Introduction

For the past 19 years, the “Working with Culture: Clinical Methods in Cultural Psychiatry” seminar series has been offered as part of the Annual McGill Summer Program in Social and Cultural Psychiatry. The seminar welcomes local and international students from postgraduate disciplines in mental health or social sciences who come to the table with wide variation in backgrounds, origins and previous clinical experience. The seminars are conducted by the authors as co-leaders. We are both child psychiatrists with varied clinical backgrounds who are active in clinical child and family psychiatry, one with primarily hospital-based and the other with a community-based shared care clinical practice. We, as the co-leaders, have divergences of experiential, ethnic, research and clinical training backgrounds that also promote a fluidity of exchanges and models. The participants have included senior international clinicians who are also engaged in cross cultural psychiatry discourse, international or local clinicians from many disciplines, graduate students in social sciences with a research interest in cultural psychiatry, psychiatrists from war regions, and local or international psychiatry residents. The course has had a clinical cultural focus encouraging reflection and discourse as well as exposure to a broad interdisciplinary knowledge base (Kleinman 1997; Good 1996; Hays 2001; Helman 2000; Lewis-Fernandez 1996).

As co-leaders of the seminar, we create a safe non-threatening climate in which participants may allow themselves to hear and experience OthernessFootnote 1 as a destabilizing process. We present not only didactic teaching but also emphasize the premises of cultural safety (Williams 1999), whilst fostering participation, reflection and discussion. The seminar space encourages the emergence of multiple voices of both participants and teachers elaborating their divergences, congruence and varied skills in applied clinical intervention. The case studies help the students be cognizant of cultural realities embedded in institutional, social, historical and political reality. The annual seminar is usually attended by about twenty to twenty-five members who also attend parallel courses in the summer school.

Group attendees have the advantage of a month of immersion and bonding in different aspects of transcultural psychiatry studies, including qualitative and quantitative research methods, overviews of transcultural psychiatry, as well as global mental health and trauma courses. Although ‘Working with Culture’ is accompanied by a course manual with optional readings and reading lists, the essence of the seminar remains centred on the discourse of the working group facilitated by the two co-leaders and our guest lecturers. The participants are encouraged to present their unique culturally embedded experience as part of the seminar exchange, sometimes in formal presentations.

The therapist–client relationship and therapeutic process are the central agendas of the clinical competency discourse. The seminar joins an evolving development of cultural competency training and perspectives (Kareem and Littlewood 1992; Strum et al. 2011; Hays 2001; Jenks 2011; Shaw and Armin 2011; Kirmayer 2011; Willen 2010). The co-leaders provide a clinical focus and continuity with the case presentations by both teachers and students. The seminar provides opportunities to question and revisit the therapy environment. Case studies within a bio-psychosocial model integrate systemic, intra-psychic, historical and socio-political dimensions. These clinical presentations are used to illustrate assessment (‘knowing’), intervention and outcome, as well as to stimulate discussion of the ‘not known’ (Last 1981), with a biopsychosocial deconstruction focused on cultural complexity in therapeutic encounters.

A Decentering Discourse: Processing Particular Tensions in the Cultural Conversation

The Working with Culture seminar series is structured around four recurring tensions that organize and mirror the clinical encounter. These tensions are maintained with the intent of eliciting in participants an interactive process including intellectual reflection and experiential awareness. Psychotherapeutic space and intervention framing clinical realities are the continuous focus of the sessions consonant with these tensions.

  1. 1.

    Holding and discomfort. The seminar leaders create a group-holding space (Winnicott 1967; Bion 1961; Williams 1999) in which interdisciplinary sources and diverse experiences are acknowledged in a respectful and safe climate. Simultaneously, the pedagogical focus highlights divergences of cultural explanatory models and contexts. Expression of ambivalence is at the forefront whilst participants are asked to interpret clinical material and encouraged to go beyond political correctness in questioning their own premises of ‘knowing’, neutrality, benevolence and capacity for therapeutic alliance.

  2. 2.

