Reflexivity and countertransference in a psychiatric cultural consultation clinic

Confronting a "big huge gaping wound": emotion and anxiety in a cultural sensitivity course for psychiatry residents

In his seminal volume From anxiety to method in the behavioral sciences, George Devereux suggests that any therapeutic or scientific engagement with another human being inevitably will be shaped by one's own expectations, assumptions, and reactions. If left unacknowledged, such unspoken and unconscious influences have the capacity to torpedo the interaction; if subjected to critical reflection, however, they can yield insights of great interpretive value and practical significance. Taking these reflections on counter-transference as point of departure, this article explores how a range of unacknowledged assumptions can torpedo good faith efforts to engender "cultural sensitivity" in a required course for American psychiatry residents. The course examined in this paper has been taught for seven successive years by a pair of attending psychiatrists at a longstanding New England residency training program. Despite the instructors' good intentions and ongoing experimentation with content and format, the course has failed repeatedly to meet either residents' expectations or, as the instructors bravely acknowledged, their own. The paper draws upon a year-long ethnographic study, conducted in the late 2000s during the most recent iteration of the course, which involved observation of course sessions, a series of interviews with course instructors, and pre- and post-course interviews with the majority of participating residents. By examining the dynamics of the course from the perspectives of both clinician-instructors and resident-students, the paper illuminates how classroom-based engagement with the clinical implications of culture and difference can run awry when the emotional potency of these issues is not adequately taken into account.

Hybridity and intersubjectivity in the clinical encounter: impact on the cultural formulation

Most case studies of the cultural formulation have focused on encounters with a single clinician. This article examines the assessment of a patient across different settings in which multiple clinicians developed separate understandings of the patient's identity. The formal cultural formulation prepared by the last clinician to work with the patient revealed a vastly different picture than what was previously recognized, reflecting both the impact of the identity of the clinician and the systematic evaluation process on the nature of the patient's responses. This suggests that cultural hybridity can stimulate new modes of inquiry as people integrate disparate cultural references to fashion a new identity. Intersubjectivity can also alter information elicited by clinicians. The conclusion highlights the need for practice guidelines for use of the cultural formulation across treatment settings.

Exploring identity, culture, and suffering with a Kashmiri Sikh refugee

Anthropology, psychiatry, and other fields that primarily rely upon verbal communication face a certain tension: to what extent is the information garnered accurate? How does accuracy change depending on context? Has the interviewer provided a safe space for respondents to share personal experiences? This paper explores concepts of identity, culture, and suffering with a displaced Kashmiri Sikh in a camp settlement in the province of Jammu and Kashmir. First, I will provide a history of the province and my project. Then, I will select the text of one respondent who uniquely claimed to follow two religions. Next, I will analyze the interview as "spoken text" for content and "unspoken subtext" for context. Finally, I will show how the respondent draws upon culture and religion for solace in an environment where secular state institutions such as the military and civil bureaucracy fail to provide justice. We shall reconcile these strands of thought by conceiving of the interview as a text co-produced and co-consumed by interviewer and interviewee and subject to interpretation.

Colonialism and countertransference: two cases of the sexual abuse of women by doctors

The presentation of encounters with two migrant doctors with a past history of extreme sexual exploitation of their female patients presents an uncomfortable coming together of cultural observation, medical ethics and therapeutic transference. Colonial and postcolonial stereotypes evoked by their actions are briefly considered.

Working with Jewish ultra-orthodox patients: guidelines for a culturally sensitive therapy

The epistemological gap between the medical reality of mental health practitioners and the sacred reality of their Jewish ultra-orthodox patients poses a major challenge for therapy. Based on our work with psychiatric patients from the ultra-orthodox community of northern Jerusalem, we propose a set of guidelines to cope with this challenge. Basically, we seek to incorporate religiously congruent elements, composed of metaphoric images, narratives and actions, into the wide range of our "secular" treatment modalities in order to respond to the patient's suffering, often expressed through distinctively religious idioms of distress. This endeavor calls for "a temporary suspension of disbelief" on both sides. The guidelines presented include three sets of factors which appear pertinent to working with ultra-orthodox patients. The first set is contextual in nature, dealing with the image of the clinic and its physical setting; the second discusses the necessary role requisites of the therapists; and the third one, accorded a central importance, deals on various levels with the therapeutic interventions administered in terms of form and content. Several case vignettes are presented to illustrate three classes of religiously informed interventions: healing rituals, dream interpretation, and the use of culturally congruent metaphors and stories. In the concluding part we discuss ethical and instrumental issues that the proposed therapeutic guidelines may raise.

