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Doman RESUME t48 968 OD 017.795 Lefley, 'Harriet Bestman, Evalina V. Psychotherapy in CaribbeakCiatures. ATE Ang 77 22p.; Paper presented at the Ann Val Convention of the American Psychological Attociation (San Francisco, California, August 26-30, 1977) ; Some parts of document may be- marginally legible 'due to quality of print as PRICE \MF -$0.83 HC -$1.67 Plus Postage. E§CRIPTORS Change Strategies; Cubans; Cultural Background; *Cultural Cohtext; *Cultural Factors; Immigrants; *Mental Health Clinics; *Mental _Health Programs; Mental Illness; *Psychopathology; *Psychotherapy; Puerto Ricans TIFIERS *Caribbean; Haitians STFACT Caribbean mental health professionals are concerned the types-of psychotherapy,that are releVait to the needs of r-, -,Clients, and with the uses of psychotherapy in ar political ftecitittit4. Thtf_. appear to be divided into two soh-Cols: one seeking to rbtote= in clients a change from: a traditional_ world _View to _a modern done; and the other seeking. resolution within the client's lifestyle wand- belief system. This paper discustes mental healthprofessionalse e at-onthip- to indigenous healing systems' endemic to-=Caribbean Fjor instance:, (1) Haitians' Voudou, (2 Obeahuor witchcraft, -prevalent' in the British west Indies, the Virgin Islands, -the -Bahamas, (3) Puerto Ricans' Espirititmo, ancU44) 4frarCubansl nteria. _Mete as well as other therapeutic modalities are discussed i=n= terms of their applicability in clinical and community settings. A -----_CondliColtponent of the paper dealt with empirical approaches to Chotherapf with Caribbean immigrant grodps in Miami. The versity of Miami-Jackson. Memorial Hospital Community Mental Health titer;- maintains six -ethnic community teams, four of which are rated; toward Caribbean populations (Bahamian, Cuban, Haitian, and etto Itican) with staff of matching ethnicity. This center has ye-loped a range of various types of therapeutic interventions. -644- tAem are the following: (1) a network of culturally homogenous ni-clinics in six diffekent communitie., (2) =group therapy within a 1SOCial -recreational context, (3) involvement of the extended family an-familf therapy, (11) knowledge of the various forms of "hexing", 5 "-consultation and informal referral to folk healers when this eemt- indicated, ande(6) merger of traditional and scientific tchnigdes in psychotherapy. (Author/AM) Documents acquired by ERIC include many informal unpublished materials not available from other sources. ERIC makes every effort to obtain the best copy available. Nevertheless, items of marginal reproducibility are often 'encountered and this affects the quality of the microfiche and hardcopy reproductk.is ERIC makes available via the ERIC Document Reproduction Service (EDRS). EDRS is not responsible for the quality of the briginal document. Reproductions supplied by EDRS are the best thatcan be made from the original. Lt Z49 IN* 1°44 Paper prestAed at the_85th Annual Convention of the American Psychologicak Association:. San Francisco, August 26-30, 1977. - 2 PSYCHOTHERAPY IN CARIBBEAN CULTURES Harriet P. Lefley, Ph.D: Director of Research" & Evaluation Evalina W. Bestman, Ph.D. Director University Of-Miami-Jackson Memorial Medical Center Community Mental Health Services Department of Psychiatry University of 'Miami School of Medicine P.O.'Box4520875 Biscayne Annex Miami, Florida 33152 U S DEPARTMENT OF HEALTH. EDUCATION WELFARE NATIONAL INSTITUTE OF EDUCATION THIS DOCUMENT HAS BEEN REPRO. DUCED EXACTLY AS RECEIVED FROM THE PERSON OR ORGANIZATION ORIGIN ATING IT POINTS OF VIEW OR OPINIONS STATED DO NOT NECESSARILY REPRE SENT OFFICIAL NATIONAL INSTITUTE OF EDUCATION POSITION OR POLICY "PERMISSION TO REPRODUCE THIS MATERIAL HAS BEEN GRANTED BY TO THE EDUCATIONAL RESOURCES INFORMATION CENTER IERIC: AND USERS OF THE ERIC SYSTEM " PSYCHOTHERAPY IN CARIBBEAN CULTURES Harriet'P. Lefley, Ph.D. and Evalina W. Bestman, Ph.D. When the newly organized Association of Caribbean Psychologists met for the first time yin Haiti last year, it was not surprising that the conference theme was entitled "Psychotherapy: What Works in the Caribbean?" For ,a number of yews now, Caribbean mental health professionals, like many others in other parts of the world, have been bemoaning the fact that the skills . .learned in the great universities of Europe and.the United States were not . 1 . always transferable to their work with their own populations. The emergence Of h mental health capability in the less developed regions of the World has highlJhted an old problem in the field; that is, the discrepancy be- teen our elegant psychodynamic theories, which appear to have universal applicability, and our technologies, which do not. fndeed,'the descriptive accuracy of psychodynamics inferred from,overt behavibr--and intellectual and perceptual functioning as4well-.