    The expert position and multiplicity of voices. The concepts of competence and expertise are challenged, emphasizing their inter-relationship as pillars in the present hegemony of medical and psychiatric knowledge. In an area in which standard practices and excellence become synonymous, culture introduces a problematic ‘noise’ within the clinical reality reflecting hybridity and divergent meanings. Cultural competence is constructed not as a comforting answer ensuring that mainstream knowledge can be adapted across cultural settings, but rather as an active engagement with diversities that cannot be reduced to universal premises. The seminar intends to elicit a multiplicity of voices influencing the transcultural clinical space. Each voice is simultaneously a source of knowledge and may contradict in some way other voices. These divergences are a constant source of critique or disequilibrium rather than resolution. Mental health expertise is thus proposed as a critical scientific discourse that is enriched by interdisciplinary sources. The seminar in some ways replicates partially the therapeutic processes it wishes to challenge. Interestingly, the established expertise of the seminar leaders often progressively erodes in the mind of some participants, as the seminar unfolds and contradictions surface. Simultaneously, however, participant’s investment in this particular field of clinical knowledge increases their willingness to tolerate complexity and relative confusion, which are necessities in clinical process.

  3. 3.

    Searching for meaning and remaining in states of uncertainty. Therapist attunement is elaborated as a delicate balance in dialogue and therapy between the quest for meaning versus a refined understanding of our responses to unknowns or meaninglessness. The appropriation of the voice of the other and the subsequent imposition of an externally constructed coherence are common forms of regaining or holding power in clinical situations. Whilst fragments of meaning in clinical processes can be uncovered, the journey towards understanding of the patient is often dominated by the uncomfortable position of uncertainty and non-closure. The seminars discuss therapeutic work that acknowledges the patient’s defences against destabilizing memory or affective states, whether from trauma transmission, pre-migratory trauma, culture change, racism or other variables. As dissonances or gaps of meaning and cultural explanatory models may complicate the patient–therapist collaboration and therapeutic process, case material is chosen to illustrate these clinical complexities within therapeutic exchanges. An understanding of defence mechanisms is discussed as part of the therapeutic work to sustain coherence and promote resilience.

  4. 4.

    The collective within us and recognition of the uniqueness of an individual’s internalized ‘collective’ voice as universal to the clinical space. This last central tension brings together the clinical imperative to consider a person as unique whilst simultaneously paying attention to the clinical encounter of collective stories, i.e. those of the clinician and those of the patient, as coexisting factors within the therapeutic space. The uniqueness of each participant’s identifications is validated and linked with implications for therapeutic alliance (Catherall and Pinsof 1987), supervision and countertransference or transference experiences.

The seminar and pedagogical methods actively generate a discourse and experience of these tensions throughout the process. The diversity of participants and invitees, the dual seminar leadership, the negotiations of power and voice within the workshop and availability of a wide range of interpretative frames and meanings for cultural narratives are used by the leaders to generate group discussion on issues of entitlement, power, embodiment and trauma transmission.

The aim of the seminar is not only to offer a toolkit for building cultural competence but also to destabilize a didactic process with the intermingling of a dialogue that welcomes the participant’s response to the material. The seminar seeks to increase the participant’s comfort with therapeutic realities that include the feeling of imbalance generated by multiple levels of meaning or interpretation. The seminar discussions enhance the tolerance of these dissonances which are key to the therapeutic transformation and to the healing process (Rousseau and Measham 2007). The decentering process of the participants needs to be sufficiently unsettling to allow them to experience the uneasiness of the clinical moment. The seminar work underlines the lack of expert position. The seminar presents the risks associated with patient empowerment and the recognition of the therapist’s ignorance or personal gaps of understanding. Seminar leaders discuss the promotion of the agency of the Other and acknowledge that this process may allow the emergence of unexpected disclosures and provoke ruptures in treatment or even unpleasant or threatening responses (such as responses that prompt either or both therapist and patient to withdraw from the task of joint problem solving). The seminar encourages members to present their own clinical challenges or experiences to promote participant involvement and collaborative learning in this learning experience.

Multiplicity of Voices, Interdisciplinary Perspectives and Pedagogical Approaches

Seminar Premises

The challenges of self-reflection and co-construction of meaning within the group discourse focus on the uncertain territory of diversity and mental health which mirror the therapeutic work of teams dealing with cultural diversity. The seminar emphasizes the need for team or group support as the seminar group struggles intellectually and affectively to address the divergent responses of each participant. The seminar replicates aspects of the clinical context of therapy teams, who must consider their divergent views on cultural diversity. The shifting representations that flow between participants in clinical and personal stories allow us to reflect on perceptions, denial and realities of culture change. The diverse representations of creolization or hybridity, refugee experiences, aboriginal health, war trauma, dominant or minority groups, communities at high risk, developing societies and institutional racism are often in the foreground.

