Advanced Psychopathology

Matt: Cultural Differences

2006-05-11T16:24:00.000-04:00

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.

Psychoanalytic Theory and Multiculturalism

2006-05-08T13:15:00.000-04:00

Jay Kosegarten
5-6-06
Psychopathology
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

2006-05-08T08:26:00.000-04:00

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

2006-05-08T00:28:00.000-04:00

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.

gasp wheeze

2006-05-07T23:57:00.000-04:00

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

2006-05-07T22:53:00.000-04:00

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

2006-05-07T18:58:00.000-04:00

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.

2006-05-07T18:53:00.000-04:00

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!)

2006-05-07T18:29:00.000-04:00

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!

2006-05-07T14:47:00.000-04:00

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!

2006-05-07T11:27:00.000-04:00

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.

Joshua, El Fin

2006-05-05T01:01:00.000-04:00

Sensitive Clinicians and Ethnically Diverse Clients

When dealing with a patient who comes from an ethnically diverse background, there are many factors that a sensitive clinician has to take into consideration. A person’s ethnic background largely shapes how they go about constructing their world. Therefore, understanding the dynamics of that culture is an important tool in understanding the unique experience of your client. Interestingly, however, a central factor in conducting therapy with ethnically diverse clients is understanding how one’s own (the clinician’s) ethnic identity is perceived in the room. When conducting treatment, a clinician may avoid addressing the obvious differences that exist between herself and the client, fearing that doing so will create some divide or barrier. Instead, the clinician may try to bridge the divide between client and therapist by identifying the ways in which the two are similar, despite their differences. This appears to be a common route taken by new clinicians, especially when attempting to build an alliance with younger clients. There are several dangers in approaching the therapeutic relationship in this way, as perceived similarities harbor the potential for conflict. A client may feel a lack of validation by the therapist if told that their experiences are similar. The marginalization and oppression felt by many minorities is not something that has a counterpart in the life of a privileged, white therapist. If the clinician is a woman, though she most likely has experienced marginalization and oppression due to sexism, it is unlikely that drawing this parallel will make her client feel more validated. Instead, the client may feel as though something about her identity, about her unique experience and struggles, has been “taken away” and grossly misunderstood.

If bridging gaps causes a divide, why do clinicians seek to find common ground? Part of the answer may involve the social privilege of the therapist, of which both the clinician and client are aware. This may lead to a sense of guilt or shame in the therapist leading to a denial of the difference and a focus upon perceived similarities. Therefore, it is important for the clinician to be aware of the differences that do exist between the client and herself and for her to not be ashamed of her position. This will allow her to examine what the differences mean to her client, how her client’s world is constructing. For example, one white, female clinician, during the course of her training, had an adolescent black male as a client. When he asked her if she was Jewish (him being Catholic), she revealed that she was but that Jewish people believe in God, like Christians. This was her attempt to strengthen the alliance between herself and her client. However, she may have benefited more by asking what her being Jewish would mean to him.

Understanding the client’s construction of their world is also important when it comes to assembling a psychodynamic case formulation of their presenting problems. As psychodynamic theory was largely conceptualized in a European and Western framework, applying it to other dynamics may result in misinterpretation or misapplication. For example, applying the theory to an extended Hispanic family may pose problems. In such an instance, a child may be raised by a mother, siblings, aunts, and grandparents. Clearly, the family dynamics of such a household would differ substantially from the nuclear families of Western society. Application of the conception of the Oedipus complex to such a situation requires some finesse. The traditional conception involves a struggle between the child, the mother, and the father. In a situation where other primary caregivers are included, the triad may become more complicated. This is an interesting idea that requires much more thought than can be achieved in a short essay. However, it is important to begin thinking about these unique dynamics.

A final consideration in dealing with ethnically diverse clients is being aware and mindful of unique expressions of mental illness that may be common to a particular culture. For example, the Puerto Rican expression of depression, especially in Puerto Rican women, is markedly different from the symptomology presented by in Western, Anglo culture and typified by the DSM. Rather than presenting with loss of interest or pleasure in daily activities and hopelessness that typifies a Western conceptualization of depression, Puerto Rican women come to therapy with a variety of somatic complaints, including tension, headaches, and muscle fatigue. In each case, the client may view some part of the self as being damaged due to the internalization of some critical love object (McWilliams). Yet, the expression is dissimilar. Puerto Rican women are discouraged from engaging in any assertive behaviors, including the honest expression of emotions. As a result, rather than expressing despair, hopelessness, or a sense of damage, Puerto Rican women’s emotions manifest somatically, and sensitive clinician should be aware of these unique presentations.

Sara's Last Reaction Paper of the Year!!!

2006-05-02T17:33:00.000-04:00

It is critical that the culturally sensitive clinician working with an ethnically diverse patient examines the cultural differences that exist between himself and the patient. The examination of how cultural and racial differences affect the therapeutic dynamic minimizes potential cultural misunderstandings, helps to elucidate the patient’s cultural perception of mental illness and mental health treatment, and allows for the uncovering of the therapist’s own biases and ethnocentric related countertransferences. But how does this really play out in reality, within the context of the therapeutic setting?

Avoiding the discussion of cultural and racial differences can be like ignoring the proverbial elephant in the room. The intrinsic power differential that exists between a patient and therapist comes with the territory of the profession, but this differential can be compounded by racial and ethnic differences, especially if the therapist is a member of the dominant culture. Therefore, it is essential for the therapist to convey a willingness to address the relevance of these differences by initiating this difficult conversation if the patient has not done so. Obviously, the sensitive clinician should not shove the issue down the throat of the patient, but he should at the very least communicate a sense of availability to the issue so that the patient feels comfortable broaching the subject.

The nature of psychodynamic psychotherapy training is such that we are taught to believe in certain universal truths regarding human development, attachment, psychopathology, etc. While there exists a high degree of scientific credibility to pyschodynamic theory, we also have to acknowledge that the theory is heavily steeped in Western beliefs and values, and that most of our theoretical notions are based off of samples/phenomena/observations of Western people made by Western psychologists. Consequently, patients with diverse backgrounds who come to psychotherapy may be misunderstood because of the enthnocentric lens from which they are viewed.

Psychodynamic theory, for instance, tends to regard the origin of paranoia as a result of persecutory, critical, suspicious parenting. However, when considering ethnic and racial factors, one can see how paranoia may actually be an adaptive defense of historically persecuted people (e.g., African Americans) in response to aversive environmental demands, not poor parenting. In fact, African American parents may actually instill certain paranoid qualities (e.g., suspiciousness) in their children—qualities that are completely adaptive to survival in hostile and racist environments. This illustrates the importance for clinicians not to exclusively rely on psychodynamic conceptualizations without considering the patient’s cultural and racial framework.

Stern: Vitality Affects, Amodal Perception, and Attunement

2006-04-25T01:18:00.000-04:00

Dan Stern describes “vitality affects” as effervescent, variable characteristics of feeling that separate active from immobile. These feeling states are induced by temporary shifts in essential life processes - motivation, appetite, and tension. Vitality affects are different from discrete categorical affects in that the former can be experienced not only during the performing of a categorical signal but also in an action that has no intrinsic categorical affect signal. Stated differently, vitality affects are patterned changes in affect occurring over time, while categorical affects are driven by distinct levels of activation and arousal. These fundamental differences underlie Stern’s argument that mother-child attunement must occur primarily through vitality affects; since attunement appears to be a fluid process, it must be associated with dynamic, not discrete, categorical affect surges.

In defining vitality affects Stern also gives examples of their connection to the performance of any behavior and their relationship with three fundamental modalities of perception: intensity, time, and shape. For instance, whether or long or short, rhythm can be presented or identified through seeing, listening, smelling, touching, or tasting. According to Stern, the omnipresent existence of vitality affects in behavior regardless of the type of perception makes them essential for inclusion in affect categories that describe caregiver’s subjective inner states during acts of attunement.

Finally, vitality affects demonstrate how attunement is an ongoing, often unconscious process; this is critical. If attunement is unconscious, the capacity for one person to “be with” another can transcend behavioral imitation, verbal reinforcement, “mirroring”, and the common understanding of empathy (all largely conscious occurrences). Thus, Stern’s argument for vitality affects not only describes mother-child attunement but lends understanding for the interconnectedness of human beings.

Stern and Affect Attunement

2006-04-24T00:59:00.000-04:00

One of the most significant aspects of the intersubjective relatedness, is interaffectivity. Interaffectivity, according to Daniel Stern, is the basis for parental mirroring and “empathic responsiveness”. The ability to know or perceive the inner experience of another develops even before the infant develops the capacity for language, at around the age of 9 to 15 months old. Since this condition is pre-verbal, there are several types of behaviors and conditions involved, which allow the infant to implicitly perceive the affect of the caregiver. The three components of intersubjective affect exchange, is that the caregiver is able to perceive the affect of the infants through the infant’s behaviors, the caregiver must respond with behavior that corresponds with the infant’s behavior which is representative of his affect, and lastly, the infant must be able to perceive the caregivers corresponding behavior as a response to their own behavior. These are essential to the development of affect attunement, which is the expression of the quality of feeling in a shared affect state. Affect attunement then creates the foundation for the ability to recognize that human inner experiences, including affect states, are sharable. This is also known as interpersonal communion.
The corresponding behaviors, or attunement behaviors, of the caregiver in response to that of the infant’s are in a way, modified imitation. They are more than just imitations, which would only indicate to the infant that the caregiver understands what the infant did, and not the inner experience which elicited such behavior. Instead attunement behaviors are a function of what is behind the behavior or the reason the behavior took place, by matching the affect on the particular dimensions of intensity, timing and rhythm, and shape of the behavior. These matching behaviors reflect back to the infant that their feelings states are being perceived by the caretaker. The modification of the infant’s behavior gives the infant a sense that the caretaker is also experiencing affect which corresponds to that of the infant’s.
The process of developing affect attunement, is implicit and almost automatic. One particular mechanism which allows for attunement to develop implicitly, are the amodal properties. The matching attunement behavior, although matching in time, intensity, and shape can still differ with regards to the sensory modalities that receive the behavior. The differing sensory modalities need to share a standard of exchange in order for the infant to understand the behavior as corresponding to their own, regardless of what sensory modality receives this information. Amodal properties are qualities, such as intensity, shape, time, motion, and number, which are common by most perceptual modalities. Therefore, they can be translated and perceived in a similar manner by any of the sensory modes. When responding behaviors are translated among other sensory modalities, these perceptions are combined to form the unity of the senses, which is the capacity to identify the perceptions that are intermodal, and translated across sensory modalities, that was originally perceived from one sensory mode. The unity of the senses combines and translates the qualities of intensity, time and shape of a responding behavior, and establishes an intermodal experience. This allows the infant to implicitly understand those qualities, received by one sensory modality to be identified by all sensory modalities, and this unique perception of the attunement behavior can be received as corresponding to their own affect induced behaviors. Therefore, as long as the particular qualities are matched, the specific sensory modality receiving that behavior is irrelevant for attunement to occur.
Vitality affects also are important for the exchange of the human inner experiences. It involves the kinetic qualities of feelings which allow an individual to discern the dynamic shifts of affect. Vitality affect is a subjective inner state, which can be conceptualized as tracking affects in all behaviors in order for the perception of intersubjectivity to be maintained at all times. This adds the coloring of interpersonal interactions as it provides the continued sense of shared inner experiences or connectedness. This ability consolidates the bond people share while interacting as they are aware of sharing the same external space, as well as inner experiences.

Stern on Vitality Affects, Amodal Perception & Attunement

2006-04-24T00:29:00.001-04:00

In his discussion of amodal perception, vitality affects and their contribution to maternal attunement, Stern seeks to illuminate the process through which the infant begins to understand the relatedness between the self and other. Stern defined affect attunement as the behavioral expression of the quality of feeling of a common affect state. Taken together, amodal perception and vitality affects are best understood as preconditions for the achievement of affect attunement between mother and child.

Amodal perception refers to the natural ability of the infant to receive information from one sensory modality and then interpret it in another. Stern cites a number of studies that support this idea of cross-modal matching. Three week old infants, for example, are able to visually discern which of two nipples they have just sucked while blindfolded. Amodal properties such as shape, intensity, motion and rhythm serve as a kind of “common currency” between sensory modalities. Furthermore, information is not encoded to a particular mode, but is rather programmed into an amodal representation which can be distinguished by any sensory mode.

Stern conceives vitality affects as “dynamic shifts or patterned changes” in the self or others which involve qualities of feeling that are not best portrayed by the vocabulary used to describe what he terms categorical affects, such as sadness or joy. He describes, for example, the “rush” associated with anger, or that evoked by music or abstract dance. Infants are thought to categorize the actions of the caregiver (such as how she picks up the infant or folds diapers) in terms of vitality affects, and a range of sensory experiences with comparable “activation contours” are experienced as analogous and organizing. The amodal experience of vitality affects and the ability for matching across modes, according to Stern, furthers the infant’s progress toward understanding the “emergent other”.

In the process of attunement, amodal perception occurs between mother and infant during what Stern calls an “intersubjective exchange”, wherein the mother reads the internal feeling state of the child and acts out a variation of behavior that relates to it. The infant then interprets her behavior as relevant to his own original internal experience. As a result of the mother’s attuning, the child is allowed the experience of “being with” another and we as adults are reminded that intimate, internal feeling states are something that can be shared and communicated even on such a nonverbal level.

stern & affect attunement

2006-04-24T00:29:00.000-04:00

Stern suggests that mother and infant share affective states and experiences via the phenomenon of “affective attunement.” Largely unconsciously, mothers undertake a range of actions – vocalizations, touching, and other gestures – that reflect and enhance some essential aspect of the baby’s behavior and presumed affective state. Stern believes that the mother’s acts of affect attunement create for the baby a kind of preverbal “understanding” of the intersubjective nature of affect regulation. Stern uses the concepts of amodal perception (a concept from the wider psychological literature) and “vitality affects” (Stern’s own idea) to portray the infant as capable of comprehending episodes of affective attunement.

At the core of affective attunement is the mother’s cross-modal transformation of the baby’s affective state. Stern observes that the mother tends to complement the baby’s actions with gestures of her own. For instance, as the baby is joyfully raises and lowers her arms, the mother exclaims, “wheeeeee,” with the pitch of her voice rising and falling in sync with the level of the infant’s arms. Stern believes that infant apprehends the matching and transformation in the mother’s gesture, and feels the mother’s gesture as an affirmation of the infant’s affective state. Cross-modality is central to affect attunement –the mother’s transformation of the infant’s behavior emphasizes to the infant recognition of internal, affective states; by contrast, if the mother were to imitate the baby, the baby would “think” (or perhaps feel) that her external behavior is the salient part of the dyadic moment. In other words, the transformation is more meaningful than mere imitation because it makes the baby feel that the mother has not understood just her behavior, but the feeling behind the behavior.

Stern believes that babies possess perceptual and cognitive capacities that are vital to affective attunement. These capacities allow the baby to participate with the mother in a preverbal intersubjective/affective experience. First, Stern draws on empirical literature to show that infants are capable of amodal perception (he gives the example of a baby being able to visually distinguish a nipple that previously he’d only been able to feel in his mouth). Stern states that infants’ ability to perceive across modalities suggests that infants are able to maintain some abstract representation of a percept. Second, Stern believes that infants are capable of discerning vitality affects, and use vitality affects as a strategy to organize their perceptions. Vitality affects concern the form, timing, shape, and intensity of a gesture, rather than its specific content; in other words, vitality affects are multi-channel descriptions of the arc of an experience or sentient state. Affective, sensory-motor, proprioceptive, perceptual, and interpersonal information all may comprise a vitality affect. For instance, either the act of standing up abruptly and the feeling of a blast of cold air might be experienced as a “rush.” Like amodal perceptions, vitality affects are based on abstract representations of phenomena. Stern believes that the infant’s apprehension of vitality affects allow her to organize feelings and phenomena before she has language to do so. Possessed of capacities for abstraction, organization, and recognition, Stern’s infant is ready for the moment of affective attunement.

James's Reaction #8

2006-04-24T00:22:00.000-04:00

Through his concept of affect attunement, Stern describes the intersubjective relatedness of an infant with his caregiver. When the infant is still preverbal, the caregiver must communicate, in some fashion, the fact that she is attuned to the subjective emotional state of her infant. Early on this usually takes the form of mimicking. However, at around the age of nine months, Stern describes how the caregiver inherently shifts her behavior to incorporate the infant as an “intersubjective partner.” The affective state of the infant becomes joined by the mother in a manner that the infant is able to perceive and feel a part of.

From an early age, infants have the ability to perceive amodally. With affect attunement they are related with the caregiver not through just one of the five senses. Attunement involves something of a ‘sixth sense’. Through this amodal perception, the caregiver and infant share affective experiences such as joy, sadness, excitement, etc. Vitality affects account for affect that is not so categorical. Stern posits that discrete displays of affect occur only sporadically, every thirty to ninety seconds. Attunement does not have to wait for these discreet displays. Rather, attunement is continuous and, as Stern says, ‘almost omnipresent’, through a variety of behaviors and affective states. Vitality affects account for the presence of attunement and relatedness between infant and caregiver in the period between discreet categorical affect.

vitality, amodal, affect attunement

2006-04-23T21:16:00.000-04:00

Affective attunement, as described by Dan Stern, refers to the responsive behaviors that a mother engages in with her infant that allow her to express a sharing of internal state. Unlike pure imitation, affective attunement has a reflective quality that involves various dimensions, namely, intensity, timing, and shape, and is a way of bringing the child in as an intersubjective partner, rather than merely a receiver. As Stern puts it, “imitation renders form; attunement renders feeling” (142).

Affect attunement is the means by which the mother can demonstrate not only that she understands her child’s feeling but that she is able to respond in a way that corresponds to this feeling, which the child, in turn, can feel as well. Stern had previously described the concept of amodal perception in infants; that is, the infant’s ability to somehow transfer sensory information among various modalities. He also identified vitality affects as the dynamicism of feeling, or life, that is brought into all behaviors and creates connections among us. Both of these concepts are very much embedded within the notion of affective attunement, as the act of attunement involves the transferring of emotional experience across modalities as well, largely beyond awareness, creating a connection of feeling states between mother and child. Furthermore, the very dimensions involved in affect attunement (intensity, space, and time) speak to the amodal quality of the exchange. For example, a mother observing her infant reaching for something with great effort can respond in a vocal manner that matches the rhythm and intensity of the infant, which then encourages the infant to push forth. In this case, while the mother is not reaching for the object herself, the infant is able to perceive an attunement to his feeling state through a different modality, her voice, as well as the aura, or vitality affect, with which the mother performs the behavior.

Stern's affect attunement

2006-04-23T19:30:00.000-04:00

The purpose of affect attunement is to share an experience of inner state between two people. This process begins when one person matches the inner state of another. Since the inner state is a latent material manifested by a certain behavior, what is being matched is some aspect of the emotion that is observable in the behavior. But Stern adds another important element to the process of affect attunement: a form of behavior that reflects inner state and manifests through one channel of communication (vocal), is matched by a different person through a different channel (touch). Stern termed this process amodal perception. By amodal perception he means that different expressions through different channels of communication can be automatically engaged and understood because of unity of the senses.
What is being matched is the person’s inner state of emotion and not the external behavior event. But, the external behavior event captures an internal state. How does it happen? To explain that, Stern adds the concept of vitality affect. Vitality affect is present continuously in the background of any behavior and is sensed by the subtle details of body posture, speed and contour of movement, minimal changes in muscle tone, and vocalizations - intensity, timing and shape. These expressions are the subjects of affect attunement and they reveal something further about the self than the categorical feelings (sadness, joy etc). Stern doesn’t further explain in this chapter what kind of inner state the vitality effect reveals. But I think what he meant was some kind of internal feeling such as tension, edginess, enthusiasm, “down-ness” that reflect a certain state of mind of the self.
Affect attunement gives consolidation to an unconscious inner state. If the affect attunement is accurate this consolidation helps in forming a true sense of self.

Vitality Affects and Amodal Perception: Lucy's Reaction

2006-04-23T13:59:00.000-04:00

Without vitality affects and amodal perception, moments of attunement would have to rely on discrete emotional "events" such as happiness, anger, surprise, etc. According to Stern, these events happen rarely. So what happens in the meantime to sustain the affective connection between babies and their caregivers? What creates the sense of being fluidly connected for long "uneventful" periods of time?

Stern answers this question by arguing that the sharing of affect states is not medium-specific and it is not relegated to the experiencing of discrete affects. Using the concepts of amodal perpection (the shared aspects of experience between sensory modes) and vitality affects (subtle affective experiences that have discernible properties), he shows that mothers do not have to mimic the movements, facial expressions, or vocal qualities of the babies (and vice versa) in order to join in their affective state. In fact, mimicry, or "mirroring" is only a small part of the story when it comes to attunement, according to Stern. Stern goes far beyond mirroring by pointing out the variety of ways in which caregivers join their infants' affect states cross-modally. For example, when the baby stretches, reaching for far away toy, the mother can "join" the infant in this state (an example of a vitality affect), by stretching her voice, in effect "reaching" with the baby for the toy.

By taking part in these subtle and ongoing "joining" experiences with their children, caregivers are setting the stage for later experiences of mature relating and intersubjectivity. This ongoing flow of attunement involving vitality affects in early infancy is surely what sets the stage for more mature awareness of and empathy with mood states in others. How this all relates to verbal relating, I'm not sure but I think he's going to tell us soon.

Kelly: Reaction Stern

2006-04-23T13:40:00.000-04:00

Sterns depicts a very active infant who taking in all aspects of his internal and external environment, formulates the parameters of himself in relation to the world. This formulation is primarily facilitated through the infant-mother dyad. Stern positions vitality affects, amodal perception and attunement as techniques or pathways through which intersubjectivity is experienced and thus internal and external reality identified. Vitality affects appears to be a sort of affective biorhythm or undercurrent that provides a constant stream of continuous affect ranging in intensity, form and rhythm. It is also the bedrock from which discrete emotions such as joy and anger emerge. In order for Stern to support his conceptualization of mother-infant attunement, Stern relies of vitality affects to provide the continuous emotional data required for the mother and child to accurately read each others cues. For without vitality affects, Stern points out that the mother would be in the impossible position of attuning to the sporadic expression of categorical emotion. Amodal perceptions is somewhat like broadband communication – it allows the mother and child to translate each others affect and represent it across a wide spectrum of senses. It allows for a collage of visceral responses and a broader mode of relating.

Joshua, Amodal Perception, Vitality Affects, and Affective Attunement

2006-04-23T13:23:00.000-04:00

Amodal Perception, Vitality Affects, and Affective Attunement

Two ways that an infant comes to know the world around himself include amodal perception and vitality affects. Amodal perception is the ability to take information received in one sensory modality and translate it into another sensory modality. For example, by three weeks of age, an infant can match the absolute intensity of audio and visual stimuli. Infants also have the ability to cross-modally match auditory temporal and visual temporal patterns. Additionally, infants can recognize audio-visual correspondences. They can associate the movements of the mouth that make a sound with the auditory presentation of the sound. Lastly, infants often correspond what they see and what they do. By two days old, they will imitate facial expressions they see others make. However, it is not known whether or not this correspondence between their actions and the actions of others is reflexive of imitative. However, amodal perception suggests that the infant already has a sense of an emergent self and an emergent other. For example, rather than perceiving a “seen” breast and a “sucked” breast, the infant could cross modally associate or integrate the two.
Vitality affects are another way that infants come know the world. Stern delineates between vitality affects and categorical affects, such as shame, happiness, or anger. Vitality affects are the forms of feelings involved in all the various vital processes of life, including breathing, hunger, waking, and the experience of thoughts and emotions. The experience of vitality affects occurs along an “activation contour,” wherein the experience of one behavior or feeling can be abstracted and applied amodally to another. For example, a mother, empathetically responding to her distressed infant, may utter, “There, there,” emphasizing the initial word and saying the second softer. At the same time, she strokes her child’s back, with the first touch being stronger and becoming gentler. In this way, the utterance and the physical touch share an activation contour and can be integrated into one emergent mother. Vitality affects and activation contours, then, may provide the explanation for the mechanism behind amodal perception.
When their children are around nine months old, mothers begin to engage in affective attunements of their children’s behavior and affective states. An example of an affective attunement is the following: A child eats a Cheerio all by himself, squirms with delight, and then looks to his mother who exclaims, “Yes!” The mother’s utterance matches the intensity of the infant’s delight. In such affective attunements, there is a cross-modal matching of behavior and affective content (or feeling state) through activation contours. Amodal perception, then, is part of the process of affective attunement that contributes to the infant’s sense of an emerging self and an emerging other who can share in one’s affective state without explicitly imitating behaviors that reflect the inner experience of the infant.

Sara's Reaction Paper- Vitality Affects and Amodal Perception

2006-04-22T15:19:00.000-04:00

How does a caregiver communicate (or shall I say ‘commune’?) to her prelinguistic baby that she understands and is attuned to her baby’s subjective inner state? And perhaps more importantly, how does the infant extract meaning from this interaction? The intersubjective exchange of affective states, according to Stern, requires the caregiver to grasp the baby’s feeling state based on the baby’s behavior (Stern initially states that the baby’s behavior must be “overt,” but later includes those more ambiguous expressions that are not simply categorical affective expressions). Next, the caregiver must reciprocate and reflect back the baby’s behavior without merely replicating the baby’s behavior. Finally, the baby must interpret the caregiver’s behavior as a genuine reaction (not merely an imitation) to the infant’s subjective feeling state. Stern argues that vitality affects and amodal perception are the mechanisms by which this intersubjective affect exchange happens.

Research has demonstrated that babies have amodal perception capacities that allow them to perceive variations in intensity, time and shape with multiple sensory modalities. For instance, babies are able to match visual and auditory levels of intensity as demonstrated by an experiment where infants matched variations in sound to variations in brightness of lights. You may be wondering what this physiological ability has to do with affect attunement. On the surface, the connection isn’t so clear, but upon further examination it becomes apparent that in order for the baby to communicate with the mother, it is necessary for the baby to “speak” cross-modally. In other words, a mother’s mirror neurons may kick in and she may react to her baby screeching in glee to the sight of a puppy, by patting the baby’s bottom with the same kind of intensity that the baby originally exuded. This attunement is cross-modal, of course, and it allows the intersubjective sharing of affect to occur.

The preceding example of the baby’s overt glee to the sight of a puppy illustrates a categorical affective expression that obviously conveys happiness. But how does the caregiver pick up on the more common, less overt behavioral expressions of affective states? This is where vitality affects come into play. Vitality Affects are defined as elusive qualities of feelings that occur constantly in contrast to more discrete categorical affects. It seems that vitality affects initially get subconsciously picked up on by the caregiver through perceptual/amodal means (e.g., speed of movement), but then transform into feeling states that attune the caregiver to the baby’s subjective inner state. This attunement is ultimately an interpersonal communion between caregiver and baby, and allows the mother to engage in the baby’s inner experience without impinging on or altering the baby’s inner experience.

Amodal Perception and Vitality Affects and How They Contribute to Affect Attunement

2006-04-22T01:49:00.000-04:00

Jay Kosegarten
4-21-06
Psychopathology
Professor Papouchis

Amodal Perception and Vitality Affects and How They Contribute to Affect Attunement

Like many of Stern’s concepts, affect attunement is subtle and tangentially related to many other concepts. As a result he spends a good deal of time explaining what affect attunement is not. After having done so, he describes the ingredients of affect attunement and what it serves to accomplish in the mother-infant relationship and the development of the infant.
The thrust of affect attunement, and what makes it different form other concepts and modes of behavior such as mirroring and imitation, is the expansion and adjustments in the reflective behavior of the mother toward the infant that contributes to a complex interactive and intersubjective experience. What these reactive behaviors accomplish most importantly is a shared emotional experience (“shared affect state”). An essential part of this, according to Stern, is that this “communion” goes beyond imitation.
In going beyond imitation, we see the utility of amodal perception. It is the ability to convey a matching affect state across modes of perception that helps accomplish several relational necessities. Amodal perception allows for versatility in the conveyance of shared emotional experience and affect attunement. It contributes to a unified perceptual experience for the infant, integrating temporally proximal information extracted through different perceptual means. And, simultaneously, it conveys a sense of connection and subjectivity, that is a sense of relating yet separation (ideas central to Stern’s theory), that mere imitation could not accomplish.
Vitality affects are very much related to amodal perception, and thus hinges on the qualities of intensity and time in the interactive behavior of the mother and infant. The fluidity of vitality affects contributes to a cohesive sense of interrelatedness and allows for responsiveness with regards to the vicissitudes of the infant’s affective states.
The emphasis and unifying notion for all three is of the form, not the content, of the interaction- the “how of the behavior”, as opposed to “the what.”

Gillian's affect attunement

2006-04-21T17:12:00.000-04:00

The sharing of affective states is vitally important to the development of intersubjective relatedness. According to Stern, around the age of 8-9 months, the chance for such relatedness emerges between infant and caregiver. Whereas previously the caregiver’s responses to the infant had been rote mimicry of behavior, now a new dynamic emerges wherein the affect of the infant can be joined with, beyond what gets conveyed through behavioral action. The recognition and mirroring of the infant’s affect requires three successful steps. First, the parent must accurately read the infant’s affective state from external action and behavior. Then, the parent must find a way to convey the same feeling state back to the infant, in a way that will show shared affect. Pure behavioral mimicry won’t work for this, since imitation can really only show mastery of the action of the other. Attunement behaviors, on the other hand, can change the focus of the attention from the behavior itself, to what affect is driving the behavior.

In order to show the infant that the driving feeling-state for behavior has been understood by the parent, Stern makes the case the parent must change the mode in their mimicry of the child, while preserving the feeling behind their child’s behavior. From an early age, infants have an ability to perceive amodally. For example, they can match intensity of sound with intensity of blinking lights. It is this amodal perception that allows the infant to recognize that the parent has understood them, through the maintenance of certain qualities that are common to all modalities of perception such as intensity, shape, time, motion, and number. For example if the infant bangs a toy on a table in a 1-2-3 rhythm, the caregiver might connect with that action by saying “kaa, kaa, kaa!” in bursts that have the same duration and rhythm as the banging of the toy.