-appari to be highly subject to cultural specificity (See especially Draeuns, 1973), Added to this are the problems' of acceptance, relevanee, cultural appropriateness,rnd remedial potential t of treatment molplities transplanted from an alien culture. When we 4.eak of a mental health capability in the 'Caribbean area, we refer prifiVrily to the long chain of islands that make up'the West Indies; the Bahamas, too, fall under this rubric, although technically they do not / bound Caribbean sea. The people are multiracial, but primarily Black-- ) / f descen4aq'ts of slave's under various colonial administrations. As a heritage / of colorpalism, the languages are English, Spanish, French, and Dutch, to- ; gethertwith their various Creoles. There are other residuals of colonialism (in some cases replaced by native dictator.hips) . Most of the people are poor, by American standards, fiti Their work has historically been agriculture and fishing, bUt-asignificarlt portion of the labor force is now in the touri.st industry. This growing reliance on service occupatfOns as a major economic base is of great concern to many,,Caribbean governments - -riot only because of the fragility ofjouri-sm as an income 'source, but because of the perpetuatiOn of servitude as a way of life. In newly independent countries in the Caribbean, with rapidly shifting power relationships and role changes, and rising economic expecta- tions, people become dramatically dissatisfied with the old ways. Additionally) ,there is the inevitable acculturative stress that accompanies the transition from traditional to modern man--today a worldwide prinomenon (see Da;ison,I970 The sociocultural context is Of great concern to Caribbean professionals, who see a profound relationship between the developmental level of a given :society and the ability of its members to benefit from traditional psycho- therapy. Moreover, Caribbean psychologists discuss not only the types of psychotherapy that are relevant to the needs of their clientele, but the uses of psychotherapy in political context. Thiifsnot the old question of whether to adapt creatively deviant patients to a_sick society. Rather, it- is whether the psychotherapist should consciously try to promote in the client a change from a traditional worldview to a modern one--a process which will facilitate adaptation to the real world around him and - not,coincidenoliy also maximize the benefits of psychotherapy. In -enmnarizing the various positions at the Haiti conference, Antonio Diaz-Royo (197Ea)found two global iiewpoints with respeCt to modernization. The first position considered modernization inevitable and postulated that the client must adjust to fit in order to solve his problems. Here, "PsYchrl therapy is seen as a springboard for socialization or conversion to modernization, thus achieving the client's adjustment." The second position ^L A. ee ei a conceptualized that modernization is not necessarily inevitable on an individual level, and seeks a,solution within the style of life that the client selects. The two viewpoints are probably best exemplified by a group of Puerto Rican psychologists on the one hand, and a group of Haitians on the.other. iviatlin and his associates (1976:1) took a hard look at the program for training local psychologists and decided that "the use of American styles tended to cure the patient of the disease of being Puerto Rican." Theliaitian psychiatrist Bijoux (1976), on the other hand, expesses enormous frustration _with his,paients% whose traditionalism makes it almost impossible for him .t.6 use the psychoanalytic techniques in which he has been exquisitely trained. Haitian patienls.have a Basically Magical -philosophy of life; like most - 4?. PeOple froth traditional cultures they are high in external locus of control- - ea, hamce the difficulty of introspection and certainly of seeking mastery over `''one's life through this non-magical mechanism. Additionally, financial' limitations--ubiquitious problem in the islands--forces the therapist into brief psychotherapy. But with industrial development, more education, and wages--the whole picture would change. "All .the adverse conditions cam:Le modified tay ;An evolution from an agricultural magical mentality to a technical industrial positive orientation, so we are raising the question. ea s. the destiny of psychotherapy linked to the socto- economical development of a specific society?" (p. 5). T111-;WAcit the islands there was a fairly uniform description of the P e, Caribbean cltient seeking psychotherapeutic aid. Diaz-Royo gives the following sumeary picture: 1. Oriented toward a particul1r problem which is what brings-him to seek psychol gical,aid, with a non- contextual expectation of 1.'ychotherapy.. He-does eot conceptualize the problem that,bringsi him for payehotherapy as rooted in his style of-life. 5 , e 2. Expecting-counsel or direction from the psychotherapist, -A and finally, , 3. Arriving with the expectation that he can implement the psychotherapist's counsel or direction and thus resolve his problem relatively rapidly. .(Ibid:1) =, ..