The expert position is diminished as the leaders amplify the group expertise by encouraging self-disclosure, reciprocity and debate. The multiplicity of voices and varied perspectives of the group members throughout the seminar series are experiential mirrors of clinical reality with its continuous experiences of dissonances, gaps, temporality and uncertainty of cultural meanings which are progressively unraveling in therapeutic encounters. Using multiple pedagogical approaches, interdisciplinary theoretical frameworks or source materials, visiting lecturers and variations on case history teaching approaches, the seminar facilitates an open-ended process approach to building cultural competencies. Seminar members may hear similar or conflicting theoretical themes presented in the narrative voices of both participants and lecturers. Stories supplied by lecturers and participants have made each seminar group experience unique and reinforce the necessary ingredient of personal and collective cultural imagination (Adams 1996).

This approach to teaching ‘cultural competence’ is clearly a process-oriented discourse situated in a broad interdisciplinary framework. Clinical cultural concerns are framed as predicaments requiring reflection and co-construction. Active processing of the complex context of cultural spaces, intrapsychic realities, phenomenology, diagnosis, institutional agendas, racism, social suffering or context, systemic and ethnographic analysis is central.

The seminar articulates the premise that tolerance of ‘not knowing’ or uncertainty is integral to therapist’s active reflection on multiple parameters, and remains a key clinical attitude in comprehending the continuously changing cultural impingements elements in clinical work (Katz and Alegeria 2009). In addition, the psychoanalytic premise of neutrality is continuously challenged and deconstructed, further implicating the therapist with the burden of examining their own assumptions, misconceptions and scotomas. We consider neutrality and objectivity key pillars of the expert discourse. Subjectivity is paid lip-service only to insist on the supremacy of ‘evidence’. Challenging neutrality and objectivity is very threatening because it shatters the internalized construction of competence and expertise (Rousseau 2002; Rousseau and Foxen 2010). Through clinical cases, the participants are asked to distinguish distress versus disorders (Horowitz 2007) and examine social determinants of mental health as part of the intent of their clinical interventions. Perceptions of the Otherness of the therapist as well as the Otherness of the patient are interactive elements of clinical relationships. Therapist identity and institutional contexts are additional parameters of this discourse which lead to exploration of privilege, power, gaze, code switching, attunement or alliance building, nonverbal transmissions, linguistic challenges, decision-making paradigms, countertransference, explanatory models and stereotyping.

Seminar Participation

From the first session, the participants are encouraged to bring their own clinical material or questions throughout the sessions. They are also invited to consider the option of making their own formal presentations to the group, usually in the closing seminar. The first seminar task is to ask each participant, starting with the co-leaders, to introduce themselves as well as share their interest or motivations for attendance. Linguistic dissonances are an immediate issue as many or most participants do not share a common working language and may have various levels of English competency. The frustration of language barriers creates issues and generates feelings for the participants which are the first introduction to the discomfort of the encounter and to mourning idealizations associated with it.

Listening to the articulation of each person’s name as it was conveyed within their family or country of origin, versus articulations created for the vernacular contexts of outside milieus of others, is an additional initial exercise. This group exercise of listening to their names begins the seminar themes on aspects of attunement, stereotyping, listening, presentation of self and creation of self within or for the other. The presentation of each member is noted as a strategic participation that involves memory, absences and unrevealed or hidden aspects of self. Reinforcing awareness or reflection on our presentation in relation to others introduces the exploration of discourse on intra-psychic and external factors which build, undermine or impede therapeutic alliance. Whilst the case study method is fundamental to the seminars from the first session, the clinical material can be presented in a variety of ways such as detailed biopsychosocial histories, vignettes, therapy process excerpts, film or video clips, role play, family systems narratives or mental health predicaments of communities.

Participants are invited to share their wide variations of experience (e.g. some may come from more homogenous societies on various continents and some from highly diverse settings) and are motivated to further discussion by the dissonances, gaps or identifications amongst seminar participants. A clinically embedded discourse on power and institutional decision making is usually situated within a broader context of social realities, medication use, ethics and legal dilemmas considered by mental treatment teams. The overlap of universal and culturally specific agenda is continuously woven through the seminars. This discussion broadens the deconstruction of events, aims and intentions in planning mental health interventions. The complexity of ethics, clinical competence, cultural assumptions and power are key agendas in these cultural competency exchanges.

Seminar members often relate their local challenges (e.g. there may be no mental health laws protecting children, entrenched asylum incarcerations, strong traditional healing legacies, complex situations of war and trauma, largely homogenous societies with rare discourse on others) or choose to make presentations on their local challenges. They have an opportunity to consider and compare the wider frame of cultural issues impacting mental health resources in their countries of origin. These discussions consider gaps or false assumptions in the application of cultural axis models and dissonances of mental health access or treatment realities. Seminar members are encouraged to struggle with theory, phenomenology and competing ideologies as they sort out universals versus social or culture-specific agendas.

