Message from the President

In Search of a Cultural Psychiatry Paradigm Based on Psychodynamic Theory

By: César A. Alfonso, M.D.
President, AAPDP, 2010-2012

Can psychodynamic psychiatry serve as a conduit to revise our antiquated and clinically ineffective cultural psychiatry paradigms? For the past two years I have been pondering about this question and will share in this column some recent thoughts derived from quite a bit of traveling, lecturing, and treatments across geographical boundaries.

In my opinion, DSM culture-bound syndromes, ending up in an appendix almost as an afterthought, are not particularly clinically useful. Culture-bound syndromes run the risk of intensifying negative cultural stereotypes and internalized racism. The way we teach cultural sensitivity and proficiency is usually experienced by trainees in the classroom or individual supervision as cumbersome, offensive, reductionistic, and usually met with yawning, dissociation, avoidance, jitteriness, grimacing, or eye-rolling.

There is some wisdom in the general critique that contemporary psychoanalysis, just as psychiatry, places more emphasis in understanding pathological states rather than attempting to comprehend normal development and ego-syntonic adjustment to the demands of our ever changing cultural milieu. Even the term “cultural idioms of distress” assigns specific characteristics to ethnic and racial groups, bypassing other culturally relevant socioeconomic, intergenerational, individual, and interpersonal dynamic features.

Ihave found inspiration in the work of Akhtar, Bullon, Cabaniss, Czarnowski, Condemarin, MA and M Cohen, Davidson, Du, Eckardt, Lana and Ralph Fishkin, Garza, Griffin, Hernandez Delgado, Hoare, Hyun, Kitt, Kent, Qizhuang Jiang, Lefer, Leli, Lopez, Marumoto, Olarte, Perman, Perry, Schwartz, Rangsun Sitthichai, Sam and Sandy Slipp, Siriluck Suppapitiporn, Rothe, Snyder, Taketomo, Tuttman, Umaporn Trangkasombat, Waits, Wells, Zaphiropolous, Jingyan Zhang, and many other colleagues who have examined cultural paradigms using alternative frameworks, such as my preferred Eriksonian prospective contextual development theory, rather than perpetuating retrospective meta-psychological hypotheses or succumbing to stale mainstream psychiatric nosology. I am grateful to colleagues for stimulating my mind, and to patients for helping me learn to listen to what is culturally relevant in treatment, to identify what is not culturally relevant, what may be nothing more than countertransferential overinvestment via extreme cultural curiosity, and what may be thinly disguised as cultural resistance in transference analyses. Psychodynamic concepts can be helpful in reframing psychotherapy interventions, separating the wheat from the cultural chaff.

A year ago at a grand rounds presentation at Harvard’s Latino Mental Health Clinic I prefaced my thoughts tentatively by saying that “...now I will begin to swim in shark-infested waters, with my critique of extreme culturalism…” To my surprise, the audience then was quite receptive. I remember seeing heads nodding as I spoke. What a relief to find out that I was not being controversial after all! Not that I am averse to controversy, but it is so much easier to effect change when ideas resonate with enthusiastic open-mindedness. To the sophisticated Latino professional audience, I did not speak of ataque de nervios, susto, fatiga, marianismo, machismo, somatization, hysterical personality traits, low physical pain threshold, paternalism, martyrdom, and other reductionistic stereotypes, but rather proposed that a psychodynamic anamnesis, when carefully crafted, may suffice to create cultural alignment. Succumbing to the temptation to categorize symptomatology or personality characteristics within psychiatrically sanctioned cultural idioms of distress may be misguided if other relevant data is ignored, such as intrapsychic, interpersonal and intergenerational conflicts, transference, countertransference, resistance, and defensive/adaptive functioning. Cautiously, I repeated my position and have continued to incubate these ideas, presenting them to professional audiences in New York, Buenos Aires, Boston, Bangkok, Lexington, and San Diego. Later in 2012 I will speak in Philadelphia, Prague and return to Southeast Asia. Perhaps what you will read in this column will permutate into a more cogent proposal as I continue to learn with humility during my transcultural academic expeditions.