For affect attunement to occur, there must be something to for the parent to attune with. Stern notes that overt expressions of affect only occur sporadically throughout an interaction, whereas affect attunement seems ongoing. Perhaps vitality affects, defined as a person’s way of being and the manner in which all actions and behaviors are performed, are the fodder for affect attunement. These vitality affects connect with amodal perception in the sense that they dictate the intensity, speed, rhythm, etc. of everything a person does. In syncing up with the vitality affect of the child using amodal perception, a parent can saliently communicate the understanding of feeling states, facilitating affect attunement.

Matt: Affect Attunement

2006-04-21T16:09:00.000-04:00

Vitality affects and amodal perception are key components of Stern’s concept of affect attunement. Taken together, they are what really distinguish it from similar ideas like affect mirroring and affect matching. One of the defining characteristics of affect attunement is its cross-modality of expression. The baby makes a verbal expression and the parent acknowledges and reflects it with a corresponding body movement. This differentiates attunement from simple imitation, the parent’s response corresponding to the baby’s inner experience and intention rather than her outer expression. (When Fonagy & Target talk about marked affect mirroring in relation to the development of reflective functioning, I think this is part of what they mean. Simple imitation of the baby’s affect might be threatening or flooding—the parent’s response must be “marked,” possibly by a change or partial change in mode of expression, so that it acknowledges the feeling instead of the behavior.) This cross-modality wouldn’t make sense to the baby without the ability to perceive amodally, that is, to meaningfully relate percepts from one sensory modality to those from another.
Stern describes what he calls “vitality affects” because he isn’t satisfied with the usual range of affects that others have dealt within the context of parent-child relations. What he terms categorical affects—sadness, anger, etc.—can indeed be attuned to, but they only occur sporadically. Affect attunement, however, is a continuous process which “feels like an unbroken line.” To fill in the gaps, we have vitality affects, which are occurring all the time, though not necessarily consciously. The attuned parent tracks the subtle moment-to-moment changes in a baby’s internal rhythm and intensity.
The centrality of vitality affects in attunement was recently highlighted for me in the experience of being with a sick baby. How does one attune to a child who does little but lie still? There was little opportunity to mirror categorical affect during Annie’s illness, and in any case one cannot spend the whole day making sad faces. But obviously there was affect in her, which could be perceived in the sluggishness of her movements, her glazed eyes, and her utter lack of intensity. As I reflect on it, I see that the slow throb of Annie’s painful experience was reflected in the tempo of my hand patting her back and the whisper that I used when holding her. None of it is particularly remarkable; these are the things any parent would do, and as Stern points out, they happen with almost no conscious thought.

Stern: Amodal Perception, Vitality Affects & Parental Attunement

2006-04-20T23:07:00.000-04:00

Stern makes the case that amodal perception plays a key role in affect attunement due to the fact that the characteristics of shape, time and intensity can all be perceived by the child and caregiver on an underground sphere (amodally) and evoke an intersubjective reciprocally related reaction from both parties. At around nine months of age, Stern observed that mothers tended to inherently sense and react to their infant’s actions and behaviors with affect laden responses. More than simple reciprocated verbal or behavioral reactions, the mothers tended to attune their responses with notions of praise, joy, excitement, disappointment, etc. and pair these affect attunements with a primary verbal response. In turn, the infant comes to understand these affective attunements and their meaning based on a system of amodal perception in which they come to understand emotion through the mother’s recasting and restating of subjective states. The amodal qualities of intensity and time relate to another key aspect of affect attunement: vitality affects. Vitality affects refer to not what behavior a child does, but rather how the behavior is performed. All behaviors incorporate vitality affects and hence provide evidence for how subjective inner states relate to persistent changes within affect attunement.

Stern posits that initially the infant’s capacity for amodal perception is what allows the child to develop a differentiated core self that in turn relates to others through the process of being attuned to others’ perceived verbal and nonverbal interactions with the infant. With the introduction of language, an entire new realm of perceptual experiences is made available to the infant and the amodal form of perception that was once primary now becomes secondary yet remains a key element concerning how the infant perceives and relates with others, particularly the primary caregiver. With the development of language, the infant is able to engage in a reciprocal process with the primary caregiver that helps to establish a sense of mental togetherness as well as shared understanding and the motivation to further develop language capabilities. Classical literature describes the nature of the child’s belief in adults’ omnipotence based on their desire to have their demands met and wishes fulfilled regardless of the child’s ability to fully communicate these desires to the parent. In contrast, Stern defines this behavior as true misunderstandings about meaning as opposed to desires for parental omnipotence. In addition, he regards these experiences as necessary struggles between mother and child for defining together the nature of language and meaning. It is through the process of failure, frustration and finally success that motivates the infant to further develop their language based interaction system, in turn adding to the infant’s cognitive and affective capabilities, which before relied on a nonverbal interaction system for relating.

After experiencing a series of repeated successes and failures, the caregiver becomes attuned to the child’s affective states that are coupled with the use of language skills and hence makes the mother accountable for the infant’s newly acquired language system. Another major aspect critical to the attunement process relates to the notion of vitality affects, personal physical and stylistic characteristics which help the child develop a sense of language and affect cohesion with the primary caregiver. The child becomes attuned to the idiosyncrasies of the caregiver’s language system and invariably the caregiver reciprocates this interaction on both the amodal perception and language capability levels in relation to the infant. Overall, the infant’s development of interpersonal relations is multi-faceted, consisting of amodal perception as well as attunement to nonverbal cues which set the foundation for the development of a reciprocally interactive language system.

Ethnic Russian Immigrants in New York: Cultural and Historical Factors that Contribute to their Psychology

2006-04-13T10:49:00.000-04:00

“Any idiot can face a crisis – it’s day to day living that wears you out.”
-Anton Chekhov

By, James Ellis

It has often been said that America is a melting pot of different cultures and ethnicities. This metaphor is problematic because it implies an integration of unique components that have melted together into one. In this metaphor individual identity is lost. Many view New York City as the epicenter of this infamous pot. In a broad historical spectrum this may be the case. However, with its rich cultural landscape and ethnically diverse neighborhoods, New York is also a place where immigrants settle and retain a great deal of their cultural and ethnic identities.
As a mental health care provider, it is essential to recognize and understand the unique cultural and ethnic factors that are an integral aspect of a patient’s psychology. Due to the heavy concentration of Russians in neighborhoods like Brighton Beach in Brooklyn and Forest Hills in Queens, it is likely that this population will be in need not only of mental health services, but a clinician who understand their unique cultural and ethnic identities.

It is estimated that up to 36% of New York City residents are foreign born. Of these immigrants, roughly 3% are of Russian descent (http://nyc.gov, April 2, 2006 ). Many of these Russians are Jews who fled their country seeking political asylum from religious persecution. However, many are ethnic Russians who share some common characteristics with their Jewish countrymen, but also exhibit unique concerns of their own.

The first wave of Russian emigration began in 1917 when the Revolution sent hundreds of thousands into exile in America and Western Europe (Althausen, pg. 680). Russia was also devastated by the atrocities of World War II and many Russians who sought refuge in the West chose not to return for fear of being persecuted as “betrayers of the motherland” by Stalin. More recently, the fall of the Soviet Union in 1991 lifted the ban on emigration which thousands of Russians have taken advantage of, seeking a better life from the economic and social upheavals of the post-Soviet era (Althausen, pg. 681).

Despite the dire circumstances that Russian immigrants might be leaving behind, abandoning their homeland is often quite difficult emotionally. Russians are well known for their attachment to their country of birth, which they call rodina (motherland) or, even more affectionately, Rossiya-matushka which translates to ‘little mother Russia’ (Althausen, pg. 680). This concept of Russia in a “parental” role extends much further than a nickname for the homeland. The nature of Soviet communism instilled a collectivistic mentality in which the government was in a paternal (provider) role with the citizens as its children, an extended network of brothers and sisters. In Soviet times citizens appropriately regarded one another as camarades, and they often still do.

In the Soviet communistic system, equality was paramount. While many think that this simply involved shared labor, it extended to gender roles, social systems, and family arenas as well (Levant, et al., 2003). Together, these ideals were intended to create a cohesive and independent society that was far more progressive than the rest of the civilized world. The impact this had on the psychology of Russians was in some cases beneficial and in other cases quite detrimental.

Children in the Soviet Union were seen as the vehicles that would carry the communist tradition into the future. Their upbringing was viewed as a delicate matter, and it was considered important to shape their nationalistic mentality from an early age. As a result, the government taught parenting to its citizens. This traditional Soviet pedagogy promoted child-rearing methods that were designed to foster values supportive of citizenship in a totalitarian socialist society. These values included conformity, loyalty, group-mindedness, and unquestioning acceptance of authority (Hart, et al., 1998). The government pedagogy did not assign the family primary responsibility for the upbringing of the child. Instead, “a collective-centered system of child rearing was developed in which families were considered to be an organic part of Soviet society…and persons outside the family were viewed as having primary roles in the collective upbringing of children”(Hart, et al., 1998). This system often involved relatives, neighbors, and, most importantly, teachers in school.

Soviet schooling was quite different than in the West. The start of school each year, the first day of September, was a national holiday. On this eventful day children and their parents attended traditional soviet ceremonies which were designed to instill a sense of nationalism and camaraderie between generations as well as an induction rite for the youngest members of the society (Goldenberg & Saxe, 1996). Once the school year was underway, subjects studied were largely vocational and historical in order to provide practical skills for jobs while still promoting nationalism. Teachers had permission to discipline students with whatever means necessary. Nevertheless, in Soviet times punishment usually involved group sanctions which were designed to threaten exclusion of group membership (Hart, et al., 1998). By the early 1990s, however, after the fall of the Soviet Union, philosophical shifts on school curriculum were evident. Both parents and teachers “appeared to favor democratic nuturant, child rearing strategies to promote more independent thinking and autonomous behavior in children”(Hart, et al., 1998).
Gender roles were also greatly influenced by the Soviet system. Although Russia has always been a predominately patriarchal society, women traditionally maintained much more responsibility than in the West. In forming their new society, early Bolshevik leaders attempted to establish equal opportunities for women in political, social, economic, and family arenas (Levant, et al., 2003). While it may seem progressive, these ideals were never fully realized as men continued to have better jobs. Women were still required to work, but were additionally relegated most child care duties as they were deemed more suited to taking care of children and the home (Kukhterin, 2000). Furthermore, men were often physically or mentally unable to help women domestically because they were “absent or disabled, due to the combined effect of three devastating wars (1914-1918; 1918-1920; 1941-1945), Stalin’s terror (1936-1953), and continued widespread alcoholism” (Althausen, pg. 682).

Russian masculinity ideology has also experienced drastic shifts depending on the historical context. In the 1970s Russia experienced a low birthrate crisis. Inadequate gender roles were blamed for this phenomenon. The government criticized men for becoming feminized while over-worked Soviet women were criticized for being neglectful of their families (Levant, et al., 2003). Bolshevik leaders insisted that men and women return to more traditional gender roles. Likewise, the fall of the Soviet Union and a move towards a market economy in 1991 was seen as a reason to reassume traditional male responsibilities. It was thought that capitalism was a system in which traditional male roles were highly valued and beneficial (Levant, et al., 2003). Yet, Russian boys during this time were at a disadvantage. Due to the frequency of absent or incapacitated fathers, they lacked opportunities to have masculine behaviors modeled and reinforced (Levant, et al., 2003).

Perhaps most startling is data which suggest that although men’s life expectancy has generally decreased since 1965, the rate of decrease rapidly accelerated in the 1990s (Cockerham, 2000). From 1991 to 1999, men’s life expectancy dropped from 63.5 years to 59.9 years respectively (Cockerham, 2000). This data also notes that women’s life expectancies also declined in the 1990s. However, they did not decline nearly as much as men’s, decreasing only from 74.3 years to 72.4 years during that decade (Cockerham, 2000). It is thought that possible factors for the decline of life expectancy in men involve unhealthy behaviors such as heavy drinking, smoking, not sleeping enough, avoiding doctors, overworking, and rarely taking vacations which are all part of the traditional notion of the “real man” in Russia (Levant, et al., 2003).

While many of these Soviet-influenced values are still inherent, today’s Russian-American family values and loyalties have formed largely in response to the prevailing conditions of economic deprivation and political oppression (Althausen, pg. 681). After the collapse of the Soviet Union, Russia essentially abandoned its insular system and joined the world economy. Unfortunately, the country lacked an adequate economic infrastructure that could handle this change (Jose, et al., 1998). The value of the ruble plummeted and citizens who were relying on government subsidies became very poor. Often parents had to take second or third jobs just to meet basic necessities for living (Jose, et al., 1998). Drawing on their collectivistic mentality, Russians often relied on the extended family’s combined resources, both financially and socially. Grandparents often lived in the house and provide care for the young as well as financial support. Following suit, adult children were expected to assume responsibility and care for their aging parents (Althausen, pg.682). This domicile structure continues even today in Russian immigrant families.

As far as mental health is concerned, Russians tend to assume the Buddhist position that life is suffering. Based on their quality of life circumstances, it is not difficult to understand why this position has been adopted. In an essay on Russian families, Leonid Althausen describes the meaning of a Russian word that is relevant to this notion, toska:
"For Russians, suffering is not only a natural part of life, but it also has a certain redemptive value. In the Russian lexicon of psychological pain, arguably the most important word is toska, which connotes melancholy, depression, yearning, anguish, pangs of love, ennui, weariness, tedium, boredom, and nostalgia all rolled into one. However, the word does not have negative connotations; almost any thinking individual was expected to have this malaise to some degree" (pg. 682).

Althausen contrasts this with the very American values of constantly maintaining a positive attitude and having the belief that a solution to life’s problems can always be found. In working with Russian patients it is important to realize that what might be conceptualized as a depressive mood might simply be a normal case of toska (Althausen, pg. 682).

Despite the social acceptance of melancholic moods, Russians are generally reluctant to discuss psychological suffering with others (Althausen, pg. 683). This is in part due to the socially valued custom of keeping “strong” and not buckling in the face of Soviet life’s adversities. Even within the family system, suffering is seldom expressed. Keeping personal information private serves an adaptive function since it is common for a multigenerational extended family to share one small apartment (Althausen, pg. 683). As a result, it is not common for Russians to engage in help-seeking behavior.

Pervasive alcoholism is perhaps the stereotype most frequently associated with Russians. Its prevalence is estimated at anywhere from 66% to 80% in ethnic Russian men (Goodman, et al., 2005). This statistic is difficult to estimate more precisely due to the fact that Russian men often avoid healthcare in general. As Leonid Althausen states, “in a nation that keeps its suffering to itself, and where neither antidepressant medication nor psychotherapy has yet taken root, vodka is widely regarded as the remedy for a range of physical and emotional problems” (pg. 683). Consequently, alcohol abuse is cited as one of the major contributing factors to the high death rates of men in the 1990s (Levant, et al., 2003). In addition to alcoholic poisoning, it is believed that pervasive drinking is a major contributing factor in the high rates of suicide and homicide among Russian men (Levant, et al., 2003). In the family system, alcohol abuse is often condoned if it makes the drinker more socially engaged and convivial. There is much denial surrounding the dangers with drinking and popular belief has it that one only has a drinking problem when one drinks in solitude (Althausen, pg. 683). It is noted that in contemporary Russia, drinking and its negative consequences are much less common among the intelligentsia than among the working class (Althausen, pg. 683).

As with many other immigrant groups, ethnic Russian immigrants’ well-being will be contingent on the dual tasks of mastering the new culture and resolving the grief surrounding the loss of their motherland (Althausen, pg. 685). While emigration is no longer prohibited, psychologically it may still elicit feelings of shame for leaving rodina and the extended family (Althausen, pg. 684). Unlike Jewish Russians who are automatically given refugee status and allowed to immigrate with their elderly parents and children, ethnic Russians can not do so until they have been awarded their U.S. citizenship (Althausen, pg. 684). This exhausting process can take many years and often times family members in Russia are rejected during the screening process due to annual quotas maintained by the federal government.

Once in New York, many Russians are lucky enough to join other expatriates in Russian neighborhoods such as Brighton Beach and Forest Hills. Still, Americans tend to perceive all immigrants from the former Soviet Union as “Russian” and, since the majority are Jewish, ethnic Russians may become “lost in the shuffle” (Althausen, pg. 684). Furthermore, ethnic Russians may not “receive the attention and resettlement resources given to their Jewish countrymen by the local Jewish community” (Althausen, pg. 684).

While Russian immigrants may underutilize mental health services this does not mean that they need fewer services. If we can better understand their cultural complexities, we may be able to ease the discomfort associated with help-seeking behavior. For starters, Russians often have shameful feelings about “resorting” to psychotherapy. In the interest of establishing a rapport with a Russian patient, “it may sometimes be necessary to de-emphasize the ‘mental health’ aspect of work by using appropriate euphemisms that are more acceptable culturally”(Althausen, pg. 684). In Leonid Althausen’s essay, he provides a case example of a young boy who was referred to therapy because he refused to continue speaking Russian with his parents. His Russian parents were reluctant to put their child into psychotherapy. However, when it was suggested that they make an appointment with Dr. Althausen, a “tutor” who can help their child emotionally reconnect with his native tongue, the parents had no objections (pg. 685).

Once in session with a Russian patient it will be important to begin by clarifying the role of the therapist. In Russian, the word “therapist” (terapevt) means “physician”, so the patient might expect a therapist to write a prescription. Also, it will be important to begin by acknowledging the Russian patient’s courage and achievement in transplanting themselves to the New World (Althausen, pg. 685). This will help convey confidence from the therapist in their ability to resolve their problems, and ultimately have a more meaningful experience in their new life.

Life Across the Border: Family Composition and Mental Health Behavior of Mexican Americans

2006-04-12T19:54:00.000-04:00

Desiree Castillo
Psyc 755-Psychopathology II
Ethnicity Paper
4/10/06

Mexican Americans

Results of the U.S. Census Bureau (2001; as cited in Sharma & Kerl, 2002) found that there are an estimated 32.8 million people of Latino origin living in the United States. It is predicted that this number will increase from about 10% of the U.S. population in 1990 to 14% or 15% by the year 2020, making this group one of the four largest ethnic groups in the country (Garcia & Marotta, 1997; as cited in Sharma & Kerl, 2002). Falicov (1998) wrote that Mexican Americans account for 64% of the total Latino population, comprising the largest Latino group in the United States. California and Texas encompass nearly half of the total Latino population, with nearly 25% of the population in each of these two states being of Mexican American descent (Garcia & Marotta, 1997; as cited in Sharma & Kerl, 2002). Estimates indicate, based on combined percentages with 2000 population statistics, that there are about 20 million people of Mexican American descent living in the United States today. Mexican Americans constitute a significant component of the overall Latino population in that they have many shared experiences and cultural beliefs representative of the Latino culture as a whole. In addition, however, they have different migration patterns and influences upon the American economic infrastructure that are distinctive of Mexicans.
Typical Family Constellations and Family Roles & Attitudes Towards Independence and Dependence:
From a family systems perspective, Mexican American families can be characterized as encompassing a preference for traditional family arrangements where lifelong, parent-child cohesion and high levels of respect for parental authority are revered and expected. Strong religious beliefs (Roman Catholicism) and a need to garner support from a variety of economic resources further encourages the tendency to have large families consisting of four or more children and with extended family members playing an active role in the activities of daily family life. The need for a sense of strong familial interconnectedness, or sense of “familismo” is especially keen among Mexican American immigrant families who have often times experienced great hardship and sacrifice due to the need for certain family members, namely women, to stay behind in Mexico while her husband or sons(s) migrate to the United States in search of better employment opportunities (Falicov, 1998). Although many Mexicans choose to migrate to the United States, many do so only out of significant economic need and if given a choice, many would choose to maintain their sense of culture and family unity by staying in their villages and homes in their native land (Falicov, 1998).
The path to better economic opportunities in the United States is often fraught with extreme physical and mental hardship, the constant threat of being detected by American immigration authorities, and the possibility of being physically harmed, robbed, or abandoned by their “coyotes,” the people who are hired to help them cross the American border (Falicov, 1998). Despite these ever-present dangers, every year millions of undocumented Mexican immigrants successfully cross the border and enter into the United States only to be met with problems related to harsh, unsafe working conditions, language barriers, the constant threat of deportation and experiences with ethnic discrimination and stereotyping (Sharma & Kerl, 2002). All of these possible negative experiences reinforce the need for strong, supportive interconnected family ties and a sense of unity with immediate and extended family members.
The importance of cohesion and sense of interdependence is the hallmark of the concept of familismo. Mexican American culture and the emphasis placed on family relations supports the notion that the family unit is more valued and more greatly revered than the individual (Sharma & Kerl, 2002). The construct of familismo is highlighted by the importance placed upon cyclic rituals by Mexicans. One example of a cyclic ritual is the la comida semanal (the weekly meal) in which all members of the extended family unit partake in the ritualized celebration of sharing stories and time together over a large meal (Falicov, 1998). In addition to household duties, the benefits of working in a collective family group extend to achieving greater financial responsibility, emotional support, help with child-rearing duties, and a more collectivistic approach to problem solving.
In terms of the roles of children in Mexican culture, it is dictated by unspoken rules within their culture that children of all ages must respect and obey their parents at all times. This is an especially difficult struggle for children, particularly adolescents, who must tow the line carefully between assimilating to the cultural norms of their adopted American culture and the traditional beliefs strongly adhered to by their parents, which tend to lie in direct contrast with mainstream American beliefs. Many Mexican American children who are first generation are expected by parents to do well in school and to adopt the English language. In contrast, they are expected to strictly adhere to the more traditional Mexican beliefs of speaking Spanish at home, participating fully in all family functions, and listening to the guidance of parents and other respected elders (Falicov, 1998).
Strong familial bonds between siblings are also a crucial component to the Mexican American family structure. Older siblings are usually called upon to take care of and protect younger siblings, in turn serving as a surrogate mother/father for when parents have become too old or have passed away and are unable to care for younger children. In addition, Mexican American siblings tend to act as a confidante and supporter to each other, reinforcing family bonds that extend to each other’s children and future generations of family members. Siblings tend to reflect the roles of their parents in that sisters tend to act nurturing and emotionally supportive towards siblings, whereas brothers tend to act protective and provide financial support and mentoring to other siblings (Falicov, 1998).
Attitudes Towards Different Gender Roles:
A major component of the family unit in Mexican American families relates to the notion of family member roles, in particular the roles of women and their position within the family system. The concept of marriage and the stratified gender roles ever-present in traditional Mexican families have come under increased scrutiny and pressure in the past three decades due to factors related to assimilation with the mainstream American culture that lie in direct contrast with more traditional notions of gender in the Mexican culture. Often the focus of marriage in Mexican society is on the concept of parenthood instead of partnerhood. Spouses often focus on their role as “mothers” and “fathers” instead of their roles as husbands and wives (Falicov, 1998). The sanctity of marriage is often held together because of obligations as parents and to firmly held religious beliefs that oppose divorce or separation, although as more Mexican Americans become increasingly integrated into American society, the divorce rate among Mexican Americans has risen significantly (Falicov, 1998).
When focusing on Latino culture and in particular Mexican culture, significant emphasis must be paid to the concepts of machismo and marianismo. Machismo relates to the idea of the concept of manliness among Latino men. This construct dictates that a Latino man should be strong in character and physicality, be virile and able to provide for and protect his family (Falicov, 1998). Initially, the concept of machismo had overwhelmingly positive connotations, but as the concept grew to be more closely associated with domination towards women and infidelity within marriage, the notion of machismo has come to embody negative aspects in more recent decades. In terms of stereotyped gender roles for women, the female Latina often times must struggle with her female identity being fused into her identity as a wife and mother. Traditional notions of womanhood categorize women into two distinctive groups “the good ones” and “the bad ones” (Falicov, 1998). The good ones are likened to the image of the Virgin Mary and maintain the image of the sacred mother and submissive and devoted wife who must only be sexual for the purposes of procreation. She maintains the concept of “Marianismo” (like the Virgin Mary) by adhering to self-sacrificing practices and a strong sense of fidelity to her husband and children, causing almost complete negation of her needs as a woman for sexual satisfaction or for her own wants, desires, drives or ambitions in life to be acknowledged. In contrast, “bad women” are categorized as those whom Latin men would engage in sexual relations with outside of the family unit, but who would remain hidden and kept on a lower status than wives. In addition, it is not seen as uncommon for many Mexican men to have separate families (“la casa chica”-the little house) with a mistress whom he provides for, but who does not garner the same level of status or privileges as the legitimate children and wife (Falicov, 1998).
Culturally Defined Symptoms & Attitudes Towards Psychological Problems and Help:
Many mental illnesses that have been categorically defined in the DSM-IV by a list of definitive symptoms that serve to characterize the illness have significantly similar manifestations in Mexican culture but are defined differently. Many culturally-bound syndromes are explained as “folk illnesses” and are treated with folk medicine cures. Harwood (1981; as cited in Falicov, 1998) conducted a study in which he found that for Mexican American traditional folk concepts the majority of ailments fall under the category of males naturales (natural illnesses) and the remaining fall under the category of mal puesto (witchcraft). In terms of conceptualizing these illnesses, the most common ailments are mal de ojo (the evil eye), susto or espanto (fright), empacho (indigestion), nervios and ataque de nervios (Falicov, 1998). Susto can be characterized by bouts of restlessness, listlessness, diarrhea, vomiting, weight loss or lack of motivation after experiencing a traumatic event such as a car accident or after watching a violent act occur. In mainstream American society, susto would most likely resemble the effects of Post Traumatic Stress Disorder (PTSD) in which flashbacks and feeling of anxiety and helplessness occur after experiencing trauma. Mal de ojo is a common ailment in many Mediterranean cultures and is usually linked with witchcraft, or the ability for a person with strong supernatural powers to exert negative influences over the health of another. A person with mal de ojo typically experiences uncontrollable weeping, fretfulness, insomnia and many other symptoms that are on par with depression-like or anxiety type symptoms. Empacho describes an ailment of the stomach where an individual experiences bloating, intestinal blockage or issues related to stomach disturbances which seems to characterize an ailment akin to indigestion, irritable bowel syndrome, or acid reflux disease. Nervios or ataque de nervios relates to experiences of crying or shouting spells, nervousness, fainting, hyperventilation and perhaps even amnesia (Falicov, 1998). This disorder tends to be more prevalent among women from lower socioeconomic status and is usually interpreted as an acceptable reaction to a highly stressful or shocking event, such as a sudden death in the family or acute trauma. Highly dramatized reactions among Mexicans, in particular women, appears to be a socially acceptable and psychologically sound way of coping with the stresses of traumatic experiences.
In terms of more severe psychological disturbances such as schizophrenia, many of these chronic and treatment-resistant illness are characterized as being the result of brujeria (withcraft). It is typically believed among Mexicans (especially those from a low socioeconomic status) that when ailments cannot be explained by natural folk illnesses, that mal puesto (bewitchment) must be at play in which those with severe and chronic symptoms are believed to have had a hex placed on them by a witch or sorcerer (Falicov, 1998). In order to cope with such ailments, it is typical in Mexican culture to seek the help of a curandero (folk healer) who are called upon to ward off evil spirits and to cure the body of all ailments through the use of rituals, candles and herbs. Many of the curandero’s ritualized treatments are related to the notion of espiritismo, or the belief that good and evil exist in an invisible world where it can attach itself to humans through spirits that in turn influence the behavior of the individual to whom they are attached (Falicov, 1998). In addition, religious beliefs, particularly those of the Roman Catholic religion, play an important role in how mental and physical disorders are conceptualized and responded to. Many Mexicans believe that if one is struck with a physical or mental ailment, it is the will of God and that one must pray to God and saints in order to receive help with the difficulties that living with these disorders presents for the afflicted individual as well as their family. It is typical for Mexicans to believe that God will protect them and forgive them for their sins as long as they perform rituals and behave in line with what the Bible dictates as acceptable behavior.
Snyder, Lopez, Polo, Karno, Hipke, Jenkins and Vaughn (2004) conducted a study that followed up on two previously performed analyses of Mexican American and Anglo American patients and families and their expressed emotion and attributions towards a family member with schizophrenia. The results of the study found that patients with schizophrenia who were discharged to a family environment with high levels of criticism, hostility, or emotional overinvolvement were more likely to relapse than patients who returned to families with low levels of the same negative emotional and/or attitudinal attributes (Butzlaff & Hooley, 1998; as cited in Snyder, Lopez, Polo, Karno, Hipke, Jenkins and Vaughn, 2004). In addition, this study found that for Mexican Americans, family warmth was a significant protective factor against the patient’s tendency to relapse whereas for the Anglo Americans, family criticism was found to be a significant risk factor for the chance of relapse for the patient (Snyder et al., 2004). The results of this study were significant in that it provided further evidence to support the notion that social factors are related to the course and treatment of schizophrenia and identified the need for family treatments that incorporate psycheducation, communication, and problem-solving skills training in order to create more positive emotional and/or attitudinal attributes in the family’s social environment. In addition, this study found that for Mexican Americans, family warmth was a significant protective factor against the patient’s tendency to relapse whereas for the Anglo Americans, family criticism was found to be a significant risk factor for the chance of relapse for the patient (Snyder et al., 2004).
Attitudes towards seeking psychological help among Mexican Americans is one of initial caution and mistrust. Mexican Americans tend to seek advice and counsel from those whom they trust, namely family members and elders within their community. Underutilization of mental health services among Mexican Americans is common due to many obstacles such as a language barrier and the lack of sufficient health insurance due to their undocumented status (Falicov, 1998). A sense of personalismo (personalism) between the therapist and client is one of the keys to allowing the client to feel more comfortable in the therapeutic setting and to allow for more disclosure on the part of the patient (Falicov, 1998).
Implications for Psychological Treatment:
When working with Mexican Americans, it is important for therapists to address cultural differences that may exist between therapist and client as well as for the therapist to outline the expectations and procedures typical of therapy in addition to addressing any concerns the patient/s may have regarding the therapeutic process (Falicov, 1998). A sense of confianza (trust) between patient/s and therapist is one of the crucial components to engaging and retaining Mexican American clients in therapy. Pamela Hays (2001) devised a model with the acronym ADDRESSING for conceptualizing cross-cultural work. The main ideas of this model are to create a foundation for the therapist to be culturally responsive to the needs of minority clients, and thus this would be a beneficial model for working with Mexican Americans. The components of the ADDRESSING model are:
• Age and generational influences (e.g., children, adolescents, elders)
• Disability (e.g., people who have developmental or acquired physical, cognitive, psychological disabilities)
• Religion and spiritual orientation (e.g., people of Muslim, Jewish, Christian, Hindu, other minority religions and faiths)
• Ethnicity (e.g., people of Asian, South Asian, Latino, African American, Middle Eastern heritage)
• Socioeconomic status (e.g., people of lower status by occupation, education, income, rural or urban habitat, family name)
• Sexual orientation (e.g., people who are gay, lesbian, bisexual)
Indigenous heritage (e.g., in North America—American Indians, Alaska Natives, Samoans)
• National Origin (e.g., immigrants, refugees, international students)
• Gender (e.g., women, transgender people)
The utilization of Hay’s ADDRESSING model with Mexican American patients would possibly provide several benefits such as an ongoing involvement in one’s own cultural self-assessment and learning about other cultures, recognition of the possible significance of diverse cultural identities and influences in a client’s life and consideration of the interaction between the therapist’s and the client’s identities as well as the establishment of meaningful connections with clients (Hays 2001).
In another study, Constantine and Baron (1997) found that educational attainment for Mexican Americans (Chicanos(as) had discouraging results. Although Mexican Americans constitute the largest percentage of the Latino population, they are also one of the least educated. In terms of successful completion rates for four years or more of college, Mexican Americans fall behind other Latino groups (20.2% Cubans, 9.7% for Puerto Ricans, and 5.4% for Mexican Americans) and also in comparison to Asians (39.9%), Whites (28.5%), African Americans (11.4%) (Aguirre & Martinez, 1993: U.S. Bureau of the Census, 1991). Constantine and Baron (1997) conducted a study in which they found that three constructs in particular are of concern when addressing the mental health needs of chicano(a) college students: acculturation, ethnic identity development, and gender role socialization. Acculturation variables refer to the notion of how assimilated or acculturated a Chicano(a) college student may be to mainstream American society. If the student is not fluent in English, it would be necessary to provide a bilingual therapist for this student in the student psychological services clinic. Ethnic Identity Development refers to how the Chicano(a) student may have internalized racial stereotypes about Mexicans and how they identify themselves culturally and ethnically. Gender role socialization concerns the degree to which the Chicano(a) student adheres to traditional gender role behaviors and how they view male/female relationships (Constantine & Baron, 1997). Assessing these three major constructs enables the therapist to take a more proactive and empathic stance towards addressing the needs of these Mexican American students more efficiently and appropriately.
Mexican Americans are a group that has a strong presence and influence in the Unites States. They are a culture characterized by deep interpersonal relationships and interdependence on family members. Many Mexican Americans encounter hardship and adversity during the transmigration process to the United States, yet many succeed in establishing a successful life and gain better employment opportunities and living conditions for their families as a result. Mexican Americans continue to be a driving force within the American economy and have shown to display better therapeutic outcomes when specific cultural needs have been sufficiently addressed by mental health workers. As the population of Mexican Americans continues to increase within the United States, so too will the need for creating better and more productive means of addressing their mental health concerns.