Evaluations of the sessions have been consistently positive, and sometimes seminar group members continue ongoing networking and stimulating exchanges years after the encounter in the seminar. However, participants find the lack of closure or resolution on topics emerging in seminar discourse both validating and frustrating. Especially for members with little prior clinical experience, the lack of closure on discussion is one of the frustrations of the seminar process and is reflected in feedback from some members.

Introducing the Complexities of Therapeutic Alliance: A Discourse on Institutional Racism, Ethnocentrism, Colonial and Post-Colonial realities

The initial seminars vary with changing input of visiting lecturers and co-leaders but share consistent themes relating to the cultural underpinnings of alliance building, listening, power disparities, privilege, recovery and attunement. The introductory sessions tend to widen the discourse on social suffering, belief systems, cultural explanatory models, institutions and sociopolitical frameworks. As complex historical legacies and processes are intertwined with political and social realities of host societies, throughout the seminar, we examine the mirroring of these legacies in current medical practice models or mental health institutions (Goffman 1961; Foucault and Murphy 2006). We often include works on the impact of slavery as a legacy of black Afro-Americans and migrants (Fanon 1967; Fernando 2002) and apply a psycho-historiographic (Hickling 2007) lens to our case discussions. The seminar leaders and guests focus on the agendas of implicit or explicit obstacles to cultural safety, mental health access and care.

A frequent visiting scholar of Sri Lankan origin with a long career in the United Kingdom, Dr, Suman Fernando (Fernando 2002, Fernando and Keating 2009), has often introduced clinical themes that are developed throughout the seminar by the co-leaders and other guest lecturers. His themes relate to the history of cultural psychiatry, institutional context, discussion of institutional racism, spiritual or religious aspects of community or self and cultural consulting expertise (Fernando et al. 1998). During the seminar, Dr. Fernando often cites the studies of Franz Fanon (1967) as a pioneering voice on the significance of Otherness in the clinical domain, relevant to the vulnerabilities of black and minority migrants in Euro-North American societies and a clinical literature with a largely Euro-North American bias.

Institutional racism (Fernando and Keating 2009, p. 14) was introduced to our seminar series by Dr. Fernando as central to the contemporary discourse on minority mental health. This term was first used in a book called ‘Black Power’ by Stokely Carmichael and Charles Hamilton (1967), then appropriated in the Macpherson Report (Home Department, UK 1999, p. 28) to describe the failure of the London Metropolitan police to fully investigate a racist murder of a young black man, Stephen Laurence. The U.K. recently refocused attention on this case, with the police arrest of some of the suspected murders in January 2012. This particular case study has been used to illustrate a widely divergent Euro-North American discourse on the themes of institutional transformations within post-colonial contexts where increasing diversity challenges institutional cultures. The inquiry report used the following definition of institution racism:

…The collective failure of an organization to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviours that amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping that disadvantages minority ethnic people. (McPherson Report 1999)

Dr. Myrna Lashley has been a frequent guest lecturer, who also builds on themes of alliance building, racism, institutional premises and cultural mistrust. Her theoretical presentations on racism and institutions relate to her research and consulting work with police or vulnerable minority populations, as well as her roots in Barbados and her migration to Quebec. Building on theoretical and cultural research overviews, she often translates the therapist–patient encounters into role-plays in the seminar with student participants. This active engagement of the participants often brings a mixture of enthusiasm, validation, discomfort, distress, conflict and anxiety that is never fully resolved in the seminar space but carries over in our discourse throughout the series. Themes of dissonance, misunderstandings, oppression, countertransference or uncertainty that can be aspects of a clinical or institutional encounter are thus presented by various lecturers from divergent perspectives. The widely varied cultural experiences of the participants also lend themselves to different perceptions. Ideas, role-plays and discussions of their identification with dominant culture versus minority positions are usually varied, complex and dynamic. The plasticity of meaning, mirroring and identifications are often part of these deconstructions.

Dr. Carlo Steirlin, who has origins in Haiti but also lived in America and Quebec, has brought a discourse on cosmocentric versus anthrocentric cultures, sharing African and Haitian aspects of experiences of Black history and mental health. He introduces issues of indigenous health models, including Haitian spiritual healing. One of Dr. Steirlin’s vignettes relates to a supervision of a psychiatric resident making a diagnostic assessment of an aboriginal hunter from Northern Quebec, to explore cultural explanatory models versus phenomenology skills:

An elderly hunter had presented with withdrawal, poor sleep, disengagement from his usual life interest, loss of appetite, and preoccupation with the spirit of an animal he had killed. He related that he felt an estrangement of the spiritual connection between himself and the fallen animal at the moment of the kill (‘something not right passed between us’), which deeply disturbed him. The psychiatric resident made a diagnosis of delusional disorder and suggested a neuroleptic medication for treatment.

