"Dèyè chak timoun gen yon fanmi e yon kilti" - Behind Every Child Is A Family & A...

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Rebâti Santé Mentale:3rd Haitian Mental Health Summit

Collaborative Care for Mental Health

in Haiti and the Diaspora:

Culturally Sensitive Solutions for Wellness Across the Lifespan

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Rebâti Santé Mentale :3ème Conférence sur la Santé Mentale

en Haïti Soins collaboratifs en santé mentale

en Haïti et la diaspora :

Solutions adaptées à la réalité culturelle pour le bien-être tout au long de la vie

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Jungle

Artiste: Stéphane Senghor

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Dèyè Chak Timoun Gen Yon Fanmi e Yon Kilti

Behind Every Child Is A Family & A Culture:Cultural Family Therapy

with Haitian Families

Vincenzo Di Nicola

Maisonneuve-Rosemont Hospital

University of Montreal

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Dèyè Chak Timoun Gen Yon Fanmi e Yon Kilti

Derrière chaque enfant on retrouve une famille et une culture :La thérapie familiale culturelleavec les familles haïtiennes

Vincenzo Di Nicola

Hôpital Maisonneuve-Rosemont

Université de Montréal

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Vincenzo Di Nicola MPhil, MD, PhD, FRCPC, FAPA

Chef du Service de pédopsychiatrie, HMR

Chief of Child & Adolescent Psychiatry, HMR

Professeur titulaire de psychiatrie, Université de Montréal

Professor of Psychiatry, University of Montreal

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Learning Objectives

1. To identify the challenges and rewards of working with Haitian children and families in cultural transition.

2. To present a model for conducting Cultural Family Therapy with families in cultural transition, adapting to living in Montreal.

3. To sensitize clinicians of the need for cultural understanding and review the clinical tools available to guide practitioners in their work across cultures.

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Dèyè mon, gen mon.

Behind the mountain, there are mountains.

—Haitian proverb

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Short Abstract: “Dèyè Chak Timoun”

• Working with children and families across cultures during periods of cultural transition is a complex and challenging task requiring knowledge of children’s growth and change in their culture of origin and their host culture.

• Vignettes of children from Haitian families in Montreal experiencing mental health problems are presented.

• The features of the author’s model of Cultural Family Therapy (CFT) are outlined to demonstrate its responsiveness to the task of working with children across cultures.

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I: “Looking Across at Growing Up”

• Working with children and their families across cultures, especially during periods of cultural transition, is a complex and challenging task requiring knowledge of children’s normal growth and change under stable circumstances in their culture of origin and their host culture as well as their adapational difficulties across cultures.

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II: “A 3-Sided Puzzle” – Kids, Families, Culture

• While child specialists often express interest in families, differential rates of cultural adaptation among the members of a family confound the perception and origins of children’s problems.

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II: “A 3-Sided Puzzle” – Kids, Families, Culture

• Moreover, the difficulties of adaptation during times of cultural transition are inadequately conceptualized, poorly documented, and often trivialized as transitional problems of adaptation or ignored altogether under the rubric of youthful “resilience.”

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II: “A 3-Sided Puzzle” – Kids, Families, Culture

• In the vocabulary of psychology, psychiatry and other health care discourses, these problems can be summed up through three complex lenses, a veritable 3-sided puzzle:

o children (development)o family (attachment, relationships, transmission)o culture (the context for the first enculturation and

subsequent acculturations of children)

• Remember that behind every child is a family and a culture!

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III: Clinical Vignette – Culturally Different, Crazy or Confused?

• The author offers an overview of Haitian families in Montreal experiencing serious mental health problems.

• A clinical vignette highlights a Haitian adolescent coping with psychosis and trauma.

• The challenges of identifying patterns of cultural adaptation with these children are identified as are the requirements for an approach that is sensitive to all three crucial aspects of their predicaments—healthy growth, family relationships and cultural adaptation.

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Key Theme: Liminality vs Community

• Victor Turner: The Ritual Process

Liminality – « betwixt and between »

• Jean-Luc Nancy – La Communauté désœuvrée (1983) –

The Inoperative Community (1986)

"The community that becomes a single thing (body, mind, fatherland, Leader) ... necessarily loses the in of being-in-common.

Or, it loses the with or the together that defines it. It yields its being-together to a being of togetherness. The truth of community, on the contrary, resides in the retreat of such a being."

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Key Theme: Liminality vs Community

• Giorgio Agamben – La comunità che viene (1990) –

The Coming Community (1993)

La Communauté à venir (1990)

A philosopher of the threshold – he has written on indeterminate being, infancy, potenza, potentiality

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L’enfance est un

couteau planté dans la

gorge. On ne le retire

pas facilement.

- Wajdi Mouawad

dramaturge

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Maya: A Cultural Changeling

Behind every child

is a family and a culture.