\ . This description, however, does net differ substantively frbm that of the \ typicaleiqwer socioeconomic or minority group client in the Uni ed States. In fact,,t1ie-edescription might apply to practically anyone who haS'little \\\ . - familiarity with the ethos and boundarf'es of ps'yChodynamic therapies. What Makes the ,Caribbean patien'e somewhat different, however, is that he oftere has alternatrve.options, that is, his traditional healing systeait. As Bestman et al (1976) have noted, while many health professionals view ethhiC healing systems. as alternates to scientific medicine or0e orthodox mental- health service delivery system, actually we are alternates'io traditional therapists pod their practices in a system which is historically an out-- growth of cultural beliefs and values specific to an ethnic population. growth Thus. Caribbean clients may use our clinics ts,a first or last resort, .or in tandem with a native healer. Additionallye the, belief system itself may be the source of mental malaiseor presenting symptomatology, requiring the services of a native healer for appropriate remcdiation. Coeimon Among these are possession crisis--in which the person is possessed by his personal or k ancestral_ spirits or gods in ritual context; bizarre behavior--bowing, hand Motions, deecing, etc. - -which is actually ritualistic (see Griffith & Ruiz, 1976); or anxiety nerosis resulting from being 'rooted,' "hexed," or "fixed"-- . all conditions whi.ch ascribe causation of ill fortune or Mental condition to the magical influence of others. $isterau. ___________ Healers -5- Obeah, Voudou or (Vodun), Espiritismo, and Santeria are prominent bief' systems in the West Indies. Although all share certain commonalit,)es from the Christian and West African religions, each-exhibits a unique form. In Obeah, ' normally, there is no group 'involvement., healers work in a one-to-one relation- . :ship with their clients. In the other three systems adherents often gather as a group and receive additional benefits to memberships such as 'social/ " support and `recreation:.. Voudou, subject of 'Western fear fantasies, appears to be, true religioh, i,e., it is a. set of be4efs &pd practices which claim to'deal with the spiritual forces ofwthe universe, and attempt to keep the individual in harmonious relationship ith them as they affect his life (Leyburn, 1966:134). As_in'Santeria, there,ita necessary propitiation of gods (logs). Dahomean slaves predominated in Haiti and their religious beliefs and practices formed, the-core from which contemporary voudou evolved. The greatest single influence- duringtheyears of evolutionary,process.'was the Roman Catholic Church. The composite system which exists today,in Haiti, as well as Miami requires that one must maintain proper relationships with the Christian God, the Catholic Saihts, the African gods and'the dead CSim4on 1940: 95). Its practitioners, k called houngans (males) ana mambos (fetal-es) aresought by their clients to foretell the future, cure illness and give protection from the misfortunes of life. They are also thought to have the power to tause illness or harm to another. Ritual voudou ceremonies involve trance, possession, and animal sacrifices--primarily goats and chickens. Ritual dances to coudou drums are actually rites to exorcise bad loss which are presumed to be a cause of the dancer's misfortunes. -6-: Bijoux (1976) has characterized Haitians--almost all of whom are Voudou adherents - -as depersonalized individuals who are exposed very easily to _dissociation. Relctions with others are dcminated by suspiciousness and envy. The mental mechanisms of adaptation most used are magical rationalization, projection, and dissociation-identification," Remedies must clearly be 'culturally appropriate Or.they are bound to fail. Mathewson (1975), describing Haitian patients in Miami, cautions against diagnostic error when Using standard psychological assessment procedures. ,First, she notes that the . - Haitian conceptualization of the world contains two major categories: the visible world including humans, and the invisible world of the dead, spirits, and other supernatural beings. Second, because of'magical belief systems; others are seen-as potential sources of danger and harm. Thus, so-called paranoid ideation is often within the boundaries of normative behavior. Standard assessment procedures for hallucinatory behavior, similarly, must take Into account a cognitive system which attributes'a communicative function to dreams. "At least one aspect.of dreams for Haitians is 'their function in- , allowing communication between humans and membersof'the invisible sub-world... ,e " . Thus, when dead relatives or spirits appgpr in a dream, Haitians tead,to per- .v . ceive the experience as something which really took place"' (lbid,, p. 8). I ' Unless an examiner specified waking hours fof the Ontext of questions, a Haitian. might very well respond that he indeed heard voices ar saW things that others did 66t--without conveying a pathological hallucinatory, experience. Obeah, or witchcraft, prevalent in the Brierih Nest Indies, the Virgin Islands, and the Bahamas, reflectS the syncretism of Ashanti rellgibus beliefs 4,.. L ,' an the Protestant Church's influence, these .,countries. ; As.,jmeall these cult systems, there is a belief in Spirits:-Whdiqypossess' humans and regdixes . , propitiation.- 1,?peah is not a religion, and no' collective rituals, according ------. ,,,.. 