Category: Multicultural/Diversity

From Leicester to Shanghai

I have been living and working as a psychologist in China for the past four years. During this time, I have been teaching psychology, counselling, and psychotherapy courses to Chinese university students. I am originally from Leicester, Britain, where I was trained as a psychologist.

In this paper, I give my perspective based on my own experiences teaching counselling, counselling patients, interviews, and conversations with friends and colleagues in China. I also learned a great deal from the numerous families that invited me to stay with them for a week at a time to observe family life, including those who are from wealthy homes, as well as peasants in the countryside who could ill afford to share their food with me but graciously did. My research with women has come from over 200 interviews with women in China who told me their stories of their lives and marriages. The majority of my clients for my private practice came from referrals from students, other professors, Chinese friends and by word of mouth. Some of my clients came from the Internet who read my profile and sent email requests for help.

Getting a feel for Chinese culture

When I first started seeing clients in China I had to rapidly adjust to a different way of thinking by the Chinese patient. Although the issues were similar to those presented in any typical Western setting, such as relationships, depression, anxiety, family disputes, and lack of self-esteem, the Chinese mindset is profoundly different from my own in regard to their cognition and their way of thinking.

For a Westerner, it takes time to understand the subtlety of the Chinese way of thinking out problems and solutions. It helps to get a feel for the society, the pressures, the traditional ideals, and the judgmental, conforming behaviour. And I am always open to learning something new. You have to take your Western training and try to match the social consciousness of those you are trying to assist. This is not an easy process and does take time. All of my friends here are Chinese and I spend a lot of my time listening to how they see things; it is the only way to understand. Most Chinese do embrace Western culture and see it as an important part of their future and improvements to society. Of course, many Western ideas are not suitable to this society, so we discuss these issues as well.

Cultural factors and psychotherapy in China

What is the culture of psychotherapy in China? What makes up the thinking and feeling processes in the typical Chinese client? Understanding these questions gives us a beginning of how to understand and make trusting alliances with the Chinese patient. Several factors play a large role in the Chinese culture and character that affect attitudes toward seeking help and dealing with emotional difficulties.

Other-centered culture: Many Chinese people see their own problems as coming last compared to the welfare of others. While this is adaptive and socially valuable for the culture at large, it also keeps people from seeking help for themselves and taking a constructive approach to emotional and life problems. The Chinese client often thinks they are troubling the counselor with trifles and are more concerned about the therapist’s welfare than their own well-being. Knowing and appreciating this feeling as normative can also help move the focus to the client in a respectful and therapeutic way.

Culture of therapy? In China, there is almost no culture of therapy that is comparable to the Western culture of therapy. Indeed, there is a great mistrust among Chinese people toward authorities in general, perhaps going back to the cultural revolution and the intimidations and damage done to openness and trust during this time. Most people do not discuss their emotional turmoil with anyone, as they will lose face. In China there is a high degree of anxiety about judgement, criticism and evaluation by the state and other people. This, as you can imagine, makes it very hard to separate social norms from inner feelings. And it adds an extra layer of caution and suspicion when the client comes to see the counsellor.

Face: A crucial thing for the Western therapist to understand is that the Chinese client before them is not going to tell the truth in a direct manner due to the issue of face. This is not uncommon even among more free-thinking Western patients. However, for the Chinese this goes deeper. Face means not being put in a position of shame. In the culture as a whole, the taboo of mental illness is high. People will not admit to anyone that a family member has a problem of this kind or that they themselves are mentally unhealthy. The awareness of shame is very high and controls the daily aspects of business, government, and personal behaviour. A man whose wife is cheating on him will simply complain of headaches to the doctor and request some medicine to help him. To admit that this is in fact stress would be to admit weakness of character—so in turn the physical complaint is easier to cope with and address.

How shame and face affect therapy: First, even if you can get the person into a therapeutic relationship, they will avoid opening up about their concerns to avoid losing face in front of you. This then requires the therapist to begin sessions with an open honest approach to talking about shame and face directly to the patient. The client will instantly understand your meaning and seek a non-judgemental attitude from the therapist in return. It still may take several sessions for the client to trust the therapist before a real exchange of information based on the true nature of their problems comes forth.

Relationships and favour: In China the word relationship carries with it the factor of favour—that is, a relationship is about what you do for each other. Often, it is to one’s advantage that a person does a favour for you. In return, at some future point, you will return that favour—often many times bigger than the original favour. This system of relationships works through government, business, and in daily life.

For example, a university student is failing his course, so the father makes a generous contribution to the University building program, and the boy’s papers are then marked higher. In the West this is corruption, in China just a relationship being confirmed. In the future, the student may become successful; in turn one day he may be asked to contribute; he will feel under obligation to do so. It is this ongoing sense of obligation that causes a great deal of unhappiness in China. In England, we have the old-boys network: the inside practice of people from Oxford or Cambridge University giving jobs and promotions to those who, like them, went to the so-called right places. In China they have these forms of relationships born out of favour and return. Understanding this helps the therapist avoid being shocked and confused when favour is played out so directly.

Family (fealty) and the one-child policy: Family has always been strong in China and from an early age, family loyalty is seen as crucial to survival in the future, as one generation relies on the next for support in old age or infirmity. The one-child policy has dramatically affected the Chinese people’s experience and the lives of families. Under the one-child policy there comes an increased insecurity amongst the elderly and the young alike. Parents put enormous pressure on this one child from an early age to conform to educational expectations, moral responsibility, and the work ethic. In the past, maybe five or six children would have shared the burden, but today that is no longer true; single children feel the increasing need to make a success of life in order to care for their parents later. Cousins become brothers and sisters, which is an adaptive social support, but they cannot share the parental burden as each has their own.

