1990s world
Life at a fast pace had no intention of slowing down. Instead, it had sped up in many aspects, but with fewer existential stressors lurking around. Most importantly, I was a permanent resident of the U.S. and had a good income, a roof over my head, and a safe place to live. The country was in the last decade of the 20th century marked by enthusiasm born in the post-Cold War era, in which America experienced an increase in economic and political power and cultural dominance in the world. In the 1990s, the Internet, cell phones, and other digital technologies came into being. I got my first personal computer, but I did not use the World Wide Web yet. I purchased the brick-size mobile phone and proudly carried it around together with a beeper. This was possible because it was still lighter than the weight of the brick. There were many other “firsts” in my life. My first job, first house, first new car, and so on. The excitement was felt in the air, even in conservative North Dakota, represented by the progressive democratic senators and congressman who seamlessly merged into the bigger picture of “Clinton’s America” characterized by the longest economic expansion in American history.
In the 1990s Americans were focused on self-fulfillment and personal happiness. This mainstream cultural “movement” was present even in the workplace. Employers used it as a means of motivating employees by emphasizing their independence and responsibility and asserting that their success or failure depends on their individual imagination and initiative. Generation X (individuals born between 1965 and 1980) came to age in the 1990s. They were typically described as being resourceful, independent, tech-savvy, and entrepreneurial. They rode on the wave of technological and economic development by creating startup companies and small businesses and like “dark horse” riders brought us Google, Amazon, Wikipedia, Apple, and made many other contributions to society and the world.
The Decade of the Brain
I was immersed in this “Brave New World”, which didn’t necessarily resemble the futuristic World State of the dystopian novel by Aldous Huxley, but was nonetheless distinguished by scientific and technological advancements, similar to those foreseen in Huxley's book of fiction, written 60 years earlier. I was living and working in the Decade of the Brain, designated by the President of the United States, George H. W. Bush, in 1990, with the purpose of educating the general public about cutting-edge research on the human brain. During this period, we learned about the extent of neuroplasticity far beyond childhood and its involvement in healthy brain development, learning, memory, and recovery from brain damage. The utilization of diverse neuroimaging techniques with significantly improved spatial and temporal resolution led to a more comprehensive picture of the functioning of the human brain in health and disease. A plethora of new neurotransmitters, receptors, and cytokines had been identified in a variety of brain disorders. Hundreds of neurotransmitter receptor genes were isolated, cloned, and studied in detail.
This paved the way for the pharmaceutical industry to develop new drugs to target specific receptors and nerve networks encoded by these genes, raising the hope for the treatment of mental illnesses and neurodegenerative diseases. We got Prozac and a lot of copycat antidepressant drugs on the one hand, and Risperdal with many other second-generation antipsychotic drugs on the other hand. A total of 14 new drugs from both categories were approved by the Food and Drug Administration (FDA) during this time. This had never happened before. The age of “Big Pharma” had arrived with fanfare and mental disorders were increasingly treated with drugs.
Working man
As can be seen from this brief and incomplete review, the general atmosphere in society was favorable to my interest, previous education, and the position in which I was placed. At my job, I was expected to be one of the leading teachers (core faculty) dedicated to the education of psychiatric residents and medical students, both in the classroom and in the hospital. Almost immediately upon hiring, I became a clinical instructor in hospital psychiatry and in consultation-liaison inpatient service for psychiatry residents and medical students. Simultaneously, I was a psychodynamic psychotherapy supervisor for senior residents. These were my “hands-on” clinical educational duties with the patients seated before me and the trainees. In the classroom, I taught year-long courses: Introduction to Clinical Psychiatry, Neuroscience, Psychiatric Interviewing, Cultural Psychiatry, and Psychotherapy Case Conference. Clearly, my educational responsibilities were considerable and varied. They required constant preparation, focus, and understanding of the educational needs of those for whom they were intended.
Cultural Psychiatry
One of my favorite courses was Cultural Psychiatry. I inherited it from Joy Query, a professor of sociology who was an adjunct professor in our department because her main job was at North Dakota State University. She originally came from England, and perhaps as a result of our common European experience, she immediately became fond of me. She held a Cultural Psychiatry course in her own home, in an informal setting, in the style of afternoon high tea with cakes and pastries. At one point Dr. Query asked me to give a presentation on Yugoslavia. I prepared an hour-long presentation outlining the geography of the region and the surrounding countries. I spoke at length about history, particularly in the 20th century, including the most recent one that was marked by civil wars and genocide. I described the mentality of the people of Yugoslavia, especially in the areas where I lived with both the positive and negative impact it had on me. Let me quote here what I said about the state of medicine and psychiatry based on my experiences in the 1970s and 1980s.
