Presentation and Q&A Recording
AGR : Tell us a bit about your current research settings, the medical setting and even from a practical point of view, what does it mean for the kinds of people you end up training and working with. But I also would like to hear a bit about going to Bangladesh and establishing a research context.
AK : So the medical school is different from a normal academic setting in a number of ways, both good and bad. Andrew, you and I have talked a lot about the deficit there is – I don’t have amazing students like you do, and so mentorship is something I really have to seek out. And I have mentored a number of young physicians who were seeking integrated research careers. And so those have been my mentees. I’ve had quite a number of them over the years, and almost all of them are physician researchers now, which I’m super excited about and they’re wonderful. It’s not quite the same as having psychologists. But that’s been the mentorship opportunities there. The medical school setting is much more highly resourced. So that’s something to think about, if anyone has the slightest remote desire to seek that path that we have a lot, we make our living by writing grants. If you don’t like writing grants which I love, then it’s not the right place for you. But we bring in quite a lot of money and so we, in a way, are more entrepreneurial, and sort of set up our own labs, and do our own stuff and don’t have a lot of other obligations or interference. Right now, I’m not teaching, so that’s a difference. But one of the ways that medical schools are very well situated is that there are these contacts in other countries. I was looking for a place to roll out a pilot study and I wanted to do it in South Asia. It had been piloted in New York in a Bangladeshi community, and someone on the Einstein faculty had an incredible contact at a research institution in Bangladesh. This personal connection put me in touch with these researchers to continue this project that started 17-18 years ago, and I only had an internal grant of 25,000. Then we sat around for 10 years because I said there was no way to get funding. Until more recently we’ve begun working again together as we’re carrying out the full-scale trial. But it’s interesting working in another context. Though I don’t speak much Bengali and that is an issue. You’re constantly saying to people, “What did so and so say?” and they’ll give you a brief rundown. And then you’re like, “No, I want to know word for word what they said.” As a qualitative researcher, I want to know exactly what people are saying. And it’s a lot of work for everybody that I don’t speak great Bengali. It’s really exciting to do cross-cultural work, it’s fascinating, and I feel very lucky. And where I was located in the Bronx at Albert Einstein College of Medicine it is, of course, the most culturally diverse Congressional District in the United States. So it was a wonderful lab, and I got to study all kinds of patients. And I will say, when I first set on to my medical school career, I got this job at this medical school, and I thought, “Oh my God, it’s going to be super conservative. After all it’s doctors, and they’re not going to be tolerant of my interest in culture and qualitative research, social structure and all that”. And I found that family medicine was just unbelievably hospitable to these ideas, much more than a typical psychology department in an academic setting. I absolutely thrived there. I think the last thing I’ll say that has been really important to me about working in primary care settings is that if you choose to investigate the impact of culture on various aspects of mental disorder, you have to be very careful about your samples. We’ve talked a lot about some of the problems of using undergraduate samples as these are often students that have been exposed to a lot of Western ideas. They’re already kind of acculturated, no matter where they are, to western structures of thought and habits of mind. So you’re not seeing the full range of difference that culture can make. And then another common setting for mental health research on mental disorder is in mental health settings. And that really drives me crazy, because those patients are individuals who by definition already have a conceptual model of their problem to regard it as a disease, often a biological disease of some sort. And they’re seeking out a treatment model that matches their understanding of the cause and the nature of their problem. So for me, going into primary care settings was way better because it levels the playing field. These are not people seeking out treatment for their depression. But the question is, “So you have depression, what are you going to do with it?” And we found that culture and ethnicity made a huge difference in what people did. Whereas if I go to a psychotherapy institute, a psych or mental health treatment center and I look at cultural differences, I’m going to see that everybody’s pretty much doing the same thing.
AGR : In terms of family medicine and how hospitable you found it, is there – I have an impression that you know, the sort of the relentless pragmatism of medical settings, which can maybe work against grand theories and really get at underlying mechanisms of, say, psychology or social science departments, actually works in favor of methodological openness. Because a family physician is not going to have a grand theory objection to a research method, they’re going to say “All hands on deck. If it’s going to help us understand this, we want to engage it to understand it.”
