-ize enough of the therapist to feel safe enough to speak about his father,because another strong safe object was inside him now. As an ego psycholo-gist I see the events of September 11th serving as a trigger disruptingthe child’s ego defense of denial. Once the ego defense is no longer securelyin place he is faced with the reality of his father’s death.

There have been numerous papers written over the last 20 yearsattempting to show the cultural relativity of psychoanalysis. Why drivetheory could be created in fin de siecle Vienna and why ego psychologywould come to fruition in America. So when supervising cross-culturallythe supervisor must be aware of his/her own culture, the culture of thesupervisee and the culture of the patient as well as the cultural relativityof the theoretical models employed by the therapist and the supervisor.This makes supervision a much more complicated process but a veryrewarding one. Getting glimpses into other cultures and other theoreticalframeworks expands ones own ability to view and understand the worldand hopefully gain tolerance for the differences. Tolerance for differences

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is something that is sorely needed in today’s new world where the yearningfor safety is now only in, to borrow Lacanian language, the Imaginary.

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Bernard, J. M. & Goodyear, R. K. (1992) Fundamental of clinical supervision. Boston, MA:Allyn and Bacon.

Davidson, L. (1987) The cross-cultural therapeutic dyad. Contemporary Psychoanalysis, 23:659–675

Devereux, G. (1982) Basic Problems in Ethnopsychiatry. Psychoanalytic Quarterly, 51:312–319

Geertz, G. (1973) The Interpretation of Cultures New York: Basic Books Inc.-Harper TorchBooks, Part I pp. 3–30

Goodenough, W. (1981) Culture, Language and Society. Menlo Park, CA: Benjamin Cum-mings Pub. Co.

Gurewich, J. F. & Fairfield, S. (1998). Introduction to the Reading of Lacan: The UnconsciousStructured Like a Language. New York: The Other Press.

Gurewich, J. F. & Tort, M. (1996). The Subject and the Self: Lacan and American Psychoanal-ysis. Northfield, NJ: Jacob Aronson Inc.

Hodgkinson, H. L. (1992). A demographic look at tomorrow. Washington, D.C.: Institute forEducational Leadership.

Holloway, E. L. (1995) Clinical supervision: A systems approach. Thousand Oaks, CA: Sage.Kessler, R. C., et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric

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What do we need to know? Counselor Education and Supervision.McNeill, B. W., Hom, K. L. & Perez, J.A. (1995). The training and supervisory needs for racial

and ethnic minority students. Journal of Multicultural Counseling and Development, 23,246–258.

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Rogler, L. H., Malgady, R.G., & Rodriquez, O. (1989). Hispanics and mental health: Aframework for research. Melbourne, FL: Kreiger.

Roland, A. (1988). In Search of Self in India and Japan. Toward a Cross-Cultural Psychology.Princeton, NJ: Princeton University Press.

Rosen, J. (2001). The uncomfortable question of anti-semitism. New York Times, MagazineSection, November 4, 2001.

Rowe, W., Bennett, S. K., & Atkinson, D. R. (1994). White racial identity models: A critiqueand alternative proposal. The Counseling Psychologist, 22, 126–146.

Shrout, P., et al. (1992). Mental health status among Puerto Ricans, Mexican Americans,and non-Hispanic whites. American Journal of Community Psychology, 20, 729–752.

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Robin Young, Ph.D., B.C.D.175 West 93rd StreetNew York, New York 10025