The resident had ignored local cultural explanatory models or seeking collateral information around this vignette. Dr. Steirlin suggests the impingement of the hunter’s belief system formed from collective embedding implicitly framed his spiritual legacy of gratitude towards the animal killed and offers an alternate framework for the diagnostic and therapeutic work. The vignette is used to elicit questions of phenomenology and possible therapeutic responses. Discussions often arise on possible alternate formulations that had excluded depression, grief embedded with spiritual meaning or social suffering perhaps reactive to collective, contextual losses or traumas inclusive of his aboriginal history. The intent of such discussion is not to avoid closure but rather to open a discourse on cultural formulation parameters within wider ethnographic or historical dimensions of the patient–healer context.

The clinical implications of identity, colonialism and religious and spiritual development (Kakar 1982; Obeysekere 1990; Hickling 2007) are actively developed in sessions with the co-leaders, along with Dr. Fernando, Dr. Lashley, Dr. Steirlin, Dr. Ellen Corin, Dr. Fredrick Hickling, Dr. Hilary Robertson-Hickling. These seminar sessions introduce a discourse of colonial gaze, projective identification and embodiment or mirroring reflected in intra-psychic, institutional and social relations in regard to Otherness. Elucidating examples of mental health scotomas dressed in religious or spiritual dimensions of cultural beliefs are framed in clinical narratives and acknowledging alliance variables involving resilience, protective factors, resistance or miscommunications. Spiritual and religious beliefs relevant to psychiatric care, recovery programmes, substance abuse programmes or the issues of traditional and religious healing systems are introduced through clinical case narratives.

The historical relevance in the west and east of spiritual parameters of treatment and collectivist value systems are presented in relation to ideological premises, such as the Cartesian and Freudian frames. Multiple influences and divergences from science to the anthropological, mythic, artistic, spiritual or religious realms often inform these discussions. A critical seminar discourse on ethnocentric western bias in mental health training literature pursues understanding of development, life cycle, biology and cultural beliefs or paradigms (Stewart et al. 2012; Kleinman 1997; Kakar 1978, Kareem and Littlewood 1992; Worthman et al. 2010) and is frequently stimulated by the participant group’s diversity. A part of this seminar discourse relates to universality versus culture-specific challenges in working with diversity of belief systems, explanatory models, embodiment, mythic organization of culture (Obeysekere 1990) and the resilience literature (Luthar and Zigler 1991; Ungar et al. 2007). Seminar members often express their distress, validation or lack of clarity as they explore these somewhat new inter-disciplinary territories with each other and begin to pose research or clinical questions.

Systemic Theory in Family and Individual Cultural Assessment

Whilst the therapist and patient dyad situated in a wider social reality begins the seminar themes, the emphasis moves between wider social frames to familial systems interwoven with individual predicaments. An overview of family systems theory is related to family intervention frameworks applying the cultural axis. Literature on collectivist versus individualistic social systems as well as cultural variations of development (Worthman et al. 2010; McGoldrick et al. 1982; DiNicola 1985a, b; Kakar 1978; Akhtar 1995; Guzder 2011; Guzder 2007) are useful in framing this discourse. The wide cultural variation in definitions of family and life cycle development processes is usually emphasized in the session on families.

Case presentations by the co-leaders form the core of these clinical presentations building on the exposure in the introductory session of a case study pedagogical method. As child psychiatry is developmentally and systemically embedded, this approach is clinically familiar to both co-leaders. Participants and therapists trained primarily with adults or in dyadic work often have less comfort or prior experience with group or family interviewing.

Systemic thinking is offered as a tool for intervention planning. Usually, genograms and video clips are used to supplement narrative process notes and clinical vignettes. The emphasis again is the clinical considerations, the transference agendas and assumptions that are crucial to ‘joining’ (Minuchin and Fishman 1981) and initial engagement with families. Murray Bowen’s (Bowen 1978) conceptualization is offered, i.e. that a therapist can do systemic work with one patient. Cultural realities of traditional societies, migrant, refugee or host societies reflect the processing of acculturation and assimilation across generations with consideration of family members encountering various stages of the life cycle. Family reunification, traumatic disruptions, toxic object relationships, loss, refugee dislocation, host society reception and culture change variables complicate the assessment of family work or dynamics. Empathy for each family member in framing intervention is presented as a therapeutic alliance building that is particularly challenging as culture change manifests across generations and across histories. Closed versus open system issues are discussed in contrasting traditional societies and urban or culture change contexts.