AK : I mean that is something when I first discovered the work of the social science pragmatists, Teddlie and Tashakkori who are the ones who wrote the book, the Bible on the Pragmatic Epistemology Handbook of Mixed Methods Research. They’re educational psychologists and I was excited, the ideas were great because they put into words something that I’ve been thinking for a long time which was do we really think that the very best explanation for the cause of anything lies in the questionnaire? Don’t we need to balance our use of questionnaires with observations, with stories from the past, with the impressions of the people around someone, with actual behavior. We have to employ all the potential weapons in our armamentarium, and the questionnaire is just inadequate.
AGR : Very good. I see someone wants to join the conversation.
Guest: Going back a bit to when you were talking about sampling, and making sure that your sample would include people who are not university students. This makes me think about what you said about using maximum variation sampling. So the two groups would differ a lot in terms of the ideas and maybe education level, class.
AK : That’s right, social class.
Guest: So I was wondering, when you’re doing kind of cultural comparative research, what is your approach towards looking at the intercultural variation within the group. How do you account for that variance? Since there’s a variance between the two groups, but there’s also the variance in-between.
AK : That’s such a great question. In medical school, we have money usually, as I said before, which is good and bad. And what often happens is that we’ll collect these massive datasets for a grant and then we’re on to writing the next grant and we write maybe one paper or something. Meaning that we have all this data that is just sitting there. And looking at class differences is extremely key, I haven’t done it especially well or very thoroughly but, sort of embedded in your question, there’s also the question of individual differences. I haven’t really gotten to that question until the last two years, when I’ve been carrying out an unfunded study looking at symptom variation in postpartum mothers, again Bangladeshi versus middle class White, European American mothers. And we’re looking at how distress in the postpartum period is reflected in different symptoms. And we ran these symptom profiles and looked at differences in the two groups. The Bangladeshi mothers had a lot more anger than the South Asian mothers. The European American mothers had a lot more guilt and a lot more anxiety. And so what that study was about was looking at the way that a person’s unique situational context, where they’re living, what their problems are, what situations they’re in and how that is influencing the kinds of symptoms they’re reporting. So we wondered what is the fear and anxiety that these White mothers are feeling? Because in general their situation in life is a lot more stable than these brand-new immigrants in the other group. And they’re living in houses as opposed to tiny apartments. And so there we did start to look at some interesting social class differences. So social class can be regarded as a cultural influence in the sense that it influences perceptions of reality, it influences social norms, it influences eating habits, it influences health behavior. But the other way that social class influences things that we should be interested in is that it influences the kinds of situations that we find ourselves in. So as an example, we looked rather carefully at social class in our more recent study, and we found that in the European American group in fact, there was quite a bit of class variation. And in the working class, situations often had to do with unstable marriages or partners, and the fear that the “husband might leave me after my baby was born.” Or bringing several children into a marriage who are not the children of the father and feeling that he’s not engaged with the kids. So they were getting a lot of anxiety based on those situations. The upper middle class, more affluent White mothers, were anxious for completely different reasons. For example, there were a lot of them who were very attuned to developmental milestones, and they were freaking out because their kids weren’t achieving the milestones on time. And there was this standard of motherhood in that affluent European American group like, “She’s already nine months old and I need to figure out where to find developmentally appropriate peers for her to play with.” The Bangladeshi mothers and the White working-class moms had no such exacting standards. So social class makes a huge impact in terms of what the kinds of problems there are. We found a lot more guilt in the upper-class group compared to the working-class group. Guilt being related to these exacting standards, “My child is having a tantrum, what have I done wrong?”. None of the Bangladeshi moms expressed that concern, for them when kids have tantrums or don’t do what they’re supposed to do instead of feeling guilty, the moms got mad. And that’s why we tied that to mothers getting a lot more anger in the group. This is a view that is completely unacceptable to White upper middle-class participants in our sample. So long answer, there’s so many different ways that class played a role in this.
AGR : If you had Dhaka women physicians and academics and lawyers, would they look like your upper middle-class New Yorkers? Or does culture intersect with social class?
AK : Well, I think they’d be somewhere in between, right? That’s our guess. And I haven’t looked at that group, although I’m actually very interested in that group. But one of things we’ve been talking about a lot over the last few years is how do you define culture? Often in cross-cultural designs, culture is defined as an ethnic group marker. In other words, the totality of the environment in which the person is living might be regarded as culture, that’s how Kleinman conceptualizes culture, as a local moral world. And I think the interesting question that we still have not addressed is, what is the difference that culture makes? And I think the reason we haven’t fully understood that is because of these more homogeneous samples that we work with in our discipline, whether it’s mental health settings or college settings. They’re more homogeneous than they should be.