8 -7-. to McCartney (197r,). Obeah men deal on an individual basis with Clients, causing: or curing ilines's, tasting spells: and countering the spells of other obeah men. Weinstein (1962), maintains that Obeah perists "because it serves as a mode of , Mt adaptation to stress, because it structures and expresses the most intense feelings, and because it organized what would otherwise be ur-nntrollable and unpredictable forces impinglngon the. individual" (Woodbury, 1975).. gsplfitiall, a more benevolent system, is widely practiced in Puerto Rico. According to Garrison /(1972), Tspiritismo is a folk system of psychotherapy end a means of coping with psychiatric illness and lesser distress; it is. both an alternative and a. supplement to seeking help fratprofeSsional mental health A services. Studies of Puerto Rican samples in San Juan and New York have shok a range Jf 31% to 80% admitting to having sought help from an Espiritista at some time during their lives (ibid). Woodbury (1975) feels that practically gr all Puerto Rican patients manifesting psychosomatic, neurotic, or psychotic / symptoms gp to an Espiritista. As in Haitian Vodun, the belief system postulates both visible and invi,.;ible Worlds, the latter populated by spirits or beings that communicate with the living. Through mediumship, the spirits give rev-lations that help to cure the living of presenting complaints. P.)jler & Hollingshead=(1961 1965) have emphasized the supportive and mainte- nance functions of Spiritist practices, particularly in the case of chronic schizophrenics. Participation in a spiritualist group serves' to structure, define, and render institutionally meaningful behavior that is otherwise perceived as aberrant. Spiritualism serves , the afflict'-:d without the stigma of attending a psychiatric clinic. Afro-Cuban Santeria similarly, provides group support and, in some cases, a isubstitute for the disintegrating extifided family, for Cuban exiles suffering \ the trauma of acculturation. Originally a cult system for lower-class blacks, the pantheon of Yoruba gods, syncretized with Catholic safQts, has become 9 Fi- \, -- --- -____:, ,..,, 8\ ,. st , . -, , ,,N\ ' increasfligly"widespread among white, middle-class and even upper class Cubans 2,. '-'-'.' .. \ ;-W -,,,, fn Miami:: The orichas, ire., the saints or dieties of Santeria, are very com= , , y , t7 `plex and, very Human personifications of nature: By forming the right alliances with the orichas, an individual can manipulate his universe and-thereby master , - , . it.(1) Problem solving and action orientation are central. Halifax and Weidman (1972) have described Santeria as an ego-intesAtive process in which denial, projection, and dissociation--i.e., the iransfer ,guilt,,ir;:the in- Aiwidual to an outside locus, and the projection of unacceptable'impulses and feelings through trance possession by an oricha--are metamorphtzed,into sense of mastery. In- this process, the Santero, through his functiOrrof V divination, acts,as "change agent" and as "theraPiSt." Through divinatfOg, options are revealed which enable-the'clicnt to act, ancrto alleviate his sense _ of vulnerability through propitiatory off:rings. The latter, in turn, place the-p. -ful oricha in a position of indebtedness. In effect, the client_is ., -1- NLN, ; 0. e "buying power," generatinOof,Ohl-,y,an aid in solving discrete prOblems, but ,..,\.- ';_ . _. greater confidence in subsequent relationships and activities--a situation highly analogous with the_aims of psychotherapy. Parenthetically, mony . , Santeros, far -front being outcasts from the mainstream, are licensed as religious; practitioners by the State of Florida. 4 Native Healers and Mental Health Professionals The culturally sensitive (and nondefensive) professional may adopt various stances with respect to native healers. Many reject their science out of hand, viewing them as charlatans, perpetuators of superstition, or workers of malevo-, lent evil. Others consider them valuable assets for learning and referral purposes. ruch depends on the belief system as well as on the presenting 1 0 . 1. -g - J symptomatology. Possession crisis,'or the hjzarre behavior that often accom- pa\ rties religious ritual are certainly-best handled by consultation with a Houngan,,Espiritista, or-Santero. But certain of the so-calldd culture-bound-- 4' . . P 'syndromes, such as "Ataque, or "Susto"--regardless of their psychiatric classification--may also require such interventions. SoMetime a gyehiatrist will work in tandem with native healers, or use them as resource persons for interpreting beha,svior. At other times, the psychotherapist himself may actually adopt the role. McCartney, (1975).a Bahamian psychologist, has described for the University of Miami Department df%Psychiatry faculty a very speedy cure- , of depressive neurosis facilitated by simulated Obeah rituals. In Marl's Jackson MemOrial Hospital', our former chief of the Crisis Service, a highly ,trained psychialrist from Guyana, successfully performed his own specialized ritual *cure a "rooted" patient. Dr. Mercedes Sandoval, a cultural historian-. anthropologist who is director of the Cuban Unit of the University of Miami- Jackson Memorial CoMMunity Mental Health Center and a world authority on Santeria,--deals with patient-believers within their Conceptual frame of reference together with a psychiatrist co-therapist. But what defines, a patient's aberrant behavior as truly pathological -- requiring psychiatric intervention--nr