Annotated Bibliography

Aguirre, A., Jr., & Martinez, R. (1993). Chicanos in higher education: Issues and
dilemmas for the 21st century (ASHE-ERIC Higher Education Report No.3). Washington, DC: George Washington University, School of Education and Human Development.
Aguirre and Martinez outline issues and dilemmas that Chicano college aged students face in higher education. A framework is provided for addressing these issues and suggestions for implementing possible solutions for these problems are addressed. An interesting source for clinicians of any level to understanding obstacles Chicanos face surrounding entering into and completing higher education.

Constantine, M. G., & Baron, A. (1997). Assessing and Counseling Chicano(a) College
Students: A Conceptual and Practical Framework. American Counseling Association, Alexandria, VA.
Constantine and Baron give detailed statistics regarding the discouraging percentage of Mexican Americans (Chicanos(as) that complete four or more years of college in comparison with other Latino and other cultural groups. Factors are identified regarding key issues clinicians should address when working with Mexican American college students and a framework is provided for implementing effective measures for addressing these issues in practice. A useful chapter for identifying specific concerns of the Mexican American college aged population.

Falicov, C.J. (1998). Latino Families in Therapy. The Guilford Press, New York, NY.
Falicov identifies typical issues related to working with Latino clients (mainly Mexicans, Puerto Ricans, Cubans, and Dominicans) in the therapeutic setting. She defines these issues through a comprehensive and detailed analysis of many components of the lifestyles and cultural specificities of these particular Latino groups. This book is a valuable tool for clinicians at any level, for it provides a comprehensive and structured model for working effectively with Latino clients and their families.

Hays, P. (2001). Addressing cultural complexities in
practice: a framework for clinicians and counselors.
Washington, DC: American Psychological Association.
Hays describes her ADDRESSING model for conceptualizing cross-cultural work. She outlines a cohesive framework for conducting an ethno-cultural assessment for working with clients who come from various multicultural backgrounds. This book is a valuable resource for mental health clinicians at any level of experience for it addresses ways for becoming a more culturally responsive therapist.

Sharma, P., & Kerl, S.B. (2002). Suggestions for Psychologists Working With Mexican
American Individuals and Families in Health Care Settings. Rehabilitation Psychology, 47, 230-239.
Sharma and Kerl discuss key cultural factors related to the therapeutic treatment of Mexican Americans. They give a thorough background analysis of typical Mexican American cultural values, attitudes, and behaviors and address these factors in explaining how to appropriately address cultural issues in therapy with Mexican American clients. A valuable study for clinicians of any level, due to specific suggestions for working with Mexican American patients being offered.

Snyder, K.S., Lopez, S.R, Polo, A.J., Karno, M., Hipke, K.N., Jenkins, J.H., Vaugh, C.
(2004). Ethnicity, Expressed Emotion, Attributions, and Course of Schizophrenia: Family Warmth Matters. Journal of Abnormal Psychology, 113, 428-439.
The authors examined the role of family factors and the course of schizophrenia by conducting additional assessments based on two previous studies of Mexican American and Anglo American patients and families. The authors found that for Mexican American families, family warmth is a significant protective factor against relapse and for Anglo American families, family criticism is a significant risk factor for the family member with schizophrenia regarding potential for relapse. Interesting study for understanding that social factors are related to the course of schizophrenia and that several changes can be made in creating family treatments which encompass components to combat negative emotional/attitudinal attributes.

U.S. Bureau of the Census. (1991). The Hispanic population in the United States, March
1990. Washington, DC: U.S. Government Printing Office.
Population statistics are outlined regarding the Hispanic population in the United States. A valuable technical resource for understanding information regarding the population statistics of Hispanics in the United States and for utilizing these statistics for research purposes.

Chinese Americans – Family Structure, Interdependence, Culturally Defined Symptoms, and Help-Seeking Behavior

2006-04-11T21:22:00.000-04:00

Chinese Americans –

Family Structure, Interdependence, Culturally Defined Symptoms,

and Help-Seeking Behavior

Jennifer Lo

Psychopathology II

Final Paper

April 10, 2006

Data obtained by the United States Census 2000 found that the Asian American population (including people who categorized themselves as “Asian and 1 or more other races”) increased by 72.2% since 1990 (http://www.awib.org/content_frames/census2000.html). The largest ethnic subgroup was Chinese Americans whose population increased 48% totaling 2.4 million people. If immigration rates maintain, as they did from 1990 to 2000, the Chinese (and Asian American population overall) will continue expanding exponentially. As their numbers increase it is expected that Asian Americans will exert more economic, social and political influence than ever before. As clinicians and social scientists, it is imperative that psychologists understand the contributing influence and acculturative processes of the various ethnic groups living within the U.S. This paper focuses upon the Chinese people, describing (1) characteristic family constellations, (2) perspectives on gender roles, (3) attitudes toward independence and interdependence, (4) typical or culturally defined symptoms, and (5) attitudes toward psychological problems and mental health services.

Chinese Americans frequently maintain a collectivist orientation toward relationships with others (Ho, 1990; Shon & Ja, 1982; Sue & Chin, 1983). Their identities are deeply embedded in the groups to which they belong, including family, company, school, or nation (Chung, 1992). Group interests and requirements often take priority over an individual’s needs. This perspective is in direct opposition to the Euro-American focus on the individual and the supplanting of one’s desires over those of the group. One significant result of the latter orientation is the preservation of the individual’s identity in spite of the groups with which he/she associates.

Because of the collectivist mindset Chinese Americans define families differently than Euro-Americans. In both cultures, the family is a central unit. However, European American parents tend to define family in “nuclear terms” (i.e. as a unit consisting of parents and their dependent children) (Shon and Ja, 1982). In contrast, the Chinese family concept typically includes the nuclear family and extended relatives (e.g. grandparents, aunts, and uncles). In fact, the Chinese family perception extends backward to all preceding generations of the family lineage as well as forward to future generations (Ho, 1990; Shon & Ja, 1982; Sue & Chin, 1983). Given this family model and collective point of reference, an individual’s actions reflect not only on him/her but also upon the entire past, present, and future lineage (Shon & Ja, 1982).

Traditional Chinese families also have specific roles and hierarchical positions for each member (Ho, 1990; Uba, 1994). The use of rank and hierarchy operates to further maintain family harmony. Ordinarily, elders hold a higher status than younger individuals and women are subordinate to men (Ho, 1990; Uba, 1994). Additionally, as a male, the father is generally recognized as the family leader and authority figure. He provides the family’s financial needs, executes decisions, and imparts discipline (Shon & Ja, 1982; Uba, 1994). The mother traditionally occupies the position of family nurturer. She is the children’s principle caregiver and typically completes the majority of household tasks (Shon & Ja, 1982; Uba, 1994). The mother is the most important route of communication between the children and the father, and she often mediates on her children’s behalf. Nonetheless, as a female, she is generally placed lower in the family hierarchy in comparison to her husband, her father, her in-laws, and even occasionally, her son (Lee, 1996).

A child’s role within the family is also highly structured. Literature on Asian American families commonly depicts children as expected to respect their parent’s interests and desires without question, even at times sacrificing their own needs and wants for the benefit of the family (Hong & Hong, 1991; Uba, 1994). Typically, the oldest son is the most cherished child (Shon & Ja, 1982). He is the younger sibling’s role model and (other than the father) their authority. In fact, when the father is absent, the oldest son is regarded as the head of the family. If he is unable to fulfill these responsibilities, the next oldest son takes up the position of family leader (Shon & Ja, 1982). Daughters typically lack authority within the family. In fact, in traditional Chinese families, daughters are brought up by their parents to marry and ultimately become part of their husband’s family (Shon & Ja, 1982; Uba, 1994). Daughters are also required to be passive (Sue & Sue, 1999). The importance placed on close family ties and commitments is based on the idea of filial piety, which refers to obedient respect for parents, grandparents, and other elders (Ho, 1990). Great significance is attached to filial piety and it is usually expected from all family members.

Unfortunately, more acculturated Chinese children are often faced with deciding between family loyalty and the expectations placed upon them by their western peers and elders. Intergenerational conflict commonly occurs when offspring born and raised in the United States defy their parent’s cultural values and opt for western ideals of independence and self-determination (Tan & Dong, 1999). In these cases, guilt and shame are often used as a means of controlling the aberrant adolescent’s behavior (Sue, 1997) with severe consequences for those who do not conform; including, emotional abandonment, exclusion from the family or community, and/or removal of societal faith and support. Rejection of a child who attempts to individuate is founded in the Confucian belief that children who act independently or disagree with their parents are disrespectful, self-centered, and thoughtless (Sue & Sue, 1993; Tan & Dong, 1999).

Gay or lesbian adolescents are at an even greater disadvantage than their heterosexual peers. They are subject to the same guilt and shame as their heterosexual peers for attempting to individuate/separate from their parents. However, their sexual preference intensifies the shame and guilt since they are stepping outside of their expected roles. As previously stated, maintaining external roles and conforming to one’s environment are highly valued traits within Chinese culture. Homosexual males who disclose their sexual preference are rejected by their family for failing to continue the family line and name by marrying and having children (Chan, 1989). Females are rejected for shaming the family line as well as failing to fulfill their positions as dutiful daughter and, eventually, wife and mother (Chan, C.S., 1992; Pamela, 1989).

A literature review of studies aimed at measuring Asian American mental health service usage revealed that Chinese American’s attend mental health services less often, have higher dropout rates, and shorter stays than whites and other ethnic minorities (Bui & Takeuchi, 1992; Cheung & Snowden, 1990; Lee, Lei, & Sue, 2001; Loo, 1982; Sue & McKinney, 1975; Sue & Sue, 1974; Sue, Fujino, Hu, Takeuchi, & Zane, 1991). The Chinese American Psychiatric Epidemiological Study (CAPES), for instance, queried participants with and without mental disorders on whether or not they had sought assistance for difficulties with emotions, anxiety, drugs, alcohol, or mental health in the preceding six months. The results showed that 17% of participants experienced problems but less than 6% of this group pursued care with a mental health professional; 4% visited a medical doctor; and 8% spoke with a minister or priest (Young, 1998). The finding that Asian Americans who use mental health services are more acutely ill than white Americans using the same services has been demonstrated in community health centers (Brown, Huang, Harris, & Stein, 1973; Sue, 1977), county mental health systems for adults (Durvasula & Sue, 1996); for adolescents (Bui & Takeuchi, 1992), and student psychiatric clinics (Sue & Sue, 1974).

One hypothesis for these findings is that Asian Americans are hesitant to seek mental health care due to their collectivist mindset. Legal infractions, unemployment, mental illness, and demonstration of intense feelings are all considered marks of weakness among traditional Asian Americans since these actions draw attention to the individual and cause disruption within the community (Ho, 1976). As collectivist cultures exist upon the understanding that every person works to maintain harmony, shamed individuals who do not exert self-control are cast off. Thus, the lack of support and empathy from their community as well as the requirement to remain inconspicuous may prevent many Chinese Americans from openly expressing distress.

A second hypothesis for the underutilization of mental health services by Chinese Americans is that families persuade disturbed members not to seek assistance until the ill individual becomes unmanageable. As mentioned previously, the collectivist view towards family structure can lead to a belief that if one person is (mentally) ill, the entire unit has a problem. Chinese Americans may avoid revealing their disorder because they believe it will bring shame not only to themselves but also family members (Uba, 1994). Additionally, since mental illness is seen as an indication of weakness, some individuals may choose to suffer silently rather than instigate family discord or abandonment.

In fact, open discussion of marital strife, academic or employment difficulties and psychological problems is generally avoided between family members so that harmony can be maintained. Members of traditional Chinese households may allow one individual to suffer in order to maintain the entire family’s cohesion, peace, and stability (Ho, 1990). This enduring and deep-rooted emphasis on submission of self to the family derives from Asian / Confucian ethics, which focuses on appropriate and harmonious social construction (Tan & Dong, 1999). Taoist influences of living peacefully with nature and with other people also stress harmony and unity within the family and outer community over the individual (Hopfe, 1983; Matsui, 1996).

In addition to fear of family shame, other specific cultural beliefs towards mental illness may prevent Chinese Americans from seeking professional treatment. For example, people may not attribute their emotional problems to mental difficulties. Many traditional Asian cultures believe that mental illness is a punishment for past wrongs of the family and lack of direction and restraint from the family leader (Chan & Leong, 1994; Tan & Dong, 1999). Belief in the existence of a spirit world and multiple gods that govern the universe may also cause Chinese to interpret their emotional difficulties as the result of demonic forces or spiritual warfare (Tan & Dong, 1999). Furthermore, in conventional Chinese culture, personal and emotional problems are attributed to bad thoughts, deficiency in willpower, and immaturity. Instead of asking for help from a friend or stranger, conservative Chinese parents may encourage their children to develop self-restraint and solve their own problems (Leong, 1986; Sue & Morishima, 1982). Chang (2000) found among high school students in Taiwan, the principal barriers for seeking mental health services included: “reluctance of self-disclosure, perceiving problems as not serious enough…unfamiliarity with the counseling process, and self-reliance.”

Self-restraint/reliance is so culturally engrained that somatization of psychological stress is a common occurrence among Chinese people (Cheung, 1982; Lee, Lei, & Sue, 2001; Tabora & Flaskerud, 1994). Somatization disorders as defined by the DSM-IV are complaints of physical pain or discomfort that cause distress and impair a person’s functioning but have no medical explanation (DSM-IV TR, American Psychiatric Association). The Chinese cultural etiology of these complaints has several key factors. First, the Chinese language lacks vocabulary to describe the affective states; therefore they must resort to physical expressions of emotion. Second, even with a more diverse vocabulary, Chinese people do not easily differentiate between affective states. Third, the Chinese holistic view towards health intimately links the mind and body as one (Cheung, 1982; Sue & Sue, 1995). Consequently, there is often no distinction made between physiological and psychological problems. Thus, some Chinese Americans may avoid mental health treatment because they genuinely experience their distress as physical, not mental pain.

Buddhist perspectives on fate and suffering may further inhibit some Chinese Americans from seeking mental health services. Ho (1976) defines fatalism as adjusting to a situation without attempting to control one’s environment. Suffering without protest is seen as testament to an individual’s strong character (Ho, 1990). Many Chinese Americans who are fatalistic may also give credence to the Chinese yin-yang philosophy. Here, there are constant opposing forces; every positive state within an individual’s life has a counteracting negative – e.g. health and sickness, wealth and poverty, power and submission. At any one time, either state has temporary dominance over the other. Because no one principle dominates eternally, all conditions are subject to change into their opposites (http://www.wsu.edu:8080/~dee/CHPHIL/YINYANG.HTM). Hence, fatalistic individuals endure pain knowing that if they remain strong, eventually their suffering will subside and become the opposite state (happiness).

With regards to parenting, some Chinese do not seek help for their emotionally distressed children out of reluctance to admit (self-perceived) failure to cope with problems (Chan, S., 1992). The avoidance is related to the values of self-reliance and shame associated with seeking help. Traditional Chinese parents would rather tolerate deviant or troubling behavior in their children than admit their own parental inadequacy. This is particularly true if their school-age children demonstrate continual learning disability and/or psychosocial difficulties at school. In these instances, the child’s behavior is viewed as lazy or oppositional and the result of their parents inability to provide proper training. Instead of seeking professional assistance for ongoing learning or emotional problems, some Chinese parents may resolve themselves to provide better instruction to their children and hope they outgrow their issues.

There are also pragmatic barriers preventing Asian Americans from seeking mental health services. One of the most basic obstacles is finding clinicians who are able to effectively communicate with clients in their native languages (Ho, 1990; Lee & Mokuau, 2002; Root, 1985; U.S. Surgeon General, 1999). Of the mental health care professionals practicing during the late 1990’s, about 70 Asian American clinicians were available for every 100,000 Americans in the United States; this is approximately half the ratio for whites (Manderscheid & Henderson, 1998). Ma (1999) found that many elderly Chinese feel frustrated and embarrassed that they cannot fully convey their difficulties with their physicians. Instead of bearing this shame and attempting to overcome the communication barrier, Chinese elders may opt to stop seeking health care altogether. While having a family member translate for a relative may appear plausible, it can be problematic when the translator is unfamiliar with medical terminology.

Lack of familiarity with the U.S. health system and limited financial resources may also contribute to Asian Americans underutilization of mental health treatment (Ho, 1990; Lee & Mokuau, 2002; Rao, DiClemente, & Ponton, 1992). Recent immigrant’s job opportunities are often limited due to: low level of acculturation and employment experience; American racial prejudice; and sexist practices. Without employment, many newly arrived Asians are unable to pay for professional health services (Ho, 1990). Even if they do acquire a job, many immigrants are working class and therefore lack health insurance or other benefits that may allow them to seek professional treatment (Lee & Mokuau, 2002). In 1999, the U.S. Surgeon General reported that 21.1% of Asian and Pacific Islanders (API’s) are uninsured, compared with 11.9% of non-Hispanic Whites. Furthermore, the rate of Medicaid coverage for most Asian Americans and Pacific Islander subgroups is significantly below that of whites. For instance, only 13 percent of Chinese American families with children and incomes below 200 percent of the Federal poverty level have Medicaid coverage. This is compared to 24 percent of whites in the equivalent income bracket. One hypothesis for this occurrence is that many Asian immigrants mistakenly believe if they register themselves or their children for Medicaid, their citizenship applications will be put at risk (Brown, Ojeda, Wyn, & Levan, 2000).

Finally, racist experiences may prevent some Chinese Americans from seeking professional mental health services (Ho, 1990). Multicultural individuals in the United States are subject to racial attack and discrimination in any public arena, because their skin, hair color, and facial features are different from European Americans. Seemingly minor negative experiences with the U.S. Health system can pressure some people of color into staying invisible in order to avoid violence and bigotry (Kitano & Kikumura, 1976). In avoiding mental health services, Chinese Americans may be afraid that clinicians will misunderstand their culture and reject, negate, and denigrate it.

Psychologists and therapists in the U.S. can help increase Chinese American mental health service usage by becoming more culturally sensitive (Lee & Mokuau, 2002). For example, clinicians should recognize the importance of cultural and ethnic matches between client and provider. Asian American clients tend to prefer therapists who are also Asian American (Tan & Dong, 1999). In fact, research has documented that Asian American clients who are matched with therapists of their same race are less likely to prematurely leave treatment than Asian American clients who do not work with a person of their same background (Sue, Fujino, Hu, Takeuchi, & Zane, 1991). However, while ethnic similarity is one of the most significant aspects of therapist match for APA’s, it is not the only one. Matching religious beliefs between clinicians and Christian Asian American clients is also vital and may be even more important than race or ethnicity. When Christian APA’s seek assistance from professionals, they are partial towards Christian professionals over non-Christian professionals (Misumi, 1993). Gender also plays an important role in therapist-client match for female Asian American clients; having the same gender and ethnicity as their therapist has shown to be crucial towards their staying in therapy (Fujino, Okazaki, & Young, 1994).

When treating Asian clients, it is also important that mental health clinicians identify a method to overcome stigma and engage parents and family members. Due to the emphasis on cohesion and harmony, family involvement has been shown to be extremely valuable towards the psychological treatment of Asian Americans (Lin, Miller, Poland, Nuccia, & Yamaguchi, 1991; Tan & Dong, 1999). Clinicians must acknowledge and respect a family’s power structure; treatment will not be successful without the family leader’s permission (Lee & Mokuau, 2002). By understanding how decisions are made and which relatives hold influence, therapists may avoid competition. There are generally two categories of authority in an APA family system: “role prescribed power” (typically given to the grandfather, father, or eldest son) and “psychological power” (often upheld by the grandmother or mother). By sharing goals or treatment plans with a client’s family members, clinicians not only avoid power conflicts but also gain inside knowledge into a client’s family life. Furthermore, by collaborating with family members, clinicians give clients an in home resource for guidance and support. Finally, partnership with a client’s relatives reclassifies a clinician’s role from expert to partner (Wu, 1999).

The Chinese American community is one of the fastest growing ethnic groups within the

United States. A dynamic acculturative process is taking place as thousands of Chinese immigrants move beyond Chinatown enclaves, establishing themselves in areas that were predominantly Euro-American. Western and Eastern traditions are commingling in a way that psychologists, as social scientists and scholars of the human condition, cannot ignore. As the definition of “American culture” continues to change simultaneously with growing ethnic communities, psychologists must learn and appreciate the needs, expectations, traditions, and attitudes of their future and potential clients.
References and Annotated Bibliographies

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental

Disorders. 4^th Edition. Revised (DSM-IV TR). Washington, D.C.: American Psychiatric Association.

Brown, E.R., Ojeda, V.D., Wyn, R., & Levan, R. (2000). Racial and ethnic disparities in access

to health insurance and health care. Los Angeles, CA: UCLA Center for Health Policy and Research and The Henry J. Kaiser Family Foundation.

This policy report gives an overview of health care access for Latinos, African Americans, Asian American and Pacific Islanders, American Indians, and Alaskan Natives. The entire report is 105 pages; two page fact sheets with tables, charts, and essential data are available for all four ethnic groups. All this information may be located at: http://www.kff.org/uninsured/1525-index.cfm/

Brown, T.R., Huang, K., Harris, D.E., & Stein, K.M. (1973). Mental illness and the role of

mental health facilities in Chinatown. In S. Sue & N. Wagner (Eds.), Asian-Americans: Psychological perspectives (pp. 212-231). Palo Also, CA: Science and Behavior Books.

Editor, Stanley Sue, is an eminent and distinguished researcher in Asian American mental health. Unfortunately, this book is relatively old and the information it contains is somewhat outdated. The book from Laura Uba (1994) [see citation below] is a better choice.

Bui, K.T., & Takeuchi, D.T. (1992). Ethnic minority adolescents and the use of community

mental health care services. American Journal of Community Psychology, 20, 403-417.

The authors examined utilization rates, treatment dropout rates, and length of treatment for minority adolescents (African American, Asian American, and Hispanic) in the Los Angeles County mental health care system. The information obtained (spanning the years 1983-1988) is somewhat outdated and may only apply to the particular California county used by researchers.

Chan, C.S. (1989). Issues of identity development among Asian American lesbians and gay men.

Journal of Counseling and Development, 68, 16-20.

This is a survey study completed by nineteen Asian American lesbians and sixteen Asian American gay men. The authors pose an interesting question regarding self-definition and choice of identity – racial/ethnic vs. sexual orientation. One drawback is the inability to understand the perspective of individuals who chose not to answer the author’s questionnaires. Another limitation is the relatively small sample size.

Chan, C.S. (1992). Cultural considerations in counseling Asian American lesbians and gay men.

In S.H. Dworkin & F.J. Gutierrez (Eds.), Counseling gay men and lesbians: Journey to the end of the rainbow (pp. 115-124). Alexandria, VA: American Association for Counseling and Development.

Using case studies, gay psychotherapists offer their perspectives on anti-gay violence, career counseling, counseling the elderly, and counseling HIV-positive patients. The book contains chapters on gay Blacks, Latinos, and Asians.

Chan, S. (1992). Families with Asian roots. In E.W. Lynch & M.J. Hanson (Eds.), Developing

cross-cultural competence: A guide for working with young children and their families (pp. 181-250). Baltimore, MD: Paul H. Brooks Publishing Co.

This book’s primary audience is professionals in the educational, health care and social services industries that work with families with children who have, or are at risk for, disabilities. Case examples are offered for working with Anglo-European, Native American, African-American, Latino, Asian, Filipino, Native Hawaiian and Samoan, and Middle Eastern families.

Chan, S., & Leong, C.W. (1994). Chinese families in transition: Cultural conflicts and

adjustment problems. Journal of Social Distress and the Homeless, 3, 263-281.

See Ho (1990) for a better review of Chinese culture and intergenerational stress/conflict.

Chang, H.W. (2000). The help seeking for psychological problems and barriers to counseling

among Chinese high school students in Taiwan. Dissertation Abstracts International Section A: Humanities & Social Sciences, US: Univ Microfilms International, 60, 3915.

A highly specific study on help seeking – see the Uba (1994) for a more comprehensive review of Asian American mental health service usage.

Cheung, F. (1982). Somatization among Chinese: A critique. Bulletin of the Hong Kong

Psychological Society, 8, 27-35.

This is a summary of cultural explanations for somatization among Chinese people. Although this was published over twenty years ago, it offers valuable insights from the perspective of someone who speaks the Chinese language.

Cheung, F.K., & Snowden, L.R. (1990). Community mental health and ethnic minority

populations. Community Mental Health Journal, 26, 277-291.

This article draws upon data from 1950 to 1980 and describes mental health treatment obtained by African Americans, Asian American / Pacific Islanders, Hispanics, and Native American / Alaska Islanders. While somewhat outdated, this research covers the entire U.S. and includes data on admissions to mental institutions.

Chung, D.K. (1992). Asian cultural commonalities: A comparison with mainstream American

culture. In S.M. Furuto, R. Biswas, D.K. Chung, K. Murase, & F. Ross-Sheriff (Eds.), Social Work Practice with Asian Americans (pp. 27-44). Newbury Park, CA: Sage.

The Ho (1990) book offers a better comparison of Asian vs. Western culture.

Durvasula, R.S., & Sue, S. (1996). Severity of disturbance among Asian American outpatients.

Cultural Diversity and Mental Health, 2, 43-52.

This article compares help-seeking among Asian and White clients seeking services from a large mental health system over a 5-year period. Subjects were compared on three measures of severity of disturbance: severity of diagnosis, ratings of functioning, and presence of psychotic features. Although the study does not cover mental health facilities across the U.S., it’s population size is large, ensuring validity of the researchers findings.

Fujino, D.C., Okazaki, S., & Young, K. (1994). Asian-American women in the mental health

system: An examination of ethnic and gender match between therapist and client. Journal of Community Psychology, 22, 164-176.

The Uba (1994) provides a better summary of the mental health needs of Asian American women.

Ho, C.K. (1990). An analysis of domestic violence in Asian American communities:

Multicultural approach to counseling. Women and Therapy, 9, 129-150.

The author discusses domestic violence in Asian American communities, and presents results from a focus group study with Southeast Asians (Laotians, Khmer, Vietnamese, and Chinese). Helpful information is offered in understanding the impact of traditional Asian values (close family ties, harmony, and order, fatalism, perseverance, and self-restraint) on acculturation.

Ho, M.K. (1976). Social work with Asian Americans. Social Casework, 57, 195-201.

This article is relatively old and outdated. More up to date information on Asian American mental health needs can be found in the Uba (1994) book.

Hong, G.K., & Hong, L.K. (1991). Comparative perspectives on child abuse and neglect: Chinese versus Hispanics and Whites. Child Welfare, 70, 463-475.

This study examined the incidence of child abuse among a sample of Chinese, Hispanic, and White participants. Cultural explanations (fatalism and filial piety) are given in accounting for the greater tolerance for abuse within the Chinese group.

Hopfe, L.M. (1983). Religions of the world. New York: Macmillan.