The one-child rule is not rigid: one can have more than one child, but the state only recognises the first child as the recipient of state benefits and schooling freedom. Additional children become a financial burden to the parents. Girls are not appreciated in the family in the same way boys are. Although both genders tend to be over-indulged and spoiled in youth, the boys are definitely given more leeway and mothers’ dotage. In the past, boys were favoured over girls, and if a baby girl was suspected in the first pregnancy, it was often aborted or self-aborted under pressure by the family.

There are many issues that lead to the one-child policy that may seem quite unfamiliar to the Western point of view: over-population, not enough food, overcrowding in the city and lack of services in rural areas, shrinking agriculture and streamlining of production—all leading to massive unemployment and in some cases starvation and poverty. While the West may talk of the legitimate role and value of human rights—the right to choose to give birth or not—practical survival overrides this consideration in the minds of most Chinese people. “The impact of the one-child policy is yet to be known in terms of the psychology of these children, as well as the impact on society and families as a whole”, but it is something that is on the minds of psychologists, the people and the policy decisions of government leaders.

Clash of cultures: In modern Chinese cities it seems as if there is a KFC, McDonalds, or another mass-market fast food outlet on every city block. These fast food restaurants take away the traditional diet of high vegetable and low meat consumption. In return, the young are now enticed to a high-fat, high-sugar, and unhealthy but trendy diet of rubbish food. You can already see the problems of anorexia and obesity in children. The increase in cars and traffic in China is explosive and driving at high speeds is common with resultant high accident rates. The intensity and rate of change is so fast with the growth of the economy, population movement from the rural areas to cities, changes in family size and value systems, making it all quite stressful to keep up with and adjust to the changes.

Education: The educational system in China is very different from that in the West. It is based on memory learning and a strict examination system with little room for failure. Chinese schools manufacture the right qualities for the work place in conformity and strict adherence to authority figures. The system does not teach critical thinking, so wealthy Chinese often groom their one child to go to an overseas University to obtain a broader education, if they can afford it. The benefits of the Chinese educational system, including discipline and basic skills, are evident, but the pressures also impact the emotional well-being of the people.

Suicide: There are 25 suicides per every 100,000 people in China each year, compared with 15 per 100,000 globally. According to the Chinese Ministry of Health the leading cause of death amongst people ages 15 to 34 is suicide, which costs the country at least $3.5 billion a year and is second only to the US. A recent report by the Ministry on the nation's biggest killers listed suicide just after road mishaps.

Language issues: One Chinese woman inquired with me about how I could understand the Chinese psyche when I had no knowledge of the subtlety and non-verbal behaviour that accompanies the Chinese language and peculiarities of expression. I had to agree that this limits my understanding in some respects, which I attempt to fill in by asking more questions of the locals. Yet, as an outsider, I can report my experiences and observations, while people inside the culture give theirs; each view has its own intrinsic and unique value.

I speak about 200 common Mandarin words and can get by in most everyday situations, like in cafes asking for the check. Most of my clients are educated Chinese women and can speak good English. They start learning English from about age 12 and they think it is very important to their careers to speak it well. Occasionally, my Chinese assistants, some who are psych graduates, may sit in and translate, but this is quite rare. I have also found that being culturally aware and non-judgemental is more important than worrying about missing something. After all, it is for the client, not the therapist, to come to an understanding of self in order to cope with life’s problems.

Gender and society

There still exists a culture of male power, ownership, and control (of the money and wife). I have seen a mild change in Shanghai, because here many women out-earn men, creating a whole new social reality for both genders. Historically, women were not seen as integral to long-term family economics. This is traditional in the sense that boys were seen as continuing the farming and family work. Daughters would be married off to another village as quickly as possible, as this saves money in the long run. Even in modern China, parents still find it hard to imagine their daughters bringing in sufficient money to keep them in old age and so encourage good economic matches for marriage. A woman’s first boyfriend is often the husband-to-be, which leaves little room for comparisons and making informed choices.

China is a society dominated by men in all political, social, and business arenas. At one company I visited it was clearly the wife who ran the business and handled the money, but it was the husband who fronted the company to visitors and potential customers. Many male businessmen instinctively talk directly to the men as if the women are not even present.

Chinese women’s relationships and marriage: My exploration of Chinese women and marriage began by accident as much enquiry does: a few remarks here and there by Chinese women, the experience of suicides on campus, the attitude of the men in China and my own experience with living in Chinese homes. These chance remarks and conversations led me to a question: why are so many Chinese women unhappy in their marriages? In most of the homes I stayed in, I could feel the tension between the husbands and wives, almost a tangible atmosphere of resentment.

Most of my clients, who were women, came to me through recommendations via their friends. They seemed to know intuitively that I would not judge them; perhaps being an outsider helped. At first, my insight was rather poor, but as I understood the culture more, I was able to help many of these women face their lives with new hope, often through the technique of reframing: helping them to re-look at their lives and make some positive moves for change.

There are many factors and social pressures that impact women’s lives and marriages in China including the question of love vs. material security, the influence of the husband’s mother on the new wife, and the gender issues between men and women with regard to economic power and control.

Love vs. material security: Often women marry for material considerations and not for love. In my experience, women agree with the wishes of the parents wanting security for their daughters, but through years of socialization, they too believe this is in their best interest. Love is a luxury you cannot afford if you want to survive in a country with undeveloped social services and poor chances of surviving on one’s own.