simply as a temporar tifact of a religious belief system? Griffith & Ruiz (1975), reporting on a hospitalized Espiritismo practitioner, looked to the patient's family-for an explanation. Their criteria for psycho- pathology were as follows: (a) The patient's possession had lasted too long--, it is typically a quiCk and transitory experience; (b) possession becoTes abnormal when there.is no perceivable stimulus or condition (e.g., a ceremony, thunder, lightening, accidents, etc.); (c) it occurs most often in the presence of believers (a secrete condition); and (c) it can have positive or negative orientation. Positive orientation is .itual possession, negative -1C- , Orientation in sickness possession. The authors state it is especially impor- , tant for menial helthprofessionals to understand this dichOtomy'for appropriate etlacpsychiatricuevaluation. Other Therapies As in th3 Uted Scates, psychoahalytically trained Caribbean psycho7.5gists continue to piactice traditional psychotherapy a select, educated, and monied rcup V.k.; 6r..a ablo to :ford and benefitfrom thetr art.With-Patients rom-tht, Icer -6:1,1slconomc grour.-:, therapeutic interventions seem to he lrgely f;t1driliws or rehabIlitetiva. In rigorously psycho-analyticHaiti, for ty:rs oT psychotherapy practiced with young-people^are:_ yry with occupational activities; eMotionai support .,,,,thcrcpy base a regimwa of rest" (Philippe, 1976). fo- Tssdic:tion and are not willing to accept withcv_t (.111'y Or Placebo are invariabie adjuncts. In- Is n t_::,,volopmental lag in terms of thn newer American therapies- re.chinc! the HC44V4r, t';hila there is little mention of the pLact-iRie transActional, or gestalt modalities Caribbean professionals Lo be wer read and conversant with their techniques. Periodically, = there artf workshops in family or group therapy organized by out-of-country :.1rofessionals, such as a FacilitPAor Development Institut& held in Curacao 1:st Airrti, with i:arl Rogers as a consultant. Dance and 14%vement therapis have been used in Surinam and Curacao, 4Hars.ntiv with s,-,me ,agrac of success. Howel:er, several innovative thorapeut;c:i , pro: hes; bc.6r :dzsticuler irentAnj One is 7ertpia de r.otas, or Goal Therapy, d..-2w.loped by Monnan rutlin e.nd his associates and characterized by him as "the first systm of p,ychotherapy int:igenous to the Caribbean" (isbtlin, 1976). 12 Goal Therapy appears to be a ,short-term step-by-step therapeutic intervention which dispenses with any inItial'accumulation of information on the client. Matlin rejects whatile terms the,"fishnet approach" of collecting diagnostic data which must then be filtered thrpu9:. .rapist's interpretive armamen- tarium, and in the end, has.little functional relevanCe to treatment. Rather, goal therapists prefer the "spear" approach which calls "foe.dealing with the client's statements one by one. The psychologist opens by asking the client to define the problem he would like to soave in cOunSeltng% The therapist then analyzes the implications ofsthe statements, comments, raises questions, and proceeds in like manner with succeeding statements. "The ,nterview con- , tinues until either the client is'satisfied that he has solved,a particular problem or the psychologist is stuck.' In the latter case, he hai a week to figure out whatthidid wrong." (ibid.) The essence-------of goal/therapy seems to be to defuse the presenting complaint by teaching the client to reconceptualize problems and to seek solutions in terms of realistic goals. Typically, the therapist's queStionS are- gearedlto elicit a reconceptualization of the urgency scope, or validity of the problem. .The model has qeneralizability and can be used anywhere at any time--one paper described a fore- minute backyard aver-the- fence therapeutic intervention which ended in a mutually satisfactor, solution. Two very interesting.therapeutic models evolved from the work of Mtchael Woodbury, a psychiatrist who is currently Executive'Director of the Commission of Mental Health in Puerto Rico. The models were originally developed by Dr. Woodbury and his wife, a social worker, in France and were subse' nAly, utilize In the Virgin Islands and in Puerto Rico. These involved a system of communtty,4 . centered psychiatric interventions with the use of mobile emergen(4 units and home hospitalization visiting teams, indluding itidigenous homemalmrs.. Essen- tially this was an attempt to treat the ptien,t and family "in situ-in itt sociocultural network (and ecological niche)--by the team as a therapeutic small group: (Woodbury, 1969:65). Two therapeutic modalities emergingfrom these 13, -12- community team interventions were (a) the "continuous group" and (b) the "multiple-family group," both of which are currently utilized_in Puerto Rico. . The continuous group is actually a family walk-in clinic, whi.7.41 started as an extension of spontaneous meetings of the team itself in their treatment mom-kitchen where they "metabolized" their anxieties about homevisits. As Woodbury (1969:70) described it: "Patients and Members of their families dropped in to say hello and talk things over, expecting us to return their hospitality." AlthOugh at first the taam was opposed to this "psychiatrization insisting that all vuterventions occur in the patient's territory," they subsequently began to realize its usefulness. The continuous group offered patients and 'their families crisis intervention and group psyChotherapy "on demand as a safety valve_that in many cases prevented a real emergesty later on." 