Advanced Psychopathology

Thursday, May 11, 2006


Matt: Cultural Differences

When it comes to working with patients from different cultures, two broad themes present themselves as areas to pay special attention to. One is the potential for differences in the normal standards of expected behavior. So much of psychology boils down to what is normal/what is abnormal that there can be a tendency to forget that, in most things, normality is largely culturally determined. In psychotherapy, this impacts everything from how a therapist hears and understands a patient’s history to the goals that are set for treatment. For example, the news that a patient slept in her parent’s bed until her late teens would be greeted by most psychologists (especially the psychoanalysts!) as an important factor in the patient’s history, and likely a symptom of family dysfunction. But if this patient was Asian Indian, we should not be surprised or unduly influenced by this information, since it is traditional Indian child-rearing practice. Some children remain in their parents’ beds right up until their wedding days. The second area concerns differences in what patients from different cultures might expect of the therapeutic relationship, and what it means for them to be in therapy in the first place. Most white, middle-class Americans (like me) are well versed in the culture of talk therapy, and know what to expect from it. They may have had a friend or relative who utilized the services of a psychotherapist. At the very least, they have picked up some knowledge from the Sopranos or Woody Allen movies. But those from different cultural backgrounds may not have this context, and may be much more resistant to the very idea of psychological treatment. For such people, the meaning of their presenting for treatment at all is different. Again, an example of difference from Indian culture, in which there is a formidable social stigma attached to help-seeking for mental health issues. In Indian society, where social superiors are expected to take an active role in nurturing their inferiors, it would be normal for a patient to expect his therapist to spend a fair amount of session time dispensing advice. In this context, the reserved psychodynamic practitioner who always analyzes, never gratifies might very well be perceived as cruel and inappropriate.
Some of these issues came up with a one of my patients at the VA. I met Bill, an African-American man in his mid-60s, while doing mental health screenings on the wards. He was personable and talkative, and engaged me in a conversation about his religious beliefs. He also admitted to feeling depressed, which was not a shock, given that he’d been in the hospital for 15 months following a leg amputation and that during this time his wife had left him. He asked me about my beliefs, and I told him my somewhat ambivalent relationship to religion. He listened carefully before seeming to decide that I was okay, and then I got him to come to Psychology for therapy next week. I’ve been seeing him for about three months now, and our sessions have never been anything like traditional therapy. We chat. He tells me what his kids are up to and how his physical therapy is going. Now and then I ask how he is feeling or delve into his history a little. I don’t think he believes in psychotherapy—it’s not a part of worldview, really—but he is open and honest and likes coming to talk for half and hour or so (he always leaves early and I don’t press him to say why). I think that this is useful to him, though it may not be life-changing. If we had another year, it might evolve into something more. I do know that if I insisted on a traditional psychodynamic approach—if I tried to analyze the questions he asks me about myself, for example—that he would stop coming to his sessions. Whatever benefit he is receiving from his time with me, he is receiving it because I’ve been very flexible in my approach to him.
Bill’s kind of attitude toward therapy could probably be found in some people from almost any culture. As such, it illustrates the need to pay attention to subtle differences between therapist and patient as much as more obvious cultural or ethnic disparities.

Monday, May 08, 2006


Psychoanalytic Theory and Multiculturalism

Jay Kosegarten
Prof. Papouchis

Psychoanalytic Theory and Multiculturalism

In discussing the short-comings of psychoanalytic theory with regard to multiculturalism, one the most obvious areas is when the theory is applied to cultures who value more enmeshed family dynamics. As psychoanalysis is thoroughly Western and European in its roots, there is a pervasive emphasis on separation and individuation in the development of a healthy individual.
Yet, as we know, many cultures are not oriented in this way at all, and often the opposite is valued, where a continued closeness maintaining a lack of separation is supported. Analytic thinking tends to present the separation-individuation model as a universal ideal for health rooted in biological drives and childhood development. But this model grew out of a culture that had already been built around ideals of personal achievement and the uniqueness of the individual mind and life. As such, societies have tended to be structured in way that rewards achievements that are individually attained. There are few economic incentives, for example, for maintaining large extended families. The work that would be done by, say, a grandmother in a Latin or Asian family, is outsourced, so to speak, to a babysitter or hired nanny. This is often because the grandmother does not live nearby because the young family has moved away, and the most common reason people move is their career.
Career, in contemporary Western culture, is at the heart of individual achievement and the desire to be in proximity with one’s extended family will not get in the way. Analytically, it might be labeled as “infantile” or “poorly differentiated” if a man or a woman chooses a lifetime of closeness with his or her parents over the pursuit and fruition of personal career goals.