Erikson was one of the most influential American psychoanalysts. Although perhaps he is best remembered for having won both a National Book Award and Pulitzer Prize in 1970 for his work: Gandhi’s Truth: On the Origins of Militant Nonviolence, his contributions to our field were quite original and clinically useful. He believed that traditional psychodynamic models tend to be excessively retrospective, and criticized the notion that most important aspects of development are set in early life experiences (I am not denying the importance of early attachments and critical periods in development during infancy and childhood, but psychoanalyses should also emphasize reparative and life-enhancing experiences in adulthood). A new paradigm that considers developmental milestones in all age groups is needed, as longevity has become a reality. When psychoanalysis was developed in Europe, most people did not live past their mid fifties. More patients now seek treatment when faced in mid to late life with states of stagnation, emptiness, lack of direction, attempting to seek solace, engaging in prosocial behaviors, while negotiating friendships and family relationships in more adaptive ways.

Erikson’s concepts of prospective and contextual development imply that there are developmental milestones that need to be attained throughout all phases of adulthood. Some, but not all of these milestones are culture-specific. Erikson’s concept of contextual development stresses the importance of the social milieu in a person’s life trajectory, and the importance of the need for adaptation, as one is faced with changes in society. Think of what is happening in China, where soon 50% of the country will live in cosmopolitan globalized international megalopolis and 50% of the population in remote rural areas. While learning about filial piety, the tenets of Confucianism, Buddhism and Taoism, Chinese mythology, or even how contemporary soap operas reflect sociologic and anthropologic realities, framing treatments with Chinese or Chinese American patients strictly within such parameters may deflect from affect- laden conflicts that may not be culturally exotic. While cross-fertilization with allied disciplines in the humanities definitely enhances our understanding of cultural and historical contexts, the realities of each treatment dyad most often will not reflect cultural differences. Globalization may have changed the way we practice, bringing us back to emphasizing the fundamental processes common to all psychotherapies, enhancing supportive interventions with psychodynamic exploration, with cultural similarities often outweighing differences in the therapeutic dyad.

Acculturation and assimilation may be understood as efforts at adaptation.
My position on acculturation vs. assimilation is pro-choice – just as individuals have the right to autonomy and self-determination, acculturation and assimilation are choices that individuals and or groups will make, at different points in time, depending on a multiplicity of variables. There is no right or wrong when it comes to acculturation and assimilation and I believe that as therapists our position should be neutral rather than directive or encouraging of syncretism, blending or isolation. In New York, the Puerto Rican El Barrio is no longer Puerto Rican – now renamed East Harlem, it is predominantly gentrified with yuppies intermixed with new groups of immigrants from Mexico and Central America. Millions of Puerto Ricans have crossed-over and blended within the New York amalgamated megalopolis. Once a year, during the Puerto Rican Day Parade, I am reminded of how rich a part of American culture Puerto Ricans are, as Fifth Avenue is flooded with over three million people, and hundreds of floats demonstrating sensational music, political, religious, and other cultural icons. Chinatown, in New York, as in other US cities, retains cultural boundaries without much renunciation of immigrant traditions or adoption of host attitudes. In the 1980s and 1990s very few would have predicted the degree of acculturation and assimilation of the Puerto Rican community in many US cities.

Intergenerational conflicts surge as families relocate, regardless of the lesser or greater extent of the geographical transposition. These interpersonal conflicts very much permeate the treatment discourse of psychodynamic psychotherapy with our patients. I firmly believe we should make efforts at decoding intergenerational conflicts, but these efforts should not be reserved exclusively to recent immigrants. Explorations of intergenerational conflicts are clinically valuable in all analyses and treatments, regardless of chronological imminence.