AGR : In the world of cross-cultural psychology, of culture and development, psychological anthropology, cognitive psychology and so on, what is the idea or ideas that you wish you could just insert into the minds of mainstream clinical psychologists, researchers or practitioners?
AK : I think a huge insight is that as soon as you start to study mental disorder in other cultural contexts, you realize the fragility of your own cultural ideas about diagnosis, about the nature of medical disorder. To go back to this paper I read, an article in the New York Review of Books by Rosemary Dinnage called Going Crazy in India. I was so thrilled and excited by this article, which was journalism, where she was talking about the mental hospitals and the temple treatment settings in India, that people were developing, were demonstrating, women in particular, were manifesting forms of mental illness that have left the West a long time ago, specifically hysteria. And it just it broke open everything, I just thought, “Oh, the world is not what I thought it was.” I have to be honest and say that I’d already had an idea that our diagnostic categories and our way of thinking about these conditions we call mental disorders, as being diseases that have some kind of internal biological origin, I already was pretty dubious of that. Thinking a little bit about my Fort Greene practice, how I integrate the work I’m doing with my psychotherapy practice – one of the things that I find is that people who come to my practice are very internally oriented a lot of the time. And they really think that their problems have come from the inside of them. And while it is true-
AGR : To clarify, Alison, Fort Greene is in the hood of Brooklyn, which itself is a borough of New York City. So this is a kind of middle-class-
AK : It’s a sort of an elite enclave in an elite city. And a lot of or most of my patients are sort of business-class kind of people. Many of them have very much internalized their problems. So helping people understand you know, that it’s the outsides of you that are really the issue and your local moral world, and less about the inside of you can also be a hard sell. Because I think one of the things that we start to understand about our own culture and sort of White middle-class culture is that, if you’re constantly anxious about everything, you’re responsible for everything in a way – at least theoretically, you have control over everything. And I think the thing that’s hard for people in our culture is to give up a sense of control. So helping people be more humble and also more relaxed is something that I find very therapeutic.
AGR : If I was to flip my original question, you interact with a lot of cultural and cross-cultural psychologists and anthropologists and so on – do you ever get the opposite experience, where you feel like you’re bringing something to the table because of your clinical training or your psychotherapy practice, that the exchange could go both ways? Maybe clinical psychology brings something to the table in the culturally-focused social sciences as well.
AK : I do definitely feel that. I feel that clinical practice and that psychotherapy is an incredibly powerful treatment. But what it is that makes a person get better or not get better? I think the jury’s still out and we don’t understand that. And yet it would be a very big mistake to dismiss these treatments because we don’t have a sufficient understanding. I don’t know if you’re implying that there is a certain amount of dismissal going on in the broader social science community of our clinical activities. I think most other social scientists, in a way, they’re too respectful. They think that what is going on is some special clinical magic in the consultation room. And the reality is we don’t really know enough about what happens in the consultation room. There hasn’t been enough research on that black box. And when there is research, it’s often too theory based, it’s too quantitative as opposed to looking more broadly at how these stories are negotiated between the patient and the therapist.
AGR : Are there directions now for our community that you wish that we go in that we’re not?