referential vs. indexical self

Psychodynamic therapy is largely influenced by a western understanding of self that may be referred to as the referential self. Within this concept the self is recognized as a bounded, distinctive, encapsulated entity contiguous with but not equivalent with the body. The self occupies the mind aspect of a mind/body split where the body is considered to be nonself. Since the self is seen to be a singular discrete entity, the concept of self as fragmented, unbounded, or manifold is deemed to be symptomatic (e.g., as Dissociative Identity Disorder or psychosis). The self is understood to be a cognitive and emotional world and the nucleus of awareness, judgment, emotion, and accomplishment. As such, it is believed to think, feel, monitor, and retain various cognitive processes. Consequently, Western culture views psychopathology as experiencing one’s thoughts and feelings as originating from an area other than the self, and the experience of cognition being ruled by someone/something other than the self as thought disorder, delusion, or obsession-compulsion. Overall, the referential self has skills, preferences, needs, wishes, and a “style” of its own that illustrate it, refer to it (thus, referential), and distinguish it from other selves. This self can be reflected upon; it can be considered, analyzed, and talked about in isolation. Accordingly, self-awareness, self-criticism, self-consciousness, self-reflection, self-determination, self-actualization, self-fulfillment, and self-change are all feasible, acceptable, and in fact expected in Western psychodynamic therapy.

Many American ethnic minorities have a different concept of the self, referred to as the indexical self. This self is not a discrete entity capable of existing independent from the relationships and situations in which it is presented. Indeed, it is comprised of social interactions, contexts, and relationships. As such, it may be invented and reinvented based upon a particular interaction and context and exists only in and through these. This self is defined as “indexical” since it “is perceived as constituted or ‘indexed’ by the contextual features of social interaction in diverse situations” (Gaines, 1982, p. 182). Because it exists only in and through interactions, it cannot be described without referring to particular, tangible encounters with others. As a result, the indexical self does not retain lasting, trans-situational characteristics, traits, wishes, or needs of its own separate from its relationships and contexts. From a Western psychological perspective this version of the self may be misinterpreted as resistant to treatment. Similarly, the inability to reflect on the self as separate from others could be misunderstood as lack of “insight”. A sociocentric client who appears to describe him/herself in contradictory ways may also be misconstrued as having borderline personality organization, a manifestation of “splitting” or compartmentalizing, as in the western defined symptom of paranoia.

Gaines, A. (1982). Cultural definitions, behavior, and the person in American psychiatry. In A.J. Marsella & A. White (Eds.), Cultural conceptions of mental health and therapy. London: Reidel.

Landrine, H. (1992). Clinical implications of cultural differences: The referential versus the indexical self. Clincal Psychology Review, 12, 401-415.


The final one...finally

It seems evident that when working with clients from ethnically diverse backgrounds, the role of the therapist, how one is perceived, and interventions the therapist may make in turn can run counter to more traditional modes of psychodynamic therapy. As a therapist, it is key to remain consciously aware of how constructs within different cultures,such as how respect is conveyed, appropriate physical contact/distance, and issues of time and humor are perceived. For example, Arab, Latin American and southern European cultures tend to prefer less physical distance when interacting with others and so if a client from one of these backgrounds was engaged with a therapist who was from a different (perhaps Euro-American Caucasian) background, the therapist would be required to reevaluate his/her role in the therapy room and engage with this client in a manner that would require more conscious awareness on the part of the therapist. The therapist would have to determine what effect his/her own culture may have on his/her ability to adapt to the client’s method of interaction and to acknowledge that he/she is not a blank slate who brings an entirely objective stance to the therapeutic interaction.

