Cultural awareness in psychodynamic practice

Long before the "cultural formulation" chapter was added to the DSM-5, it had become apparent to me that, in order to provide patients with effective treatments, we needed to have an understanding of their cultural framework.

Much of what I’ve learned about the importance of cultural competence comes from my work with abducted child soldiers in Uganda. And much of the trauma suffered by those child soldiers in Uganda can be compared with the difficulties experienced by communities of color here in the United States.

Psychotherapists must examine our subjective understanding of trauma in individual and communal narratives. We must figure out the extent to which an understanding of non-Western practices can enrich our competency as psychodynamically informed therapists working from a Western cultural orientation within Western contexts with client populations representing Western and non-Western cultural orientations. We must explore how our implicit cultural assumptions, operating within the transference-countertransference field, can have an impact on our clinical technique, clinical stance, and decision making.

Effective treatment hinges not only on a deep understanding of the patient’s cultural influences but on the ability to identify therapeutic goals that are culturally syntonic and responsive to the patient. Empathy, mutuality, power and authority, use of self, and effective communication are other vital components in the treatment process.

Impact on children, families

Children and adults found themselves in incredibly difficult circumstances in the aftermath of the devastating armed conflict involving the Lord’s Resistance Army in Uganda, an East African nation of 34 million people. During the war, which lasted from 1986 to 2006, almost the entire population in the northern part of the country was forced into internally displaced persons camps.

Much of my research has focused on children and families involved in armed conflict in northern Uganda. Toward that end, I have conducted three qualitative studies. One, conducted in 2005, looked at the resettlement of formerly abducted children; a second in 2008 examined the resettlement of internally displaced individuals; and the third, conducted in 2014, looked at the effects of armed conflict and displacement on women’s social, cultural, and economic roles and responsibilities.

Several themes emerged from my studies. The first revolved around the societal impact of the war on people living in the camps for the displaced. People complained of not being able to move as freely as they wanted because of military restrictions and not having enough to eat. They also complained about violence in the camps. Even people who were able to return to their communities had to rely on their relatives because they had lost everything. Some adults could not afford even a bar of soap and had to live with their parents.

The second theme was tied to family support. Returning victims of the war often were welcomed by being provided with money, housing utensils, and food to help them start a new life. This usually was accompanied by a cultural tradition of a welcome ceremony involving dancing and singing, in which the community expressed joy at having abducted children back, provided advice on how to live with the community, and offered support, usually from the elders of the society.

The third theme was connected to community support. Most of my work was focused on the Acholi people, the dominant tribe in the country’s Gulu district. The Acholi have a history of communal work, with community members, as a group, taking turns to work on one another’s farms. Normally, community members were welcomed back with offerings of perhaps sheep, cows, or goats, but the community could no longer do that because of poverty. This tear in the social fabric represented war trauma to the whole group.

The fourth theme was that of community acceptance. The communities accepted the victims of war and reminded them that what happened was not their fault and encouraged them to live a normal life. This community narrative of the abduction supported community acceptance and reintegration efforts. Most formerly abducted children and community respondents provided examples of helping or being helped by another person in the community.

In populations like these, the impact of armed conflict, social expectations, norms, and the communal nature of the clients’ relationships are important to understand. Certainly, here in the United States, the idea of individualism rather than the collectivism we see in many African countries often shapes the way we view ourselves and our clients. Still, the results that I saw while working with clients in northern Uganda have relevance across geographical boundaries. Clients are influenced by multiple cultures: the client’s, the therapist’s, and the relational space.