When the therapist and patient are from different cultures, there may be impediments to the development of empathy and a therapeutic alliance. South India culture provides an example of contrasting values and customs about which patients may be reluctant to discuss. The initial case history is of a South Indian who sought treatment in the United States. The remaining cases, drawn from a village in South India with which the author has had a 55-year history of research, illustrate cultural factors potentially inhibiting or facilitating the development of empathy and a therapeutic alliance.