'Approximately 20-30 persons utilized the service each day. The second modality is a variant of.family-group psychotherapy which at its inception involved 30 families being served in the community- intervention =- service, plus teams, center personnel and professional visitors. As Woodbury describes it, families with problems become theraOtsts,for other families With prbblems--rather like the extension of a self -help group with clinical back-up. "All members learn rather quickly our basic techniques of psychotherapy= and are expected as a matter of principle to participate in the resolution of one another's conflicts. As the 30 families we have at any one time on our `service become acquaisited with each other's problems:they are.encouraged to assist one another in their neighborhood without our mediation...Family treats family" (Woodbury, 1969:70). It might be-noted, that this type of mutual aid is most likely to work in cultures where it is not considered shameful or threatening to talk about emotional problems in the family. Dr. Mercedes Sandoval, director of the Cuban 14 a Unit of the University of.Miami-Jackson Memorial Community Mental Health Center, = has noted that the Anglo emphasis on confidentiality is alien to her patients, 4 who are willing to discuss their problems openly and do not understand the need for closed doors, soft voices, locked record files, and our other paraphernalia of privilegrdcoinmunication. Ironically, the emphasis on privacy-may-be-perceived, by her patients as an overt indiCttion.that their disclosures are something shameful--else why should they be hidden aria protected? In that seise, the superimposition of this most potent of Anglo taboos might even) be counter- therapeutic. But while family might treat family in Latin_cultures, it would , - be counterindicated for Haitiant. In fact, because of normative suspiciousness of others--whlchBijoux (1976) has described as core qualities of his culture-= -group therapy is not ,used with Haitian patients in Miami. Caribbean Patients in Miami Miami- is the closest and most culturally congruent point of entry_ for Caribbean immigration. Three years ago, the University of Miami4ackson--Memorl Community Mental Health Center (eMHC) was initiated with' an innovative ethnic 1 connunity team model based on the needs, population_lAstribution, and cultural configuration of its catchment area. The program has six teams specifically -96 ed-toward serving the following populations: Black-American, Bahamian, --Cuban, Haitian, Puerto Rican, and Geriatric-the latter rimarily fihglo. Teams are by indigenous paraprofessionals and directed by social ccientists, all of matching ethnicity to the populations served. Clinical staff, also, are Or almost entirely of the same cultural extraction. The_work of this innovative program has been comprehensively described elsewhere (Psychiatric Annals, August, 1975, Whole issue; Lefley, 1974). Our 15 work with Caribbean clients has similarly been described in greater detail than _ can be afforded here (Bestman, Lefley, & Scott, 1976; Bestman & Leflek, f976). However,_ since the present paper has largely' been-devoted to Caribbean psycho- . therapy in situ, it would be- of interest to indicate possible commonalities, and di fferences in deal ing with -transplanted populations. First, the problems of adapting psychotherapy to the needs of IltradjonaTM: and "modern" cultural personal i ties , ,so well depicted by Aiitonio =097 are compounded in immigrant groups by the experiences of ufroottnTind sequent acculturatiw stress._ The 144e to an alien society, voluntary 4orllot inevitably brings anxiety and a sense of loss of the familiar'. There, are 6, e reality problems to deal witheconomic, linguistic, social, and in the case _ Haitian illegal ininigrants, political barriers as well In all of our_Caribbe groups, extended families_ have-been -bftken-up by the act of_emigration,,and= there is mourning for si_9nif-itant others -remaining in the home -country.. Ankle and depression -are _common phenoniena. - 44 Our 'our Caribbean groups face different types and levels faccu1Iturativev sfress. For Puerto Ricans, Diaz-Royo's (ibid) traditional-modern -dichotorky,it- quite germane, with traditional male-female -role =relationships particularly- vulnerable tO ,cul tural erosion-. For 'Bahatians, the di cnotomy*-1 teS yather- . = "Bahamian" versus "Black,American" identity choice. Our Haitian ty.ientS, _ many of-them illegal innigrants, face such overwhelming reality problems that attending to survival needs is _the_most basic type of psychosocial thertapyT*,-In. its clearest, Maslowiin sense. Of the four groups, it is probably the Cubans who eXperiew,e aCculturattv problems most severly. As the predominant ethnic co-culture in Miami, Cubans._ re predonrinantly well educated, European, and primarily hem non-poverty backgrounds. Briefly `acculturative _problems include: value confl -ict; eConomit, .and often social role reversal; erosion of the close-le:lit extended family; 16 -1 fchanges in mafe:female role relationships; and ,above all, Intergenerational Conflict, compounded by theoculture gap between grandparents, parents, _and- . English-speaking Americanized children. And_ overall is the overwhelming -sense of loss.f.67 the old identities and the lost country.