Cultural camouflage (Friedman 1982: 502) is also presented as an impediment to understanding, empathy and resistance to shifting family or individual functioning. Cultural camouflage is a concept borrowed from Rabbi Friedman in McGoldrick et al. ’s (1982) paper ‘Ethnicity and Family Therapy’:

… It is the failure to appreciate how emotional processes are camouflaged rather than determined by culture that enables family members to blame the background of others as the source of their discontent and their inability to change. Cultural camouflage encourages family members everywhere to avoid taking personal responsibility for their own points of view. It may be worse. The constant focus on and interminable discussion of background factors either amongst family members or with family members and their counselors, allow important emotional forces to operate in their pernicious way, undetected.

The seminar discussions challenge therapist assumptions that culture rather than object relations or social determinants such as poverty, marginalization or racism can be the overriding source of distress (Fernando 2003). As therapist’s assumptions frame a set of intervention directions in therapy, case studies are used to illustrate the complexity of presentations, unexpected outcomes and the need to maintain an openness to the uncertain territory of ‘not knowing’ as one proceeds in family or systemic interventions or triages important aims of therapeutic work.

Ethnocentrism of the family system literature is positioned with the relevant invisibility of mental health literature involving Asia, Africa and other regions. The seminar encourages participants to use their own clinical material from their country of origin, host or diaspora context as opportunities to pursue understanding through film, arts, fiction or academic pursuits. The group process often validates the participants as experts and encourages each member to expand their understanding, writing, research and application of cultural and systemic framework to clinical work.

Trauma Teaching: Building Meaning and Assuming Absurdity

Throughout the seminar, trauma and traumatic memory recur as themes developed within the multiple perspectives of individual, social and cultural contexts. The seminar leaders spend some didactic time defining trauma as a process of metamorphosis and then move to resituate the dominant trauma discourse and its clinical directions in the wider context of historical bedrocks, colonialism, war, refugee or migrant experience. We refer to a trauma literature that includes psychiatric or psychological disciplines, medical disciplines, social sciences, fiction and autobiography (Semprun 1998; Sebald 1992). These multiple sources are cited throughout the seminars to explore the issues of memory and the embedding of socio-cultural assumptions.

‘A House of Stories’ Session

One session that focuses specifically on trauma themes is built around a group exercise called ‘a house of stories’. This pedagogical model was generated from an intensive trauma intervention workshop held in Argentina by Dr. Elena de la Aldea with the survivors of the ‘disappeared’. Dr. de la Aldea originally used this theme in a full week therapy workshop to build a group reflective experience around participant trauma stories. These sessions were in small groups where members were still actively transforming or experiencing the trauma of the ‘disappeared’. The ‘house of stories’ often began with content that was distant from the group’s catastrophes of death or disappearance of family members, war or dislocation to microaggressions of the more immediate transient disruptions of everyday life with late buses or food price inflation. The group approached latent catastrophic issues cautiously, bringing these issues to sessions after the group had built sufficient trust to become a working group (Bion 1961). The house of stories was a movable process of sharing stories and tolerating versions of trauma between group members who would then remain connected over years sometimes with follow-up groups. In contrast, the ‘house of stories’ in our seminar is an adaptation as a single group exercise in our working group, with a transient time frame and offerings of fragments of stories not necessarily based on their lived experience.

The modified version used in our seminar is a one-session exercise. Prior to the session, the participants are asked to think of a trauma story from any source (i.e., personal experience, journalism sources, narrations, clinical vignettes), which they will write out and share for the group. The group is supplied with markers and large pieces of paper and invited to write (or draw) something alluding to their story. It could be a few words, a sentence or a short text. These story fragments are posted around the room and usually cover all the walls. Some of the participants have prepared a pre-written story. Others will stare at their sheet and stay still before writing a few sentences, in large or small letters. The calligraphy often introduces the trauma transmission. Rarely are drawings used. For example, a Japanese participant drew the Hiroshima Bomb, the associated devastation and the survivors were introduced with a few lines. The group associations on this drawing include an emotionally charged sharing of complex political context and the intermingling of despair and hope being transmitted from generation to generation.