Adolescent – 16 years

Ambiguous, ambivalent, fluctuating identity

Charming/attachante

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Maya: A Cultural Changeling

Family

Culture

• Haiti (parents)

• USA (born in Miami)

• Montreal (since age of 10)

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Maya: A Cultural Changeling

Family

Culture: Identity vs Belonging

• Haiti

• USA

• Montreal

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“I’m American”

or

“I’m bisexual”

Maya lives an ongoing process of change,

adaptation, change …

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Maya: A Cultural Changeling

Family

Family Culture

• Haitienne/“American”/québecoise

• Mother: older, single parent, déracinée

• Evangelical Christian who reads the Bible daily

• Bible reading and prayer are sources of comfort and healing

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Maya: A Cultural Changeling

Family

School, Social and Health Care Services

• School:

Équipe ad hoc / “Ad hoc team” (en français)

• Social services:

CLSC team – SMJ – Santé mentale jeunes – Youth Mental Health (en français, anglais et créole)

• Health care services:

Child & Adolescent Psychiatry (ER, Outpatient, Inpatient)

(en français, anglais, créole)

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Collaborative Care

Collaborative mental health care refers to a family physician or other primary care provider working together with a psychiatrist or other mental health worker in a mutually supportive partnership.

The responsibilities of care are shared and apportioned according to the respective skills of the providers and the (changing) treatment needs of the patient.

– Nick Kates (2009)

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Maya: Psychiatric Diagnoses

Outpatient Psychiatry:•Dx Deferred – no evidence of psychotic disorder or ODD•Parent-child relationship problem•Possible search for sexual identity

Inpatient Psychiatry:•Schizophreniform Disorder•Borderline intellectual functioning

Neuropsychology: •Dyslexia,•Language Acquisition Disorder

Speech Therapy: •Severe language disorder

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Maya: Psychiatric Diagnosis

Family

Narratives of suffering,

Beliefs, rituals

• “Psychiatric problems

belong in the asylum”

• Prayer and Bible reading are healing

Culture

Explanatory models

• Haitian Creole culture

• Religion

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Maya: Predicament

Family Culture

Cultural translation

• Haiti (parents)

• Miami (birth)

• Montreal

(since age of 10)

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Therapeutic

Therapeutic translation

• Parent-child conflict

• Attribution re:

illness and recovery

• Alien and alienating symptoms

• Lack of insight in psychosis:

• unawareness

• misattribution

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Maya: PredicamentDèyè Chak Timoun

Therapeutic Translation

“The Kraepelinian paradigm encouraged an ‘us’ and ‘them’ distinction between the mad and the sane ... [yet] we are mad to varying degrees, ... the boundaries of madness are subject to negotiation, and ... some of us get on very well despite being (in psychiatric terms) quite psychotic for much of the time.”

– Richard Bentall, Madness Explained (2004, p. 496)

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Maya: PredicamentDèyè Chak Timoun

There are two sources for this paradigm ...

• Emil Kraepelin’s categorical classification, and

• Karl Jaspers’ phenomenological psychiatry which established psychosis as ununderstandable due to an unbridgeable empathic chasm between psychiatrist and psychotic patient

Therapeutic Translation

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Maya: PredicamentDèyè Chak Timoun

“[T]he trouble is, you want to cure hallucinators, whereas I want to liberate them. I think they are like homosexuals in the 1950s – in need of liberation, not cure.”

“[W]hy not help some psychotic people just to accept that they are different from the rest of us? Fear of madness may be a much bigger problem than madness itself.”

– Richard Bentall, Madness Explained (2004, p. 511)

Therapeutic Translation

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Maya: Themes

Negative conceptions

• Shock• Trauma • Anxiety• Grief

Theme:

Rupture and loss

Positive conceptions

• Surprise• Learning

• Enchantment

• Celebration

Theme:

Discovery and growth

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IV: “Cultural Family Therapy”

• The features of Cultural Family Therapy (CFT) are outlined to demonstrate its responsiveness to the complex task of working with children across cultures.

• Key clinical tools of CFT are summarized to guide practitioners.

• The presentation concludes with a summary of gaps in current thinking and practice in working with children across cultures and a call for more studies of children in cultural transition.

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Family therapy is the starting point

for the study of ever wider social units.

—Mara Selvini Palazzoli (1974)

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Family Therapy

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Family Therapy

• Family therapy is the space that we open to explore the possibilities of the family

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Family Therapy Interventions

Family therapists do three simple things:

• enhance uncertainty

• introduce novelty, and• encourage diversity

(Di Nicola, 1997)

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Cultural Family Therapy (CFT)

An integration of cultural psychiatry

(McGill social and transcultural psychiatry

with elements of French ethnopsychiatry)

and family therapy

(Milan systemic family therapy with Bakhtin’s dialogism and

Andersen’s reflecting team)

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Key Features of CFT

• Recognizing families as unique cultures

• Immigrants as threshold people in transitional states

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Elements of CFT

Milan family therapy: Positive connotation

Andersen: Reflecting team

Nathan: Bombardement sémantique

Bakhtin: Dialogism

Lévinas: Face-to-face encounter

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Transcultural child psychiatry – What “changelings” can teach us

• “Changelings” – Defining transcultural child psychiatry

• “Cultural blindspots” – Gaps in current thinking and practice in working with children across cultures

• “On the threshold” – A call for more studies of children in cultural transition.