- It is not surprising , that mental health workerS report rises in anxiety and depressive neuroses, paranoid, ideation, and psychosomatic disorders. c,. In attempting to develop appropriate treatment modalities to deal-with \ . these multipls problems, it was first necessary to offer therapists_Who-couidco-__ ,.. . \ ...,f- =f, 4 itunicate_ --both \ 1 inguiitical ly and. culturally. This We- have done 'withfOur- - -\ ethnic community'-team model and with-our catUrallyAnowledgeable ainicaLsta , , .--- - While kur program continues to offer more itradittonal -forms- Of _psyCht;atrid treattent---cheMotherapy-, traditional- psychotherapy, and the like, 4 havt_ AeVeioped A_ range of other _types .of therapeutic= interventions. =Some- examples _ r ; \ _ =are ,at- follows: , -\ - - 1. A network_ of Culturally homogeneous 1"mini;_clinics" in -sixfdiffei4nt = communities, et, many. of which function asfneighbor+oodl centers- offering Clatset, , _ . recreational faCIlities etc. In this setting, paititularly good for aftercare-_ , ,___- , . cases, 1.4chtatric_ patients mix eith neighborhoOd- peopie, in the same =position . - , as- other people seeking Servicesfacilitating the deinstitutionalizatiOn- i process. The mini-clinics alsO have a "drop-in" quasi day-treatment atmospher _ . . Which have some, simi "continuous to Woodbury's "continuous group." 2. Group therapy 'within a-social-recreational context. In the Puerto . .. _Rican, and Cuban teams, for example,' group therapy may be conducted,dUringfa Macrarrie class, with the focus On a shared task. - 3.- Involvement of extended farnily-in family therapy. Bestman (197§Lha - written- about the- need, particularly in the Black-American and Caribbean , -culture for exploring the family structure to determine which adults play a significant_4 role in child-rearing and family dynamics. Involvement of the nuclear family alone is ofter- inadequate in extended systems, 4. Merger of traditional _and sc-4mtific techniques in psychotherapy. For example, a Bahamian, child suffering from "falling out"(2) or blacking-out---speill (attributed-to seeing a dead CO.11011.5 spirit) was also using her conditionto, manipulate her parents. Since culturally appropriate treatment was required, to -get rid of the spirit, the girl was instructed to wear ,altross and place- . -e --Coins around her bedrooni door, while the parents were instructed in_ 001010, raddification techniques (see B_estman et_ al, 1-06 for -further descriptionl._ _-_ . -fz::--- ----- 5_. Knowledge of the -venous forms of "hexing",-their symPto-Matolo_gy_-_-arKL- .. correlative therapies; =knowledge of cultural normt-4oundarie-s _between-non-hat . __ , ___ and-deviant behaviorin order to avoid inaccurate diagnoses and inappropria --- --.,-- -case- dispoSition. A pr'iae,- example is-the ubiquitous diagnosis -o-f _",paranbidi --- . -__ schizophrenia" given to _yoUng Black males,_ particularly atfong liaitians,--duti-, . __, ,, ,, . _ misinterpretation of verbalintip.ps -of persetution that were- either based:on_ - _ _reality or within the -boundaries_ of cultural ly normative behavior. 6. Consultation and informal referral to folk--healers when this seems indicated. We concur with our Caribbean coll -agues that trail tional spsYthoanalytiCal, oriented psychotherapy is largely inapprlyp.riAte for the populations we serve. In the, main, our clients share charkieristicS similar to the ones,_describeth by DiazF-Royo K id). Froin these clients and their expectations,_ come-the . - "following indicators for effective psychotherapy: We a) It must be problem-oriented,_ and focustd on attainable goals: goal-attainment .scaling as a treatment plan and evaluation meature.)- - The vague, permissiVe-ainbience of the Freudian therapeutic hour is incoMpteh-e-n_L- sibl-e and-IoMetimes anger-provoking to most of these .clients. = _ = 4- th_ apist must establish rapport through warmth, ,Iir=ietidl_ines,_ ,' for Lati'rclients, willingness sto talk abo,:t himself. Many 5naniSh--.= scak:ing _el i eats perceive therapy; I i ke any other huMan interaction-r, as e quid. A uo. If liou ask them- to self,.distlost,... they request et least minimal -Se ___ ___ di scl sure fr:o4 you (e.g., How many children _dejou have?: :Wnere de_th_ey , -_--= S'thool _SuCh*vue_stions .-epresent interpersonal: Contact, notresistance.,-- _ c)- Alt ot.sgh the therapist may be asked_ "personal' quest:lei_ sf- she is nevertheless an authority figure. They are looked to- as experts-_a, expected 6 coups 1 -and give advice-. It may take -Consiterable_-s_ 11_ l , i t this insistence_, and the therapy may indeed require -.a direct. 4e_ _,P=o_s_ ute _. 11 El. _-_te,,be sucqs-_s_ful. , It must be relatively short-tcm, Aside from financ most _patie ts _want -a quick solution -and will not tolerate _- ,. _Sovie-comientatort have attrisbutedth. impatiente of:rower ,---i!