In many cultures across the globe, the notion of separation/individuation and the importance of the mother-infant interaction seem to be at odds with what is deemed as successful development by classic psychodynamic theories. For example, in more collectivistic societies, such as various Asian cultures, childcare duties may be dispersed among several generations of family members, including extended kin networks who form primary bonds with infants and appear to safeguard against possible negative interactions experienced with “mother.” In addition, complete separation from primary caregivers and the ability to see oneself as a fully-functioning whole individual who is separate from those they have had the closest interpersonal experiences with is often not seen as a positive developmental outcome. In contrast, the ability to see oneself within the context of others and to attempt to strengthen the concept of cohesion instead of separation is often a goal of childrearing practices. Due to this notion, it would be important for therapists working with these clients to acknowledge what is valued in their society and show a sense of empathy and respect for how cultural differences oftentimes help define the course of therapy and to meet the client where they are in terms of the idiosyncrasies that constitute their psychological past.

Sunday, May 07, 2006


*gasp* *wheeze*

When working with a population as diverse as LIU’s, there are some important cultural aspects to keep in mind. Because psychodynamic theory is embedded in the subjective experience of one’s own self, family interactions, sexuality, etc. it is difficult to make statements about how psychodynamic theory may or may not play out in other cultures. However, it may be possible and necessary to hypothesize about how certain cultural aspects might affect psychodynamic treatment.

The roles of gender are markedly different cross-culturally, which may affect both men and women of that culture in ways different from the western nuclear family model that some psychodynamic theory seems to be based on. If we consider Hasidic Jewish culture we will note very different expectations of men and women from those discussed in psychodynamic theory, and the different ways that such attitudes might impact on the growing child, and on the adult who eventually presents for treatment.

Within Hasidic Jewish culture, men are rather reified. Elaborate rituals usher boys and young men into every successive aspect of the religious study that characterizes male life within the Hasidism. Men are celebrated in infancy when they are circumcised, as toddlers when their hair is shaved into the traditional Hasidic style, when they begin their religious education, and finally when they get married. Women have no such rituals, and are really expected just to carry out the day-to-day duties of cooking cleaning working and child rearing so that the men have the time and mental space needed to truly understand religious texts. In this environment, young children may not even have a chance to bond with the father enough to experience any sort of oedipal/electra feelings, and in this context sibling rivalry has the potential to either be explosive, or completely absent. Probably young Hasidic girls have some sort of feeling about their male siblings getting such different treatment, though they may not be able to express such feelings within the context of the Hasidic family. In general however, the women of the Hasidism need to deal with a certain absence of male figures and an inherent inequality between male and female siblings early on. In this culture, women are also considered dirty and unclean, particularly when menstruating. During this time they are not supposed to touch and contaminate any male, and even contact with their infant sons is allowed only begrudgingly. In such a climate it may be difficult for the young toddler to feel the sort of bond with his mother that is discussed within psychodynamic theory, as he is being taught that he should separate from the impure feminine influence as soon as possible.

It is important to understand the role that things like gender often play within a certain culture, in order to understand the context that helped to mold and shape patients presenting for therapy. The beauty of psychodynamic thought is that it allows for a deep understanding of integral parts of life. However, the cultural contexts of these aspects cannot be ignored, or else the deep understanding will forever elude.


Adieu, Adieu, to you and you and you-ou

While recent strides have clearly been made to include a cross-cultrual understanding in psychodynamic theory, an effort on the part of each clinical psychology student must still be made. Much of traditional psychoanalytic theory assumes that optimal mental health is predicated on the upbringing and lifestyle typical of an upper-middle class nuclear family: Mom and dad, lots of breastfeeding, toilet training at just the right time, consistency and closeness during early infancy, dinner on the table at precisely 6 o’clock, and plastic on the furniture. I jest, but it is no surprise that there are many variables and contributing factors to healthy development that are skewed towards Western upper-class ideals.