Following the silent period of preparing their papers and hanging them around the room on the walls, the seminar members are then invited to read all the stories. To do so, they must often walk in silence around the room stopping in front of each story for a few moments. This is often an intense sharing with a peculiar silence filled with respect and shared pain. Each group member places a mark on the story they wish to discuss. Those stories receiving the most marks of interest by the group are discussed, the co-leaders emphasizing that the silent stories which are not chosen are as significant as those which are chosen or heard.

Year after year, the stories posted around the room represent the multiple faces of recognized and unrecognized trauma, with dimensions of the singular and collective. In the North American context of the seminar, overt and graphic trauma stories are often chosen for discussion. For example, terrible rape and killing scenes of war zones are vividly represented, which arouse the group’s shared feeling of fear, disgust, sadness or shame. Whilst the stories allude to the way in which trauma is invested in clinical milieus, the seminar considers therapeutic and social representation of catastrophic suffering and the voyeuristic and sadistic impulses whether linked to extreme man-made suffering or media accounts. The choice of stories are a mirror of the group’s representations, distancing, dissociation or unreality versus their actual experience of violence. At times the trauma stories are attributed to barbaric others and often ignore more immediate personal, local or microaggression experiences as well as organized violence toward indigenous people, minorities or the mentally ill in local context. Interestingly, the same exercise led by De la Aldea and Rousseau in Lima (Peru) following explicit violence experiences of the participants elicited a similar range of stories. The Lima group, however, chooses to divert their discussion from the ‘unsafe’ agendas of macrotraumas of political upheaval to more accessible microtraumas such as the stress of riding the chaotic small urban buses or the untold violence of controlling couple relations. The selection of memories or associations is integral to the house of stories process, as each participant considers their group’s choices of both the told and the untold vignettes. Their stories move between distant or intimate events, microaggressions or blatantly catastrophic events. The processing of stories opens discussion around disclosure processes in therapy influenced by cultural embedding. Disclosure is integral to therapeutic intervention that might pursue a path of uncovering, processing or restraint in approaching trauma memory. Avoidance not only shapes what is brought by the patient to therapy but also may reflect the therapist’s attentiveness, inattention, focus, blind spots and interpretations.

The variations in the choice of stories in this session move from close (i.e. intimate, cathartic, personal) to far (clinical, or journalist accounts, distant from their personal experience). The stories elicit reflection on the participants’ own representations, memory and attention, including their attunement to universal issues of daily life or object relations, not only catastrophic traumas such as war or torture. The group members often speak of their individual and collective capacity to handle hurt and survive it. The group process around the shared stories allows the group to appreciate the variations in perceptions and the gaps in story telling which may be inherent to personal and collective trauma. Apprehending the distortion of stories does not deny the existence of historical truths or clinical truths but clearly establishes that clinical narrative is not a straightforward truth-seeking enterprise. This exercise emphasizes the central role of the political dimension of clinical interventions in trauma situations, whether in our listening, recounting, remembering or interventions (Vinar 1993). Reflections on the reluctance to provide a story, the group’s selection or exclusion of stories, or the variable use of the group to process a current or past trauma create unique group encounters. At times personal catharsis during this session may be distressing for the group, especially when an individual participant may share intense affects whilst connecting with a personal or family story. The co-leaders guide a discussion of personal engagement and risk to the therapist as part of the engagement with trauma.

Trauma stories are continuously shared by the co-leaders and as well as visiting guest speakers in teaching. Dr. Ellen Corin, as one the visiting lecturers, presents trauma vignettes from her psychoanalytic practice. She brings a long career experience as a research anthropologist in Quebec, Africa and Asia, with a later shift to a career as a psychoanalyst. Her case vignettes usually relate single sessions as a window into individual worlds. Whilst psychoanalysis has not been a transportable methodology across cultures for many reasons, the use of a single session dyadic exchange offers a microcosm approach of therapy content to balance the macrocosm agendas of social or systemic theory. Her thoughts on gaps and dissonances again raise questions about working with uncertainty and unknowns inherent in clinical processes. At times the group will shift the focus to her anthropological or ethnographic experience rather than pursue the dyadic intimacy of the therapeutic impasse or selected narrative. The group process of each seminar proceeds within a working group context.