In the United States about 50 percent of all marriages are now ending in divorce and these marriages were apparently based on love matches. The Chinese use this information to support the notion that love is just a temporary madness that soon dies. They have a point, but there may be other ways of understanding this issue. Most research shows that in order for a relationship to last, the couple needs to have common interests and shared goals in life. It is often when these areas diverge that divorce rears its head in the West. For the Chinese, marriage is about security, loyalty, and family, with love not being a valued factor, at least before marriage.

The wife and the mother-in-law: The new wife is traditionally seen as a new servant by the husband’s mother. Even today, women are often expected to join their husband’s family. Today, some young couples are talking about getting their own apartments and with it some privacy and freedom. Two things seem to get in the way of this: first, the spiralling costs of apartments in China reinforce the old ways, and second, the husbands often invite their mothers to live in the same house or provide her a room for whenever she wants to stay (often months at a time).

The traditional husband: The traditional husband sees the wife in ownership terms and believes her first loyalty is to his family and particularly his mother. Therefore, many wives feel marginalised in the marriage by the husband’s family. Chinese men rarely talk about these issues and they have great difficulty expressing themselves when they do. However, many women reported to me that they suspected their husbands of having girlfriends on the side. For the most part, men seem satisfied with this arrangement of wife and girlfriend, as the wife takes care of all his domestic needs and the girlfriend is his emotional outlet.

In most relationships and marriage difficulties, it takes two to make it and two to solve the problems. The man’s side of relationships and marriage is certainly worthy of more study and investigation. However, at the time of this writing, it is highly unlikely that a husband would come to a therapy meeting, let alone discuss his personal feelings. Perhaps this will change as the men and culture change, as well as new methods are developed to connect to Chinese men in ways that make sense to them. Women in China, however, given the opportunity to talk to a therapist, will open up and share their experiences. “The most important factor for them is a non-judgemental attitude from the therapist and confidentiality; these bedrock therapist traits and attitudes transfer just about anywhere in the world.”

Case examples

A few examples will help give a sense of the common themes that women have brought to counselling. One 27-year-old woman, Jiang (pseudonym), had been married for a few years and contacted me for a talk. She explained how, having married for the prospect of security, she now found herself mostly alone and with no common interests with her husband other than daily hassles such as rent and food. He ignored her emotional needs and Jiang felt isolated within his family.

I have heard these same stories so often now that it has become somewhat of a pattern. The issue is often one of security over emotional needs. For the woman, at first, emotional needs are not as important if she is secure from poverty, but as time goes by the loneliness of two people with no common feelings eventually leads to a major sense of loss and depression.

Another client, Li Ching (pseudonym), met her boyfriend at the university. They were together for four years, and in the final year they had sex for the first time in a backstreet hotel. Li Ching did not enjoy it. They married a year after leaving the university. Now married five years, Li Ching is extremely unhappy. Moreover, in a country with a history of a one-child policy from the government, Li Ching did not want any children; this is frowned upon by all in the husband’s family. She approached me to discuss her worries. Li Ching is now 28 years old and the first thing she told me was, “I do not love my husband and never have.” She had been unhappy for some time and often frequented night clubs with her girlfriends to dance out her frustrations. She had recently started to learn the Spanish language and at a club met a Spanish man. After a few months, she started to have an affair with this man and reported to me that she has discovered her sexuality and thinks she is in love.

Li Ching found a way to temporarily alleviate her pain via the affair, though of course such a method brings other difficulties and challenges such as divorce and potential shame from family. I am certainly not recommending an affair as a means of coping, only that in this case that is how this woman sought relief from her situation. Many Chinese wives do not see a way to improve their marriages or to find a way out—and rather than face the shame of divorce and the loss of face in the family, become severely depressed and feel that taking their life is the only viable option. Even in the countryside, some women take their lives with industrial fertilizer or pesticide, easy to obtain on farms.

The suicide rate amongst young women in China is high, as I have noted earlier, and it is often an option expressed by those who feel hopelessness. I have heard too many of the women report they had contemplated this end, and this has made me more determined to help where I can. Therapy is not a cure, but a system to help people cope in the world they inhabit. I am happy that, in my experience, most clients report improvement and the increased ability to control their own lives and decisions.

I have witnessed some happy marriages in China, but my research was not to look for happy marriages, which could be the topic of another paper. Instead, my research was to look at what was going on in the unhappy marriages that so many women were talking about.

One great thing about the Chinese clients I have seen, and in this case it is overwhelmingly women who come for counselling, is how loyal they become to people who have a therapeutic relationship with them. Even after treatment has ended many go on to write regular emails to let me know how they are getting on and many are on MSN, Yahoo, and Skype and often say hello and bring me up to date. The Internet has been an important tool for ongoing client support.

Psychotherapy training in China

When I first came to China four years ago, I worked in the research department of the Hubei University in Wuhan (central China). I am currently in Shanghai where I work as Clinical Director for a counselling training company and an EAP provider. At this company they train counsellors for the China licensing body. One of my assigned tasks here in China has been to train a new generation of young therapists with a Western perspective on client treatment. Another task is to supervise the trainers, who are often Chinese professors. The therapy organizations that do exist in China are not training on a wide scale. A beginning-level licensing system does exist and it is fairly easy to pass if you have enough money and time to train.

In China the students learn about the different forms of psychotherapy over an 18-week period, followed by 18 weeks of training in cognitive behavioural therapy and 18 weeks of transactional analysis. This educational background, coupled with experience counselling patients with supervision, gives them a beginning foundation from which to counsel clients.

The classes I teach are at different levels, ranging from undergraduates in their third year (they all do four-year degrees here) through Masters Degree students. Most of the Masters students concentrate on School Psychology and counselling for children with difficulties at school as well as how to handle exceptional children and mental retardation. Many of these Masters-level students go on to become teachers in middle or primary schools where they also act as the school’s counsellor and teacher advisor.