I began reading the Dan Stern book while vacationing in Thailand over winter break. While his research and theories are quite impressive and useful to clinical psychologists, I couldn’t help but feel jarred by the environment in which I was reading it. I spent some time in one of the local villages down the hill from the touristy resort where I stayed. There it was quite common to see an infant being breastfed by multiple women. I wasn’t certain whether or not this was a result of the devastating tsunami that destroyed the region last year. Perhaps these infants had lost their biological mothers. However, one woman who spoke English fairly well told me that it is a common practice irrespective of the tsunami. All Thai women work, she explained, so other women who are home from work assume childcare responsibilities for the mother. She then said that all children have one mother who they live with, but that all of the men and women in the village are also their ‘mother’.

According to much of the psychodynamic literature, this scenario conflicts greatly with the optimal mother-infant dyad, from which all things wonderful stem. Most likely, being thrown around from one breast to another would foster some sort of insecure attachment. Yet, witnessing the psychological resilience that the majority of Thais have maintained after such inconceivable loss, I was truly amazed.

Aside from my time in Thailand, my experiences as a gay man have made me reevaluate many of the pivotal aspects of analytic theory. Most importantly, many gays are having families these days. Research has indicated that children of gay parents are likely to be as psychologically well-adjusted as the children of straight parents. Traditional analytic theory makes conceptualizing this phenomenon quite difficult. With two men as the parents, there is obviously no breast, no contrasting gender roles, and there was likely a separation from a birth mother whether through adoption or surrogacy. While this is not a cultural or ethnic difference, its increased prevalence is something that current clinical psychology students should be informed about.


the last one

When working with a patient from a different ethnic background, it is essential to determine the nature of the distress of the patient but in addition, the sensitive clinician must pay attention to issues that may arise from the cultural context of the patient. It is important to understand that ethnicity likely plays an enormous role in the way the patient defines their identity and view of the world. Thus, a well-versed knowledge of the particular culture is necessary. However, even with this knowledge, it will be important not to stereotype or pigeonhole a patient, thereby taking away their sense of being human. Therefore, a balanced approach should be taken. Furthermore, it is necessary that the sensitive clinician take note of his or her own beliefs and ethnic identity as it functions in the therapeutic relationship.

An article by Cardemil & Battle (2003) encourages discussion of some of the ways in which the culturally sensitive therapist takes into account racial differences. In establishing an effective therapeutic alliance, it may be important to examine the impact of the patient perception of the therapist, particularly if the concept of “white privilege” comes into play. While the novice might attempt to avoid discussing differences, it may be helpful in establishing trust and empathy. Rather than attempt to bridge the gap by pointing out similarities rather than differences, which might undermine the patient’s sense of individuality and be interpreted as being condescending, it is important to take cues from the patient as to how comfortable they might be in these discussions.

Much of psychodynamic theory involves Western conceptualizations and more individualistic ideology, which may pathologize aspects that are characteristic of a culture. For example, someone of Caribbean origin may believe in voodoo, which might be conceived of as being psychotic or lacking in reality testing. However, an understanding, or certainly respect, for the roots of this belief and the adaptive nature it has within the culture can lead to effective therapy. In Jamaican culture, it is more customary to hit children, which would counter Winnicott’s ideas about good-enough mothering, but again must be taken into consideration with good therapy.

Psychoanalytic theories hardly ever seriously included race, ethnicity, class and culture as an ingredient of psychic development. Cultural diversity can be an animated aspect of one’s subjectivity and unseperatable component of one’s sense of self. According to psychoanalytic work, though, culture has only a superficial effect on the deep universal motivations of people. Perhaps analysts and clinicians, as well as theoreticians, want to see themselves as above sociopolitical influences, or one can say, under those influences – underneath the skin we are all the same; we are one species framed by similar psychological mechanisms. The assumption that culture is not embedded in the construction of the self may lead us, clinicians, to believe that cultural differences should stay out of the transitional space between the patient and the therapist. But in fact they may be vibrantly there without our awareness. Without our awareness they may play a significant role within the transference and counter transference. For example, a movement between the therapist and the patient of the good and the bad object, the sadist and masochist may be a manifestation of power differences between the white therapist and the black patient and not only between the disintegrated representation of the patient’s mother.