Bullon and colleagues (Harvard Review of Psychiatry, 2010, 18:247-253) wrote about the vicissitudes of cultural sensitivity and cultural competence training of health professionals. In the old prevailing paradigm, basic assumptions include that there are disparities in access to treatment (which is true and validated by research) and existing treatments are ineffective and need to be “culturally” modified (I would be cautious to think of this latter assumption as a truism). What I want you to consider is the following: obsessive cultural competence discourse may lead to over-generalizations and stereotyping.

Is language or cultural affinity necessary for psychotherapy? A categorical answer would be no, not essential, but definitely helpful at times. However, we have all probably experienced that some degree of cultural familiarity helps strengthen therapeutic alliance and improve adherence to care. In the same way that as clinicians we are not ethically allowed to express sexist or homophobic attitudes, we need to be culturally sensitive rather than xenophobic or racist. We should desensitize ourselves not to fear our neighbors or those who come from different backgrounds and have had different life experiences.

I will end this column with a tale that symbolizes globalization.  Chillies are an American fruit, known to exist in the wild for 12 millennia and domesticated for at least eight millennia. Chile, the name of the country, is derived from the Quechua word chiri (cold), the Aymara word tchilli (snow), and the Mapuche word chilli (meaning “where the land ends”). Chile and chilli share no etymological antecedents. Chilli, the spelling of the fruit in Nahuatl, rather than the conventional spelling ‘chili’, is the preferred spelling as per the Oxford Dictionary. Please make an effort to add the extra “l” from now on… Ají, the word for chilli in the Caribbean, is of Taíno origin. Ajíes tend to be milder in flavor since they contain less capsaicinoids.

How chillies traveled around the world and influenced other cultures could be viewed as a metaphor of globalization. Chillies are no longer an exclusive or predominant American staple. They arrived in Asia not so long ago; believe it or not, even in the Indian subcontinent, South Asia and Southeast Asia, there were no chillies in Asian cuisine until the 17^th to 18^th century.

I remember having a conversation with friends in Thailand about the history of Thai food, and they were quite aware that old imperial Thai cuisine was quite bland until American chillies arrived to the old capital of Ayutthaya. My friends also told me that sushi originated in Thailand. I did not believe this but was too polite to argue. I looked it up later in the book The Zen of Fish and corroborated they were right.

The next time you order a vindaloo dish at an Indian restaurant please remember the following and you will impress your guests. The Portuguese, who brought chillies to India, also brought their other traditional dishes. Vindaloo derives from a traditional Portuguese Christmas dish, “carne de vinha d’ahlos,” which basically translates to pickled garlic pork. Indians in the Goa region spiced it up by adding American chillies. A few centuries later, vindaloo curries stand among the spiciest. As Akhtar poignantly states in his recent book Freud and the Far East, psychoanalysis is no longer Eurocentric or an American phenomenon and our academic exchanges should renounce colonialist attitudes. We learn from each other and psychodynamic practice takes on the color of its host countries, with ensuing modifications of theory and practice. Exchanging psychoanalytic theories with international colleagues should occur with respectful reciprocity.

Traveling around the world is no longer necessary to teach or treat. Distance learning through videotelephony technologies and clinical encounters using SKYPE^TM or ooVoo^TM are now well established and accepted by most clinicians. Research validating the effectiveness of these efforts is under way and I predict will corroborate that technological advances are effective and can be integrated into our clinical and didactic armamentarium to reach undeserved areas or supplement our local endeavors.

To conclude, unaltered psychodynamic theoretical concepts and technique may provide a balanced framework to work through resistance and avoidance behaviors when these are disguised as cultural differences. Cultural humility rather than excessive countertransferential investment, which primarily reflects the therapist’s cultural curiosity and not necessarily relevant aspects of the process, may protect the integrity of treatment by allowing the therapist to work with the material that is of greatest relevance to the patient. A new paradigm that takes globalization into account will help cultural psychiatry evolve to enhance our therapeutic actions. Psychodynamic psychiatry may well serve as a solid substrate for cultural psychiatry to build upon.