Many students will end up in fields other than psychology, having achieved better people skills and management potential. However, many also become counsellors at schools and colleges. Some who become full-time counsellors often keep in touch with me when they need help or advice. I have set up a peer supervision group for trainees to overcome the shortage of supervisors since many counselors often report to non-professionals. As for post-graduate internships, this is almost unheard of here.

It has been my experience that most Chinese clients are generally not good candidates for Western-style cognitive behavioural therapy—it is too direct and challenging and makes them withdraw. Although CBT has been seen as quite useful for many Asians in the US because of these directive qualities, that has not been my experience. (See a different view of CBT in Chinese Taoist Cognitive Psychotherapy article and in Commentary below.) From my experience, it seems that traditional psychodynamic therapy is often not active nor supportive enough in its Western form for the Chinese client. (See Psychoanalysis in China, September Archive for another take.) I have found that transactional analysis (TA) works very well here.

Chinese people and clients readily understand Eric Berne’s model of the Parent, Adult, and the Child ego states. TA also talks about drivers, life positions, OK-ness, critical parents, and nurturing parents, which are all clearly understood. The one area of TA they all agree on is the position and dilemma of the adapted child—the child who seeks to do anything to survive by following the parents' lead.

Chinese psychotherapy students

Generally, my Chinese psychology students really enjoy learning about therapy and the techniques applied in a Western counselling format. Most had serious arguments with their parents about their choice of majoring in psychology. Parents would argue that there is no money or jobs in psychology, it is not secure, and would not help with getting a good marriage, as well as many other future catastrophes. For the students who managed to stand their ground, they had to endure enormous pressure. This means as a teacher you end up with strong-minded students, keen to prove their choice was the correct one and wanting and demanding the best teaching. For a teacher to have a room of 30 to 50 students who are attentive to your every word is heaven sent, and I am quite grateful.

At first, “many students find it hard to let go of their cultural prejudice and allow clients to be themselves versus a preconceived idea of the Chinese social norm.” Many students report great difficultly in getting their clients to talk to them about feelings and they spend a greater part of sessions hearing about the goals and plans of the client, subjects clients present to avoid dealing with their emotional turmoil.

My students commonly reported that their clients do not trust them to keep confidentiality, which is as much based on distrust of authority as it is a view on therapy. The most common client reasons for hesitance to open up are, “I am okay, these feelings will not last,” “I will have to suffer,” and “It is the Chinese way.” Clients are part of a collective culture and mindset of shame-based attitudes, distrust of authority, and a persistent stigma about emotional troubles, thus making trust a difficult task to accomplish in therapy.

New counsellors in the West find it hard at first to relax a client enough for them to feel trusting and confident, but the clients usually expect and accept that therapy is a supportive tool despite their fears. In China the counsellors must work extra hard to gain the trust and confidence of the wary client. Unlike my students, I have had many years of experience as a therapist and know how to help most clients relax and open up fairly quickly. The counsellors I have trained directly have had rocky starts but they pick up these skills in time and soon find their own style of doing things, just as any Western trained therapist does.

In class exercises, when students practiced counselling each other, the female students found it particularly hard to get male clients to talk or share. The male students found it impossible to discuss personal problems with women. Thus, gender roles and issues must be considered and accounted for in working with Chinese clients as well.

Each student has to see psychotherapy clients over the training period at the undergraduate level. They produce a three-part report after each session to the supervising psychologist. At the end of ten sessions they must produce a three-page report summarizing their experience—a case biography, their assessment in technical terms of the clients presenting problems and their action, and exploration of their own feelings that came up while conducting the therapy and how it affected their thinking and outlook. This information enables the supervisor to interview the students and to understand the insights they gained.

The future of psychotherapy in China

It is my hope that mental health services can expand in China and different forms of psychotherapy and counselling will be accepted as normal for ordinary people to access with confidence. However, much progress in the view toward people who suffer from mental and emotional difficulties is needed so that help can be sought out without the fear of shame or losing face; it took a great amount of time for this to occur in the West, and there is still progress to be made there as well.

Certainly, new theories and techniques that are tailored to the Chinese people must be developed as Western and Chinese therapists alike gain more experience and insight. There are signs of greater acceptance of counselling and psychotherapy as witnessed by the training programs and the numbers of students interested in pursuing training, as well as the people who come to and benefit from counselling.

A personal note on my experiences in China

I have found the Chinese people to be friendlier and more willing to help others in a crisis than the people in most of the nations I have been to. I have been made more welcome in Chinese homes than ever in the West with its fortress mentality. The Chinese see each other’s efforts as having a direct effect on everyone and therefore are very considerate of others’ feelings and opinions. I have seen that they sometimes find a Westerner’s directness very unsettling, which I have learned to adjust to. In therapy, I have found that it is key to take into account the relationship as being of greatest importance to the client. I imagine that is true everywhere, and no less true here.

I would rather live in China than most of the hundred-plus countries I have visited over the years. The lifestyle is relaxed and informal—and I feel quite happy each day, since I am treated well by most everyone I meet. There is also a rich cultural history here and beautiful scenery, buildings, and art, which I enjoy often.

My appreciation: Thanks to the following participants in my explorations into Chinese life, culture, and relationships: ZheJiang Normal University, Institute of Psychology; Hubei University, School of Psychology; Shanghai Pinghe International School; the over 200 women in China who told me their stories, and the numerous families that invited me to stay for a week at a time in their homes in the city and the countryside.

Suggested readings

Xue, Xinran (2002). The good women of China. Vintage Publishing.

DK Publishing (2007). China: People Place Culture History. DK Publishing.