Health insurance and education were free, and these two factors determined the organization of medicine and the social role of the medical profession. Traditionally, the medical profession was respectful and important. But in the socialistic society, it was not supported enough by the government and as a result, the quality of care varied significantly. Everyone could become a doctor sooner or later if one wanted. One could stay enrolled as a medical student indefinitely without any consequences. Training at the school of medicine lasted five years but I knew students who were there for 10, 15, or more years. Here in the United States supervision and evaluation are very important parts of training so that patients can be sure about the standard of care doctors provide. In Yugoslavia, generally speaking, that was not the case. It was possible to receive top-quality care from dedicated and excellently trained professionals, but also the opposite was possible and likely. Lawsuits almost did not exist. Hospitals and clinics were full of patients. Doctors were usually overworked and unsatisfied. Their salaries were miserable and not much different from those of factory workers. Most of them received 500 or $600 per month. Psychiatry was on the fringes of the medical profession. Psychiatrists were not seen as true doctors and frequently doctors who chose psychiatry as their specialty did it as a last resort. Modern psychiatry was practiced mainly at big university centers. At other places, psychiatrists were usually poorly trained, poorly motivated, and practiced both psychiatry and neurology. In Yugoslavia psychiatry still hasn't experienced a biological revolution. On the contrary, in the last 20 years, psychotherapy has become more and more present. Different psychotherapeutic approaches blossom, for example, group psychotherapy, social psychiatry, and therapeutic communities. The role of a psychiatrist was much broader than here. He was also an addiction counselor, family therapist, psychotherapist, and neurologist. Supportive services were still undeveloped such as group homes, boarding homes, and support groups. Commitment law did not exist. State hospitals were still warehouses. Community mental health centers were not common. Patients were less educated. Mental illness was a big stigma.
When I was assigned a Cultural Psychiatry course, I organized it in my own new home. I was the proud owner of the first house and wanted to host psychiatric residents welcoming them into my home. We met late in the afternoon, which was in keeping with the tradition established by Dr. Query for that course. Our training program has traditionally accepted physicians that came from all over the world. For example, we had doctors from Romania, Vietnam, the Philippines, India, Pakistan, China, Norway, and many other countries. Almost like a United Nations community gathering. Recently, when I visited my alma mater, the present director of the residency training program Robert Olson showed me a map of the world populated with pins with colored heads. He explained that he began the tradition of placing a pin on the map of the country from where the resident came to our training program. It was impressive to visually appreciate the cultural diversity represented by the pins that populated many locations on the world map.
Multi-cultural world
Cultural (or trans-cultural) psychiatry is an important branch of psychiatry in today’s world due to the mobility of the population and the diversity of cultural groups that are encountered in the practice of psychiatry. Diagnostic and Statistical Manual (the psychiatric “bible”) has recognized the importance of understanding the cultural context of the illness experience for effective diagnostic assessment and clinical management. It defines culture as a “system of knowledge, concepts, values, norms, and practices that are learned and transmitted across generations. Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, customs, and ways of understanding health and illness, as well as moral, political, economic, and legal systems.” *
From this formulation, it is obvious that my assignment was not easy in incorporating the ambitious requirements as stated above with such an impressive range of subjectively experienced cultural phenomena. I was pondering how to do that in a way that was interesting and engaging. I decided to start by asking each resident to talk about their own cultural backgrounds and how they and their families reconciled them with the prevailing culture of the place where they found themselves living at the present time. This approach was a resounding success. The course's informal setting, late workday hours, and supportive group therapy style provided a safe environment for intimate sharing. Residents enjoyed talking about their experiences, similarities and differences in their responses to the stress triggered by language barriers, race, religion, clothing, weather, and many other factors.
Personal viewpoint
I was able to discuss my own adjustment struggles in the first year of arrival. Most of all, difficulty communicating in English. Every time I was paged, I panicked because I was supposed to make a phone call as soon as possible and talk to the person who had paged me. At first, paging was limited to the hospital nurses calling about the patients and asking for my response regarding patient care. This was exceedingly hard for me. Another difficulty was less dramatic but still challenging. It was eating lunch in the cafeteria. At that time of the day, the cafeteria was crowded. People were hungry, in a rush to get their food, eat it and go back to their job duties. I was not accustomed to smoothly navigating through the multi-step process of getting food and beverages quickly enough to not delay others. It made me nervous, and my social fear that everyone was looking at me made things worse. So on numerous occasions, I went to a vending machine and got a can of diet coke and a candy bar instead.