- ____ an inablility-to-delay_ -gratification -ethott. hawever,, it is_imor=e-Aike_ _ _. pres-ent-time value -erientati_on is _the critical variable-. With ip_Op__ -.- It ..__ _ futures hSve always been problematical, looking- ah-ead_ for -relief seems_=an additional! burden., la t, Tina) ly, at each stage of the therapeutic process from initial. contact-, through diagnosticS and into the treatment protess itself, cultural- variables_ should-, when necPcsary,_ be taken into account-. With our Caribbean_ Cliett . this is essential . Miens Abel (1973)- for example, indicates that-rotet the Bender-Ge.stalt is normative_ rather than deviant Caribbean..-children- or further -before interpreting this as _a diagnostic `sign of= _o_rganic_ . ther tests, simi 1 arly , are evaluated in 'Cul tural centg..xt. In the =tree me- . process, phsnemena of transference, resistance, and the must be _r=eeval-uate to determine whether the patient'3 behavior is actually reactive to_a- Ablation =CU tural :norms. Finally, every effort is. made to insure -that psycho-, _ - grapy is -aimed towardThehavl or that will, i n, the long run, _strengthen er-.than-_-weaken the client in his cultural- milieu. I NOTES . Our inferences regarding the dynamics of Santeria are based largely On :_discussions with our colleague and _Santer-it expert Or, _Merced-6Si _ _Sandoy_al,, and on her unpublished paper- "the- Gods of Santeria."- She has al so--publi_s_hedira -book- _n- Spanish:- Lalleligio Pl-ayor-, 1975. _ "Falling,out" was initially i"dentified" as-e_ discrete, syndrome by D. Hazel_ Weidman, Professor of _Social _Anthropology-and Investigator of the University of Miami is Health Ecology Project, from data.dollected in this _research-ieffOrt-. This- work=generated', the Subsequent _paper: -Suss-ex, James N. StriWeidnian-, -_,==_ SOMe dynamtc functional- characteristics of -a-dult-Ure_,,botind syndrome -- in urban' U.S.A. : Faflingllout in Miami. Paper presented at the 72nd . Annual Meeting of -the_ American:-AntbropolOgiCal Association, New Orleans, November 28-Decemder,-2, 1973. I. - - ZO: _ = -= I REFERINCES - Abël. J M and R Metraux Culture and pslchoth py New Haven. College -aitd Univesity Press, l974 --8estnan, E 4 Lefley,J1 P ,.and Scott1 C Culturally appropriate tre4tment paradigms and pitfaUs Paper presented at the 53rd annual meeting of the Am°rcan Orthopsychtric Association, At1anta, Gorgia, March, 1976 aestn, LW and Lefley, H P Tretment of Cribbean pat{encs in Mam1 A cor'inunity mental health program Paper presented at the First anival rneeting of the Association of Caribbean Psycho1ogists Port Au Prince, U1'ti 3u1y1 1976. - . - S Bijou, L The practnce of psychotherapy in Haiti Paper presented at4.the First annual rneetng of the AssocLtioi of Cariobean Psychologists, 19Th bawson, J I M Aboriginal attitudes and social conditions Sydney Australia -UiversityPress,lO Oiaz-Royo, A Agreement and disagreement Caribbean Psychotherapists. Peport to the Annual General Meetng, Association of Caribbean Psychologists, Port uprince, Haiti; 1976. (a), Diaz'-Royo,. A. Identity among Puerto Rics" Notes on the development of a moder of psycho1ogcal treatment. Paper prêsntedat the First annualrneeting of the Association of Caribbean Psych'àlbgists, ?Jt.Au Prjnce, Haiti, 1976. (b) Praguns, J Comrons øf psychopathology across cu1turs Journaf ross Cultura] PychQ1o9y, 1973,4,. 9-48. GarrTon, Viv1aoEspir1ti'smo implicatIons for provision of ment&1 hlth servicéi roPueito Rican populations. Paper presented at the eighth annUa meeting f the Southern Anrthopolbgicai Society Columbus, fib. Feb., 1972. Grifflth & Rui,z, P. Cultural. facts in the training of psychiatric residents In a Hispanic comun4ty. Unpub. paper abstracted in iranscultural Psybiatrc Review, 1976. J4alifa, J. &Weidman, H.H. Religion as a mediating institution inacculturatioiiT the case of Santer1a -in Greater MIami. In R.H. Cox(ed.) Systems of Human - -Guidarwe, N.-Y. C.t.Thornas, 1972. Iefjey, H P Cànununity mental health in six ethnic comunities Paper presented 83rd annual convention of the American PsychoiogicaLAssociation, Chicao, Aug 30-Sept 3, 1975 leyburn, J. G,ThenHaitian people. New Hayen: Yale University Press, 1966. lathewson, ii I crazy Anglo, craLy Haitian? Issues of ethnic accountability. in-crisis intervention. resented at the9th annual meeting of the Southern Anthropological Society, B1aCkburg, V, 1974.. - I=iiii ---=5 i:i-= tizin--- IL. The net- and the -spear:: models = fbr the use Of Paper-_-Pretented-t the = lst annual meeting of the- Associat bbea n :Psyth-61 1uiti, 1 926. / infOrmat on. On -,IsitGartney_3. ul1euroses the sun-: some psychOsbcial -and,psy_d_h-60:at 07 -0 aspects of _Bahamian so ety_. Paper ,PresenTed- at the Scientific Jackson Meirorial Ho'spita_- Institute? Department of =_Psychiatry, y-=-1,-975-+ '_---_- Jeane._ Psychotherapy w th the youn_;in -Haiti. Paper at the ist-annUal meeting of t . -Association : df:;CaribbeatizOt atti-,7497=6.- --Rog) ers, L. and _ Rol 1-ingshead , : ned!, famil iet-and New résétêd Tien a, _--WoodburyA -M.A. Witch,- lunati4 or sinner? The -relation-ship_? c Ccirrtunity--psythiatry, and religion in the VirTh Islands Poipqf!"----prd'sefited- _at the Meeting-: of the C-ail_bbeari -Mental ea, Pederatien, -CarataSi--'Vereittela -