Psychiatrist, traditional healer and culture integrated in clinical practice in Bali

This paper considers the psychiatrist-traditional healer relationship in clinical management of mental disorders in Bali. It also concerns the role of sociocultural factors in the etiology and management of mental disorder. The basic concepts and therapeutic strategies of Western psychiatry co-exist with the beliefs and methods of traditional healers. Often psychiatrists and traditional healers are involved with the same patients. A clinical case study of an episode of mass dissociative disorder (trance state) in which psychiatrists acted as consultants illustrates the integration of concepts of Western psychiatry and Balinese culture in the diagnostic evaluation and therapeutic strategies.

Paradise regained: "miraculous healing" in an Israeli psychiatric clinic

The articulation of the experience of distress in terms of prevailing cultural idioms is deemed a crucially important factor in the effectiveness of healing devices across the globe. This curative factor, however, is not easily attainable in multicultural settings where therapist and patient do not share the same world view or explanatory models. In the following case presentation we report a culturally sensitive employment of strategic therapy with an ultra-orthodox psychiatric patient in Jerusalem. Despite the enormous cultural gap between the parties, the therapists were sufficiently sensitive to the patient's mythic world to enable him to recast his traumatic experiences in the mold of key idioms of his cultural background. These idioms were amplified by providing the patient with a myth-congruent metaphor and manipulated to afford a dramatic resolution of his emotional conflict. In what follows we discuss the setting of the therapy, the patient's background and diagnosis and the course of treatment. Following a verbatim account of the last therapeutic session, in which the patient's self-reconstitution had been completed, we discuss the cultural idioms synthesized in the text and the pertinence of hypnotic and metaphoric therapies to multicultural settings.

The multiple meanings of ataques de nervios in the Latino community

Ataques de nervios ("attacks of nerves") have been discussed in the psychiatric and anthropological literature for over thirty years. The early psychiatric articles focused on the pathology expressed by the ataque. More recent articles by anthropologists and Latino mental health professionals have reconceptualized the ataque through understanding its cultural meaning and the social factors which provoke an ataque de nervios. This article is a contribution to this reinterpretation of the ataque de nervios among Latinos. Through a series of case studies, we argue that the ataque is an expression of anger and grief resulting from the disruption of family systems, the process of migration, and concerns about family members in peoples' countries of origin.

Supportive ties: a political economy perspective

The growing body of evidence linking social support and health has important implications for health promotion, disease prevention and treatment. But serious unsolved problems remain in the areas of research, practice and policy. Key among these are the ethical issues which arise when the reality of the importance of social support is translated simplistically into a policy emphasis stressing individual and interpersonal responsibility for health and justifying major cutbacks in health and social programs. This article examines the interdependencies between supportive ties on the individual and community levels and the larger social and political environments within which social networks operate. The effectiveness of families and other micro level support systems is seen as heavily dependent upon the adequacy of programs and policies on the local state and national levels which provide help with income maintenance, housing, transportation and other basic necessities. The cutting back of these more basic programs and services will be seen to disrupt the delicate web of natural relationships. Professionals concerned with the application of social support and health findings need to look beyond the individual and interpersonal levels toward policy and institutional level interventions. They thus may make an important contribution in advocating on behalf of those policies and programs which are critical to the effective functioning of natural helping networks, and which are at the same time faced with cutbacks. By helping alert colleagues, policy makers and the public both to the promise of the social support and health findings, and to the interdependence of support on local, state and national levels, health educators and others in the health professions may help to facilitate the effective application of these findings in policy and practice.