AK : I think we need new directions in our interventions. And as I’ve said many times during the talk and just now, I think our interventions are based on very narrow theories. Like Freud’s was based on a very narrow theory, in a very narrow cultural context, with a very narrowly defined group of highly affluent hysterical patients. And we also have very narrow theories. And Freud was interested in ethnography and he could have been a very good ethnographer, as you can see by his beautiful book Interpretation of Dreams. But he kind of left it behind in the direction of pseudoscience and became very involved in this clinical theory, which he wrongly assumed applied to everybody. So I think we need to be looking beyond our narrow more cognitive based theories, to broader theories of mind that can help suggest more treatment models that have a better chance of working. Because right now the outcome data is glum. And so, I’m very interested in whether we can design interventions that address what I think are the cause of this rampant epidemic of common mental disorder and depression, which is alienation, disconnection, failure, and exclusion. And if we can start thinking about treatments that address these existential concerns, I think we’re going to be on the right path in that regard. And my study addressing giving people money, it’s not just giving people money, because when you give people money, you give them something to do, you give them a business to focus on, you give them colleagues. And more than anything else, you change their status and their family, because all of a sudden you are the one with the goats. And so we are expecting to see improvements in family relationships and in participation, in household decision making and so on. So we think a lot of the depression in our low income rural women are really because of gender-based and class-based exclusion and devaluation. And the other thing I’m really interested in is that I don’t think we’ve taken on the problem of symptom heterogeneity enough across cultures and across contexts. We know that the diagnostic system is dying. But we have nothing to take its place. So how are we going to understand what mental disorders are? And how are we going to build theory that helps us predict what symptoms people will actually manifest? And so I think our tiny unfunded study looking at why symptoms differ from both across-cultural groups but also from person to person, is I think a really important direction that we could be thinking about as a sub discipline.
AGR : What advice would you give to trainees just starting out, or hoping to start out, or wondering if they should start out in cultural clinical psychology specifically? And the sub question is, is there anything in particular you’d tell them that they simply have to read in order to advance their thinking in the field?
AK : Well, one thing I tell the doctors that I teach, I think it’s the same for clinical psychologists, I think it’s a mistake to do just research or just clinical work. I think doing just research means that a lot of the warmth and the sort of lifeblood of a lot of what I do is related to my clinical work, which I find incredibly nourishing as it keeps me grounded. And I wouldn’t want to be a researcher only, I just don’t think that’s good. And then certainly we know that full-time clinical work is associated with burnout and it’s not good either. So I always try to get my medical students and say to them, “Please, please, please consider! Try to look at some data. Write a tiny paper, make a few presentations. Think about a research fellowship, because you know, in ten years you are going be so sick of full-time practice.”
AGR : What else would you read?
AK : Kleinman’s work has had a huge impact on me. Some of his colleagues, Byron Good, Richard Shweder is incredible, the introduction of the idea of the cosmos into perceptions of cleanliness and past restrictions and shame has been a huge influence on me. Some of the great ethnographies, The Varieties of Religious Experience and Interpretation of Dreams are two incredible ethnographic works that didn’t set out to do ethnography, but that sort of say everything about the culture that they come from and are really valuable. Well, Dr. Ryder’s work I think is really great and really important. I think one of the things I mentioned in my talk that I didn’t really talk very much about is that we have all these theories that haven’t really been tested and we don’t even know their behavioral correlates or how some of these psychological constructs are represented in experience. And so introducing qualitative work methods into some of the work that you’re doing, I just think could have such a strong effect to start to test and develop and add to some of our theoretical models.
AGR : Just a little follow-up, you’ve mentioned anthropology, but maybe you have a sociological heart more than even an anthropological one. What about mental health sociology? That’s something that I know less about actually.
AK : There’s The Discovery of Grounded Theory, Glaser and Strauss, it’s not about mental health in particular, it’s about studying the manipulation of knowledge of imminent death in a terminal cancer ward. And how it is that some people come to know they’re dying, and others haven’t. And how that information is generated and used for social control. It is an incredible book. And then Erving Goffman who did the incredible asylum study, that’s an incredible work. And he’s sort of a game changer in terms of the way he came to ethnography inside an institution.
AGR : OK, I see a suggestion Durkheim on suicide.
AK : Ah, sure, Durkheim on suicide. There are some very interesting ethnographic works on mental disorder, some of them come with a culture theory that is a little bit hard to swallow. Sort of a differentiation between the primitive and more advanced forms of humankind, and how certain forms of mental disorder- oh! the paper that had a huge impact on me was Mark Nichter’s paper called “Idioms of Distress,” about Havyaka Brahmin women in South India and the various weird somatic symptoms that they had and understanding symptoms as a language. And that was something that just had an enormous impact on me, and I think about a lot in my clinical practice, what are patients expressing about their predicament?
AGR : We’re slightly past time, we might be ending at this exact moment, depending on what Alison has coming up.
AK : I have to leave right now, my patient is coming up the stairs. But more to come and thank you, everybody. Fascinating talk. Thanks for giving me this opportunity.
AGR : Very good.
AK : Alright, great.
AGR : Very good. OK, thank you.