This is an excellent reference for individuals involved in religion and the study of religion. The book focuses on the lives of particular religious founders, their fundamental teachings, and their current status in the world. Information is offered on Native American and African religions as well as Jainism, Sikhism, Zoroastrianism, and Baha'I. For more specific information about religious beliefs and psychotherapy, see the Handbook of psychotherapy and religious diversity Tan and Dong (1999).

Kitano, H., & Kikumura, A. (1976). The Japanese American family. In C.H. Mindel and R.W.

Havenstein (Eds.), Ethnic families in America. New York: Elsevier.

This book is outdated; more current information can be found in the Uba (1994) book.

Lee, E. (1996). Asian American families: An overview. In M. McGoldrick, J. Giordano, & J.K.

Pearce (Eds.), Ethnicity and family therapy (2^nd ed, pp. 227-248). New York: The

Guilford Press.

This is considered to be an essential textbook for acquiring and enhancing cultural competence in clinical practice. A third edition of this book was published in 2005.

Lee, J., Lei, A., & Sue, S. (2001). The current state of mental health research on Asian

Americans. Journal of Human Behavior in the Social Environment, 3, 159-178.

This information can be found in greater detail in the Uba (1994) book.

Lee, E., & Mokuau, N. (2002). Cultural Diversity Series: Meeting the mental health needs of

Asian and Pacific Islander Americans. National Technical Assistance Center for State Mental Health Planning, February, 2002.

This is an excellent and current summary of research on mental health concerns within the Asian American population. The entire publication can be downloaded from: http://www.nasmhpd.org/general_files/publications/ntac_pubs/reports/ASIAN.PDF

Leong, F. (1986). Counseling and Psychotherapy with Asian-Americans: Review of the

Literature. Journal of Counseling Psychology, 33, 196-206.

This literature review is relatively short and outdated – see Uba (1994) for a better summary.

Lin, K.M., Miller, M.H., Poland, R.E., Nuccia, I., & Yamaguchi, M. (1991). Ethnicity and family

involvement in the treatment of schizophrenic patients. Journal of Nervous and Mental Diseases, 179, 631-633.

This is a relatively specific study comparing family involvement of 26 Asian and 26 Caucasian patients. The Uba (1994) offers more information on mental health, cultural practices, and the Asian emphasis on family.

Loo, C. (1982). Chinatown’s wellness: An enclave of problems. Asian American Psychological

Association Journal, 7, 13-18.

This study is relatively old, did not include Chinese-American men, and its findings may be location specific. More up to date information can be found in Uba (1994).

Ma, G.X. (1999). The Culture of Health: Asian Communities in the United States. Westport, CT:

Bergin & Garvey.

This readable book summarizes existing research on health care issues affecting Asian Americans. The topics addressed include: sociocultural approaches to health, illness, and health care; clients' experiences in acquiring health care services; and the critical role of alternative practices in primary health care.

Manderscheid, R.W., & Henderson, M.J. (Eds.). (1998). Mental health, United States: 1998.

Rockville, MD: Center for Mental Health Services.

A summary of the state of mental health within the U.S, updated and published every two years. This book is an excellent complement to the Surgeon General’s report on Mental Health: Culture, Race, and Ethnicity.

Matsui, W.T. (1996). Japanese families. In M. McGoldrick, J. Giordano, & J. Pearce (Eds.),

Ethnicity and family therapy (2^nd Ed, pp. 268-280). New York: Guilford Press.

This is considered to be an essential textbook for acquiring and enhancing cultural competence in clinical practice. A third edition of this book was published in 2005.

Misumi, D. (1993). Asian-American Christian attitudes towards counseling. Journal of

Psychology and Christianity, 12, 214-224.

This article addresses the topic of help-seeking behavior and ethnic/cultural match. It is, however, relatively specific. A more general summary on this topic may be found in the Uba (1994) book.

Pamela, H. (1989). Asian American lesbians: An emerging voice in the Asian American

community. In Asian Women United of California (Ed.), Making waves: An anthology of writings by and about Asian American women (pp. 282-290). Boston: Beacon.

This is a collection of historical and sociological stories, poems and essays by 53 Asian-American women. The topics covered include stereotypes of female docility and subservience. This anthology does not specifically address the issue of psychotherapy and Asian Americans. However, the personal perspectives and histories may provide a background for better understanding clients.

Rao, K., DiClemente, R.J., & Ponton, L.E. (1992). Child sexual abuse of Asians compared with

other populations. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 880-886.

The authors reviewed clinic charts of children with substantiated cases of sexual abuse. Asian victims were compared with random samples of black, white, and Hispanic victims. Asian children were found to have a distinct demographic profile along with unique survivor issues. The problem with this review is it was done with charts from one clinic in California, thus the results may not apply across the U.S.

Root, M.P. (1985). Guidelines for facilitating therapy with Asian American clients.

Psychotherapy, 22, 349-356.

More up to date and detailed information can be found in Ethnicity and family therapy or Uba, 1994.

Shon, S.P., & Ja, D.Y. (1982). Asian families. In M. McGoldrick, J.Pearce, & J. Giordano (Eds.),

Ethnicity and family therapy (pp. 208-229). New York: Guilford.

This is considered to be an essential textbook for acquiring and enhancing cultural competence in clinical practice. A third edition of this book was published in 2005

Sue, D. (1997). The interplay of sociocultural factors on the psychological development of

Asians in America. In D.R. Atkinson, G. Morten, & D.W. Sue, (Eds.), Counseling Americ an minorities: A cross-cultural perspective (5^th ed., pp. 205-213). Boston: McGraw-Hill.

A more recent version (2003) of this book is now available and may contain more pertinent, up to date information.

Sue, D.W., & Sue, D. (1999). Counseling the culturally different: Theory and practice (3^rd ed.,

pp. 255-271). New York: John Wiley.

This is the revised edition of a best-selling, classic reference on cross-cultural counseling. The book addresses general issues in cross-cultural psychotherapy as well as approaches toward counseling particular ethnic populations. A special section with case examples is included.

Sue, D., & Sue, D.M. (1995). Experiencing and counseling multicultural and diverse populations

(3^rd ed.)., Philadelphia, PA, US: Accelerated Development, Inc; 63-89.

Using research and clinical material, this textbook discusses the needs, experiences, and characteristics of 13 ethnic-American subgroups encountered by psychotherapists. The more recent book Counseling the culturally different: Theory and practice is probably a better reference since it provides more case examples and useful information.

Sue, D., & Sue, D.W. (1993). Ethnic identity: Cultural factors in the psychological development

of Asians in America. In D. Atkinson, G. Morten, & D.W. Sue (Eds.), Counseling American Minorities: A cross-cultural perspective (pp. 199-210). Dubuque, IA: Brown & Benchmark.
A more recent version (2003) of this book is now available and may contain more pertinent, up to date information.

Sue, S., & Chin, R. (1983). The mental health of Chinese-American children: Stressors and

resources. In G.J. Powell, J. Yamamoto, A. Romero, & A. Morales (Eds.), The psychosocial development of minority group children (pp. 385-397). New York: Bruner-Mazel.

The information offered by this chapter is relatively outdated – the Ethnicity and Family Therapy textbook is a better reference.

Sue, S., Fujino, D.C., Hu, L, Takeuchi, D.T., & Zane, N.W.S. (1991). Community mental health

services for ethnic minority groups: A test of the cultural responsiveness hypothesis. Journal of Consulting & Clinical Psychology, 59, 533-540.

This article is relatively old – more up to date information on help seeking behaviors within the Asian American community can be found in Uba (1994).

Sue, S., & McKinney, H. (1975). Asian Americans in the community mental health care system.

American Journal of Orthopsychiatry, 45, 111-118.

The information offered by this article is relatively outdated – the Uba (1994) reference is more useful.

Sue, S., & Morishima, J.K. (1982). The Mental Health of Asian Americans. San Francisco:

Jossey-Bass.

The information offered by this article is relatively outdated – the Uba (1994) reference is more useful.

Sue, S., & Sue, D.W. (1974). MMPI comparisons between Asian Americans and non-Asian

students utilizing a student health psychiatric clinic. Journal of Counseling Psychology, 21, 423-427.

The information offered by this article is relatively outdated – the Uba (1994) reference is more useful.

Tabora, B., & Flaskerud, J.H. (1994). Depression among Chinese Americans: Review of the

literature. Issues in Mental Health Nursing, 15, 569-584.

More up to date information on Depression among Chinese Americans can be found in the Lee, E., & Mokuau, N. (2002) reference.

Tan, S.Y., & Dong, N.J. (1999). Psychotherapy with members of Asian American churches and

spiritual traditions. In P.S. Richards & A.E. Bergin (Eds.), Handbook of psychotherapy and religious diversity (pp. 421-444). Washington, D.C.: American Psychological Association.

This book summarizes the beliefs, traditions, customs and organization of religious communities and their impact on the therapeutic process. Among the topics discussed are: the therapeutic process, establishing relationships with clients, assessment and diagnosis, customary clinical issues, and interventions that correspond with client’s beliefs.

Uba, L (1994). Asian Americans: Personality Patterns, Identity, and Mental Health. New York:

Guilford.

This book is an excellent summary of existing research on Asian American psychology. Topics covered include: cultural values, family characteristics, personality patterns, ethnic identity, mental health needs, psychotherapy, and service utilization. Information is given on a variety of ethnic groups, including: Chinese, Japanese, Filipino, Korean, Samoan, and Southeast Asian Americans. A more recent edition (2003) is also available.

U.S. Department of Health and Human Services (1999). Mental Health: Culture, Race and

Ethnicity – A Supplement to Mental Health: a Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

The U.S. Surgeon General presents an excellent and readable summary of Mental Health amongst several ethnic groups. A more up to date report (2001) is also available.

Wu, S.J. (1999). Counseling Asian families from a systems perspective. In K.S. Ng (Ed.),

Counseling Chinese families: A postmodern approach (pp. 41-54). Alexandria, VA: U.S. American Counseling Association.

This book describes several ethnic groups comprising Asian cultures and emphasizes their diverse educational, political, socioeconomic, and religious backgrounds. Information is offered on culturally relevant treatment strategies.

Young, K. (1998). Help seeking for emotional/psychological problems among Chinese

Americans in the Los Angeles area: An examination of the effects of acculturation. Unpublished doctoral dissertation, University of California, Los Angeles.

This study concentrates on Chinese Americans in the Los Angeles area; the Uba (1994) book offers more information regarding Asian American help-seeking.

Country Clubs, the Ivy League, and the Episcopal Church: The Cultural Constellation of White Anglo-Saxon Protestants in America

2006-04-10T22:13:00.000-04:00

Country Clubs, the Ivy League, and the Episcopal Church: The Cultural Constellation of White Anglo-Saxon Protestants in America

Jay Kosegarten

Introduction and a Brief History of WASP Culture

White Anglo-Saxon Protestants were the first Americans. Leaving England in the early seventeenth century for religious, political, and economic reasons, they settled in Jamestown, Virginia and Plymouth, Massachusetts. Wanting to leave behind a people and a culture from whom they were alienated in order to allow their own burgeoning culture to blossom and thrive, they nevertheless brought with them the vestigial attitudes and beliefs that had inextricably molded and influenced them. Once isolated from its British roots, White Anglo-Saxon Protestant (WASP) culture evolved in distinct ways from its British counterpart the way a species evolves separately from its family when geographically separated by a mountain range or body of water.

The cultural manifestations of WASP values as descended from its British heritage took on unique and colorful forms, as well as some problematic and antiquated notions about family life, class, and status. As Robert Locke put it in Frontpage Magazine:

The WASP establishment was the world of the Ivy League, Fifth Avenue, gentlemen’s clubs, the Social Register, elite country clubs, top New York law firms and investment banks, Boston Brahmins, Main Line Philadelphia, the upper management of great corporations like the Pennsylvania Railroad, certain parts of the military, the OSS and its successor the CIA, the Episcopal Church, New England boarding schools, and the old diplomatic corps. It ruled America from Plymouth Rock until the late 1960’s.

The same values, that by the late twentieth century had become less relevant, were the contemporary expression of the same values which had integrally shaped the U.S. and led to the establishment of the country and its Constitution. Richard Brookhiser, in his article Three Cheers for the WASP, writes, “…the WASP’s greatest legacy [is] the American character. Whether we like it or not, all the rest of us in becoming American have become more or less WASPs. Americanization has historically meant WASPification… WASPs gave America its first laws, religion, and rhetoric, as well as a characteristic mental and personal style.”

When once the WASP represented the vast majority of those who inhabited Colonial America, he now represents, in number, another of myriad minority groups. This comparative numeric decline has meant little, however, socially until very recently because WASP cultural has been so transmittable- almost anyone can be a WASP. The emphasis on individual identity, consciousness, conscientiousness, productivity, and achievement meant a person willing to assimilate their values could be a WASP without being White, Anglo-Saxon, or Protestant. The WASP cultural dominance has long outlasted their raw population dominance in part because of the appeal of these values. These are the same values which became exported and romanticized as the “American Dream.” WASPs have tended to deemphasize the importance of extended family, as compared to most cultures around the world, while at the same time emphasizing bonds formed through work and morality.

In the end, however, the transmission of WASP culture to non-WASPs gradually led to diffusion and with that the decline of the WASP. WASP values have, over the last 35 years, become more and more subordinate as other minority groups with different value sets gain social, economic, and political power. There has long been an inevitability to this phenomenon, when as early as 1859 Abraham Lincoln believed WASPs to make up less than half the population, whereas only 75 years earlier they made up two-thirds of the population, and nearly all of the remaining third was protestant (Brookhiser, 1993). In 1991, only 23% of American children had two parents of English descent, and 71% of children had one parent of English descent (Waldrop, 1991)

Immigration and open borders had always been part of the American- and thus WASP- economic plan. New immigrant groups significantly helped to propel the rapidly growing U.S. economy by taking the lowest jobs for little money in exchange for ideals in the form of “liberty” and the opportunity to “make something of oneself.” The hope was that unlike the countries form which they came, in America, with elbow grease and a nose-to-the-grindstone attitude, a man could take advantage of the class system. Yes, America has always had a class system, but unlike typical class (or caste) systems, there has been, traditionally, a level of fluidity. Being working class did not mean your family would continue to be so for generations to come. It was reasonable to believe (and indeed even expected) that with determination a family’s fortune could grow along with its status, and, over the course of a generation or two, this same family could be middle, upper middle, or even upper class. This entailed, consciously and unconsciously, an osmotic absorption of American values- WASP values.

Now, it seems the osmosis has become more bidirectional than ever. The once dominant presence of WASP culture has become part of a vast American landscape where its voice is now only one of many, no louder than many others, when once it was the only voice. The form of the dialogue, now, throughout the American political landscape may be and always will be the echo, the cosmic radiation, of the initial American Big Bang, but the content is rapidly metamorphosing and evolving as other subcultures gain influence.

In writing this paper, it became clear that there is a significant dearth of research on WASPs and their culture. Perhaps this is because of two reasons. One is that it is WASP culture itself which provides the taken-for-granted backdrop of psychological, sociological, and cultural research. Secondly, WASPs and other groups do not seem to be all that interested in examining WASPs, partly because the culture provides such an embedded context for all of the research that is conducted. This paper will attempt to examine some of the current research about WASP culture in the U.S., as well as its place among the cultural cohorts in the American landscape.

The Dominance of WASP Culture and Its Place in Modern America

As discussed, WASP culture has formed the foundation for American culture, and the reverberations of the colonial and Constitutional ideals continue to provide the backdrop and form of the dialogue in contemporary America. Opinions differ however as to the level of current dominance of WASPs themselves. The extent of WASP influence and tangible presence has arguably been in a steady decline since the early (or at least late) 1960’s. Some data point to and highlight evidence of continued WASP decline. However, many would argue that WASPs are still the dominant culture.

A strong case can be made for the continued ubiquity of WASPs. While less than a quarter of American children are of entirely WASP descent, well over half of the children whose faces we see in advertising are WASP faces (Waldrop, 1991). WASPs, at least in college classrooms, are much more likely to occupy the center of the classroom. Similarly, other non-WASP subgroups are more likely to sit somewhere around the periphery, with the more “marginal” groups sitting further out away from the center (Haber, 1982). The author of the research argues that the space occupied within a room containing various subgroups, will mirror “the space,” so to speak, that the groups occupy in society in general. This has been a common social trend throughout much of the world. Haber writes, “ …the gypsies of Hungary were relegated to territory distant from the village by dominants and had to live on the outskirts of villages…” She also noted, “…the central position of the noble’s dwellings and the peripheral dwellings of peasants and retainers surrounding the noble’s castle or manor.” WASPs being dominant, occupying the center of American society, they tend to sit in the center of the room, where typically the center represents the area associated with the most importance.

The heightened status of WASPs has ramifications for education and health. As compared to Asian American and African Americans, WASPs have been shown to maintain their cognitive acuity into old age significantly more so than Asian Americans and African Americans (Shadlen, M. F. Larson, E. B., Gibbons, L. E., Rice, M. M., McCormick, W. C., Bowen, J., McCurry, S. M., Graves, A, B., 2001.). The major reason for this it seems is the quality of the educational background. While most WASPs typically complete higher education, it is significantly less common in the African American population. In the geriatric population, the mean number of years of education for WASPs is 12.5 as compared to only 9.3 for African Americans. Further, it seems that education throughout the early part of a person’s life affects their health later in life. “Low educational attainment is a known risk for both Alzheimer’s Disease (AD) and cerebrovascular disease,” write Shadlen, et al. and as such African Americans are three times as likely to develop AD as WASPs. In examining the cognitive functioning of African American and WASP Alzheimer’s patients using the Mini-Mental State Examination, performance differences were erased when level of educational attainment was controlled for. Thus the level of cognitive deterioration that accompanies AD can be parsed out from a person’s educational background, which in turn is highly associated with a socioeconomic system which is highly skewed in the direction of WASPs and away from African Americans. Education is a strong predictor of socioeconomic status, and, importantly, an even stronger predictor of stroke and heart disease than race (Winkleby, Jatulis, Frank, et al). Unfortunately, race is intimately tied to education via socioeconomics.

Other writers argue that the WASP hold on the upper echelons of American culture is waning. Politically, when once the Republican Party, usually the party of the wealthy, was almost entirely WASP, it is now more culturally mixed than ever. Economically, traditionally WASP institutions, like the Girard Trust and the Philadelphia Saving Fund Society, are now owned and operated by non-WASPs. Contrary to other research sited above (Haber, 1982), WASPs, it is agued, are the ones being marginalized and squeezed out politically by both parties. The Economist writes:

The Democrats created huge political machines, powered by immigrants from Ireland, Germany, and Italy, which pushed them out of traditionally WASPish cities like Boston and New York. Then, even more painfully, they were pushed to the margins of the Republican Party by a combination of demographics and Richard Nixon’s southern strategy.

Other authors have wondered where the “sting” of the WASP has gone, that going back a few decades “there were hints of a new elite, of non-status-seeking pursued with unimaginable vigor” (McGrath, 1998). This included a new set of values and measures of social achievement that did not include the elevation of property and hierarchy. The same institutions that the WASPs built are now leaving the WASPs behind to some extent by the Darwinian selectivity of heightened admissions standards. This has also translated to a different cultural constellation of politics. It was the Wilsonian politics of the early twentieth century Democratic Party (decades later ruled by the Kennedys) that highly valued the graduates of Ivy League schools (attended almost entirely by WASPs), and placed them in the highest positions in government. What occurred was a subtle shift in emphasis away from wealth, ownership, and a degree of nepotism, to intellectual power and academic achievement (It was also at this time that the U.S. became intelligence-testing-obsessed.). The Economist writes: Now university humanities departments are dominated by multiculturalists who treasure every culture except the Anglo. Now that admissions into the Ivy League and other top schools is up for grabs in a way that it was not before, as well as influenced by Affirmative Action, the notion that politics should be dictated by those who achieve the most academically takes on a multiracial twist. And the more new subcultures, like Asians and Latinos, become embedded and invested in American policy, the more they will parlay academic achievement into political influence (McGrath, 1998).

Cultural Values and Religion: The “Protestant” in WASP

The typical view of the role religion has played in shaping the cultural values of the WASP is that of hard work (“good works”), self-effacement, a reverence for the past (McGrath, 1998), and a strict internal moral compass, as Brookhiser writes, “The WASP could feel guilty all by himself,” (1991). And thus the conglomeration of these religiously derived values becomes an emphasis on the individual. It was up to the individual to work hard, to know right form wrong, and to figure out his own solutions to his own problems.

Some of the most powerful results of the WASPs’ protestant values are the notions of hard work and wealth. Max Weber, in his famous work The Protestant Ethic and the Spirit of Capitalism, discusses at length the relationship between the evolution of capitalism and the protestant, and in particular Calvinist, work ethic. “In order that a manner of life well adapted to the peculiarities of capitalism,” Weber writes, “could come to dominate others, it had to originate somewhere, and not in isolated individuals alone, but as a way of life common to the whole groups of man.” It was the shared Puritanical beliefs system among WASPs that uniquely combined secularism with hard work, as well as the accumulation of wealth with feelings of guilt about spending it. This led to a massive trend of investment, which in turn created a booming U.S. economy and a capitalistic democracy. The pursuit and amassing of wealth was not despite one’s religion, in a sense, but because of one’s religion (Weber, 2001).

In the current state of the American multi-cultural landscape, it is worthwhile to compare the attitudes of WASPs and the newest immigrant wave, Latinos, about wealth and money. It has been argued that there is a large difference typically between these two groups and that the difference primarily lies within different beliefs systems regarding family and individualism, that is individual boundaries (Falicov, 2001). There is much less personal separation among the members of a family in most Latin American cultures. What might be considered unhealthy enmeshment in a WASP family is normal for a Latino family. And what might be a painfully fractured family picture in a Latino culture is healthy and normal in WASP culture (Saetermoe, Beneli & Busch, 1999). Indeed, in many Latin American cultures, the word “individual” in Spanish, “individuo,” has strong negative connotations about one being an outsider or a rebel (Christian, 2006, personal communication). Falicov concludes:

Basic ideologies about collectivism and individualism, balance of work and leisure, traditional and egalitarian marital relationships, and religious beliefs that construct life circumstances as being more or less under individual control shape and inform diverse attitudes and uses of money among Latinos and Anglo-Americans.

In Latin culture, money is pooled and shared among the members of a family, businesses hire their relatives, and leisure time is spent almost entirely with the extended family. Money is used to bring family together- sometimes with mixed results, as combining family and business can create tension that spills over into both spheres. WASPs, on the other hand, use money to empower the individual. Money is not exchanged among family members with a high degree of fluidity, as that of Latino cultures. Business and family are often kept very separate, and leisure time is usually spent with immediate family and friends, often at the expense of close relationships with extended family (Saetermoe, Beneli & Busch, 1999).

While both cultures are typically patriarchal, WASP culture, in traditional pragmatic fashion, has increasingly promoted women in the workforce, and often it is the wife who is in charge of family finances and bill paying. In Latino communities, it is less often the case that the matriarch has such a prominent role in the financial doings of the family (Falicov, 2001).

Conclusion

WASP culture has garnered mixed reviews over the past decade- a unique phenomenon in these times of cultural sensitivity, when cultural relativism is a necessary way of life for the American. Are WASPs still in a descent or is there a recent resurgence? Clearly, in numbers, they are taking up less and less of the population pie. But this is of little import. WASP values have made an indelible mark in American history, the broadest marks of any culture. While new subcultures assimilate and make there own mark, American culture will continue to change. The context in which these changes will occur will be the context of entrenched, immobile American values, the same values out of which the American culture grew four hundred years ago. These are the values that are not just embodied by WASPs, as was the case then, but by all those who wish to participate and thrive in American society- flawed as it may be. It is difficult to image an America without its democratic capitalism, work ethic, and individualism.

William Faulkner gave a lecture in 1954 entitled A Guest’s Impression of New England (included in the collection Lion in the Garden), and in it he describes an actual incident in New England wherein his car is about to run out of fuel without a gas station in sight, and up ahead is a small mountain. He asks a local for some direction. Before telling his audience what happened that afternoon in New England, he tells of what would happen if this event were to occur in other regions of the country. In the South, the local asked for direction would give him a ride to the nearest gas station on the other side of the mountain, fill up a container with gas, and drive him back to his car with more than enough fuel to get him over the mountain.

In the Midwest, the local would call his friend for help, the two would chain Faulkner’s car to their truck, and then tow him over the mountain to the nearest gas station. In New England it was handled differently.

“Excuse me,” said Faulkner to the local New Englander, “My car is running low on fuel, and I wonder if there is a gas station up ahead over that mountain?”

“Yup,” replied the New Englander. Faulkner began to drive away. Getting part way down the road, Faulkner stopped and backed up his car.

“Excuse me,” said Faulkner to the local, “Do I have enough gas to get over that mountain?”

“Nope,” said the New Englander.

Faulkner’s personal tale was not to disparage the New England-WASP rugged individualism, but to admire it. The value implied by the story is that of freedom- the unique brand of WASP freedom which underscores the substance of the American ideal of freedom. A man is allowed to do what he wants to do, unimpeded, as long as he is not encroaching upon the liberty of anyone else. There is no shame. His conduct is left up to his own internal sense of morality and responsibility. A man’s fate is wholly individual and in his own hands. Faulkner’s story illustrates how this broad abstract value, which has helped shape a nation, permeates all aspects of life, even the mundane- even running out of gas.

Annotated Bibliography

Brookhiser, R. (1991). The Way of the WASP. New York: Free Press.

In this book, Brookhiser argues that the foundation of American life, even today, is based on the values of WASPs as first embodied by the original settlers. At one time, each new immigrant wave assimilated WASP values, which happen to be conducive to assimilation. Recently, however, there has been an erosion of the implementation of WASP values even if they still provide form to the content of contemporary American values. This is a refreshing take on a topic that has gone largely ignored in reminding readers of the importance of WASP values for Americans.

Brookhiser, R. (1993, Fall). III cheers for the WASPs. Time Magazine, 142, 21, 78-79.

This article is a concise version of many of Brookhiser’s central points in The Way of the WASP. Again, he highlights the influence WASPs have had throughout American history. This brief article helps in getting oriented to Brookhiser’s broad argument.

Falicov, C. J. (2001). The cultural meanings of money: The case of Latinos and Anglo-

Americans. American Behavioral Scientist, 45 (2), 313-328.

Falicov shows data that points to cultural reasons why Anglo-Americans have a different concept of and orientation toward money and how it should be invested and spent. The major cultural differences revolve around attitudes about family and individuation. This article served as a good sample of how WASP values can contrast with those of many, if not most, other cultures.

Haber, G. M. (1982). Spatial relations between dominants and marginals. Social

Psychology Quarterly, 45 (4), 219-228.

Haber presents an argument supported by her data that WASP tend to occupy the center of most classrooms. This, she argues, is symbolic of the still central position within American culture. This article is highlights some of the more subtle, even unconscious, effects of the WASP position in the American landscape.

McGrath, C. (1998 November 15). The decline of WASP reserve. New York Times

Magazine, p. 67.

McGrath discusses what the character of the typical WASP used to be, how it has changed, and eventually how it had become challenged over recent decades. He concludes by wondering about the future of WASPs and the propagation of their values in the U.S.

Saetermoe, C. L., Beneli, I., & Busch, R.M. (1999). Perceptions of adulthood among

Anglo and Latino parents. Current Psychology, 18 (2), 171-184.

This group discusses the results of the respective cultural values of Anglos and Latino and how these values permeate notions about adulthood, and thus, the direction adulthood typically takes within these cultures. This article provides a concise summary of the important differences between Anglo-American and Latino cultures.

Shadlen, M. F. Larson, E. B., Gibbons, L. E., Rice, M. M., McCormick, W. C., Bowen,

J., McCurry, S. M., & Graves, A, B. (2001). Ethnicity and cognitive performance among older African American, Japanese Americans, and Caucasians: The role of education. Journal of American Geriatric Sociology, 49, 1371-1378.

This article provides a concise synopsis of the socioeconomic connections between education and health, as well as their own original research regarding this area. Further, the article highlights the education disparities among some of the different subgroups in the U.S. and the statistical connection these disparities have with health risks such as heart disease and Alzheimer’s disease. This article serves as strong evidence that WASPs are still the dominant culture in the U.S.

Waldrop, J. (1991). WASP children are waning. American Demographics, 13 (5), 21 (2).

This article extrapolates from raw census data about the WASP continued dominance in areas of American life despite their continued decline in population proportion. This article is valuable in highlighting the continued diffusion of pure WASP heredity despite the WASP children still being the prototypical American.

The WASP in the ointment: WASP establishment and 2000 republican convention.

(1993, July 15). The Economist, 356, pp. 34-35.

This article, written without an author being sited, discusses the changing U.S. political landscape and its mirroring of the general American landscape. The article suggests that WASPs, while not the dominant influence in either the Democratic or Republican Parties, have adapted and diversified so that they are a significant voice in both parties.

Weber, M. (2001). The protestant ethic and the spirit of capitalism. New York:

Routledge Classics.

This treatise is that classic statement on the economic, political, and cultural ramifications of WASP values and how they have shape the U.S. and had international influence. Weber argues that there is a unique paradox that exists with WASP secularism and thriftiness which led to a thriving American economy. This is as important a document as there is if one is going to discuss the influence of WASP culture.

Winkleby, M. A., Jatulis D. E., Frank E. (1992). Socioeconomic status and health: How

education, income and occupation contribute to risk factors for cardiovascular disease. American Journal of Public Health, 82, 816-820.

This article provides medical research for the complex interaction between socioeconomic status and health ramifications and risks. WASP have been shown to have a distinct advantage over other subgroups in both socioeconomic status and health maintenance. This article provides evidence of the continued dominance of WASPs in American culture.