Monsieur D. arrives at the Centre Georges Devereux

Now, a year and a half after his arrival in France, Monsieur D. sits in the Centre Georges Devereux, an ethnopsychiatry clinic in Paris. Congregating around him, a group of professionals and student interns face the task of sorting out his past in order to assure his future. Observing this calm, dignified man from across the room, I have no inkling that our interactions will have such a profound impact on my understanding of psychotherapeutic intervention. His face and ears are heavily scarred, one eye is a deformed mess and the other barely able to perceive moving shadows, but he has fully regained his intellectual faculties and participates readily in the discussion. Meanwhile, his baby daughter gurgles and bounces energetically in the arms of her mother, who followed Monsieur D. to France when she could get no news of him and feared the worst.

As long as Monsieur D. needs acute medical treatment, the safety net provided by French social services will care for him; but his wife and child have no official status, and only charitable organizations help them struggle on from one day to the next. So after surviving two apparent attempts on his life, Monsieur D. and his family will remain in legal and material limbo unless they can attain permanent refugee status. Otherwise, they must return to Africa.

Given Monsieur D.'s utterly fantastic history, any forced return to Africa would constitute a death sentence. Unless, that is, the clinicians at the Centre Georges Devereux can help unravel his mysterious past, identify his invisible enemies, and activate the necessary forces of protection.

Monsieur D. eventually agrees with Marie, the Antillean psychologist leading the session, that his fall from the hospital window represents a logical continuation of the gunshot fired in Africa, both events the result of very powerful witchcraft. A tentative idea emerges in the clear, dignified voice of Christophe, a Catholic priest and trained psychologist from a nearby African country and one of the cultural mediators at the Centre. “Christophe gently hints that during the course of his Western education and rise in status, Monsieur D. has perhaps neglected to sufficiently honor his ancestors, who in turn allowed his enemies to attack him with impunity.” If so, he would need to mend his relationship with his ancestors as a first step in protecting against future attacks. Monsieur D. nods thoughtfully and rubs the scar that bulges behind his huge, thick eyeglasses.

This is not a case of the experts announcing a diagnosis and course of treatment to the trusting patient. Monsieur D. knows that the professionals at the Centre Georges Devereux have entered his territory and will negotiate on familiar terms. None has more expertise in the intricacies of his culture and world than he does, and he is being enlisted as a partner in this brainstorming session. Though nearly blind, powerless to provide for his family, and wracked by nightly terrors, in this place Monsieur D.'s impediments melt away. So, when he responds to Christophe's suggestion, the patient presents an alternate interpretation in measured, professorial tones: "Yes, you could look at it as a failing on my part that allowed such catastrophes to befall me. “On the other hand, it is equally possible that I actually survived the pernicious attacks thanks only to my powerful ancestral protection.”" A crucial distinction that, if true, would point to an entirely different course of action. With ancestral protection already intact, Monsieur D. would need to look elsewhere to bolster his defenses, perhaps in his twin sons, since twins often have special status and powers in his culture.

Three hours later, the point remains unresolved, but clinicians and client agree on some provisionary steps and work out various practical details of the couple's life, such as how to keep the baby fed during the coming month. After shaking hands with Monsieur and Madame and watching them disappear out into the hall, I look vaguely around the room and then follow in their footsteps to exit the building. Welcome to the Centre Georges Devereux, I think to myself! Monsieur D. will return in a month for a second consultation. I'll be back tomorrow morning.

Ethnopsychiatry: Treating cultural phenomena at face value

Despite their home away from home within Paris, African immigrants face many obstacles in the highly traditional French society. And when they run up against cultural barriers, there is one place in particular within the official French social service network where immigrant families can hope to be understood and taken seriously: the Centre Georges Devereux, housed in the University of Paris VIII. “It is there that a French social worker can bring a Moroccan man who refuses to support his wife, claiming she is possessed by a jinn”; there that a French judge can refer a Malian family with two delinquent kids who, alienated from both their parents' culture and the French mainstream, have forged an identity in a gang. The epicenter of research in the emerging field of ethnopsychiatry, this clinic focuses on developing new methods for treating people in psychological distress.¹

The innovative theories and methodology at the Centre Georges Devereux ensure that it is not only a cultural island compared to the rest of French society, but also an ideological island compared to mainstream clinical psychology in France, which is rooted in the Freudian tradition. Rather than weekly therapy that may go on for years, clients at the Centre go only once a month for two to six months for an intensive three-hour group problem-solving session. Each consultation brings the client (or family) together with several clinical psychologists who come from all over the world, as well as with other specialists—anthropologists, linguists, lawyers, social workers, physicians—and various interns. The sessions are often conducted in the patient's native tongue, with the help of an interpreter/cultural mediator who shares the client's native culture and has studied its traditional therapeutic methods.

Much of the work focuses on constructing an explanatory narrative, some coherent interpretation of (and then antidote to) the clients' experiences, which have often been invalidated or misunderstood by the various other professionals with whom they have had contact. As in the case of Monsieur D., many clients talk about ancestral spirits or witchcraft, phenomena that Western psychology generally finds itself unequipped to address (Are these people hallucinating? Are they psychotic?). At the Centre Georges Devereux such phenomena are accepted at face value, and the therapeutic methods of all practitioners—whether Western psychologists or folk healers and priests—are taken as clinical theories, all equally valid for study. Instead of diagnosing patients with a psychological or psychiatric disorder, the Centre tries to treat people using their own cultural references and, often, treatment methods. In this way, ethnopsychiatry has taken some bold steps to expand the field of psychology so that it might apply in a meaningful way to non-Western populations. What's more, marginalized by French society, the clients find that at the Centre Georges Devereux, their culture is taken seriously.