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“Cultural Blindspots”

“Cultural blindspots” – Gaps in current thinking and practice in working with children across cultures

• “Scotomata” –

Minimizing/denying/misunderstanding cultural differences

• “Cultural camouflage” –

Attributing to culture what is better explained by individual or family levels of functioning

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“On the Threshold”

“On the threshold” – A call for more studies of children in cultural transition

• Culture change means a change of language, values, routines and recipes for living, including how problems are experienced, understood and communicated and what solutions are socially sanctioned and culturally acceptable

• Children are especially vulnerable to such changes because they rarely make the choice to change culture and are dependent on their families whose members experience their own adaptational challenges

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Conclusion: Après-coup

• Nachträglich - deferred action – Freud

• Après-coup – Jacques Lacan

A chronologically anterior event as supplement to a posterior one

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Conclusion: Après-coup

• Après-coup – Jacques Lacan

A chronologically anterior event as supplement to a posterior one

What has always troubled me about “King Lear” is that Shakespeare gives his characters no past. In “Ran,” I have tried to give Lear a history. —Akira Kurosawa

Examples: Film or novel “prequels” that fill in the backstory of the characters

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Conclusion: Therapy as Après-coup

• CFT can be understood as “après-coup”

Understanding cultural context, which means going into the “backstory” of persons to elucidate their predicaments, creates this paradox – what happened “before” is a supplement to what is happening now.

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Defining Transcultural Child Psychiatry

At the crossroads of 3 domains:

• Mental health• Developmental studies • Social and cultural sciences

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Defining Transcultural Child Psychiatry

Domains

• Psychiatry

• Developmental studies

• Social and cultural sciences

Discipline

Child Psychiatry

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Defining Transcultural Child Psychiatry

Domains

• Psychiatry

• Developmental studies

• Social and cultural sciences

Discipline

Social and Transcultural Psychiatry

McGill University – 1950s and 1960s

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Defining Transcultural Child Psychiatry

Domains

• Psychiatry

• Developmental studies

• Social and cultural sciences

Discipline

Culture-inclusive developmental psychology

Jaan Valsiner (1987, 1989)

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Defining Transcultural Child Psychiatry

Domain

• Psychiatry

• Developmental studies

• Social and cultural sciences

Discipline

Transcultural Child Psychiatry

McGill Conference – 1991

Di Nicola (1992)

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Defining Transcultural Child Psychiatry

TCP is a field of study

that poses developmental questions

about child and adolescent mental health

in the context of culture

– Di Nicola (1992)

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Contact

Vincenzo Di Nicola

VincenzoDiNicola@gmail.com

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References / Bibliographie

Culture, Families and Therapy

• Di Nicola, V.F. Le Tiers-monde à notre porte : Les immigrants et la thérapie familiale, Systèmes Humains, 1(3), 1985, p. 39-54.

• Di Nicola, V.F. (1992). De l’enfant sauvage à l’enfant fou : A

prospectus for transcultural child psychiatry. In Grizenko, N., et al. (éd.), Transcultural issues in child psychiatry (pp.. 7-53). Montréal, Éditions Douglas.

• Di Nicola, V. (1996). Ethnocultural aspects of PTSD and related stress disorders among children and adolescents. In A. J. Marsella, M. Friedman, E. Gerrity, & R. Scurfield (Eds.), Ethnocultural aspects of posttraumatic stress disorder: Issues, research, and clinical applications (pp. 389-414). Washington, DC: APA Press.

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References / Bibliographie

• Di Nicola, V. (1997). A stranger in the family: Culture, families and therapy. New York, NY and London, UK: W.W. Norton & Co.

• Di Nicola, V. (1998b). Children and families in cultural transition. In S. O. Okpaku, ed., Clinical methods in transcultural psychiatry (pp. 365-390). Washington, DC: American Psychiatric Press.

• Di Nicola, V. (2004). Famiglie sulla soglia. Città invisibili, identità invisibili. In Maurizio Andolfi (ed.), Famiglie immigrate e psicoteraopia transculturale (pp. 34-47). Milano: FrancoAngeli.

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References / Bibliographie

• Di Nicola, V. (2011). Letters to a young therapist: Relational practices for the coming community. New York and Dresden: Atropos Press.

• Di Nicola, V. (2012). Family, psychosocial, and cultural determinants of health. In Sorel, Eliot, ed., 21st Century global mental health (pp. 119-150). Burlington, MA: Jones & Bartlett Learning.

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References / Bibliographie

Collaborative Care

• Craven M, Bland R. Better practices in collaborative mental health care: an analysis of the evidence base. Can J Psychiatry. 2006; 51(6) : S7-S72.

• Doherty W. The why’s and levels of collaborative family health care. Family Systems Medicine. 1995; 13(3-4) : 275-81.

• Kates N. Shared/collaborative mental health care. In JS Leverette, GS Hnatko & E Persad, eds., Approaches to Postgraduate Education in Psychiatry in Canada: What Educators and Residents Need to Know. Ottawa: Canadian Psychiatric Association, 2009, pp. 183-197.

• Kates N, Craven M, Bishop J, et al. Shared mental health care in Canada: the way ahead. Can J Psychiatry. 1997; 42(8) : 809-812.

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