Consultation to Vulnerable Minorities or Aboriginal Communities

The ambiguous and conflicted role of expert or consultant in cultural work is a theme that continues throughout the seminar. Dr. Fernando often introduces a vignette about his medical legal work as a cultural consultant psychiatrist in the United Kingdom. Dr. Myrna Lashley (2000) shares her experiences within clinical sessions, training police or consulting with youth protection systems involving minorities. Dr. Fred Hickling (2007) and Dr. Hilary Hickling have shared their work on deinstitutionalizing Jamaica, working within a post-slavery social space as well as understanding migration resilience and vulnerabilities of Caribbean populations. Often members of the seminar group have considerable prior experience in war, or in minority health or aboriginal community consulting. They may be invited or offer spontaneously to present their experiences of clinical challenges. Various other guest lecturers and the co-leaders have worked with community consultation including Dr. Radhika Santhanam (Australian aboriginal communities), Dr. Lucie Nadeau (Inuit and Cree in Quebec) and Dr. Toby Measham (cultural consultation in Montreal), who discuss community consultation predicaments. Some participants have trained with consultants who tend to erase the cultural axis from psychiatric intervention or training promoting a universalistic mental health model. Others have been trained within shared care multicultural clinical settings or have experience in co-construction of clinical services with minority communities, who may have a primary role in defining mental health agendas. Otherness is often resituated in this discourse in terms of training perspectives, models of care, post-colonial legacies, gender politics, variations in community trauma and collectivist ‘voices’, in setting agendas which vary amongst the international examples shared in the seminar. Research questions and sharing training concerns are raised in approaches to minority health and are encouraged throughout the seminar.

Closing Session: A Co-construction With the Seminar Members

The closing seminar is focused primarily on the participant contributions or their major presentations (e.g. a clinical case, a film they have prepared, a power-point on a project, a model of intervention they have proposed in their countries of origin), discussion and unanswered questions. Often there is a discussion of unmet needs of the seminar process. Sharing with fellow participants, or reflection on disappointments, anticipations prior to the seminar, or unexpected ideas emerging on training or clinical work are common themes. The seminar group often shares their own work, thoughts on their previous training, hopes for further clinical or research experiences, projected training impact of the seminars or hopes for continuing networking links. The use of the seminar group as a temporary holding environment (Winnicott 1967) that functions like a transient clinical team leads to discussion on the essential aims and challenges in building teams. The seminar experience is often linked by members to the essential role of teams in supporting each therapist to tolerate the strain of gaps and dissonances, traumas and failures that are a usual part of a closure and unfinished process. The premise of transitional process or the third individuation (Akhtar 1995) process as an unending and unresolvable state returns as a theme in this closing phase of the working group.

Conclusion

This article has described a seminar experience which attempts to elicit a multiplicity of voices and perceptions, whether intra-psychic, systemic, socio-political, professional, mythic or historical, in order to strengthen the therapist’s reflective capacity on the place of culture in the clinical space. Our teaching approach to clinical cultural psychiatry focuses on cultural competency embedded within the complexities of therapeutic process. Whilst simultaneously transmitting multidisciplinary knowledge, the ‘Working with Culture’ seminar facilitates a decentering position and takes a critical stance toward an expert position, emphasizing the dynamic internalizations of self and collective awareness within the patient and healer. The diversity of the participants is fundamental to the group process and presents immediate access to co-existing dissonant frames of reference or language. Dethroning the expert position and shifting towards promotion of team work or group exchanges opens the door to a widening discussion on supervision, intervention, alliance and clinical realities. The seminar process encourages discussion on the dynamic plasticities of cultural meaning, theory and representation whether from psychiatric, inter-disciplinary academic sources, artistic, journalism or personal accounts.

The seminar group work is at the centre of this learning experience. The fact that the members have widely varied cultural frameworks and academic backgrounds, and the dual leadership of the seminar, aim at anchoring a reflective process around power negotiation and subversion in clinical work. During the seminars, encountering Otherness in the patient or ourselves remains essential to promoting affective attunement and tolerating the experiential awareness of the discomfort, joy, and solidarity which are bound to emerge in clinical work.

Intensive seminars such as these have a limited role and cannot replace continuous supervision and team reflection in learning how to work with culture. They can, however, initiate critical thinking in clinicians who are immersed in mainstream services and support by providing theoretical tools to those who are struggling to transform clinical settings. Finally, they may empower clinicians who question the cultural competence paradigm and may feel fragile within services and institutions that emphasize excellence and expertise yet minimize the political and clinical utility of uncertainty. The seminars encourage members to consider the place for working groups in their training setting or supervision groups in their clinical contexts. The seminar series works at balancing the impingements of clinical experience, cultural realities, and institutional constraints, and to work towards clarifying local cultural challenges as well as the need for continuing research and training involving inter-disciplinary sources that support our roles as clinicians.