EMERGENT ISSUES IN PSYCHOTHERAPY WITH INDIAN PATIENTSAshwin Mehra, PhD

LEARNING OBJECTIVES

Cultural considerations with Indian patients

Clinical issues with Indian patients

Special sub-populations issues

Historical systems of Indian psychotherapy

CULTURAL CONSIDERATIONS FOR IMMIGRANTS

SUE & SUE’S RACIAL / CULTURAL IDENTITY DEVELOPMENT MODEL

Conformity Stage “a preference for the dominant cultural values; downplay and feel negatively about their own cultural group”

Dissonance Stage “questioning of one’s beliefs and attitudes held in the conformity stage”

Resistance and Immersion Stage

“an endorsement of minority-held views and a rejection of the dominant values of society and culture”

Introspection Stage “more ‘pro-active’ in defining and discovering the sense of self”

Integrative Awareness Stage

“a sense of security and the ability to appreciate positive aspects of both their own culture and the dominant culture”

ASIANS IN AMERICA

CATEGORIZATIONS OF INDIAN PATIENTS Geographical

North Indian vs South Indian Differences of language, dress, cuisine, values

Religion Hindu, Muslim, Christian, Sikh, Jain, Buddhist, Parsi, Jewish, Atheist

(Nastik), etc.

Caste-based (Hindu) Brahmin, Kshatriya, Vaishya, Shudra

Level of Conformity profession: doctor, engineer, lawyer, MBA, etc. social standing: community elder, higher socio-economic status skin color: fairness creams and bleaches annual sales around $500 million.

CULTURAL CONSIDERATIONS FOR INDIAN PATIENTS

Personal self vs unified Self Experiential exercise – You/I statements

Immigrant vs. first generation patients Level of education in the United States as a rule of thumb for degree of

socialization - elementary/ middle/ high school/ undergraduate/ graduate.

Indian-American vs Indian in America.

Social/public stigma vs. self-stigma (Corrigan, 2005) Family honor vs self-reliance

Honor killings as an extreme example

CULTURAL CONSIDERATIONS FOR INDIAN PATIENTS

VALUED BEHAVIORS (DAS & KEMP, 1997)● Individual

○ Nonconfrontation or silence as a virtue○ Respect for older persons and the elderly○ Moderation in behaviors○ Humility○ Obedience○ High regard for learning○ Marrying within versus outside ethnic

group○ Importance attached to preserving the

original religion○ Personal self vs unified Self○ Devaluation of individualism

● Family system○ Structured family roles and

relationships○ Strong sense of duty to family○ Harmony between hierarchical roles○ Protect honor and face of family

● Sexuality○ Modest about sexuality○ Little to no PDA○ Dating vs arranged marriages

COMMON CULTURAL BIASES TOWARDS INDIAN PATIENTS

Valuing the personal self over the unified Self Negative view of the family and extended community influence on

individuals Arranged marriages Choice of vocation Pre-marital sex Elder care and living with parents

Dependence vs interdependence Mahler’s stage of separation-individuation; individuation without

separation Dismissing spiritual and religious beliefs

Belief in the supernatural Use of marijuana by adults during festivals (Hindu patients)

STATEMENTS VERBALIZED BY INDIAN PATIENTS

● “My parents are against my relationship and are actively trying to sabotage it. Even though I live far away, they are spying on me and have turned my old friends against me.” (Diagnosed with delusional disorder and psychosis NOS)

● “I am getting married to an unknown person at the wish of my parents. I am very stressed out.” (Diagnosed with dependent personality features and goals set in therapy for self-assertiveness)

● “My daughter is in high school and is going out with a (insert non-Indian race/ethnicity here) boy! Has she no shame?”

● “My son is gay. He might as well die because his life and our life is already over.”

● “My life is controlled by a deva / devi (demi-gods). I have no personal agency over my actions.”

CLINICAL ISSUES / AVOIDING COMMON PITFALLS WITH INDIAN PATIENTS

Eastern experiences; Western lenses

Role-to-role vs person-to-person (patients vs clients); “I” as vulnerability; “You” as criticism Using “We/One” statements rather than You/I statements.

E.g. “When we/one get(s) depressed, it is difficult to get out of bed”

Living up to the myth of the model minority Crisis presentation “Flight into health”

After one “good” day, patients likely to thank the therapist and terminate. Set expectations regarding symptom improvement vs lasting change Set expectations regarding length of treatment

CLINICAL ISSUES / AVOIDING COMMON PITFALLS WITH INDIAN PATIENTS

Incorporating family systems models in therapy Patients’ birth order; overt role in family Named relationships: e.g. elder sister-in-law, father’s sister’s husband

Gifts and celebrations Patients may feel obligated to give gifts and invite for celebrations May feel slighted if the favors are not returned

Termination issues Individuation without separation

SPECIAL POPULATIONS ISSUES● Intimate partner violence

● Lifetime prevalence rates of 41% among South Asians (APIIDV, 2012)● Open ended questions (“How is your relationship?”) vs. specific inquiry (“Have you ever been hit?”)

● LGBTQ issues● LGBTQ awareness & acceptance● Decriminalization of Section 377 of Indian Penal Code in 2009 by Delhi High Court● Sex against the “order of nature,” punished upto 10 years in jail, British legacy.● Indian Supreme Court upheld Section 377 in 2013.● Family issues intersecting with LGBTQ issues; conceptualizing the issues in a family systems

perspective● Normalization for family members post coming-out ● SALGA: South Asian Lesbian and Gay Alliance

● Child and family therapy issues● Lifetime prevalence of 80% for child corporal punishment for SA immigrants (APIIDV, 2012)● Subjectivity in children; role-conformity in parents

INDIAN FORMS OF PSYCHOTHERAPY● Overarching goal of Indian psychotherapy

● Liberation from “suffering” by transcending the personal self to the unified Self

● Yoga ○ Hatha yoga: Path of physical alignment ○ Jnana yoga: Path of knowledge and intellectual pursuit○ Karma yoga: Path of service○ Bhakti yoga: Path of devotion

● Vedanta○ Non-duality of subject and object, awareness of Brahma, Tat tvam asi: ‘that

thou art.’

● Buddhism○ Absence of subject, impermanence, nothingness (shunyata)○ Third wave CBT therapies (DBT, ACT, MBSR, MBCT, CFT, etc…)

THANK YOU!Q & A