Founding of the Centre Georges Devereux in France

The university setting fosters this astonishing variety of research. At the same time, it provides an avenue for educating the community in ethnopsychiatry, alongside future clinicians and researchers. Many of the psychologists at the Centre Georges Devereux double as instructors at its host institution, the University of Paris VIII. They also give a year-long lecture series specially designed for professionals in various fields who work with immigrant populations. And the clinic itself is structured to host student interns, often Masters or doctoral candidates conducting research. Nearly as international a group as the staff, the interns during my time at the Centre included French, Italian, Argentinean, Rwandan, and Japanese students. “In researching the clinic itself rather than a specific thesis topic, I was a free-floating anomaly, and the staff often simply introduced me to clients as "our American."”

Thanks to the group structure and university setting, I enjoyed the opportunity of observing and even participating in intensive clinical consultations with patients. Of course, in reality the experienced clinicians and staff tended to direct the sessions, calling on the others' input under highly specific circumstances. I recall one session with a woman who complained of recurring nightmares in which her adolescent daughter was kidnapped and raped. Fatou, the Senegalese psychologist directing the session, aimed to discuss the client's onset of puberty in order to draw connections with her daughter; but the woman claimed to have forgotten the circumstances surrounding her first menstrual period. With her usual calm ingenuity, Fatou proceeded to ask each female in the room to recount the story of her first period. We had only gotten halfway around the circle when the patient broke in with her own story, and Fatou carried the discussion forward.

Then again, there were also times when the various experiences and perspectives in the room made truly independent contributions to the session, rather than merely serving as tools for the clinician directing the consultation. One memorable case involves a young girl who recently arrived all alone from the Ivory Coast and is inexplicably failing school. In a halting near-whisper, she insisted that French was her only mother tongue. The clinicians in the room seemed mystified, as they guessed that another language from her past has a hold on the child. Finally, a woman who had worked for years with the Parisian African population in another setting offered an explanation. According to her, the French spoken in the Ivory Coast differs greatly from the French spoken in France, more so than in many other areas of francophone Africa. Despite her reading and writing proficiency, the young girl was struggling to understand the classroom lessons and the teacher's instructions because of the unfamiliar dialect, but felt too ashamed to voice her difficulty. Without this crucial piece of information, the clinicians could not begin to work with the girl and the caseworker on ways to overcome this basic obstacle.

The group structure serves as more than a reflection of formal communal gatherings in Africa, then, and all the participants feel justified in their presence. When I happened to contribute a useful comment, I went home that day with the whole consultation thrilling through my chest, and the long subway ride home passed in just a short instant.

Between Two Worlds

In the evenings, I returned to the prestigious École Normale Supérieure (ENS) in the studenty, touristy Latin Quarter of Paris, where I immersed myself in an ancient but breathing symbol of French tradition. There I lived with the country's future academic and political leaders, a group with no more ethnic and socioeconomic diversity than Harvard had in the 19th century. I knew of one Arab student and no Africans, and even the considerable population of foreign exchange students come almost exclusively from the United States and Europe. Across disciplines, the array of seminars offered there covers the roots of Western civilization—from Greek to Roman to French—as it has for hundreds of years. Most people I told of my work at the Centre Georges Devereux responded with eyebrows raised in slightly bewildered surprise, as if I were working with exotic birds rather than a large population living in their own city. I learned quickly to keep the worlds separate and generally succeeded.

Occasionally, I experienced a glitch in the transition, when the disconnect between my day at the Centre and my evening at the ENS sent shock waves through me until my brain froze with exhaustion. One day I arrived at the ENS breathless from the metro and ran straight to a rehearsal of my baroque chamber music ensemble. “I floated unconscious through the leader's explanation of the subtleties of grace notes in Couperin, my heart pounding, my throat aching, my mind unable to expel the grisly, heart-rending image of the walking skeleton I'd met that day.” I had never seen anyone dying of AIDS before, let alone a young woman, unidentifiable as such, who looked as if she had already died. The skin stretched taut and shiny with sweat over her huge eye sockets, and the wide mouth quivered, a shiver that spread to her whole emaciated body and wildly darting eyes while she listened to her seven-year-old daughter's estranged father, seated several chairs away. He wanted custody of the child and spoke in oily tones, drawing upon his royal West African heritage, while the mother's long, bony hag's hands trembled against each other in her lap in time with her only words, in a firm, ghostly whisper, "That's false. That's false."

Several times Marie paused the consultation to calm the mother, as her shaking grew more wildly uncontrolled, and in fear that she would fall down in a trance (or seizure, depending on your point of view). The child watched her mother worriedly from the corner, magic marker poised over untouched paper, while her father continued to wheedle unabashedly and display legal papers with such blatant callousness towards the mother's terrifying condition that I again shuddered with nausea as I raised my flute to my lips. No sound came out. Bach and Couperin had no more substance than a dream, but the AIDS-ravaged woman and her orphan-to-be proved ever more real in my dreams that night.

Healing Spirits

One of the first consultations I attend involved a family with a young boy who kept on falling. His most recent accident, a fall from a ladder, had landed him in the hospital for a month. I understood very little of the ensuing discussion, but I gathered in the end that the family somehow neglected to perform certain rituals at the burial site of a maternal ancestor. The completion of these rites would close the circle of ancestral protection, which had clearly suffered some punctures, allowing such ill fortune to befall the boy. Perhaps his repeated falls were actually occurring in order to remind the family of its neglected duties to its ancestral protectors. The parents and children left the session with many smiles and warm handshakes, highly satisfied and full of plans for follow-up after performing the rituals. I was enthralled and enthusiastic. And then, inevitably, the thought: But what happens the next time he falls? How could I wrap my mind around what seemed so obvious to the others, patients and professionals alike—that if they have correctly diagnosed the situation and prescribed the appropriate remedy, then the boy would not fall again? I could not, and still I tried.