To understand the construction of the self in terms of ethnicity, I look at myself and my own upbringing and the process of clarifying my sense of self. Growing up in Israel in the 70’s and 80’s in a mixed ethnic family - where my father immigrated from Europe and my mother who her family emigrated from a Middle Eastern country - always defined who I am. I was struggling to settle the huge partition in social stigmas and practices. One side highly values education and intellectualization while the other is defined more around family rituals and submissiveness. One is considered to be superior to the other. I always wanted to be on the superior side even though my skin color and features define me as the other side. I was also struggling to emancipate from, and not automatically internalized - as I look so similar to my mother - her view of the world – which is a world where white (in Israel white and black is attributed to Ashkenazi / Sephardic ethnicity) men dominate and women are supposed to serve all men’s needs at all time. Ethnic stigmas, superiority, inferiority, and power differences - were all embedded in my personal journey of recognizing who I am and what I am made of. For me, it is impossible to separate my mother’s personality from her ethnicity, family constellation, and values. Her cultural ethos passed on for generations because it worked. It is engrained and invisible. For her this is the way to be.
If I was sitting in a clinical room with a white (in Israeli terms) male I may automatically feel inferior, identifying with my mother’s side. If I had a Sephardic therapist, I may feel superior to her as I also carry the identification with the aggressor. Shame and guilt are not only a result of intrapsychic conflicts but are also a result of conflict between heritage and history. Shame and guilt are rooted in the subjective identity of being a submissive Middle Eastern wife to a superior European husband. But shame and guilt are also a burden of a white superior racist over inferior Middle Eastern identity.

In the transitional space between a clinician and a therapist, inter-subjectivity of diverse ethnicity, class, or race are present. They are present because they are a crucial component of who we are. They can be camouflaged as psychodynamic processes and denied since we are above it or under it – but – that wouldn’t change the fact that they are there.
A careful understanding of all parts of personality needs to be taken under account even though the theory doesn’t address it. Freud, Klein, through Winnicot, Kohut, and even Bowlby, all brilliantly decipher the different players who promote or dis-promote psychic development. They have, though, neglected to seriously consider that who we are is part of the culture we grew in. Not all of us are driven by the same psychological urges, and widely different cultures can produce widely different personalities.


konetz, radi Bogu (fight the Romance language tyranny!)

Clinical psychology students (read: us), in order to do effective work with minority clients, should be sensitive to a wide range of potential sources of miscommunication, misunderstanding and mistrust based on the cultural and socioeconomic gap between themselves and their clients. Clinical psychology students must make no assumptions about how much clients understand the nature of psychodynamic treatment, how much they understand their own illness and their role in it, or how they perceive the therapist and the therapist’s authority, whether the therapist be from the dominant culture or not. In a way, it seems that although there is a lot that clinical psychology students needs to know about people from different social and cultural systems, what they need most is to adopt a stance of humble exploration of the cultural and personal meanings of their clients’ relationships and other important life circumstances.

With that in mind, I suggest that family relationships, and the different configurations they can take, present several potentially confusing areas ripe for misunderstanding between the young student and her client. For example, when writing my paper on West Indian culture, I was surprised to learn about the amazing flexibility of family structure both on the islands and in the United States. Women are often the unofficial heads of households, and men are culturally sanctioned to father children with several different women. These were called ‘visiting’ relationships on the islands which established kin networks all over in a weird web of illegitimate children. However, this pattern is not the rule and there are many households in which there are two ostensibly monogamous parents, one parent with a grandparent or two, etc.

What may present a challenge to the therapist treating a West Indian client, particularly a woman, is the idea embedded in Western culture and in female psychology that women are masochists, object-oriented and in need of monogamous relationships with men in order to sustain themselves psychically. Accordingly, infidelity in marriages and relationships is thought to have psychic consequences for both men and women, but particularly for women, which may not hold when crossing into West Indian psychological territory. In the literature I reviewed for my paper, it seems that West Indian women often see their husband’s ‘visiting’ relationships as opportunities to be household heads and free to raise their children and manage their lives largely as they see fit. Of course, although this could be the predominating feeling, there could be any number of contradictory feelings and meanings attached to these kinds of arrangements, which the therapist should be open to perceiving and exploring. If a young student is not in touch with this basic cultural meaning, though, an exploration of a more subtle nature will certainly not take place. This is the kind of combination of cultural knowledge and exploratory stance I was referring to above


Sheila: Le Fin, Merci a Dieu!