An Exploration of Orthodox Jewish Culture: Values, Norms, and Mental Health Implications

2006-04-10T12:44:00.000-04:00

Running Head: AN EXPLORATION OF ORTHODOX JEWISH CULTURE

An Exploration of Orthodox Jewish Culture: Values, Norms, and Mental Health Implications
Sara Petrasso
Long Island University

Professor: Nick Papouchis, Ph. D. Introduction

Effective psychotherapy is grounded in a supportive and nurturing therapeutic working alliance. When ethnic, cultural, and religious differences exist between the therapist and patient, the therapist must be sensitive to the patient’s values, even when those values diverge from the therapist’s own values (Grodner, 2004). The therapist’s attunement to the patient’s culture will facilitate the development of a therapeutic relationship since cultural identity influences many aspects of who we are and how we perceive the world. Moreover, a richer understanding of the patient’s particular culturally-influenced attitudes toward mental health—including those attitudes related to seeking out mental health treatment, the causation of mental illness, and the meanings ascribed to mental illness—will serve to enhance the therapeutic process.
In this paper, I examine the American Orthodox Jewish population, the particular cultural and religious practices, attitudes, and values that distinguish this group from the broader American culture within which it exists. In order to establish a therapeutic alliance, a therapist who works with an Orthodox Jewish patient must work within the patient’s particular religious and cultural framework. By exploring certain facets of Orthodox Jewish culture, this paper seeks to inform culturally sensitive therapeutic practice.

Who is an Orthodox Jew?

An Orthodox Jew is someone who leads a traditionally Jewish life by strictly adhering to the written and oral laws of the Torah, which Orthodox Jews believe was handed down from God to Moses (Shamir & Shavit, 1987). Orthodox Jews believe that it is God’s will for Jews to follow the 613 commandments or mitzvoth that comprise The Torah (Margolese, 1998). The laws, or halakhah, concern themselves with the proper observance of the commandments, which govern all aspects of daily living, including business, charity, family, sex, diet, and observance of holidays among others (Margolese, 1998). In general, American Orthodox Jews consider themselves to be members of a community often living within walking distance to a synagogue (since Jewish law forbids mechanical means of transportation on the Sabbath) (Margolese, 1998). They also place great value on their children obtaining a traditional Jewish education, even at the expense of financial success (Grodner, 2004).
Of course Orthodox Jews are not one big, homogenous group. Intra-cultural diversity manifests itself in countless ways, many of which, however may be indicated by different degrees of adherence to Jewish law. Though the laws of the Torah are immutable, different Orthodox subgroups may interpret them differently (Grodner, 2004). This is reflected in varying degrees of engagement with secular society and varying attitudes toward modernity (for example in educational choices and manner of dress) (Eliezer, 2005). However, one difficulty I experienced in attempting to differentiate the various Orthodox subsets was inconsistency among the labels used for making these distinction. The most common delineation separates American Jewish Orthodoxy into three types: “Modern Orthodox,” “Strict Orthodox,” and “Ultra Orthodox” (Eliezer, 2005). However it is notable that many Orthodox Jews find such categorizations to be culturally insensitive and grossly oversimplified (Margolese, 1998). Nonetheless, it is essential for therapists to try to assess the degree of the patient’s religious adherence; by doing so the therapist may gain a wealth of information that influences the treatment approach.
In general, “Modern Orthodox” Jews tend to have a more frequent and deeper engagement with secular life and to take a more adaptive approach to interpreting Jewish law, reconciling it with modern values (Eliezer, 2005). They are more likely to permit sexually mixed educational and social settings than their more strict peers (Heilman, 1997).
By contrast “Strict” and “Ultra” Orthodox Jews have less involvement with the secular world. Very little is explicitly written about “Strict” Orthodox Jews, but the literature suggests that they fall somewhere between the “Modern” and “Ultra” Orthodox sects.
The most easily identifiable “Ultra Orthodox” sect is the Hassidic Jews. They are defined by their rigorous observance of Jewish law, and tend to isolate themselves from secular society (Ribner, 2003). They enforce strict adherence to traditional values and norms; live in cloistered communities; send their children to traditional Jewish schools; or yeshiva; prohibit contact between females and males; dress in a distinctly uniform and modest manner; and grant the utmost authority to the rabbi, whose authority extends to personal and social matters as well as religious matters (Ribner, 2003).
By contrast, Non-Hassidic “Ultra Orthodox” Jews are slightly more assimilated—their dress is not as distinctly traditional and they have a broader range of occupational roles, even though they are equally religious (Margolese, 1998). It is important for the culturally sensitive therapist to be aware of these differences in religious adherence, as they may have far-reaching implications. For the purposes of this paper, however, I will explore the common cultural themes and values shared by the Orthodox community at large.

Orthodox Values: Family, Marriage and Gender Role Distinctions

Orthodox Jews generally have large families, and are particularly devoted to family cohesion and parental involvement. Issues concerning their childrens’ well-being, education, marriages and careers dominate parental concerns, and parents generally assume an authoritative position in the family (Patai, 1977).
Family size and family cohesion can perhaps be best understood in their historical context, as the result of the long history of persecution against Jews. In the face of that persecution, perpetuation of the Orthodox Jewish religion became a top priority, and large families help to ensure that perpetuation (Ribner, 2003). High parental expectations not only helped preserve the religion itself in the face of this persecution, but also served to increase the odds of success in hostile environments. For instance, their emphasis on intellectual endeavors had a real survival value—historically Jews could not own land and therefore had to seek alternative ways to earn a living (Patai, 1977).
Likewise, parental devotion may be better understood through a historical lens. The familiar stereotype of the “feeding- obsessed” Jewish mother may have some validity to it, but should be understood in its historical context. For hundreds of years, both in Eastern Europe and in the Middle East, Jews lived in poverty and food was scarce (Patai, 1977). During times of extreme scarcity, children would be given priority and fed while mothers would go hungry (Patai, 1977). In this context, then, it is easy to see how feeding came to be symbolic of a mother’s love for and devotion to her child.
Note that high levels of parental involvement and high expectations may be met with resistance from children or adolescents, and may at times create familial issues concerning enmeshment, independence and privacy.
Another critical facet of the Orthodox family structure is the relationship between husband and wife. Premarital courtship, as accepted in the Orthodox community, is characterized by a short introductory period between the man and woman, with minimal dating prior to marriage (Grodner, 2004). A type of culture-specific anxiety disorder called shidduch, meaning “matching,” involves anxiety around marriage (Margolese, 1998). Large social and familial stressors surround the finding of a suitable husband or wife for one’s child, resulting in shidduch anxiety. Shidduch anxiety may arguably affect the parents more than it does the child, and is a good illustration of the ways in which specific problems can arise in the Orthodox family dynamic that are distinctive to the interplay of religious observance and emotional and familial discord (Margolese, 1998).
Sex between an Orthodox couple is forbidden during menstruation and for the following week, and sexual relations can only resume once the wife has cleansed in a bath, or mikvah (Ribner, 2003). While this may seem to interfere with aspects of husband-wife intimacy, a potential benefit may be increased sexual interest after two weeks of abstinence (Ribner, 2003).
According to Jewish law, the role of the woman in the Orthodox marriage is “complementary and not competitive or subordinate” (Margolese, 1998). However, by secular American standards, Orthodox gender roles do follow traditional gender-role conventions, though this should not imply that women are subordinated. Rather, Orthodox Jews perceive gender-role distinctions as the natural state, as set forth in the halakhah, which governs all human interactions including those of husband and wife (Grodner, 2004). From this perspective, men and women are viewed as having different—but complementary—roles. For instance, Orthodox men are encouraged to study the Torah at a yeshiva, which is a traditional Jewish academy devoted to the advanced study of the Torah (Shamir & Shavit, 1987). Orthodox women are generally responsible for the household, and may have to work in order to finance their husband’s yeshiva education (Margolese, 1998). Historically, women were discouraged from becoming Torah scholars and from learning other advanced Jewish texts, though they were expected to obtain a practical working knowledge of the principles in order to uphold the principles of a legitimate Jewish household (Patai, 1977). While these illustrations may seem iniquitous, Orthodox women take great pride in their role within the family and view themselves as central to the success of the Jewish home (Grodner, 2004).
While the importance of the woman’s role in the Orthodox household is a common element throughout all the Orthodox subdivisions, the rules of engagement surrounding women’s roles in the public, religious, and work spheres vary according to the degree of religious adherence. For instance, Hasidic Orthodox Jews believe that it is unacceptable for women to take leadership roles in religious or political spheres, while Modern Orthodox Jews take a more liberal position and argue that certain Jewish laws offer more lenient interpretations of the role of women (Patai, 1977).
Still, certain rules are not subject to interpretation regardless of one’s level of Orthodox affiliation, such as whether women can lead services in Orthodox Jewish synagogues (Grodner, 2004). Overall, gender roles in the Orthodox Jewish community are clearly defined, although subject to minimal variation depending on one’s level of Orthodox affiliation.
Modesty is a central principle applicable to almost every aspect of Orthodox life. This is most overtly evidenced by their distinctly reserved style of dress, but is especially crucial as it pertains to female sexuality. Starting from an early age, children are separated by sex while at school, to shield the girls from the boys and preserve their modesty (Ribner, 2003). From childhood to adulthood Orthodox women generally do not touch, gaze at or spend time with another man in seclusion, other than their husband (Ribner, 2003).
This carries enormous implications for therapeutic situations because Orthodox patients will likely be apprehensive about being treated by members of the opposite sex (Margolese, 1998). Therapists treating opposite sex Orthodox patients can take precautions by, for example, leaving the door ajar during sessions in order to alleviate their patients’ discomfort (Margolese, 1998). They should also refrain from initiating handshakes with members of the opposite sex, and should not interpret failure to establish eye contact to be a sign of resistance (Margolese, 1998).

Orthodox Attitudes Toward Mental Health

Orthodox Jews tend to greet therapy with great ambivalence and shame (Margolese, 1998). Mental illness carries with it a deep stigma and, if made public, may negatively affect one’s own marital prospects or those of his or her family member, and reflects poorly on the family overall (Greenberg & Witzum, 1991). Therapy may be perceived as heretical: seeking out help from an external—and secular—third party may be interpreted as questioning God’s ability to heal and provide comfort (Greenberg & Witzum, 1991).
With respect to the source of mental illness, some Orthodox Jews may perceive it as punishment for not being devout or pious enough, or they may even interpret it as a test of one’s faith (Margolese, 1998). Part of the reason why mental health treatment is so stigmatized by the Orthodox Jewish community is that language is considered to be a powerful force. This may have obvious implications in the therapeutic environment, since therapy is largely premised on a verbal exchange between two parties. The Jewish law of loshon hora, which literally translates into “evil speech,” actually prohibits speaking negatively about other people (Grodner, 2004). Prospective Orthodox patients may therefore be reluctant to enter therapy because they are scared that they will violate loshon hora (Grodner, 2004).
Given the enormous stigma surrounding mental illness, therapy will likely be sought only as a last resort, only because of some failure (real or perceived) to meet cultural expectations (e.g., marriage, education, working, or raising children) (Margolese, 1998). Orthodox Jews will typically only come to therapy after having unsuccessfully consulted their rabbi in an attempt to resolve their problems, and it is the rabbi himself who often directs the patient to therapy (Grodner, 2004).
Despite loshon hora, Jewish law places an enormous value on physical and mental health, and even permits the violation of certain Jewish commandments (like loshon hora), in circumstances that endanger one’s mental or physical well-being (Patai, 1977). Nonetheless, the social stigma of mental illness pervades the Orthodox community, so that patients are likely to seek mental health services only in extreme cases: for an Orthodox patient to seek treatment, his or her problem must be severe enough to warrant the risk of being “found out” and ostrasized by members of the community.
Some Jewish scholars argue that, collectively, Jewish people are chacterologically more anxious due to having endured “psychic conflict” for centuries (Patai, 1977). According to this theory, because Jews have been a historically persecuted people, a “perpetual state of anxiety” developed in their collective unconscious (Patai, 1977). Furthermore, anxiety stemming from survival issues may combine with the strong ego ideals specific to Judaism, resulting in even greater elevations of anxiety (Patai, 1977). For instance, high expectations involving religious devotion, intellectual pursuits and familial achievement, and the renunciation of socially-condemned impulses and strivings illustrate the emphasis placed on superego control over the forces of the id (Greenberg & Chir, 1984).
From a Freudian perspective, compulsive rituals are employed to protect against feelings of anxiety that arise when an unacceptable urge surfaces. Orthodox Judaism seems to lend itself particularly well to the development of obsessive and compulsive symptoms since so many of its practices are steeped in strict rituals that emphasize adherence, concerns over devotion to God, and guilt over sexual and aggressive strivings (Greenberg & Chir, 1984). Sexual mores and strict dietary behaviors (e.g., a kosher diet) are considered the norm in the community, but they nevertheless bare some similarity to the obsessional’s fear of contamination (Greenberg & Chir, 1984). It is easy to see how someone with an obsessive personality structure may actually have aspects of his behavior reinforced by such highly ritualized religious observances. One cautionary note for therapists however, is the dilemma in determining whether the patient’s behavior is a genuine expression of religious adherence, or whether it is something more pathological (Heilman, 1997). One suggestion for therapists is to evaluate whether the religious compulsion is experienced as distressing, and whether it interferes with the quality of other areas of religious practice and in other areas of their lives (Greenberg & Chir, 1984). It is also important to examine whether the patient seems to have an excessive concern with an area of minimal religious significance that interferes with larger religious principles or practices (Greenberg & Chir, 1984).
Of course, it is also crucial for the therapist to distinguish between psychotic symptoms and religious beliefs. By familiarizing him or herself with the basic tenets of the religion, in order to weigh the experiences of the patient against commonly held community beliefs, the therapist is in a better position to understand what are normal religious beliefs versus what is atypical (Greenberg & Witztum, 1991).

Conclusion

In order to establish a therapeutic alliance, the therapist, who will initially be viewed as an outsider by Orthodox Jews, must have a lot of patience and not expect patients to immediately accept the therapeutic process (Margolese, 1998). In order to facilitate the alliance building process, the therapist may want to establish a relationship with the patient’s rabbi (with the patient’s consent) and be open to modifying the treatment in order to conform to the patient’s religious scruples (Ribner, 2003).
Perhaps the most important aspect of engaging in therapy with an Orthodox Jewish patient is examining transference and countertransference reactions triggered by the patient’s religious commitment versus the therapist’s more non-religious/secular values (Greenberg & Witztum, 1991). For instance, therapists may become envious based on their patient’s unwavering faith, and patients may feel as though their therapist is a disapproving secular moralist wanting to change the patient’s values (Greenberg & Witztum, 1991) Therefore, the therapist should examine his own religious attitudes in order to reduce countertransferential feelings, and by doing so, reveal his own prejudices and biases (Greenberg & Witztum, 1991). Ultimately, it is up to the therapist to respect the patient’s belief system, regardless of how much it conflicts with his own. For the therapist to really understand his patient, it is up to him to try to understand him within the patient’s cultural-religious framework. Though this does not necessarily ensure a successful treatment outcome, it will lay a more secure foundation for the development of the therapeutic alliance.

Annotated Bibliography

Orthodox Judaism
Eliezer, D. (2005). Orthodox Jewry in Israel and North America. Israel Studies, 10, 157-187.
The article compared the differences in Jewish Orthodoxy between Jews living in Israel with those living in America. The author gathered his information from multiple surveys conducted by various Jewish research institutes. This article was valuable to me because it provided understandable criteria for me to use in differentiating the different Orthodox subsets in America.

Greenberg, D., & Chir, B. (1984). Are Religious Compulsions Religious or Compulsive: A Phenomenological Study. American Journal of Psychotherapy, 38, 524-532.
The authors, both of whom are Israeli behavioral therapists, examine four clinical case studies of Orthodox patients with religious compulsions. Examples are made to illustrate the difference between religious and compulsive rituals. The distinction made by the authors helped me get a sense of how to differentiate religious from compulsive rituals—the extent of disruption in the client’s life is the main basis for their distinction.

Greenberg, D., & Witzum, E. (1991). Problems in the Treatment of Religious Patients. American Journal of Psychtherapy, 45, 554-565.
The authors, both of whom are psychiatrists and psychotherapists, presented guidelines for working with strict Orthodox patients based on their clinical experiences. They also distinguished religious beliefs from delusions, and religious rituals from compulsions. I thought their suggestions would be beneficial to all therapists who work with religious clients. In particular I think the point they make about the need for the therapist to examine his own religious attitudes and countertransferential feelings associated with those attitudes, is of particular importance.

Grodner, Elana. (2004). Domestic Violence in the Orthodox Jewish Home: A Value Sensitive Approach to Recovery. Journal of Women and Social Work, 19, 305-316.
Grodner explores domestic violence as a largely unacknowledged issue in the Orthodox Jewish community. She uses a case study to demonstrate a value-sensitive approach to addressing the issue with Orthodox clients. This article was especially useful to me because it provided me with a comprehensive examination of gender role distinctions and marital norms in the Orthodox community. It would also be particularly useful for someone interested in research regarding therapy approaches in the treatment of domestic violence for female minorities.

Heilman, S. (1997). Value-sensitive therapy: Learning From Ultra-Orthodox Patients. American Journal of Psychotherapy, 51, 522-542.
The author focuses on the implications of therapy when the patient and the psychotherapist do not share a common religious value system. He uses his own clinical experiences working with Hasidic clients to explore this issue and presents three, in-depth case studies. I found this article to be extremely helpful in that it illustrated ways for the therapist to engage in value-sensitive therapy with clients who do not share a common value system with the therapist.

Margolese, H.C. (1998). Engaging in Psychotherapy with the Orthodox Jew. American Journal of Psychotherapy, 52, 37-52.
The author explores the literature regarding the particular issues related to conducting psychotherapy with Orthodox Jewish patients. Case studies are not used, but rather, a critical and thorough review of the prevailing literature on the subject is conducted. I thought that this article was especially useful because it provided comprehensive, yet understandable, background information on Orthodox Judaism, as well as information on particular treatment approaches, and culture-specific issues. It was also refreshing to have a general overview of the issues instead of the more anecdotal, case study approach that most of the research in this realm takes.

Patai, Raphael. (1977). Journey into the Jewish Mind. New York: Charles Scribner’s Sons.
Patai argues that the historical events and circumstances of the Jewish people have largely influenced who they are as a people in terms of their psychological makeup and intellect. This source provided me with a wealth of information about the history of the Jewish people because it explored the broad ranging implications of having survived generations of trauma and persecution in multiple areas of their lives, including familial dynamics, cultural values, and psychological consequences.

Ribner, D. (2003). Determinants of the Intimate Lives of Haredi (Ultra-Orthodox) Jewish Couples. Sexual and Relationship Therapy, 18, 53-62.
Ribner examines the religious and cultural rules governing the sexual lives of Hassidic couples, and presents the challenges to engaging in marital therapy when addressing issues involving sex and intimacy. He conducts a thorough review of the literature and also includes one case study for illustrative purposes. This article was especially valuable for me because out of all my sources, it provided me with the most specific information on gender role distinctions, sexual practices, and rules of intimacy in the Orthodox population.

Shamir, I., & Shavit, S. (Eds.). (1987). Encylopedia of Jewish History. New York: Viking Kestrel.
This encyclopedia contains a wealth of comprehensive information on Jewish history and clearly defines Hebrew words. This book is a valuable tool for people who are not familiar with Hebrew words and terminology and who want clear explanations about Jewish religious holidays, rituals, etc.

Lucy's Annotated Bibliography: Working With Jamaican and other British West Indian Clients

2006-04-10T10:38:00.000-04:00

Annotated Bibliography: Working With Jamaican and other British West Indian Clients
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Baptiste, D. A., Hardy, K. V. & Lewis, L. (1997). Family therapy with English Caribbean immigrant families in the United States: Issues of emigration, immigration, culture and race. Contemporary Family Therapy, 19 (3), 337-359.

This article focuses on the adjustment difficulties experienced by British West Indian families when emigrating to the U.S. Although it does address gender roles and family relations, it deals mostly with the particular social, identity and legal issues with which the average British West Indian will be coping at different phases in the immigration process. I found this article to be most helpful in understanding the immigration process as one made up of distinct phases, in which different issues become salient for the client.
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Brent, J. E. & Callwood, G. B. (1993). Culturally relevant psychiatric care: The West Indian as a client. Journal of Black Psychology, 19 (3), 290-302.

The authors are native British West Indians working on the Islands, so they are able to present a rich description of the belief systems, family patterns and child-rearing practices and influences on cultural presentation of symptoms in the British West Indian client. They also use several brief vignettes to illustrate more complicated points, which add dimension and interest to the theoretical arguments. Although I did not cite it in my paper, I used this article to give me a general sense of what the British West Indian “looks like” and how they might present themselves in treatment.
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Brice-Baker, J. (2005). British West Indian families. In McGoldrinck, M., Giordano, J. & Garcia-Preto, N, Ethnicity and family therapy (3rd ed.), (pp. 117-126). New York: Guilford Press.

This book is indispensable, not only for the family therapist, but for anyone who treats minority patients. Each chapter covers a specific ethnic group in depth (e.g. Salvadoran, Lebanese, Scots-Irish, etc.) and does not treat members of broader, socially-recognized groups (e.g., Asians, African-Americans or Whites) as the same. The chapter on British West Indians covers geography, social history, migration and identity issues, family relationships and help-seeking attitudes in an easy-to-read style, but at an intellectually sophisticated level. This chapter served as the basis for my paper.
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Handwerker, W. P. (1992). West Indian gender relations, family planning programs and fertility decline. Social Science Medicine, 35 (10), 1245-1257.

Handwerker presents a comparative study of decline in Barbados and Antigua, using historical and social contexts as evidence for his argument that changes in the gender relations vis a vis the political economy are largely responsible for fluctuations in fertility in these countries. Although the topic was not directly related to that of my paper, I found the explanation of kinship and economic exchange very useful in understanding the roles of women and men in the British West Indies. The paper demystified a lot of the outwardly inconsistent patterns of parent-child and romantic love relationships on the islands.
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Harris-Hastick, E. F. (2001). Substance abuse issues among English-speaking Caribbean people of African ancestry. In Straussner, S. L. A. (Ed.), Ethnocultural Factors in Substance Abuse Treatment, (pp. 52-75). New York: Guilford Press.

Harris-Hastick makes a detailed examination of the nature and history of slavery in the British West Indies and contrasts that with that of slavery the United States. She explores the ramifications this has had for identity and culture of the British West Indians on the islands and in the United States. The treatment of substance abuse issues is a bit general, and is just as applicable to treatment of any issues as it is to drugs and alcohol. I primarily used this article for its explanation of the social and economic structure of the colonial and post-colonial British West Indies and how this has shaped the British West Indian’s attitude about themselves and their “minority” status in the United States.
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McKenzie, M. V. (1986). Ethnographic findings on West Indian-American clients. Journal of Counseling & Development, 65 (1), 40-44.

McKenzie collected ethnographic data on nine Black West-Indian youths in the United States to understand their environment, counseling, and help-seeking attitudes in order to enhance counseling experiences for this group. He also interviewed eleven counselors working with them. Using lengthy interviews and participant observation, he found strong taboos against counseling and family conflict around emotional issues. This article was particularly useful in understanding conflict between parents and children around issues of acculturation.
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Ohene, S., Ireland, M. & Blum, R. W. (2005). The clustering of risk behaviors among Caribbean youth. Maternal and Child Health Journal, 9 (1), 91-100.

Using a large-scale survey method, the authors examined how early sexual activity was correlated to clusters of other risk behaviors for Caribbean youth living on the islands. They paid particular attention to behavior and clustering differences between boys and girls, and found that early sexual activity was much more common than previously expected for girls, but that it was an equally serious risk factor for violence and drug use for both boys and girls. The paper isn’t particularly useful for working with British West Indian clients, but was useful for understanding attitudes toward sexual behavior and adolescent socialization on the islands.
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Payne, M. A. (1989). Use and abuse of corporal punishment: A Caribbean view. Child Abuse & Neglect, 13 (3), pp. 389-401.

Payne surveyed Barbadian adults (aged 20-59 yrs) regarding their approval or disapproval of corporal punishment in child rearing, the perceived advantages and disadvantages of such punishment and the methods and circumstances thought most appropriate for use. There was a considerable amount of consensus that corporal punishment was appropriate and effective. This article was useful in gaining a balanced view of attitudes and reasons for corporal punishment and the possible effects of this technique on children.
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Schreiber, N., Stern, P. N., & Wilson, C. (2000). Being strong: How Black West-Indian Canadian women manage depression and its stigma. Journal of Nursing Scholarship, 32 (1), 39-45.

The authors used semi-structured interviews and participant observation to examine the subjective experience of Canadian British West Indian women with depression. The article presents a rich picture of the women’s lives, their concerns and fears, and their noble attempts to cope with mental illness in a culturally acceptable way. The authors explore how their attempts at coping may be both adaptive and maladaptive, and how their attempts intersect with wider cultural beliefs. I used this article to get to know the British West Indian women better, and used it to guide my reading of more theoretical or research-related articles. I would recommend this article to anyone working with any African-American or African-Canadian woman.
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Smith, D. E. & Mosby, G. (2003). Jamaican child-rearing practices: The role of corporal punishment. Adolescence, 38 (150), 369-381.

This theoretical article presents a lengthy review of the evidence of the harmful effects of severe corporal punishment on children. It discusses the specific nature and practice of corporal punishment in Jamaican culture and the sources of belief that it is acceptable. Although the authors consider the origins of harsh and often unkind parenting, they come down harshly against Jamaican parents and have little to say about what might be done other than parenting education. I used this article for its explanation of gender-based parent-child relationships and how children are differentially disciplined by their mothers and fathers.
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Sobo, E. J. (1996). The Jamaican body’s role in emotional experience and sense perception: Feelings, hearts, minds and nerves. Culture, Medicine and Psychiatry, 20, 313-342.

Sobo, having been a participant observer in a rural Jamaican village, describes in ethnographically rich detail the Jamaican experience of feelings, emotions, the body and how these culturally-determined experiences are integrated to interpret symptoms of mental illness. In particular, Sobo explores the experience Jamaicans have of “nerves” as a bodily-generated experience of what Western psychiatry might call “anxiety.” This article challenged the Western category of “emotion” as universal, and explained linguistic and cultural differences around emotions that could be very confusing to Americna therapists treating Jamaicans.
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Thrasher, S. (1994). Psychodynamic therapy and culture in the treatment of incest of a West Indian immigrant. Journal of Child Sexual Abuse, 3 (1), 1994, 37-52.

This is a case study in which Thrasher describes the treatment of a survivor of incest of West Indian origin. Thrasher presents cultural background necessary to understand the case and her theoretical approach to treating survivors of sexual abuse. The article is less useful for understanding cultural issues in the treatment than it is for understanding treatment technique. I used this article to orient myself to the basic cultural issues in treatment and for Thrasher’s useful guidelines for working with immigrant minority clients.
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Kohut, Bromberg & Narcissism

2006-04-03T20:48:00.000-04:00

Bromberg proposes several modifications and additions to Kohut’s seminal theory of narcissism. Bromberg’s most radical departures from Kohut are in his treatment approach for narcissism and, in defining the roots of narcissism, his movement away from a strict “blaming the parents” model. Bromberg implicates inevitable existential disruptions and a self-obsessed culture in forming the narcissistic personality.

While departing from Kohut at times, Bromberg remains on the Kohutian theoretical trajectory in defining narcissistic disorders. In describing narcissistic personalities, Bromberg and Kohut agree on a developmental arrest model, an unstable, fragmented self, and a typical constellation of behaviors.

Bromberg departs from Kohut in several ways, however. Where Kohut suggests that the developmental roots of narcissistic disorders are parental failures to manage normal childhood narcissistic needs, Bromberg suggests that narcissism develops as a defense against the inevitable pain of development. Bromberg suggests that movement from the womb to the outside world is the original trauma for the child, as he moves from an illusion of utter self-sufficiency to an awareness of need and vulnerability. The movement from the womb to the world establishes the paradigm for the rest of life, in which every new developmental stage contains discrepant challenges and in turn, the difficulty of adaptation. While it is possible to infer from Bromberg that the parents have a role in facilitating the child’s movement through life’s challenges, his theory (or the holes in his theory) seems to place greater emphasis on the individual – something about the individual (is it his ego strength? is it temperament? Is it object relations) will allow him to use narcissism and its defenses adaptively or maladaptively. Kohut also suggests that narcissism protects the self from vulnerability, but Kohut’s vulnerability stems from unmet narcissistic needs in childhood. For Kohut, narcissists are developmentally stuck at the point before transmuting internalization turns ideal parental imagos into ego ideals. For Kohut, insensitive parenting drives insufficient resolution of narcissistic challenges. Bromberg seems to suggest that life itself throws challenges in our way, and our narcissistic stance is a buttress against it; of course, if the narcissistic stance is used inflexibly, it becomes destructive.

Bromberg’s mirror & mask metaphor presents a less polar version of the narcissist than Kohut’s theory. Bromberg suggests that the narcissist moves between a self-experience based on how others view them (the mirror) and on the success of his operations/manipulations of others (the mask). Kohut suggests that the narcissistic self typically will be organized in a unipolar fashion, pertaining either to the grandiose self OR the idealized object.

Bromberg goes beyond the parents – the prime suspects in Kohut’s developmental failures -- in looking for environmental roots of narcissistic disorders. Citing Becker, Bromberg contends that narcissism is tied up in and defends against humans’ sense of mortality. Bromberg also contends that narcissism is valued in contemporary Western culture, as the perfection of self is valued over community, religion, and family. Interestingly, Bromberg sees the analytic situation as a cultural alternative to larger culture’s encouragement of narcissistic self.