Having since worked as a research coordinator in psychiatric genetics at a major U.S. hospital, I sometimes have trouble believing that, not long ago, I pondered the desires of ancestral spirits on a daily basis. But I certainly did, and with increasing ease. The discussions moved seamlessly from school performance or legal residency papers to honoring ancestors while remaining faithful to the Christian God . . . and back again! “The invisible and the spiritual inhabited the same plane as the utterly mundane.”

Eventually I learned to enter into this mindset, a way of thinking about the world that grew more and more familiar—but always as an outsider, sheepishly wearing another's clothes. I wondered uneasily whether I needed to feel sure of the existence of the phenomena we discussed in consultations for the work to be legitimate, whether it mattered as long as it functioned therapeutically, one way or another. It seemed all right to me as long as my place was mostly that of an observer, but what if I occupied the role of the psychologist directing the consultation? Although they would likely refute the idea, the legitimacy of the whole system seemed to me to rest in large part on the clinicians having cultural backgrounds comparable to those of their clients. When the Senegalese psychologist, Fatou, described how a patient should buy a small live chicken, feed it to her family, and then bring the contents of its stomach into the next consultation, she was not "playing" at something; she wore nobody's clothes but her own.

In this light, I came to understand ethnopsychiatry's disdain for the widely held idea that its therapeutic interventions work merely through "suggestion," influencing patients' psychologies for the better rather than actually affecting the supernatural forces under discussion. Although I myself have not resolved this issue in my mind, the idea of suggestion does seem patronizing. Setting it apart from much other cultural psychological theory and practice, which sometimes uses cultural sensitivity to facilitate essentially Western treatments, ethnopsychiatry takes the logic of intercultural respect quite seriously, audaciously, all the way to its conclusion. And I came to see why anything less—no matter how much more comfortable for the Western-trained intellect—falls short.

On the other hand, transferring this logic from social/psychological to more biological/medical areas seemed to me problematic, from both a scientific and a humanitarian perspective. For example, in many parts of Africa, HIV/AIDS is generally viewed as the result of a witchcraft attack. And much as it makes me squirm, I can understand why one Western-trained African doctor I met (outside of the Centre Georges Devereux) regularly tells his African patients that the antiretroviral drugs serve as antidotes to witchcraft. The clinicians at the Centre Georges Devereux would certainly never use such methods. But who am I to decry this patronizing "ghost story" if it increases compliance with the treatment regimen and thereby prolongs lives? Interestingly, many HIV-positive Africans in France understand perfectly the way they physically contracted the virus as well as the biological course of their illness. And yet, simultaneously, they see a witchcraft attack as the underlying explanation for why they contracted the virus when and how they did. From this perspective, then, the antiretroviral drugs really do fight witchcraft, or at least the illness it causes (though strictly speaking they do not defend against further attacks). So while I never fully understood how ethnopsychiatry manages to integrate Western medical science with traditional etiologies and treatments, perhaps, there is ultimately no real conflict.

Bridging Troubled Waters

“The clinicians prove a wonderful resource for parsing out normal cultural practices from aberrant behaviors”, a particularly important distinction when making decisions about a child's future. One social worker's report of a mother's rough handling of her infant in the bathtub resulted in the baby's placement in foster care. The mother regained her child months later after a mediator at the Centre Georges Devereux explained to the social worker the cultural practice of firmly molding a baby's body to ensure its proper growth and development. Thus, as a constant undertone to whatever other therapeutic intervention they attempt, the clinicians work to improve communication and clear up misunderstandings between the social workers, judges, and educators on the one hand and their immigrant clients on the other. They succeed by using their mastery of both languages, literal and figurative, to bridge the two worlds.

Yet their work does not always consist of pure translation from one world to another. Sometimes it seemed to me that the Centre Georges Devereux created and worked with one multi-faceted language. True, the interpretation of a symptom sometimes varied depending on one's cultural viewpoint, determining whether someone was in a trance or having a seizure. But that was not always the case. For example, Dominique, a French psychologist and trauma specialist, runs special consultations for survivors of intentionally induced trauma.

Back to Monsieur D.

Importantly, the clinicians at the Centre also recognize when some symptoms are most easily classified in agreement with Western categories. A Haitian student intern reported to the group on her first attempt at a private mediation between a Haitian woman and the social services. The intern described to us how she explained the client's references to the Voodoo religion to the doctor and social worker present, so they might get a sense of the cultural framework behind her seemingly incomprehensible utterances. Then Marie, the psychologist who supervised the mediation, spoke to the intern: "You did a fine job explaining the various Voodoo figures and rituals the patient mentioned. “You neglected, however, to point out that the way the patient was talking about Voodoo actually made very little sense, and that the woman was on the verge of becoming totally delusional.”"

Whether or not in sync with Western categories, the professionals at the Centre are certainly well equipped to identify behaviors that are pathological within their cultural context. I recall too vividly the case of an eight-year-old boy accused of witchcraft by his aunt and uncle, his guardians in France. They had plenty of evidence according to traditional standards to convict the boy of trying to kill them slowly by witchcraft, probably by order of his grandmother. Among this Congolese people, I learned, a convicted witch is branded according to a traditional ritual in order to identify him/her, so that the witch can no longer go out at night to work destruction on innocent people. This small boy's uncle woke him up in the middle of the night and dangled him outside the open window for several minutes before bringing him back inside. He proceeded to bind the boy's hands and feet with rope before branding his shoulder with a hot iron. The child has an iron-shaped scar on his shoulder to this day.