I recall one of my first conversations with Dr. Stadter when he warned me that I was going to have a culture shock. He was right. He also tried to be helpful, which was the case with many others who demonstrated a midwestern hospitality spirit. Upon our arrival in Fargo, Dr. Stadter brought my missing suitcase from the airport to the apartment, which would have never happened in Yugoslavia by the individual in his position to do so. He even donated some of his furniture to help us with the essentials we were without. As a result of these experiences, I was able to gain a better understanding of the similar challenges residents shared during the course. More importantly, I was equipped to help many Bosnian refugees when they arrived in 1995 because of the wars that tore up the country, I left not so long ago in one piece.
The intersubjective perspective
The intersubjective (cultural) perspective is one of the fundamental ways how we get to know the world through our collective, interior experiences: shared values, meanings, language, relationships, and other cultural attributes. Cultural programming is the powerful mechanism of indoctrination into socialization that operates under the radar of awareness but with the force of core beliefs that are difficult to recognize or get rid of despite their maladaptive nature in changed circumstances. Cultural psychiatry explores in detail the relationship between culture and mental health, especially in etiology, manifestation (so-called culture-bound syndromes), and acceptance of treatment. Culture influences the manner in which psychiatric disorders are expressed. For example, major depression is expressed more in cognitive terms in western societies, while somatic presentations are more common in India. **
The more relevant consideration of cultural influences is related to the acceptance of treatment options. For example, psychotherapy as a treatment modality is more commonly used among Caucasians than among other ethnicities. Patients coming from Asian cultures may feel more comfortable when their doctor takes on an “expert” role and may dislike the more collaborative approach that is common in Western, more individualist cultures. Hence, it is important to understand and offer culturally sensitive services to patients with different cultural backgrounds. For example, VA recognized traditional Native American healing practices for veterans who expressed the desire to use them. One of them (Sweat Lodge) was built on the hospital grounds. Traditional Native American healer (Medicine Man) performs a purification ceremony. Preparations are conducted in a sacred manner by cleaning and caring for the grounds, building and tending the fire, and covering the lodge. During the ceremony, hot stones are placed in the center while the healer guides participants in prayer or song and uses the rocks, heat, sacred herbs, and water. Sweat lodge represents the womb of Mother Earth, as a sacred place to ask for healing, forgiveness, hope, vision, give thanks, or anything else one needs during the healing journey.
Another practice that I used myself under different circumstances is called Talking Circles in which participants sit in a circle and begin with a prayer and smudging with the smoke from sacred herbs to create a healing space. A feather or talking stick is passed around the circle, in a sunwise direction, to each person. Holding the feather serves as an invitation and an encouragement to speak from a place of sincerity and truthfulness. The Talking Circle provides a place for healing and resolving trauma and an opportunity for each person to speak heart-truth without interruption, criticism, or judgment. This practice resembles what we would label group therapy “on steroids.”
Cultural sensitivity and competence
We all benefited from both the informational and experiential elements of the course. In today’s world, it is crucial to develop cultural sensitivity and competence in working with diverse groups of people and to be able to understand a variety of belief systems derived from their race, ethnic origin, sexual orientation, gender, or other significant elements that make up the cultural identity. Cultural sensitivity and competence incorporate the development of empathy and compassionate action through the necessary training needed to function effectively in a pluralistic society consisting of people with different cultural backgrounds. Cultural awareness sensitizes us to take into account our own personal values and biases and become aware of how they may influence our perception of the patient, his presenting problem, and the therapeutic relationship. Cultural knowledge is related to the acquisition of relevant information about the patient’s culture, worldview, and expectations for the treatment. Cultural skills are our ability to intervene in a manner that is culturally sensitive and relevant. ***
I have learned that the best way to acquire knowledge and skills about any subject is to teach it. This proved to be true for the Cultural Psychiatry course. By teaching it, I became more competent in providing psychiatric services to patients from a variety of cultural backgrounds. I adopted the integral worldview which combines inner (subjective), outer (objective,) and inter-subjective (relational) perspectives on any phenomenon. In this way, and to paraphrase the motto of my spiritual gathering place (Center of Universal Light), “to use a rich blend of ancient and contemporary wisdom, practices, and traditions to enhance the paths that unite us and blur the lines that divide us.” ****
* Diagnostic and statistical manual of mental disorders (5th ed., text rev.), by American Psychiatric Association, 2022
** Cultural diversity and mental health, by Siddharth Sarkar and Varghese P Punnoose, Indian Journal of Social Psychiatry, 33: 285-287, 2017
*** The Case for Cultural Competency in Psychotherapeutic Interventions, by Stanley Sue, Nolan Zane, Gordon C. Nagayama Hall, and Lauren K. Berger, Annu Rev Psychol., 60: 525–548, 2009
**** https://centerofuniversallight.com/
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