Bromberg proposes technical interventions to Kohut’s therapeutic technique as well. Bromberg’s therapy consists of two elements. The first order of business is to give the patient a self-experience and structure through empathic acceptance. The analytic relationship fills a developmental void. Then, in time, Bromberg suggests using interpretation to augment the patient’s understanding of himself and the interpersonal situation of analysis. Further, Bromberg suggests tailoring the analytic situation to the ego strength, developmental level, and anxiety tolerance of the individual patient. Bromberg’s proposed therapeutic stance is more active than Kohut’s. In Kohut’s therapeutic model, the analyst remains empathic but non-interpretive, and waits for the patient to be disappointed by the analyst’s failure to meet all of the patient’s narcissistic needs. In the Kohutian model, this naturally arising disappointment spurs growth.

bromberg vs. kohut - reaction paper #7

2006-04-03T13:59:00.000-04:00

Bromberg’s position on narcissism both reflects and diverges from Kohut’s beliefs. In describing pathological narcissism, Bromberg borrows Kohut’s conception of a “grandiose self” - one that believes itself to be flawless, independent, and completely fulfilled in order to protect an exceptionally fragile ego. However, in terms of approach to treatment, Bromberg does not differentiate between “analyzable” and “unanalyzable” patients. From his perspective, patients who are deemed to have potential for psychotic transference are not necessarily incapable of benefiting from analytic treatment. Their ego development may limit the extent to which they improve over time but does not completely obstruct their capacity for psychological and emotional growth. In contrast, Kohut differentiated between analyzable (narcissistic) and unanalyzable (borderline, schizoid, and psychotic) patients. From his perspective, the former experience minor and temporary regressive states in reaction to narcissistic injury (perceived rejection/slight; absence of anticipated approval; the environment’s lack of concern). However, through psychoanalysis the patient can learn to identify the specific events leading to a regressive state. Kohut believed that borderline, schizoid, and psychotic individuals also experience regressive states in reaction to personal injury however, their fragmentation is acute and may lead to severe disintegration of the self. This deterioration prevents them from improving in analysis because they do not have sufficient ego strength to learn to identify the source of personal slight/injury.
Bromberg also differs from Kohut in his belief that a balance between empathy and confrontation must be established in order for individuals with severely narcissistic pathology to improve. Bromberg’s description of Kohut’s therapeutic approach is in fact, almost condescending. He seems to describe Kohut as overly-empathic and foolish in tolerating a patient’s unrelatedness, entitlement, and self-centeredness. By confronting a patient’s narcissistic demands, Bromberg hoped that the patient could begin to utilize the analyst’s previous mirroring and integrate it within his own ego, eventually breaking down the rage, emptiness, and despair permeating the patient’s pathology.

James reaction #7

2006-04-03T13:44:00.000-04:00

The understanding of narcissism is conceptualized by both Bromberg and Kohut quite similarly. Yet, each makes his own contribution to the understanding of this personality style.
For Kohut, narcissism involves the Freudian idea of the infant’s view of the caretaker as being magically omnipotent. Rather than gradually integrating the good object and bad object to form a cohesive self-identity, the infant is traumatized by parental disappointment. The child is then forced to give up the idealized internal object before he/she is ready. Because this is quite difficult for the child, often the he/she will interject the idealized object as a substitute for his/her self. Narcissistic rage is then projected at the disappointing ‘bad’ object, which is now part of the self. Feelings of grandiosity surround the inflated ‘good’ object which has been idealized to protect the vulnerable self. Kohut believes that narcissism must be diagnosed through transference in psychoanalysis.
Bromberg’s understanding of narcissism, especially its pathological form, has to do with ruptures in the separation-individuation phase of development. Still, Bromberg does not assign responsibility to object failures. Instead, he maintains that the child has difficulties with the self-individuation process and establishes a ‘grandiose self’ to compensate for implicit shortcomings. More importantly, he believe that narcissism develops pre-psychologically, meaning before the development of an integrated ego.
In treatment, Kohut views the narcissist as developmentally arrested from the point of the initial trauma that disappointed the infant. According to Kohut, therapy must involve a nurturing and supportive environment where the narcissistic patient can be reparented through selfobject transference. Bromberg sees the narcissistic patient as an adult who has not fully integrated idealization and devaluation in a rational manner. Essentially, Kohut advocates working from childhood forward towards the present, where Bromberg suggests that we work from the present backwards and look at how the past might be intruding on the present.

2006-04-03T13:35:00.000-04:00

Jay Kosegarten
4-3-06
Psychopathology II
Professor Papouchis

Bromberg and Kohut on Narcissism

With regard to the theoretical model of narcissism, Bromberg shares a great deal in common with Kohut, while also combining elements of Kernberg and, for an existential twist, Becker.
As with Kohut, the narcissistic detachment also stems from a terror of relationships, which Bromberg described as, “a functional consequence of a dimly recognized need for any relationship at all.” It is the repressed sense of relatedness which further contributes to the pathology. In this view, relationships are so threatening because of the bad internalized objects. For the narcissist, prospective relationships are unconsciously viewed as being qualitatively empty or destructive as the bad intojects, while also serving to painfully activate those bad objects.
In Kernberg, Bromberg points to his theory that ultimately narcissism is a massive defense against rage- rage against early-life caretakers and the internalized representations of those objects. This introduces an important element to Bromberg’s conceptualization which are the elements of paranoia stemming form the projected envy, rage, and exploitation. For the narcissist, their existence is often defined by this sense that they will do to others what they anticipate will be done to them. The grandiosity is a reaction to a deep sense that they are in fact of little value and the objects, which are pathologically idealized, are actually bad or empty, creating a tremendous sense of loss, abandonment, and emptiness. The interpersonal isolation is an attempt at mastering the omnipresent sense of loneliness.
Bromberg also disagree with Kohut and does so, among other things, through his references to Becker. Unlike Kohut, who saw the adaptive necessity of narcissism as healthy, Bromberg and Becker believe that while it may be necessary, it is not healthy. Bromberg believes that it is a delusion implemented to deny the terrifying acknowledgement of our own mortality and existential vulnerability.
Another difference between Bromberg and Kohut is Bromberg’s emphasis on making interpretations in analysis with the narcissist while also maintaining the Kohutian method of identifying with both the grandiose self and idealized parent imago, as manifest in analysis through the narcissistic transference. This is the heart of mirroring, which Bromberg endorses. It seems like the incorporation of and emphasis on interpretation is a Kernbergian element. As derivative if the theory, Kernberg would help to activate the repressed rage and make interpretations throughout the course of analysis. Bromberg tempers this more aggressive approach with elements of mirroring.

it's all about the mirror neurons - response #6

2006-04-03T11:12:00.000-04:00

I’m not entirely sure why I have dragged my heels in writing this response, particularly since much of what I have read in the area of interpersonal/relational psychoanalysis resonates so strongly with my own experience and the way I perceive the world. However, following my attendance at the Biology of Mind conference this past weekend, I am grateful for having delayed my writing because I have gained an entirely new perspective that further validates and builds upon what has felt intuitive for me all along.
The basic tenets of interpersonal/relational psychoanalysis come from Sullivan’s view that no one can be understood apart from his relationships with others. Humans are relationship-seeking creatures, with these relationships as the defining feature of one’s self. On a grander scale, the human environment of continual interactions forms the basis of what we term to be “culture.” Ultimately, we live in a social world; it is impossible to divorce one from the social milieu in which he exists. Therefore, in this view, psychoanalysis must take into account not only the experience of the patient, but that of the therapist as well, and the relationship that is created between the two through the experience of intersubjectivity. Mitchell’s relational view sees the human mind as an interactive phenomenon whereby self and world are continually organized through recurring patterns. In his theory, interpersonal experiences are internalized and there is a dynamic interaction between the intrapsychic representations and interpersonal encounters, as each serves to inform the other. Development, then, occurs through the emergence of various organizing schemes of this nature.
Using the paranoid personality style as an illustration, the chronic fear, self-reference, characteristic use of reaction formation and projection, and general mistrust of others, appears to be in response to intrapsychic representations that have been based upon interpersonal experiences of humiliation and overwhelming anxiety. Repeated experience with caretakers who either failed to provide a sense of comfort or who were utterly frightening lead to a self who self-consoles through the distortion of feelings and general world view; McWilliams has indicated the behavior of paranoid people as a response to confusion about basic feelings and perceptions emanating from patterns of distorted maternal responsiveness. Given this set of internal representations and way of approaching the world, a paranoid’s interpersonal experiences, involving mistrust and self-referential cognitive biases, will only serve to confirm what he already believes to be true.
At the Biology of Mind conference, I had the good fortune of hearing two amazing speakers: Dr. Dan Siegel and Dr. Marco Iacoboni, both of UCLA. Dr. Siegel has pioneered the field of Interpersonal Neurobiology (IPNB), an interdisciplinary theory which weaves together the subjectivity of relationships and the objectivity of neurobiology to create a sense, and deeper understanding, of the ways of being a human. Together with Dr. Iacoboni’s research on mirror neurons, which imply that the mind is not simply the activity of one brain (“one-skull”) but a representation of the actions of others, based upon our experiences with such actions, Dr. Siegel has put forth the notion of the brain as an associational, social organ in which experience directly affects the connections within (neural plasticity); expectations about the goals and intentions of actions are then based on past experience. He speaks of the adaptive effects of interpersonal experience in terms of defense systems and character structure whereby synaptic connections change as a means of self-regulation, shifting aspects of consciousness. Mirror neurons and neural plasticity, therefore, form a neurological basis for internal representations which then affect interpersonal experiences and are continually changing and integrating new experiences. Dr. Iacoboni continues by adding that mirror neurons allow us to understand the intentions of others within various contexts. With respect to psychotherapy, going back to the preceding example of a paranoid, or anyone with psychopathology, who comes to therapy with mental representations that are negative and harmful, Drs. Siegel and Iacoboni suggest that change occurs through “nonverbal knowing” whereby pre-language activation systems, such as mirror neurons, are used to understand people, as a window into their minds. The therapist, through the use of regulatory super mirror neurons which regulate the reflective nature of interpersonal exchanges (based on the functional idea that there are certain occasions where an exact mirroring is not entirely useful; in therapy, the therapist does not want to become the patient but wants to reflect empathy, that the patient’s experience has resonated), can provide a “face” for the patient whereby the social interactions can be used to effectuate changes in the brain that will ultimately be integrated within a dynamic character structure. IPNB and the mirror neuron system (MNS), then, can be seen as real validation of the original ideas of Sullivan and Mitchell; a fundamental understanding of these theories seems to be an important, promising direction for the future of interpersonal/relational psychoanalysis.

Matt: Kohut & Bromberg

2006-04-03T08:48:00.000-04:00

Kohut and Bromberg have some strong similarities. Both see modern culture an important culprit in the rise of narcissism as an increasingly common pathology. More significantly, both begin from an interest in the patient’s experience. This is reflected in the way that they each define narcissism in terms of lived experience, with little if any attention paid to behavioral symptoms.
Bromberg’s approach looks beyond Kohut, however, when it comes to the treatment of narcissism. He is trying to bridge the gap between Kohut and classical analysis. To this end he introduces the concept of an “empathy-anxiety gradient” as a way of understanding the gradual changes in the analyst’s way of being with a patient that he wants to take place in the course of treatment. For a severely narcissistic patient, it begins in an almost Kohutian manner, with the analyst’s statements weighted heavily on the empathy end of the spectrum. Unlike Kohut, he believes that there is an important place for interpretation right off, but these are specifically limited. For Bromberg, the purpose of this phase of treatment is the development of a capacity that is very like reflective functioning. It “accustom[s] the patient to looking at himself from outside as part of an interpersonal process.” Before interpretations can become more complex and confrontational, the patient “must first modify the sovereignty of the grandiose self enough to permit another person to exist as a separate entity in his representational world.” This is a necessary step in the development of anxiety-tolerance, which itself is a key ingredient in the birth of the self. (It is interesting that Fonagy and Target have not picked up on Bromberg, at least not in Psychoanalytic Theories, because this sounds remarkably like their theory, where reflective functioning underlies affect regulation, which facilitates the development of the self. They apply their ideas mainly to the treatment of borderline pathology.)
As the treatment goes on, the analyst shifts the emphasis from empathy to interpretation, as much as he or she feels the patient can tolerate. Thus begins a more traditional analysis which is not really Kohutian at all, but completes Bromberg’s “big tent” platform. It is his intention to unite competing theories/techniques (e.g. Kohut’s and Kernberg’s) under this big tent, expanding the boundaries of what is to be considered psychoanalytic.

Sheila's Reaction: Kohut & Bromberg on Narcissism

2006-04-03T01:24:00.000-04:00

Kohut normalizes narcissistic rage as natural part of maturation and provided that the environment is appropriate, asserts that it should result in a healthy sense of self-confidence and assurance. The self is then capable of maintaining stability, as it understands itself as both a part of and simultaneously distinct from the world. Bromberg, too, believes that narcissism can appear in either a healthy or pathological fashion. Drawing upon the work of Mahler, Bromberg, points out what is a central issue in pathological narcissism: the problem of being both separate from and “fully in” the world. However, he suggests that the potential for either type of narcissism is present as early as birth. Kohut’s timeline, on the other hand, is extended past the first few months of life and into the child’s second through fourth years. This is the period in which it is believed the critical conversion of grandiosity into ambition occurs by means of adequate mirroring.

Where Kohut and Bromberg differ most, perhaps, is not as much in their conception of narcissism as in their approach to the narcissistic individual in the analytic situation. Kohut’s therapeutic method would welcome the patient’s idealization of the therapist, favoring the establishment of an environment in which narcissism is essentially supported. In his view, the best therapeutic atmosphere for narcissistic individuals is one in which the therapist is very highly attuned and refrains from interpretation. Bromberg, too, emphasizes the importance of empathy in the treatment. Yet he takes issue with what he perceives as Kohut’s use of it as a “technical maneuver” to basically infantilize the patient in an attempt to heal developmental deficiencies. For Bromberg, narcissistic adults are just that: adults whose ego functions are not fully mature.

Bromberg’s approach to the therapeutic relationship is decidedly more confrontational than that of Kohut. He maintains that interpretation is indeed possible and productive, as long as one’s definition of it is not restricted to examining only transference resistance. Bromberg advocates strongly for an affirming, understanding environment, particularly at the outset of treatment. The goal is for the patient to gradually develop an observing ego and to visualize himself as part of an interpersonal process. Optimally, the therapist seeks to increase the patient’s tolerance of anxiety and confrontation while still providing warmth and understanding. Bromberg holds that Kohut’s view of the transition into this “new phase” of treatment is simpler than is actually the case for most individuals with a narcissistic personality. In truth, Bromberg believes that the therapist needs to “push” the patient to activate his newly formed observing ego and use it to explore not only his external reality but also the narcissistic transference.

Narcissism: Bromberg v Kohut

2006-04-02T23:58:00.000-04:00

One of the main differences between Bromberg and Kohut’s notions of narcissism concern the concept of the “grandiose self.” Bromberg postulates that the grandiose self embodies the job of always being perfect, never being dependent or feeling lacking in any way, which ironically employs the need for constant intrapsychic protection and does so by treating others as a need-satisfying object instead of a differentiated other. Bromberg states that pathological narcissism develops when the psychological self recognizes a need to have fully interactive, cohesive relationships with others which serves as an attack on the grandiose self by uncovering or “unmasking” the illusions of complete self-sufficiency. Bromberg sees the persistence of the narcissistic personality as the continual effort by the grandiose self to maintain and protect its structure and sense of well-being. Kohut’s notions regarding the development of narcissistic pathology share many components with Bromberg’s theories, yet Kohut retains distinctive views relating to the development and course of this disorder. Kohut sees the onset of pathology as being a direct result of developmental arrest. He dictated that disturbances in the amount of integration between parents’ failure to meet narcissistic needs, the archaic grandiose self and the idealized parent imago relate to the level and intensity of pathology later experienced by the individual. Kohut maintained the view that narcissistic personality disorder relates to the inability of a caregiver to appropriately mirror the child’s grandiosity, thus leading this sense of grandiosity to remain separate and unintegrated with the child’s reality-based sense of self. The child’s sense of self is thus unable to be fully developed and integrated, lending only the fragmented part of intense grandiosity to be accessible, enhancing infantile narcissism. This over-reliance on grandiosity leads to an unneutralized persistence of the grandiose self, causing severe disruptions in an individual’s ability to relate to others in an independent fashion.

Other differences between Bromberg and Kohut’s notions of narcissism relate to their views on analyzability and course of therapeutic treatment. Bromberg disagreed with Kohut’s idea that therapy will naturally progress if the empathic “ambiance” is correct during periods of time in the treatment when a narcissistic individual feels that they do not need to work. Kohut seems to take a more empathic and optimistic stance regarding the analyzability of narcissistic individuals in general. He sees the presence of a consistent empathic response on the part of the therapist as the key to neutralizing the grandiose self and the idealization of the parent figure, which in turn will activate healthier relational patterns with others. Bromberg sees the most effective form of therapeutic treatment to be that of allowing the patient to perform for the therapist and then to be rewarded for doing the work themselves and receiving the “cure” as the ultimate goal.

Narcissism, Joshua's Response

2006-04-02T23:02:00.000-04:00

Though theoreticians differ as to how it is established, at the heart of narcissism is an internal structure referred to as the “grandiose self,” whose role it is to maintain an air of perfection and independence. According to Bromberg and Kohut, this grandiose self and “illusion of self-sufficiency” serve to disguise the narcissist’s lack of a fully individuated self-identity.
According to Kohut, narcissism and narcissistic rage are developmentally normal. Pathological narcissism, then, is reflective of developmental arrest or fixation at a primitive level of omnipotence or grandiosity. In normal development, the separation-individuation process the infant marks the beginning of the loss of this sense of omnipotence. When the mother is empathetically responsive to her infant, sharing of omnipotence or power occurs and the infant’s self and object differentiation and experience of individuation and efficacy are strengthened. Pathological narcissism, fixation at this stage of omnipotence, occurs when the infant’s mother is empathetically unresponsive to her infant’s needs. Therefore, Kohut believed that analysis with narcissistic patients should allow for the emergence of mirror and idealizing transferences, which reflect the unmet infantile need having an empathetically responsive love-object. Therapies that allow for the emergence of this need will “unlock” the point of fixation and allow for the continuation of normal development. In this way, the early stages of analysis are dependent upon the analyst’s capacity for mirroring, rather than interpreting.
Contrary to Kohut, Bromberg believed that interpretation was necessary in all stages of analysis with narcissistic individuals, including the early stages. He identified two forms of “interpretation” appropriate to and necessary during the early stages of therapy. The “structuralizing interpretation” encourages the patient to identify parts of his character structure (i.e. the patient’s use of detachment to avoid feelings of inadequacy) without pathologizing. The second “interpretation” involves encouraging the patient to identify the minute details of interactions with others, details that, in an effort to manage appearances, would not normally be attended to or disclosed. Exploring these details, or simply being aware of one’s resistance in providing them, may further elucidate to the patient aspects of his character. The second stage of analysis involves interpreting and addressing the issues that identified in the first stage of the analysis transferentially.
Where Kohut’s approach emphasizes the importance of empathy and mirroring during an interpretation-free period of therapy, Bromberg stressed the importance of interpretation from the start of therapy. However, here the word interpretation is used loosely and appears to be more closely tied to guided discovery as the patient is made aware of aspects of his character.

Sara's Response Paper- Narcissism

2006-04-02T22:21:00.000-04:00

Kohut views pathological narcissism as disturbed or incomplete narcissistic self structures that stem from early developmental failure by selfobjects to respond appropriately to the child’s normal, narcissistic needs. Selfobject failure specifically results from insufficient (or absent) mirroring and idealization, or from a premature confrontation with reality over the idealized self-object’s fallibility before the child is able to process this. This results in the development of five narcissistic personality types: the mirror-hungry personality, the ideal-hungry personality, the alter-ego personality, the merger-hungry personality, and the contact shunning personality. All are characterized by an on-going search for external affirmation and acceptance, and a deficient and incomplete self-structure.
Kohut promotes an interpersonal therapeutic process that seeks to help the narcissistic patient complete his disrupted development. This approach starkly differs from traditional psychoanalytic procedures in that it relies on the therapist to take on the role of the selfobject through the means of empathy and mirroring, rather than providing insight and interpretations. This notion also fundamentally contrasts to Kernberg’s more confrontational approach. Kohut’s supportive technique is premised on the idea that the narcissistic patient will be able to internalize the faux selfobject (played by the therapist) and in doing so, repair his depleted self-structure.
Bromberg, in contrast to Kohut, does not entirely cite selfobject failures as the source of narcissism. While he acknowledges that the narcissist does not have an individuated self-identity, he does not fully blame this on early object failure, though he still attributes its source to developmental failure. He accounts for it, I believe, in more ambiguous (and less object blaming) terms— by attributing it more to the infant’s denial of the self-individuation process, and to the infant consequently erecting a defensive structure that allows him to maintain his grandiose self image. For the most part, Bromberg agees with Kohut regarding the ineptitude of classical interpretation in achieving success with narcissistic clients, especially because of their inability to examine their own narcissitic transferences before having established a more coherent self-structure via an empathic mirroring experience with the therapist. However, he feels that a certain type of empathic interpretation (not in the classical sense) is necessary so that the patient can view himself as engaged in an interpersonal process. Gradually, as the patient’s ego capacities are strengthened, and reality is brought into clearer focus, the interpretations will become more confrontational. The patient will tolerate this because by now, he trusts his selfobject replacement, the therapist. One caveat Bromberg points out is that not all patients with pathological narcissism are analyzable, especially those with particularly deficient ego development.

Bromberg Vs. Kohut

2006-04-02T22:03:00.000-04:00

Bromberg’s metaphor for the narcissistic patient illuminates the trap that the narcissistic is present in. His sense of self is “stuck” between the mask - an unreal perfect persona, and the mirror - appraised reflections from others affirming the grandiose being. The mask, Bromberg explains, is needed because of the insufficient sense of self that had been developed. And once established has to be maintained in all costs. Therefore the narcissistic patient is not grasped, according to Bromberg as an infant in disguise, but as an adult with underdeveloped ego. Kohut, on the other hand, comprehend the narcissistic patient as a young child who needs unconditional empathy in order to regain its self.
The treatment process according to Bromberg is of dual components with a delicate balance. In the first phase of treatment, the outside nourishment of the patient with unconditional positive regard and empathy is balanced with anxiety induced by interpretations. Unlike Bromberg, Kohut discovered that interpretation is actually destructive for the narcissistic. Since it may emphasize the analyst’s separateness and thus interfere with the patient’s immersion in the developmentally necessary selfobject experience. Thus, a flowing empathy in an unstressed environment will establish the fragile self. According to Kohut the natural imperfections of attunement gradually, like in healthy development, will allow the patient to adapt more realistically with a vital sense of self.
The narcissistic patient of Bromberg, while would meet, in the first stage of treatment, a biased weight on the side of empathy, would meet in the next phase, interpretation that may push him out of the fantasy of entitlement. Hopefully at this stage the patient internalized the previous common history of being understood and will use the rage and emptiness to facilitate the individuation process that will establish an authentic sense of self.

Bromberg and Kohut on Narcissism: Lucy's Reaction

2006-04-02T13:19:00.000-04:00

Bromberg’s vision of the development and treatment of narcissism is not completely different from Kohut’s, but does depart in some interesting ways. Although Bromberg seems to believe that there is a form of developmentally healthy narcissism that provides a sense of agency and pride throughout life, his understanding of pathological narcissism has more to do with separation-individuation crises than with lack of mirroring and idealization experiences in childhood. Bromberg does not see the patient as being in a state of developmental arrest as Kohut does, and does not think the patient should be treated that way, either. While Kohut sees the patient as a (metaphorical) child to be re-parented in the selfobject transference, Bromberg sees the patient as an adult for whom a fragile self is protected from intense anxiety stemming from separation-individuation issues in early life.

Kohut reasonsed that treatment of the narcissist primarily required empathy from the analyst and a provision of a hostility-free, interpretation-free environment in which the patient could develop and experience mirroring and idealization-based relationships with the analyst in order to unfreeze him from his state of defensive grandiosity. For Bromberg, the task is a little different; the analyst must strike a delicate balance between empathy and allowing some anxiety in to motivate the patient for change. Bromberg believes that early in the analysis, empathy is most useful, but that interpretations can be made that gently address stuctural patterns/object needs (avoiding content interpretations). Gradually the analyst can segue into more content and behavior-based interpretations, but should not explicitly link them to the transference. As the patient becomes more able to explore inner states with the analyst’s protection of his core vulnerability, the analyst must encourage a certain level of anxiety to creep in and “push” the patient toward relinquishing their defensive fantasies and developing a real, interpretable transference relationship. According to Bromberg, this transference relationship is analyzable even though it produces rage and envy in the patient, because the analyst has already earned some credibility with the patient.

Gillian: conceptualization of narcissism

2006-04-01T19:35:00.000-05:00

According to Bromber’s conceptualization, narcissistic presentations of grandiosity and a lack of genuine relatedness are in place to protect the fragile, poorly diffentiated self from the threat of annhiation from internal and external experience. Narcissistic pathology may stem from a trauma at 7-8 months, when development of stranger anxiety and the first capacity for an outside and an inside to be created in the mind of the infant has its origin. This is when an autonomous self can emerge that is separate from the fusion with the all-powerful other. Development of individuated self and object representation is dependent on the presence of an emotionally available mother. If this good object experience is missing, and particularly if there is a trauma at this stage, external reality may seem too different from the experience of self-contained gratification, and the infant will prefer fusion with the internalized idealized object and a retention of the resulting magical omnipotence. The infant will feel the need to control rather than internalize reality, and this may continue into adulthood manifesting as difficulty with full immersion in life, and a constant sense of shame, rage, and self-consciousness. The grandiose self may be seen as an attempt to retain the all-powerful nature of the internalized object with whom the patient is fused.

Kohut’s conceptualization of narcissisim is similar, in that traumatic parental disappointment can shock the child’s system and force her to let go of the idealized view of the all-powerful object before she is ready. In response to this, she may just interject her entire idealized parent and use this as a makeshift self. She has no time to integrate the good and bad aspects of the object, and no time to create a differentiated self in the accpeting and present environment of a real object. The idealized object is seen as part of the self, and rage and grandiosity are both conjured; rage at the disappointing object, and grandiosity to protect against a fragile fossilized infantile self, and infantile view of the object and the world. Kohut disagrees with Bromberg’s position that narcissism develops pre-psychologically, before the creation of an ego. Instead, Kohut puts narcissism in the category of those pathologies that occur after some sort of cohesive self has developed, albeit a feeble one. While in Bromberg’s conception the major injury predisposing one to narcissism occurs around 7-8 months, Kohut’s conception suggests that normal, necessary narcissism in the development of the child is still underway well into the second year, and that in normal maturation healthy grandiosity does not change into ambition with the help of appropriate mirroring and gentle parental disappointments until the ages of 2-4. Thus in Kohut’s conception, narcissism is an important developmental stage that only when interrupted with a trauma gets fixated, and those traumas which lead to narcissistic pathology may occur well into toddlerhood, rather than in the first year as posited by Bromberg. Bromberg recognizes that narcissism to some degree is present in most people, but does not see total grandiosity as an essential step in development, as does Kohut.

Kelly: Bromberg and Kohut

2006-04-01T16:40:00.000-05:00

Although Bromberg stresses the importance of empathy in the therapeutic stance with narcissism, his conceptualization of therapeutic action differs in several ways from Kohut (although, admittedly I’m struggling to clearly identify them). Bromberg maintains the active agents of therapy with the narcissist are both interpretation and internalization. In this way, treatment of the narcissist does not require a different set of therapeutic techniques; rather certain facets are relied on more heavily than others and at different phases in the treatment. Bromberg believes that in the initial stages of analysis, the narcissist actively wards off direct experience of the transference neurosis (therapist as an object of value). This transference, he believes is too threatening to the narcissist’s weak self structure or “mask” of grandiosity. Instead, the narcissistic transferences serve to maintain the patients mask allowing him to perform for the analyst. Bromberg warns against the analyst too hastily dismantling the narcissistic transference. However, for the patient to develop a more accurate observing ego and genuine sense of an autonomous self the patient must be able to internalize the analyst. So for Bromberg, a main aim of the therapy is to lessen the over-reliance on narcissistic transferences and replace these with a more reality based transference neurosis in which interpretation plays a more central role.

For Kohut, in the right therapeutic environment – “optimal responsiveness”- the narcissism will resolve and transform into healthy self assertiveness. Rather than focusing on the “target of the instinctual investments”, Kohut is more concerned with the “quality of the instinctual charge” (grandiose and exhibitionistic). In this way, Kohut believes the therapeutic action takes place within the narcissistic transference and the analyst as a selfobject. Here this is unlike Bromberg’s view that it is primarily as a defensive maneuver that walls off the potential for growth.