I was horrified—not only that such horrendous abuse has occurred, but also by my frightening question, "Could this possibly be culturally normal? What then?" Apparently, the judge in charge of the uncle's hearing wondered the same thing, sending the boy to the Centre Georges Devereux to help herself as much as the traumatized child to make sense of the situation. There, the clinicians understood immediately that, whether or not the child was practicing witchcraft, the uncle certainly reacted abnormally. “He acted alone, outside of the codified, traditional system of communal witchcraft hearings, thereby transforming a ceremony with a preventive purpose into a form of private, vindictive torture.” What relief to discover that his act was pathological from any point of view! I can only guess at what precipitated the horrific branding: whether the craziness or evil of this individual or his displacement from a certain cultural/social context, or some combination of both. I know only that the judge could send the uncle to jail with a perfectly clear conscience.

A Delicate Balancing Act

One Algerian client we saw exemplified this challenge. She had turned her husband out of the house, but still felt conflicted and allowed him to return to see the children. She reported that he destroyed things in the house and even hit her when she intervened as he disciplined the kids. As I listened to their story, I held my breath as the tone of the consultation became almost accusatory, with comments on how the woman had reduced her husband to less than a man. Finally, she rose abruptly and crossed the room with tears in her eyes. The clinicians were trying to jolt the patient into recognition that she still wanted and needed her husband, if only because she had fallen very ill since his departure and could not care for the children alone. They wanted her to agree to bring her husband to the next consultation, because their family would only continue to fall apart until she reconnected with her place as wife and mother. Practically speaking, they were probably right. Her brazenness had left her in an untenable situation, utterly isolated from both family and the larger community. In another culture, she might have had an opportunity to end an unhappy marriage and rebuild her life. But the world she was born into holds no place for a divorced woman. Still, I sat there sweating uncomfortably at the scene, acutely aware that this woman's brave resistance went unvalidated in this setting. The individualistic voice in my head cried out, Does she not have the right to disagree with the logic of her own culture?

And what about the clinicians? Did they have the right to disagree with the logic of their client's culture? This seemed even thornier a problem. I wonder how far to go in accepting the patients' culture at face value when some normal practices might run contrary to certain moral principles. If I believe that women are oppressed in certain parts of Africa, by tacitly accepting such cultural elements when working with the people, was I promoting intercultural understanding or perpetuating the oppression? Does the very presence of this question in my discomfited mind merely reflect my own ignorance and cultural biases? I cannot say for certain either way.

To add to my confusion, the power structure at the Centre Georges Devereux appeared extremely egalitarian—a far cry from my later experience (ironically, in the land that championed feminism) working at a U.S. hospital among many female research coordinators quietly waiting on almost exclusively male doctors. In contrast, female professionals at the Centre had equal voices, which they did not hesitate to use, and an equal share of power at all levels of the loose hierarchy. These independent, empowered women must have somehow reconciled their multiple university degrees and packed professional lives with their daily defense of the traditional values and practices of their cultures of origin. I never understood exactly how they did it, unless I vastly misunderstood those traditional values and practices. How could a female clinician legitimately press a client from a similar cultural background to stop resisting a traditional role, when the clinician had refused that role herself?

Perhaps, unable to sidestep my feminist perspective, I was failing to grasp the actual nature of the therapeutic interventions. I sensed, but could never articulate, the nuances in ethnopsychiatry's delicate balancing act. “Like a spider suspended in a doorway, thanks to the tension in its fine-spun web, the Centre Georges Devereux fosters the creation of a space between the extremes of cultural isolationism and total assimilation; a space where Africans can stay African while sustaining life in France.”

An Inconclusive End

My arrival at the Centre Georges Devereux felt like a leap into freezing water: I grew accustomed to it quickly, but I never forgot that I would feel cold again the moment I set foot on dry land. My discovery of ethnopsychiatry has certainly modified my educational and professional future; in fact, it has transformed me, or perhaps it has rather transformed the world for me. And now I must return to my previous world, alone, carrying the weight of an experience that is incomprehensible or merely of exotic interest to the inhabitants of that world. To my knowledge, ethnopsychiatry as defined at the Centre Georges Devereux does not exist in the United States. And yet, I would like to find a way to integrate what I have learned over the course of this year into my future studies and work. But attempting to "do" ethnopsychiatry on my own would not only be crazy and pretentious, it would also run counter to the fundamental principles of its practice. I would of course need a group. But how can I explain to others ideas and practices that I have not myself mastered, especially with the theoretical literature almost entirely inaccessible to non-French speakers? How can I avoid one of the risks of transplantation, in which the techniques and terminology become inactive, empty husks, having lost along with their roots the underlying depth of thought and their therapeutic powers? I do not know how to resolve these problems, among so many others. But I will search for a way.

And I am searching. I came to the Centre Georges Devereux to try to understand ethnopsychiatry: whether it works, how it works, why it works. After a year of attending consultations, I still have no clear idea how to answer those three questions. There was no introduction to the start of my time there and certainly no conclusion at the end; yet I have gleaned bits and pieces that will stay with me, even if I have not figured out how they all fit together. Most of all, I have gained another pair of eyes. Because ultimately, the Centre Georges Devereux works at the cusp of vastly different cultures in order to shake up the kaleidoscope through which we view the world, to offer the field of psychology a different, perhaps broader and more inclusive, and certainly a more varied and colorful perspective. In my desire to help foster that vision, I know only one way to begin. And so I offer my own story.

Notes