Perhaps the most important factor in working with any patient, for both seasoned and clinicians-in-training, is knowledge of context. This is all the more critical when treating patients whose ethnic background differs from one’s own. In the course of my research for the culture paper, I came across one article that addressed what Kozuki and Kennedy (2004) refer to as the “cultural incommensurability” in psychodynamic therapy in Western and Japanese traditions. One aspect of psychoanalytic and dynamic theories – that of the process of separation and individuation – is particularly problematic when applied to Eastern societies.
The authors regard the object-relations theories that emerged from the work of Freud as quite restrictive in terms of defining what it means to be a “good” mother. The process through which children separate from the caregiver and become increasingly autonomous is seen as a healthy model for development. Yet it is a model that may be ill-fitting in a society where interdependence is highly valued. There is a considerable body of literature that discusses Japanese mothers and the nature of their strong bond with their children. It is not at all uncommon, for example, for mothers and children to share a bed or a bath together. Japanese mothers also tend to play a very active role in the child’s education. This bond extends into adulthood, where it is expected that children care for their elderly parents. It is unsurprising, then, that Western therapists who become aware of such relationships may interpret them as dysfunctional, as signs of dependency and “enmeshment”.
The above is only one of numerous examples of the kinds of misunderstandings, and quite possibly misdiagnosis that can occur in the therapeutic relationship as a result of cultural difference. It is the obligation of not simply the sensitive, but the effective therapist to be informed and to work hard at perspective-taking. Really, when you think about it, therapy is essentially about the clinician first learning to see the world through the eyes of the client and then translating that experience into a treatment plan that makes sense for the individual. What’s important to remember, I think, is that while psychoanalytic and dynamic theory provides a useful base from which to conceptualize an individual’s problems, it becomes counterproductive when the boundaries become so rigid that it obscures who is sitting in front of us.


Kelly: Le Fuckere el Fini Celebrationes dans la Pantalone!

When working with a client from a different background it is important for the novice therapist to consider the presentation within the cultural context of that person. Cultures express, experience and cope with feelings of distress in ways that differ from the Western orientation. This is especially important to bear in mind in relation to the diagnostic criteria outlined in the DMS-IV. For example, what may seem like auditory hallucination according to a diagnostic definition may actually be considered a highly valued skill in the community of origin. To arrive at a diagnosis, one must determine if the client’s symptoms and behaviors impair their functioning at home, work, school and in their community. Hence, the patient’s level of functioning and experience of their own agency may trump the Western criteria for aberrant behavior and prove inaccurate when viewed from the context of the patient’s culture.
Certainly psychoanalytic conceptualizations make little room for cultural deviation. Freud’s conceptualization of the self, for example, minimally considers external influences and only as secondary to the internal drives. Even in the more relational perspectives, influence on the self is predominately relegated to the mother-infant dyad and little attention is paid to role siblings, family and community. Sullivan seems to broaden the realm of influence to the interpersonal and accords the “chum” with some developmental impact. However, in the psychoanalytic literature (to my limited knowledge) the self is considered as an entity whose development and motivations are primarily due to influences independent of a larger cultural identity. This seems counter-intuitive to the dominant role that siblings, extended family, religious affiliation, and community values play in many non-western cultures. Here I am thinking of the point that the speaker in our first colloquium made about self-identity in Asian cultures as more of an amalgam of self-other and less of the I-You individualistic self in Western societies (and psychoanalysis).
Considering the embeddedness of one’s identity within their culture seems to be part of a larger thread that I as a novice therapist want to keep tabs on; namely understanding how one makes sense of themselves and their experience and knowing that inevitably this differs from what I hold true for myself.


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