Relational Theory on psychopathology, diagnosis and treatment

2006-03-28T05:38:00.000-05:00

Relational theory has made a significant contribution to the evolution of psychoanalysis, particularly in North America. It has provided a distinctive view towards the diagnosis of mental illness, and established a revolutionary method of therapy. An obstacle for relational theory, however, is that it does not provide a coherent theory for distinctive disorders and is in a way, naïve in its assumption regarding the development of various pathology.
The assumption in relational theory, in regards to psychopathology, is that it is the result of considerable disturbance in a significant relationship. It is also assumed that when an infant’s relational needs are disrupted, this results in anxiety. This anxiety is specified to indicate the need for security. The individual will attempt to protect the self from the anxiety, by performing various security operations. However, in some cases, the individual is unsuccessful in his attempt to stymie the anxiety. This brings about negative feelings towards the self, preventing the integration the thoughts or memories of other relationships or interactions that did satisfy the needs of the individual. This splitting off or relationship memories, causes the individual to assume that all relationships will have the same, negative consequences. The individual develops an “illusory personification” in which all future relationships will be filtered through a relational template, causing the perception of present relationships to be impacted by, and comparable to the past, anxiety provoking relationships. This distorted view towards relationships and the maladaptive pattern of interaction that ensue, along with the rigidity of this pattern, essentially impairs relational and personality functioning. The relational pattern is said to be responsible for the development of the self. However, impairment in this area and disruptive relationships that follow, will cause parts of the self to be hidden and expressed, instead as various forms of neurosis.
The relational theory provides a distinctive approach to psychopathology, in that mental illness is essentially due to a disruption of needs, or provoked anxiety, from a significant relationship within a person’s life. Because the focus is on interpersonal patterns, there are no real diagnostic labels or criteria of symptoms that can be used as a guide to diagnose, and provide treatment based on that diagnosis. Instead, the relational assumption regarding the interpersonal pattern provides the information on development and course of pathology. This approach does have its holes, in that this particular theory does not account for individuals that have traumatic relationships, yet do not develop pathology. There is evidence of biological and genetic pre-determinants of mental illness, as well as biological motivation behind certain behaviors, thoughts and feelings towards relationships. The inability to assimilate these factors of human development into the theory causes some loss of credibility, although the contributions to the therapeutic process have been quite noteworthy.
An objective of treatment is to uncover the maladaptive relational pattern and improve interpersonal functioning, as well as increase the flexibility in the perception of relationships. The therapist is much more engaged in the therapeutic process, providing an authentic and collaborative interaction with the patient. Instead of interpretations of the analytic data, the relational model suggests the patient and analyst work together to infer the patient’s interpersonal reality. There are many variations on the general approach to treatment, but a significant feature is the analysis of the relationship with the analyst and its correlation with interpersonal patterns that would most likely occur with others in the individual’s social life. As the patient is made more aware of their relational patterns, and as the analyst provides an authentic form of interaction, the patient can experience his authentic self. Since there was once a rigid perception on relationships, the patient must be made aware that not all relationships will be as traumatic as was the original initiator of the anxiety. Through the authenticity of the analyst and the freedom to work through interpersonal relations in a safe setting, the patient gains confidence in his ability to interact with others

James's reaction # 6

2006-03-27T13:01:00.000-05:00

McWilliams discusses, at length, the defensive adaptations of the paranoid person. Essentially, unwanted personal traits and inferiorities are difficult to tolerate, or even sublimate for this type of person. Disowning and projecting these unwanted traits onto another object becomes the dominant way of protecting the ego. Thus, the paranoid person can easily invent explanations for persecution. The inferiorities can become distorted as dangerous in the projected object, depending on the level of paranoia in the individual. Sullivan conceptualizes this developmentally by looking at the failure to establish meaningful interpersonal intimacy during infancy and childhood. He views the projection as a defense against the ‘persecutory parent’.
From a relational standpoint, Sullivan’s theory makes sense. McWilliams addresses the need, as a therapist, to accept the hostile transference of the paranoid patient and to create an environment of safety and acceptance. If Sullivan is correct, the internalized persecutory parent is a barrier that needs to be overcome and can be through the therapeutic relationship. Traditional analytic therapy could easily interfere with the progress of a paranoid patient, according to McWilliams, as the analysis can irrationally confirm inferiorities. Instead, she advocates devoting the most attention to the development of a strong and trusting working alliance. That way an environment can be created which allows the paranoid patient to feel comfortable enough to express raw hostility. The therapist’s job then becomes “unflustered acceptance of powerful degrees of hostility”(pg. 217) so that the patient can overcome his irrational view of the meanings and implications of his inferiorities.

Relational Theory and the Diagnosis and Treatment of Paranoia

2006-03-27T12:51:00.000-05:00

Jay Kosegarten
3-26-06
Psychopathology
Professor Papouchis

Relational Theory and the Diagnosis and Treatment of Paranoia

At the heart of the relational approach to paranoia is the belief that the early formative experiences of the child who later has a paranoid character organization had an anxious and critical mother/caregiver along with the absence of another significant relational presence who could compensate for this experiential pattern.
As Fonagy and Target write about Mitchell’s theory, “…individuals cling to pathological patterns because these are the only relationships they know,” a dependence on the external environment, especially the mother, for cues about the subjective, internal experience becomes the organizing factor of the personality. This paradigm results in a particular type of enmeshment with the internal and external worlds of the individual- a unique brand of poor differentiation. In terms of Mitchell’s theory, the major relational disturbance is in “affect permeability,” what Fonagy and Target define as “the shared experience of intense affect across permeable boundaries.” In therapy, which would be emblematic of the paranoid’s other relationships, this pathological disruption in relational mode would become manifest in projective identification, that is “the analysts own emotional experiences are seen as reflections of the patient’s own emotional turmoil.”
Unlike many post-Freudian analytical theorists, Mitchell wisely has a great deal of respect for fantasy, developing subtle, complex notions of the interaction that occurs between fantasy and reality. For Mitchell, fantasy functions as both the inevitable projection of wishes onto others and, in other ways, a reaction to intrapsychic and interpersonal anxiety. Depending on circumstance and character make-up, fantasy can be the impetus causing problematic distortions in relationships (and object relations), whereas at other times, fantasy is secondary, a defensive reaction to intrapsychic and interpersonal anxiety. Fantasy in the former only becomes problematic when the distortions are maladaptive, and this is the case of the paranoid’s projective operations. The defining feature of the paranoid character, projection takes on the unique, multilayered function of disavowal, that is, projecting the parts of the self which are intolerable and highly anxiety-provoking onto others. In the paranoid, the projections are infused with the defensive characteristics of denial and reaction formation.
Therapeutically, goals of treatment would revolve around Sullivanian and Kohutian approaches, including corrective emotional experiences and an emphasis on the subjective experience of the paranoid.

Relational understanding of paranoia

2006-03-27T08:50:00.000-05:00

The interpersonal approach distinguishes itself from other psychological theories by emphasizing collaborative investigation of a patient’s problems. It differs from Classical theory by stressing intersubjectivity instead of intrapsychic phenomena; pragmatic explanations not descriptions of fantasy; and observation of the analytic process not analytic interpretations. Thus, instead of analyzing drives, defense mechanisms, and conflicts between id, ego, and superego relational analysts try to understand a patient through insight into the therapeutic relationship. Accordingly, their notion of pathology stems from Fairbairn’s concept of internalized ‘bad’ objects, attachment, and transference. Information gathered in analysis is thus used to mediate the anxiety (and psychopathology) caused by unsatisfactory relationships.

One significant consequence of the relational perspective is the de-emphasis of the therapist as a blank slate and expert interpreter of unconscious issues. It is understood that the analyst’s reactions to a patient can be prompted both by the material presented (actual countertransference) or the analyst’s own struggles (subjective countertransference).

Interpersonalists believe that stressful relationships bring about rigid relational patterns that then lead to psychopathology. From this perspective, paranoia is seen as a reasonable reaction to anxiety created by difficult relationships with primary caregivers / significant others. According to Sullivan, the core conflict of the paranoid individual is transference of blame stemming from awareness of one’s own inferiority and an inability to tolerate this awareness. Thus, in order to defend against unpleasant feelings about the self, the paranoid individual projects the insecurity outward, inventing explanations for persecution. Sullivan attributes the etiology of paranoia to incomplete development occurring in the preadolescent and adolescent phases.

Interpersonal/relational take on paranoia

2006-03-27T01:37:00.000-05:00

The commonalities of interpersonal and relational theorists point toward a therapeutic approach that seems useful for paranoid clients.

First, the interpersonal/relational belief in relationships as the central aspect of subjective experience dovetails well with the paranoid’s defensive structure – the paranoid individual desperately needs other people, if only to serve as targets for projection. The interpersonal/relational therapist and the paranoid patient already share the belief that one’s experience is a product of one’s relationships to others. It is the therapist’s job to get the paranoid client to see that this relatedness is a good thing; to move the client towards understanding which relationships are salient (as opposed to imagined, as in the case of conspiracies), benign, and even benevolent. This movement is effected via the therapeutic relationship and unusual, sensitive interventions -- McWilliams, for example, suggests humor.

Second, the interpersonal/relational technique of staying in the “here and now” and experiencing the therapeutic moment with the paranoid client is more likely to disarm the client’s defenses than interpretations, which the paranoid individual is likely to find threatening. In addition, by removing the therapist from the role of expert interpreter, this therapeutic stance may diminish the analyst/analysand power differential, which in turn may engender in the client a feeling of trust and even closeness. According to Sullivan, it is such experiences of warmth, trust, and intimacy that are frequently lacking in paranoid clients’ histories. (Presumably, interpersonal/relational therapy is meant as a corrective emotional experience to the emotionally arid upbringing common to paranoid clients; I don’t think Sullivan says this directly, however.) Privileging the interpersonal/transferential content of the client’s associations over their manifest content also gives the therapist a meaningful focal point – rather than having to parse the client’s latest elaborate plot, the therapist may look instead to the emotional content in the room as the patient spells out his theories.

The Interpersonal-Relational Approach and Paranoid Personalities

2006-03-27T00:35:00.000-05:00

Reaction Paper
The Interpersonal-Relational Approach and Paranoid Personalities
Sullivan views psychopathology as originating when the satisfaction of interpersonal or relational needs is upset by anxiety. In contrast to classical Freudian therapy, anxiety does not arise when the ego is met with a potential threat (from some demand of the id or the superego) but arises in relation to the primary caregiver. When an infant senses that her tension has produced anxiety in her caretaker, the infant internalizes this perception of anxiety. A sense of self is constructed in which those behaviors that create a sense of warmth and approval from the caregiver are attributed to the “good self” and the infant has succeeded in avoiding creating anxiety in her mother. To the “bad self” are attributed those behaviors that create anxiety in the caregiver. A third dimension of the self, the “not me,” arises to handle behaviors that are perceived to be so straining for the mother that the infant dissociates from them. Psychopathology, then, results when early anxiety is so intense that the dissociative aspect of the self, the “not me” could not be contained. Such a view is not incompatible with McWilliams’ formulation of the paranoid personality. According to McWilliams, children who are temperamentally aggressive or irritable may find it difficult to incorporate this aspect of their self with a more positive self-image. Caretakers who respond negatively to such a demanding and exacting child would then reinforce the divide between the child’s “good self” and “bad self.” In an attempt to integrate the two parts of the self, or simply as an effort to accept the “good self” the child may begin to view the outside world and others as being persecutory. In more extreme cases, the negative reaction and anxiety created may be so intense that the “not me” is personified. The dissociative aspect of the “not me” is compatible with the use of projection at the psychotic level, where upsetting aspect of the self are completely projected onto another object. The psychotic, without an observing ego and intact reality testing, projects regardless of whether or not there is a fit with the external experience. Such indifference could be attributed to a dissociative process.

Matt: Interpersonal/Relational Psych & Paranoia

2006-03-26T21:36:00.000-05:00

An Interpersonal/Relational Approach to Paranoia
The DSM definition of paranoia (i.e. paranoid personality disorder) is fundamentally at odds with the core concepts of the interpersonal and (especially) the relational schools of thought. The central tenet of these theories is the concept that the therapeutic relationship is necessarily created out of the meeting of two equal subjectivities, and that there is no basis for privileging the therapist’s perspective. The therapist has no greater claim on reality than the patient. The DSM, in contrast, defines paranoia in terms that make the clinician’s subjective view the last word on the reality of the patient’s position. The diagnosis can only be given if the patient’s fears and suspicions are judged to be unrealistic, and the criteria use words like “without sufficient basis,” “unjustified,” and “unwarranted.” Even aside from the fact that the relationalists reject the notion of diagnostic labels altogether, clinician’s role here is undeniably privileged.
The relational argument specifically highlights the weaknesses of the DSM version of paranoia, with implications for both diagnosis and treatment. First, there is the very sensitive and essentially untenable position of the DSM-guided therapist. To be forced to judge the realities of another person’s life in this way places therapists in a role that many probably never wanted to be in. If we have chosen the therapy trade it is likely out of an affinity for empathy and a tendency to withhold judgment. Who but a therapist should know better than to believe in the fallacy that one can know the facts of patient’s life better than the patient? Second, there is the not-unlikely possibility that the therapist may judge incorrectly, applying the labels “unjustified” and “unwarranted” to fears that are actually realistic. Third, there is the possibility that a patient facing obviously real dangers may still be under the influence of a paranoid dynamic. Just because you’re paranoid doesn’t mean they aren’t following you, as the saying goes.
McWilliams, as is her wont, occupies a sort of middle ground in this conflict. While she is quite ready to apply the paranoia label, she is careful to emphasize that the clinician’s judgment of the realism of the paranoid’s fears is not the crucial criterion. Instead, it is the use of projection of disowned feelings and thoughts, which then take on the appearance (to the patient) of external threats. Of course, the relational people would take issue with this formulation too, noting that it has only shifted the object of the clinician’s judgments, from what is external to the patient to what is internal. Still, McWilliams’ formulation has implications for treatment that I think these critics would applaud. Namely, she eschews interpretation and direct confrontation and instead emphasizes humor, frankness, and as much genuineness as possible while simultaneously upholding the boundaries of the therapeutic relationship.

The Relational Model: Implications for Diagnosis & Treatment

2006-03-26T21:14:00.000-05:00

Relational theorists contend that psychopathology results when individuals become wedded to dysfunctional relational patterns that originate in childhood. These patterns are so rigidly held that they color social interactions well into adulthood. Stephen Mitchell, a significant contributor to the interpersonal-relational school, contends that children learn from a young age just how to interact with parental figures in a way that minimizes anxiety. These patterns then become pathological templates, maintained simply because the child knows no other way of interacting. If tension between particular relational patterns and the main “self-shaping” patterns occurs, they will find ways of expressing themselves covertly and give rise to neurosis. It could be suggested that paranoia, for example, is the product of parental failure to confirm reality and a child’s normal reactions. Instead of feeling validation, the child is filled with shame, fear and confusion that he or she carries into adulthood.

The process of relational psychotherapy is entirely different than that of classical psychoanalysis, particularly because of the very active role in which the therapist is cast. The task for the relational therapist is to understand the subjective world of the patient and to assist in broadening his or her interpersonal interactions despite the limits imposed by childhood experiences. The patient is also encouraged to examine why the chosen manner of relating is seen as the only way to forge a bond with the therapist. In contrast with classical analysis, the emphasis of the relational style is on current social relationships as well as the interactions occurring within the therapeutic context. The connection between therapist and patient is socially constructed by the two parties, neither of whom is the “expert”. Self-disclosure is not limited to the patient and transference is understood not as a simple projection but as an authentic social reaction to the therapist. Grand interpretations are unnecessary; the vehicle through which change occurs is therapist participation. Progress and healing take place through the shared experience, which teaches the patient that his modes of relating need not be so restricted. In other words, successful relational therapy results in the patient’s ability to understand and experience a range of relationships in a variety of ways.

Relational Persective on Paranoia: Lucy's Reaction

2006-03-26T20:23:00.000-05:00

For a supposedly Freudian analyst, McWilliams does an excellent job of laying out the diagnostic and treatment issues that would be relevant to a more ‘relational’ analyst. As usual, not only does McWilliams describe what the patient experiences internally and behaves like outwardly, but she describes the patient in terms of the interpersonal dynamics their illness invokes and what they feel like to be with in the room. She places patterns of countertransference and transference at the center of her understanding of the patient and treatment, much like a relational analyst would do. She provides a nice two-person view of the paranoid experience, which was a welcome complement to Shapiro’s more cognitive-intrapsychic presentation.

In McWilliams’ view, the struggle of the paranoid is essentially a relational one, in the sense that the paranoid is primarily guarding against potential shaming, humiliation and harm by the other (as opposed to some internally-located discomfort, like guilt, although the paranoid does experience diffuse guilt). The paranoid accomplishes this largely via projection, and McWilliams describes in great detail the interpersonal (relational) dynamics involved in the use of this defense. She argues that the paranoid engages in a complex form of projection -- projective identification -- in which he empties himself of his disavowed fear and overwhelming weakness by projecting it into the other person, and then recognizes it in the other. The other person thus becomes the container for the paranoid’s most frightening feelings.

Although McWilliams doesn’t say this outright, one can infer from her writing that analyst’s countertransference can confirm the paranoid diagnosis, since the feelings evoked by the paranoid are quite distinct. For example, she reports that the analyst often reacts with vulnerability, anxiety and certain defensiveness and these reactions are much stronger and come to the fore more quickly than with other patients with personality disorders.

In terms of treatment, McWilliams argues that it’s very important for the analyst to resist temptations to “set the record straight” with the patient about the accuracy of their perceptions or the benevolence of the analyst’s own motivations. For her, the working alliance is the central part of the treatment with the paranoid, and in fact, she claims that when the paranoid trusts his analyst, the treatment is essentially over. This focus on the development between the relationship between the patient and analyst as curative is totally congruent with the relational position on therapeutic action.

Relational Approach to Diagnosis & Treatment of Paranoia

2006-03-26T18:29:00.000-05:00

The main constructs of the interpersonal-relational approach relate to the notion of the analyst and analysand participating in an interrelational, interactive shared activity. Interpersonalists place considerably less emphasis on analytic interpretations and instead see the interplay of the here-and-now transference and countertransference interactions as providing the greatest source of information to be observed by the analyst for defining the progress of therapy. Development of psychopathology as dictated by relational theorists centers on the child’s negative relational experiences with “bad” objects that cause the child to develop maladaptive behavior patterns involving defense mechanisms. These negative relational experiences become deeply embedded within the psyche of the child and set the foundation for the manner in which the individual will handle and utilize these methods of engagement in future relationships. The goal of therapy from the relational viewpoint seems to be for the analyst to challenge the patient’s negative relational patterns by entering into the patient’s subjective world and helping him/her to see for themselves the reasons for which these maladaptive behavior patterns have developed. Also, an additional goal of therapy would be for the patient to identify what he/she can do in accordance with the analyst to create a more adaptive way of relating to others in spite of the difficulties encountered in childhood relations.

McWilliam’s postulates that many paranoid individuals have negative experiences with object relations during critical phases of development. They tend to have suffered instances of severe humiliation and overpowerment in relation to encounters with primary care givers. In addition, many paranoid individuals have had experiences with parents who modeled suspicious or overly anxious behavior which therefore imbued the child with a sense of fear and suspiciousness towards others who fell outside of the protective and trustful family realm. It seems that from the relational perspective, therapeutic treatment with paranoid individuals would center around the therapist joining with the patient and helping them to see how the patient has come to see others as dangerous and persecutory. Engaging the patient’s intense suspicion and mistrust of the analyst while simultaneously exploring why this appears to be the main interactional pattern the patient has for relating to others seems to be one of the necessary components of the therapeutic intervention. The therapist’s ability to accept the high level of hostility and mistrust coming from the patient will serve to foster a sense of safety for the patient, in turn helping him/her to experience a more adaptive way of relating to others. In addition, this technique would aim to allow the patient to gain insight into their problematic manner of relating to others and to develop more adaptive methods of interaction.

Sara's Response: Relational Conceptualization of Paranoid Personalities

2006-03-26T17:56:00.000-05:00

According to Sullivan, the failure to establish meaningful, interpersonal intimacy during infancy and childhood is the source of paranoid personality development. Of course there are different levels of paranoia: psychotic, borderline, and neurotic, but the crucial common denominator among these levels of functioning is a fundamental feeling of inferiority that stems from deficient or punitive early object relationships. People with paranoid personality organization typically have affects that exude a palpable sense of hostility and anger. However, this is not to say that the paranoid is incapable of love. According to Nancy McWilliams, in fact, it is the paranoid person’s capacity to love that distinguishes him from the psychopath. Aside from their manifest hostility, their unconscious affective state is plagued by fear, shame, and guilt: such feelings are, in part, a consequence of disconfirming and humiliating treatment by parents. Furthermore, these unbearable feelings of guilt and shame are disowned, projected, and transformed into externalized threats.

Sullivan views this projective defense (that serves to target the ‘persecutory parent’) as the primary barrier that prohibits the paranoid from repairing and reestablishing interpersonal intimacy. In actuality, the paranoid person deeply desires human connectedness, but because he is so suspicious of other people’s true feelings and intentions, he will likely reject the person’s (or even his own) good faith effort at establishing intimacy, and instead become more vigilant and fearful. His very need for intimacy is a threat in and of itself. Often times, this need for human connection gets misperceived as being homosexual in nature. Consequently, he comes to perceive homosexuality as an extremely menacing threat. What this illustrates is that the paranoid has an overwhelming inability to preserve his self-worth in connection with other people.

The relational outlook on treatment for paranoid patients requires the therapist to accept the hostile transference of the patient in an effort to instill in him some degree of safety (which was so utterly lacking in childhood), thereby planting the seed for trust. McWilliams believes that typical psychoanalytic methods (e.g., analyzing defenses and unconscious processes) will inevitably backfire with the paranoid patient. Instead, the therapist should: focus more on the patient’s affective cues and reactions, lend interpretations in a non-definitive and good-humored way, and maintain confidence and power so that the patient will not perceive his destructive fantasies/tendencies as having the capacity to sabotage yet another relationship.

Gillian's interpersonal/paranoid response

2006-03-26T14:54:00.000-05:00

Classical Freudian models of the psyche indicated an internal turmoil between id ego and superego, as biological imperatives acted on psychodynamic functioning. Freudian theories took drive reduction as the main behavioral motivator and as the basis of psychological material. According to this model all interpersonal relationships were secondary to, and mainly relevant to the drives only as they provided a conduit for the discharge of aggressive or sexual impulses. The role of the Freudian analyst was that of a neutral party, who simply provided a space in which the repressed unconscious of the patient could eventually come to light. The interpersonal school of psychotherapy, on the other hand, taught that the analyst should take an active role in therapy and that the therapeutic currency was not in the patient admitting to their repressed impulses, but rather in the relational dynamics that were played out between patient and therapist. The interpersonal school drew from object relations theories the idea that human relationships, rather than discharge of libidinal energy, were the main “drives”, and components of psychological material. Rather than focusing on the internal struggle of an independent individual, the interpersonal school focused on the relationships in a person’s life, with the idea that there could be no independence without interdependence, and that humans were defined by their relationships.

The interpersonal school viewed development as a process through which the child sorts his own impulses and behaviors through the filter of reactions elicited from caregivers. In this way, the child groups all interactions with the caregiver into either “good mother” or “bad mother” interactions, and also classifies all of his or her own actions and impulses as “good me” or “bad me” depending on the type of anxiety evoked in the caregiver, and in the amount of anxiety then experienced by the child. Those with a paranoid style may experience themselves as intrinsically bad. Guilt and shame are prevalent in those with this style, and they may be imbued with a sense that they are constantly at risk, either through an internal giving-in and relinquishment of hypervigilance, or through external domination and aggression that they must defend against and keep watch for. According to the relational school, this style may have been learned through an environment in which most organic parts of the child elicited anxiety in the caregiver, and were relinquished to “bad me” status. This sort of environment would likely be unfavorable and perhaps even dangerous for the young child, thus adding real external threat to the internal perception of badness. These early relationships and the internal expectancies created by them may produce a person who has given up most organic and spontaneous responsiveness, trading authenticity and spontanaeity for a carefully constructed act to evade those who are perceived as threatening. The internal “badness” may be projected onto others, manifesting as a paranoid style requiring the constant search for and overblowing of clues that suggest external threat.

Kelly: Interpersonal and Paranoid Personality (Uhg)

2006-03-26T13:46:00.000-05:00

McWilliams describes the paranoid style as predominantly relying on projection to disavow one of negative qualities. These negative self attributes are disowned and projected outward such that the external environment is viewed as threatening and harmful. As a result, the paranoid is disposed to mistrust relationships and may only seek help as a last resort. The paranoid may present along the psychotic – borderline – neurotic range, depending on intactness of reality testing. At the extreme end, the paranoid in a psychotic state may exhibit extreme delusions of persecutions (for example). McWilliams however, cautions the therapist not to discount the possibility that the paranoid’s fear regardless of how delusional may actual have a basis in reality – here she points to Howard Hughes as an apt example.

Developmentally, McWilliams cites speculations that paranoids may be temperamentally endowed with higher levels of aggressive energy and suffered severe insults to their sense of self efficacy. Difficulty managing and integrating aggressive impulses may have strained early interpersonal relations and these interactions biased the paranoid’s view of the external world as rejecting and hostile (here, an interpersonal/relational view). The paranoid stance is dominated by a combination of fear, shame and guilt – all of which are denied and projected outwards. McWilliams differentiates the paranoid from the narcissist in that the paranoid chiefly defends against malevolence of others whereas the narcissist against injury to the self (revealing inadequacies).

Taking an interpersonal/relational perspective will inform how one conceptualizes the paranoid organization and intervenes in the therapeutic situation. The interpersonal/relational therapist would pay attention to the subjective experience of the patient and therapist in relation to patient to decipher the patient’s ways of handling current anxieties and experience. This organization is then considered as a strategy adopted by the patient enabling him to interact with others. The therapist would focus on focus on how this strategy played out in the context of the current relationship.

McWilliams highlights distortion in the sexual identity as common in the paranoid (also emphasized by Klein’s paranoid-schizoid). Namely, the paranoid exhibits a tendency to misinterpret the need for same-sex intimacy and connectedness with sexual orientation spurring homophobic anxieties and fears. Here, the interpersonal/relation view posits that “sexual difficulties are sexualized expressions of relational conflicts.” The paranoid’s misattribution of same sex intimacy needs to homosexuality would be conceptualized as indicative of prior formative relations. The interpersonal/relational therapist would explore ways in which this relational pattern is playing out in the patient's current interpersonal relations and analytic relationship.

Freud V. Independent School of Psychoanalysis

2006-03-20T15:17:00.000-05:00

Sara Petrasso

The British Object Relations School primarily departed from classical Freudian theory in its emphasis on the fulfillment of the baby’s quest for object fulfillment--a quest that can only be satisfied by the object’s capacity to provide a safe haven for the child’s developing ego. According to the British Object Relations school, the libido is object-driven, and not reduced to a mere, pleasure-seeking apparatus that operates off of libidinal and aggressive need gratification, as the classical analytic camp proposes. Rather, pleasure is determined by the quality of the object-relationship, thus shifting the focus toward the importance of emotional relations in the context of the infant’s environment.

Winnicott believed that the infant’s successful development largely depends on the mother’s sensitive attunement to the infant, and her ability to provide him with the ‘illusion’ that she is operating under his omnipotent control, effectively acting as though she is psychically “of one” with the infant. The infant’s ego can only successfully emerge from a holding environment where the infant was protected from trauma (e.g. brought on by the premature experience of self-differentiation, parental impingement, or neglect). Both Winnicott and Fairbairn, as opposed to Freud, exclusively attributed pre-oedipal, environmental failure/trauma as the source of future pathology. Thus, the most critical aspect of pathological development does not stem from repression of conflict at the oedipal stage, but rather, from deficiencies in early object relations. The British Object Relations School minimized inter-structural conflict (i.e., the ego repressing the strivings of the id), and emphasized crucial and formative environmental/relational influences.

Fairbairn further elaborated on developmental psychopathology proposing that schizoid and antisocial
personality disorder are reactions to pre-oedipal experiences of object/love deprivation, resulting in an infant who withdraws inwards in an attempt to preserve his wellbeing. However, this self-initiated withdrawl is a double-edged sword in that conflicts over dependence and autonomy dominate so that fears of engulfment and identity loss co-exist with fears of isolation and loneliness.
Something that still remains unclear to me is how, specifically, Freud would account for the development of schizoid personality.

The Contributions of Fairbairn and Winnicott

2006-03-20T14:34:00.000-05:00

The Contributions of Fairbairn and Winnicott

Fairbairn’s changes to Freud’s structural model are drastic enough to consider it a distinct model of personality formation. The central distinction of Fairbairn’s theory from Freud’s is a dramatic reworking of the ego. Fairbairn focuses a good deal of attention on an expanded view of the ego and its role in personality formation in addition to extrapolated applications of repression. Through a series of shifts motivated by inconsistencies he saw in Freud's Structural Model and Klein's theory, Fairbairn replaces the concepts of id and superego with a more dynamic view of the ego itself, wherein there is a perpetually fluid energic exchange among the ego, the libidinal ego, and the internal saboteur. Thus the major contention is that the ego exists from birth not a result of redirected libidinal energy. In so doing, Fairbairn is able to account for a broad range of pathology, including more regressed pathology such as schizophrenia, as it is the splitting of the ego which is the seat of psychological disturbance.

Winnicott’s ideas represent several changes in psychodynamic theory. In the sense of a broad, formal shift, Winnicott’s moving forward from development to pathology, as opposed to moving from pathology backwards to development, in constructing a theory of personality is an important contribution, as it moves away from what tended to be an over-pathologizing of common character organization. Another major contribution, which may at first seem paradoxical, is his belief that mother-child differentiation leads to individuation, which in turn leads to integration. It is in the ability to perceive the other as separate from oneself, a paradigm formed through the development of the mother-child relationship, that allows for the accommodation of anxiety-provoking, confusing, and hurtful interactions with those who one cares about without major disruption to the overall functioning of the relationship. The integration of disparate interpersonal experiences is ultimately a reflection of intrapersonal and intrapsychic integration. The self is experienced fluidly and compassionately.

Fairbairn and Winnicott Response

2006-03-20T13:09:00.000-05:00

The Independent School of British Psychoanalysis is an aggregate of independent theorists, with their own distinctive concepts and ideas around a general theme, yet lacking any one cohesive theory. The independent nature of this particular school was thought of as beneficial, since it allowed for open-mindedness in their theoretical development, and allowed for the ability to freely make adjustments to an idea when a challenge to that theory arose. The more general tenets of the Independents expanded on and challenged some of Freud’s central theories. While rooted in Kleinian thinking, the independent school incorporated aspects of the interpersonal relationships and the environmental effects of the developing child and their implications. Two predominant theorist in the Independent school, were Fairbairn and Winnicott, both of whom added coherent elements to the developmental process and arrest of the child, as well as technical innovations to the therapeutic process.
Two of the more generalized views of the Independent school challenged some of Freud’s theories, particularly when incorporating aspects of object relatedness. There was a shift away from the idea that libidinal drives were motivated solely for the fulfillment of pleasure and reduction of anxiety. There was also a shift away from the structural model, and instead, a focus on the different aspects of the ego, and the dynamic interactions among the ego itself was the significant factor involved with the sense of self and pathology. In addition, one major distinction between Freud’s theory and that of the independent school, is the role the environment plays on the development of the child. Freud did consider the constitutional factors involved in a child’s development, including biological predeterminants. The independent school, on the other hand viewed the environmental factors as the sole determinant in a child’s healthy or pathological development, considering nurture explanations over nature.
Fairbairn in particular challenged Freud’s ideas of libidinal drives. Fairbairn theorized that the libido is driven towards object-seeking. The pleasure gained and anxiety reduced comes secondary to object relatedness. The motivation of the libido is less so a matter of discharging energy, but more so relating to ego-objects, both internally and externally. Fairbairn also is distinguished for his notion of conflicts among the ego, challenging Freud’s structural model. The classical psychoanalytic view towards pathology, simply put, involves the repression and unconscious anxiety manifesting in intersystemic conflict which eventuates in symptom formation when that conflict is reactivated. The conflict that arises is between the id, ego, and superego functioning. Fairbairn, on the other hand, believes that pathology is a result of conflicting ego-object systems. If there is early trauma such as insufficient intimacy with the primary object, this memory will become dissociated from the ego and as a result, the ego (the self) will split among itself. This lack of integration of the ego causes conflicting multiple ego-object systems, which, for Fairbairn, is the root of pathology.
Winnicott challenges Freud’s theory on the basis of the frustration of needs and the ability of the infant to differentiate his self from his environment. Freud’s structural theory suggests that there is a frustration of instinctual wishes and this frustration cause the wishes to be repressed into the unconscious, which as described above, is foundation for pathology. Winnicott, on the other hand believes that frustration of ego needs is the significant determinant of pathology. The child’s ego needs are not met by an unresponsive caregiver, or one who is lacking good enough mothering, which causes a fragmentation of the continuity of being, leading to the disintegration of the sense of self. A False-self structure may develop to protect the fragile true self from this disintegration. The child is able to, in a sense, realize the environment is not meeting his ego needs, because he can in fact distinguish or differentiate between himself, as a separate physical entity, from the environment. This challenges Freud’s notion that infants are unable to differentiate. When there is a indication for the child that his ego needs are not being met, a false self is formed, acting as a defense or “caretaker” for the self, in order to protect the true self from further trauma.
The Independent School of British Psychoanalysis, with particular theorist s including Fairbairn and Winnicott, contributed to a more coherent theory regarding the effects of the environment and interpersonal relationships on a developing child, whether it facilitates or causes an arrest in development. There are many aspects of this theory that distinguishes itself from that of Freud’s, and even alleviates some of the controversial aspects of classic psychoanalytic theories. However, other aspects actually absorb some of Freud’s ideas such as the notion of unconscious conflict as a basis for pathology and made significant adjustments that can now be explained by empirical research. A few of these adjustments include the conflict that is among a fragmented ego, or that the developmental frustration is brought on by ego needs that are not being met due to insufficient interpersonal relations.

Freud, Fairbairn, and Winnicott

2006-03-19T22:15:00.000-05:00

Freud, Fairbairn, and Winnicott
The Independent school of British psychoanalysis produced such theorists as Fairbairn and Winnicott. Following the direction of Balint, these theorists believed that the desire to be loved was primary, unlike the Freudian concept of primary narcissism, which theorized that infant self-love precedes object love. In the Independent school’s view, the infant views itself as undifferentiated from the love object, which exists to serve or to love the infant. The infant’s ego experience is one of omnipotent control over the object. As long as the object is available and under the infant’s control, it is viewed as being loving.
A further difference between Freudian theory and the Independent school was articulated by Fairbairn. He viewed the libido as being primarily object-seeking, versus being primarily pleasure-seeking. In his view, pleasure is a secondary gain of object relatedness.
Both classical Freudian theory and the Independent school view adult psychopathology as reflecting some early trauma. The classical model applies to conflicts that arise during the oedipal phase of psychosexual development (3-4 years of age). The Independent school’s theory applies to pathologies that arise before the oedipal phase. Both Winnicott and Fairbairn view schizophrenia as the result of a total lack of a maternal care while the infant still is dependent upon the mother, viewing her as an undifferentiated part of himself. Personality disorders, according to Winnicott, result from having had a “good enough mother” who then was lost (deprivation).
Fairbairn also identified certain pathologies as originating during infancy. Schizoid personalities result from an infant viewing his love for his mother as being destructive. Depressive personalities result at a later stage when the infant views his aggression was destructive of the mother.
The dialectic view of the infant is a final difference between the Independent school and classical theory. Freud viewed the infant as being unable to differentiate the self from the environment. However, Winnicott viewed the infant as perceiving itself as a separate physical object.

Robert's Reaction: Winnicott, Fairbairn

2006-03-19T22:12:00.000-05:00

Fairbairn and Winnicott propose many theoretical innovations that diverge dramatically from Freud’s developmental theory, adding new concepts to the psychoanalytic literature. At the same time, their infancy-centered theories revitalize some key Freudian concepts, including the ego, drives, and ambivalence.

Fairbairn and Winnicott seem to eschew, or at least sidestep, two key elements of Freudian theory: structural theory and psychosexual stages. For the British Independents, drives are present, as are parental influences that delimit experience and impart rules, but explicit mentions of the id and superego are nowhere in sight. Drives are no longer pleasure-seeking, but object-seeking: high-quality interactions with the object bring pleasure and relief from anxiety. The ego is the paramount psychic agency for Fairbairn and Winnicott. It is the job of the caregiver, they believe, to facilitate healthy ego development. Winnicott’s belief in the psychogenic primacy of infancy led him to abandon Freud’s psychosexual stages. Winnicott seemed to believe that psychological health or disorder arise NOT from the child’s handling of oral, anal, and oedipal conflicts, but instead from the sense of self founded by early dyadic interactions. The child’s “true self” begins in infancy, as he moves between experiences of fusion to experiences of independence, between experiences of “me and not me.”

Fairbairn’s and Winnicott’s emphasis on early environment ascribes more influence to caregivers than Freud. An adroit caregiver must be able to facilitate (and tolerate) a range of emotional states in the infant. On the one hand, the mother’s affective mirroring, anticipation, and “comprehension” of the infant’s affective state help to create the infant’s self-esteem. On the other hand, inevitable failures to anticipate baby’s needs and wants (a) present opportunity for reparation (b) let baby know that he and mom are separate, and not a fused, omnipotently-controlled pleasure machine and (c) give the baby chance to make “creative gestures” (like distressed crying in response to discomfort). Both Winnicott and Fairbairn highlight the importance of caregiver’s regulation of the baby’s ambivalence – his primal fears of losing himself when he’s dependent and of isolation when he’s independent. This dyadically regulated ambivalence differs from Freud’s depressive ambivalence, which is a cycle of unsuccessful, sexually-charged cathexis, repression, and introjection.

Winnicott’s theoretical perspective also suggests a clinically helpful addition to Freud. Thinking about patients’ utterances and patient/therapist interactions as creative gestures makes form – how and when patients speak, for instance – as important as content. Attention to form (e.g., timing, affective tone) might be especially helpful when working with inarticulate or disorganized patients.

fairbairn, winnicott, and dear old freud

2006-03-19T21:54:00.000-05:00

The Independent School of British psychoanalysis, including Fairbairn and Winnicott, made major contributions to theories of early development and psychopathology with respect to their move away from a structurally-driven model to one much more relational in nature, creating a theory of “selfobject” and positing a dynamic interaction of complementary internal and external objects that comprise one’s self organization.

Rather than view it as a complete departure from Freud’s libidinal theory, I tend to see the ideas of Fairbairn and Winnicott as deepening the exploration into the unique elements that make up interpersonal interactions, particularly those between mother and infant, and how these interactions affect both intra- and extrapsychic representations thereby determining one’s sense of self as well as the way one behaves in certain situations. Freud viewed the infant as a pleasure-seeking, isolated entity; Fairbairn and Winnicott challenge this notion by seeing the infant as a relationship-seeking, social being, affected by the social environment in which he lives. As environments are ever-changing, the theory involves a sense of dynamicism about relationships, as well as the representations thereof, that allows for socialization as an adaptive measure for various circumstances.

The theories of Fairbairn and Winnicott, while logical and insightful, largely stem from notions of environmental factors exerting great influence on development and potential pathology. This beckons the question of causality, which seems to be somewhat lacking from these theories. Indeed, upon further inquiry into the nature versus nurture debate, in this case, biology seems to win out, with studies of twins reared in separate homes demonstrating that pathology may arise regardless of good or bad environment. Therefore, it is essential that any theory of object relations use the idea of temperament as a starting point from which to describe the influence of social interactions. In that respect, the theories of Fairbairn and Winnocott are perhaps best viewed, not as complete upheavals, but rather as complementary additions to the biological framework of Freud.

Sheila's Reaction: #5

2006-03-19T21:53:00.000-05:00

The emergence of the Independent School represented a movement away from the classical structural theory pioneered by Freud toward a “self-object” theory. While wishes remained a focus, the interaction was now between different parts of the ego, or “self”. Fairbairn and Winnicott were particularly influential figures who emerged from the Independent tradition, making significant contributions to developmental theory.

In his writings, Fairbairn highlighted the role of emotion and the self, and saw them as inseparable; an individual cannot have one without the other. His theoretical framework characterizes libido as object-seeking, while Freud’s libido is driven by pleasure seeking. In Fairbairn’s view, pleasure and the reduction of anxiety is more closely related to the quality of an ego-object relation. The goal is maintaining relatedness, not the release of energy. If the desired level of intimacy with a primary object is not attainable, the self will split. Fairbairn is perhaps best known for positing that psychopathology is not a product of conflict among systems but a result of lack of integration. Thus, we see repression fading into the background as the focus shifts to “incompatible ideas”. While Freud’s emphasis was on conflicts occurring during the oedipal stage, Fairbairn and his contemporaries in the Independent School saw disorders of the self as emerging from trauma occurring before that stage. He posits that serious trauma at this early age is not repressed, but actually “frozen” or dissociated from the “functional self”.

Winnicott took issue with the Freudian idea that the infant is initially incapable of differentiating the self from the environment. He believes that indeed, infants can do so and there is a substantial body of research that supports his claim. Like Fairbairn, he does not see the infant as subject to uncontrollable, unconscious urges. Instead, the infant is seen in close relation to the mother and the focus is upon the quality of the “holding environment” that ideally the “good enough” mother provides for him. In this environment, the mother displays a special sensitivity to the infant’s moods and mirrors his affects, so much so that for a time the child believes she is under his control. Eventually, Winnicott writes, the “good enough” mother’s failure is unavoidable, but it is this failure that actually facilitates healthy growth and development. Fonagy writes that Winnicott’s work shows a particular understanding of the therapeutic process. One might say that the therapist in a sense supplies a similar “holding environment” for patients, a safe space in which they can integrate and learn to tolerate feelings of ambivalence.

Freud vs. Winnicott & Fairbairn

2006-03-19T18:56:00.000-05:00

Both Fairbairn and Winnicott are major contributors to the British / Independent school of psychoanalysis. Theorists from this school departed from Freud’s libidinally driven, structural idea of development towards a self-object model. Emphasis was maintained on unacceptable desires and wishes however, parts of the self/ego came to be viewed as interacting with each other, corresponding with internal and external objects.

Fairbairn’s greatest contribution to modern psychoanalytic theory is the concept of splitting. Here, insecure attachment to primary caregivers generates conflicting ego-object systems, resulting in psychopathology. Another Fairbairnian contribution is the idea that emotion does not exist separate from the self. As a result, the libido is primarily object (not pleasure) seeking. From this perspective, if the developing child has strong ego-object relationships, he/she will have greater pleasure and greater anxiety reduction. This contrasts Freud’s belief that discharge of libidinal energy causes anxiety reduction.

Winnicott emphasized the individual’s desire to develop a sense of self and the human capacity to conceal or misrepresent portions of the self. According to Winnicott, the mother-child interaction is critical and is comprised of three primary functions leading to healthy development: holding-integration, handling-personalization, and object-relating. The first and second actions refer to a mother’s ability to literally and emotionally hold an infant, leading to the solid, organized construction of sensorimotor abilities. The latter interaction describes a mother’s heightened state of awareness to herself, her body, and her infant, facilitating the infant’s view of the mother as an extension of him/herself and his/her wishes. Another important contribution made by Winnicott is the idea of transitional objects – items used by an infant to assist in achieving independence. Transitional objects help infants navigate the distance between “me and not-me” as they become aware of the separation between themselves and their mothers.

Desiree-Freud v Winnicott & Fairbairn

2006-03-19T18:49:00.000-05:00

In contrast to classical Freudian theory, both Fairbairn and Winnicott’s theories concerning early development center on the dynamic interaction of emerging parts of the self and their relation to and interaction with the ego (itself) as well as external objects. Fairbairn argued that infants are hard-wired to seek gratification and pleasure through ego-object relations and that the foundation for the development of pathology is set when difficulties arise within the course of the infant’s interactions with the primary object. Unlike Freud, Faribairn’s object relations theories did not consider narcissistic unconscious libidinal drives to be the primary driving force for the infant’s progress throughout the course of development. Sufficient levels of nurturing and proper “mirroring” interactions appear to constitute the foundation of Winnicott’s “good-enough-mothering” theory. In this theory, he posits that the mother’s ability to attend to the infant’s needs while simultaneously frustrating the child encourage the development of successful adaptation to the external environment and allow the child to appropriately perceive the mother as a separate other whom the child can relate to but does not have omnipotent control over.

Deeply rooted in Fairbairn’s object relations theory is the notion that early severe trauma during critical ego development stages sets the foundation for the development of pathology. In particular, he saw the presence of the schizoid reaction of withdrawal as being directly linked with feelings of being unloved or unacknowledged from the primary love object, resulting in a defensive need to withdrawal from environmental stimuli or future interactions with others in order to defend against repeated object interaction failures. In close agreement, Winnicott’s model for the development of pathology centered on the idea of having mostly positive and nurturing interactions with the primary object and thus he saw the onset of disorders such as schizophrenia as the result of having had a primary love object who then had been lost, causing the child to feel forever maternally deprived. Both Fairbairn and Winnicott’s theories emphasize the importance of positive object interactions and contrast Freudian notions of pathology resulting from repressing intrapsychic conflicts encountered during psychosexual stages of development.

reaction paper #5

2006-03-19T18:37:00.000-05:00

How does a child’s mind develop?
The main factors impacting child development may be described as a continuum where drives and inner conflict are on one hand and relationships and environment are on the other. Winnicot and Fairbairn built on other theorists like Klein and Bion and shifted their interest towards increasing emphasis on relationships and attempts to understand development as a unit in interaction. Therefore, they shift away from Freud’s conceptualization of development. Winnicot and Fairbairn emphasize object relations as being more crucial in their impact on the development of mental structures and functions. Freud’s theory of development, as we all know by now, emphasized unconscious intra-psychic factors (such as instincts and fantasy) as the main forces which impact mental structures. Thus, for Freud, relationships are secondary to instinctual drives and limited to only one sort of object relations: the one that evolves out of ungratified drives.
The Independents no longer restricted themselves to a libidinally driven structural model and developed a self-object theory. In this theory, although drives and whishes play some role in the development of mental structures, a new explaining system, where parts of self are seen in “dynamic interaction with each other and complementary internal and external objects”, is taking a major role.
For Winnicot, who worked with mothers and their infants as well as severe adult psychopathology, very early relational experiences with real behaviors (holding, handling, good enough mother, non-intrusive) and real parents (mainly the mother) are crucial for healthy development of the true self. Freud on the other hand, didn’t emphasize early childhood experiences or real environmental determinants.
Fairbairn pointed out that the basic desire is not for pleasure but for relationships (“object seeking”). Moreover, attainment of desired relationships reduces anxiety. Thus the root of psychopathology is not a consequence of unconscious content but of lack of intimacy in early relationships that resulted in multiple self-object systems.

Matt: Fairbairn, Winnicott, Freud

2006-03-19T14:40:00.000-05:00

The biggest difference between Freud and the British Independents lies in the latter’s focus on variations in the environment as a source of both normal development and psychopathology. To simplify somewhat, Freud is concerned with the infant’s intrapsychic conflict and treats the parents as though they are almost static figures, playing a biologically determined role. Winnicott and Fairbairn are more interested in the minutia of how the parents fulfill their role, and detail the impact that this has on the developing child. It’s all about relationships for these guys. In stark contrast to Freud, Fairbairn sees the trauma of not being understood, recognized, and loved as the basic root of psychopathology. Winnicott spent his career examining the mother-infant relationship in minute detail. For him, psychopathology is caused by flaws in this relationship—especially in the mother’s responses to her infant’s dependence and then emerging independence. (He overdid it on this point, even to the extent of denying a role for constitutional (genetic) factors—another area where he differs from Freud). His ideas on the centrality of the self are precursors to Kohut and self-psychology, even to the extent of viewing the role of psychoanalysis as a kind of re-parenting experience.
The writings of the British Independents are both an elaboration of Freud’s theories of development and a challenge to them. While Winnicott and Fairbairn were in fact building on Freud’s concepts, using them as a point of departure, they put their emphasis on very different concerns. A day in the consulting room with Dr. Freud would look a whole lot different from one with Dr. Winnicott.

Reaction #5

2006-03-19T12:39:00.000-05:00

The Freudian notion of id gratification shaping infants is abandoned by the British school, namely Fairbairn and Winnicott. For Fairbairn, the infant is not seeking pleasure. It seeks an object for relatedness. Anxiety and displeasure are not soothed by the discharge of energy, but by the quality of relatedness to an external object. Fairbairn talks not about repression and the unconscious, but about deprivation of intimacy leading to potential pathology. If needs with the primary object are not met, “splitting” of the ego can arise. Ultimately, ideas will lack integration and Fairbairn posits that this is precisely how pathology develops.

Ideal developmental circumstances between Freud and Winnicott seem quite similar. For Freud, parenting is a balancing act where the parent should not be overly harsh and dominating, but should also not be too indulgent. For instance, in toilet training the parent should not constantly scold a child for making mistakes. Yet, the parent should also avoid being overly praising for a job well done. In either situation, an unrealistic ideal can be internalized by the child and negatively impact personal development. Winnicott’s idea of ‘good enough mothering’ seems to compliment Freud’s idea of optimal parental involvement. Winnicott assumes that shortcomings are inevitable in parenting. These shortcomings should be embraced, as they become the primary motivator for growth. For Winnicott, development is primarily concerned with achieving autonomy. The infant’s idea of the caretaker being ‘magically omnipotent’ gets challenged and selfobject differentiation ensues. Like Freud, this process should not be too abrupt and should follow a series of steps: holding-integration, handling-personalization, and object relating. The struggle in parenting, according to Winnicott, is a balance between privation and deprivation. With privation, the infant is too overwhelmed to recognize an external object. While severe deprivation can lead to mistrust in the caretaker and early object loss.

Kelly: Fairbairn and Winnicott

2006-03-17T15:04:00.000-05:00

Fairbairn’s theory is a radical departure from Freud’s drive/structural model. First, for Fairbairn, all meaningful human activity from infancy onward is relational with the ultimate goal of self-expression in relationship. The infant seeks not indiscriminant discharge and a return to homeostasis rather the primary goal is relationship with the object. In this way, Fairbairn inverts Freud’s conceptualization by positioning pleasure as secondary to object relations. Second, Fairbairn views endopsychic structure as inherently schizoid and pathological. Fairbairn’s infant (here, not unlike Stern) is born whole and hardwired for experiencing itself in relation to others. Endopsychic structure forms as a result of “bad”/intolerably unsatisfying experiences of self with other. At the risk of losing the life sustaining object, the infant splits - internalizing an aspect of the self, an aspect of the object, and the affective, purposive relationship between them. This internalization forms a subsystem that comprises the endopsychic structure: Libidinal Self and Antilibidinal Self. Hence, for Fairbairn the endopsychic structure is pathologic because it is formed by splitting the self in relation to other and maintained via repression. Third, drive/structural theorists allow for the internalization of both good and bad objects, all of which dictate levels of internal structure. For Fairbairn only “bad” objects are internalized to form endopsychic structure. Good objects are subsumed by the Central Self and constitute certain conscious endowments such as learning and memory. Structure, though inevitable, is not necessary for healthy development.

Winnicott plays the middle-man and maintains an allegiance with the drive/structural model although his concepts are fundamentally relational. He works hard to cast his work as a continuation of Freud and Klein while snubbing any association with Fairbairn. Winnicott stresses the developmental importance of object relatedness, specifically the mother-child dyad. For Winnicott, to view the newborn infant as an entity outside the maternal dyad is useless. The infant and his mother are inextricably linked in a developmental dance of holding, containing, object-relating and object usage. Winnicott stresses object relations not as a derivative of drive gratification or defense (Freud) but rather as an autonomous developmental need.

Winnicott and Fairbairn Challenge Freud: Lucy's reaction

2006-03-12T18:00:00.000-05:00

Theoretically, both Fairbairn and Winnicott represent a dramatic shift away from classical Freudian ideas. Winnicott’s divergence from Freud is best seen in his understanding of the mental life of the young infant. For Winnicott, the infant’s psyche is embedded in the environment, leading him to claim that there was “no such thing as a baby,” implying that the baby did not have an elaborate intrapsychic experience that was in some way not regulated or mediated by the presence of mother. Winnicott did not understand the infant to be autistically awash in id impulses (Freud) or internally-derived fantasy (Klein), but thought that the infant experienced and benefited from attuned maternal responding (and other objects in the environment) from a relatively early period. Of course the infant often misinterprets attunement as being under her omnipotent control, but the role of the enviroment in her self and personality development is crucial nonetheless. This is all in opposition to a Freudian position that the environment is an obstacle that requires the toddler/child to develop defenses and comprises in order to function.

Winnicott also opposed the Freudian notion that pre-oedipal traumas did not necessarily lead to psychopathology; in fact, both Fairbairn and Winnicott (like Klein) attributed the greatest importance to pre-oedipal failures and traumas, and argued that these were responsible for the most serious disorders of the self and psychotic illness.

Fairbairn seriously overhauls/replaces Freud’s intrapsychic model. Fairbairn does not believe that object-relatedness is the accident that Freud does, but believes that id-drives and urges are necessarily object-directed. For Fairbairn, there is no such thing as an urge or aim that is not object-seeking. Accordingly, Fairbairn’s conception of the nature of psychopathology entails failures in object-relatedness and the development of the self in relation to others.

Fairbairn, like Winnicott, stressed the importance of pre-oedipal failures in the development of the self and understood much of what we now understand as personality disorder (particularly schizoid types) to be the result of unrecognized, invalidated object love in infancy. Consideration of these issues at this period of development are not really present in Freudian theory.

Gillian's Freud V. Independents response

2006-03-10T18:09:00.000-05:00

Freud V. Winnicott and Fairbairn

The Independent school of British psychoanalysis emerged in the 1950’s, building on and amending some of Freud’s theories particularly about early development of the child. In general, Object Relations theories were developed in this school of thought, shifting the focus from Freud’s structural model of the id the ego and the superego organized according to drives and discharge of energy, into a model focusing on the ego in relation to itself, and specifically in relation to internalized objects as a means of getting emotional, rather than physical needs met.

Fairbairn was a major proponent of object relations theories. He believed that the libido was primarily object seeking, rather than pleasure seeking, and that anxiety was reduced by a high quality relationship between the ego and the object, either the external object or its internalized form. This differs from Freud’s view that objects were valued only as they facilitated the gratification of physical drives. According to Fairbairn, the major inroad for psychopathology was no longer repression and neurotic compensation, but rather the confusion of several incompatible egos in the self, caused by splitting in response to a lack of intimacy with a primary object. Ultimately, Freud’s model of repression in the development of psychopathology is still seen to apply if a trauma or conflict arises when the child is at an oedipal level of development. However Fairbairn postulated that traumas occuring earlier in development were stored in memories that were dissociated from the central ego, causing psychopathogenic multiple self-representations.

Freud and members of the Independent school agreed that the task of development was to move from fusion to separateness. However, while Freud believed that the infant could not initially differentiate the self from the environment, members of the Independent school such as Donald Winnicott believed that they could, and that this understanding of the mother as a separate being was key to development. According to Winnicott, the “good enough mother” created a holding environment for the infant, wherein during early development she was so attuned to the infant that he could feel that he had omnipotent control over her. Healthy development depended on this initial sense of magical omnipotence, followed by appropriate frustration of that omnipotence once the child was old enough, allowing an opportunity for a reparation with the newly separate mother, and the early development of the true self.

Ultimately, the British Independent School built on Freud’s idea that internal conflict and the thwarting of needs lays the groundwork for psychopathology. However, where Freud saw the internal conflict structurally, with the ego working to repress the desires of the Id, the members of the Independent school saw the conflict as occurring between multiple self-representations in the ego. While Freud believed that the fodder of conflict came from ungratified physical urges and drives, the ego psychologists postulated that it was the ungratified need for intimacy with a good object that led to internal conflict, and eventuallyl to the splitting of the ego.

that was hysterical!! (or was it compulsive?)

2006-03-06T13:17:00.000-05:00

The obsessive-compulsive and hysterical characters seem to lie on opposite sides of a continuum, in terms of their cognitive and defensive styles. On one hand, the obsessive tends to overthink, overvaluing rational thought and intellectualization while the hysteric tends to be overly feeling, operating through pure emotion and sexualization, often regressing into childlike states. In a sense, one might argue that the two complement one another and could probably benefit from a mutual exchange of characteristic traits in order to achieve a better balance in their lives. In reading about these two personality styles, I could not help but think of two of my closest friends, whom I shall call Katie and Allison.

Katie was brought up in a Midwestern suburb, the younger of two. Her family is the picture of the “ideal” American family: her father is the head of a successful family business and her mother, a former homecoming queen, is a homemaker who maintains a perfect, immaculate home. She was raised to be a high achiever and to always present an outward appearance of perfection. While Katie is extremely personable and does not present with the typical isolative quality one might expect from an obsessive-compulsive, she is consumed with constant feelings of guilt at not doing enough, in spite of a highly successful record of professional achievement as a medical resident in dermatology (in addition to graduating first in her class from medical school) as well as having many close interpersonal relationships, including one with her husband of almost two years. Much of her daily life is characterized by an overarching need for control, manifested through her compulsive list-making, her intellectual dissection of problems, and many sleepless nights spent cleaning, cooking, or doing whatever she thinks it will take in order for things to be perfect. She tends to make decisions based upon what she thinks will please others, devaluing her own desires, yet often expresses feelings that somehow she has disappointed them regardless. During her adolescence, she suffered mildly from bulimia.

Allison, on the other hand, in spite of great intelligence and genuine concern for others, often comes across as being overly dramatic and insincere, as she tends to seek attention, looking for affirmation from others. Her parents are very doting; however, her mother is a rather helpless, anxious individual who has been further enfeebled by her father’s desire to take care of her. While her relationship with her father is very loving and seemingly nurturing, the implicit expectation for Allison has always been that she will rise above and be better than her mother. Unfortunately, although she is quite a capable individual, Allison often falls prey to feelings of being overwhelmed and unable to take care of herself. She frequently seeks out male companionship in order to feel good about herself and gain some sense of power, using seductive tactics to attract them to her. While she can certainly be manipulative at times, it is generally due to an intense anxiety that overcomes her, forcing her to act out in ways that appear to be self-serving and appear to quell her sometimes overly emotional state.

These two women, while perhaps not the most extreme examples of obsessive-compulsive and hysterical personalities, respectively, certainly exhibit strong degrees of each in their respective character organization.

Advanced Psychopathology

Matt: Cultural Differences

Psychoanalytic Theory and Multiculturalism

referential vs. indexical self

The final one...finally

*gasp* *wheeze*

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

the last one

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

Sheila: Le Fin, Merci a Dieu!

Kelly: Le Fuckere el Fini Celebrationes dans la Pantalone!

Joshua, El Fin

Sara's Last Reaction Paper of the Year!!!

Stern: Vitality Affects, Amodal Perception, and Attunement

Stern and Affect Attunement

Stern on Vitality Affects, Amodal Perception & Attunement

stern & affect attunement

James's Reaction #8

vitality, amodal, affect attunement

Stern's affect attunement

Vitality Affects and Amodal Perception: Lucy's Reaction

Kelly: Reaction Stern

Joshua, Amodal Perception, Vitality Affects, and Affective Attunement

Sara's Reaction Paper- Vitality Affects and Amodal Perception

Amodal Perception and Vitality Affects and How They Contribute to Affect Attunement

Gillian's affect attunement

Matt: Affect Attunement

Stern: Amodal Perception, Vitality Affects & Parental Attunement

Ethnic Russian Immigrants in New York: Cultural and Historical Factors that Contribute to their Psychology

Life Across the Border: Family Composition and Mental Health Behavior of Mexican Americans

Chinese Americans – Family Structure, Interdependence, Culturally Defined Symptoms, and Help-Seeking Behavior

Country Clubs, the Ivy League, and the Episcopal Church: The Cultural Constellation of White Anglo-Saxon Protestants in America

An Exploration of Orthodox Jewish Culture: Values, Norms, and Mental Health Implications

Lucy's Annotated Bibliography: Working With Jamaican and other British West Indian Clients

Kohut, Bromberg & Narcissism

bromberg vs. kohut - reaction paper #7

James reaction #7

it's all about the mirror neurons - response #6

Matt: Kohut & Bromberg

Sheila's Reaction: Kohut & Bromberg on Narcissism

Narcissism: Bromberg v Kohut

Narcissism, Joshua's Response

Sara's Response Paper- Narcissism

Bromberg Vs. Kohut

Bromberg and Kohut on Narcissism: Lucy's Reaction

Gillian: conceptualization of narcissism

Kelly: Bromberg and Kohut

Relational Theory on psychopathology, diagnosis and treatment

James's reaction # 6

Relational Theory and the Diagnosis and Treatment of Paranoia

Relational understanding of paranoia

Interpersonal/relational take on paranoia

The Interpersonal-Relational Approach and Paranoid Personalities

Matt: Interpersonal/Relational Psych & Paranoia

The Relational Model: Implications for Diagnosis & Treatment

Relational Persective on Paranoia: Lucy's Reaction

Relational Approach to Diagnosis & Treatment of Paranoia

Sara's Response: Relational Conceptualization of Paranoid Personalities

Gillian's interpersonal/paranoid response

Kelly: Interpersonal and Paranoid Personality (Uhg)

Freud V. Independent School of Psychoanalysis

The Contributions of Fairbairn and Winnicott

Fairbairn and Winnicott Response

Freud, Fairbairn, and Winnicott

Robert's Reaction: Winnicott, Fairbairn

fairbairn, winnicott, and dear old freud

Sheila's Reaction: #5

Freud vs. Winnicott & Fairbairn

Desiree-Freud v Winnicott & Fairbairn

reaction paper #5

Matt: Fairbairn, Winnicott, Freud

Reaction #5

Kelly: Fairbairn and Winnicott

Winnicott and Fairbairn Challenge Freud: Lucy's reaction

Gillian's Freud V. Independents response

that was hysterical!! (or was it compulsive?)

gasp wheeze