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Psychodynamic Psychotherapy and Global Health Rachel L. Moster and Craig L. Katz Abstract: This study surveys and examines the literature about psychodynamic psychotherapy in low and middle income countries. Although much has been written on this topic, the literature remains disjointed, unsystematic, and lacks randomized controlled trials. This trend is in stark contrast with a growing body of systematic literature and randomized controlled trials that exist in other types of psychotherapy used in low and middle income countries. While there is evidence that other types of psychotherapy are useful in these countries, questions remain regarding the implementation of psychodynamic psychotherapy. Is psychodynamic psychotherapy relevant to non-Western cultures? Are changes necessary to make it relevant? Is psychodynamic psychotherapy economically feasible in low and middle income countries? Although definitive answers to these questions do not yet exist, as psychodynamic psychotherapy is open-ended and client-centered, it is likely to be flexible across a wide range of cultures.
Global health embodies “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide” (Koplan et al., 2009, p. 1995). Global health is commonly equated with a focus on infectious diseases such as malaria and HIV. However, as efforts to eradicate these diseases achieve greater success, the field increasingly looks to address non-communicable diseases. The emerging field of global mental health applies the principles of global health to mental health and seeks to improve access to mental health throughout the world (Patel & Prince, 2010). The field of mental health embodies a wide range of therapeutic interventions spanning somatic treatments such as medications and electroconvulsive therapy to residential treatment to the psychotheraRachel L. Moster, M.D., Fellow in Public Psychiatry, New York State Psychiatric Institute at Columbia University Medical Center. Craig L. Katz, M.D., Director, Program in Global Mental Health, Clinical Associate Professor of Psychiatry and Medical Education. Psychodynamic Psychiatry, 42(4) 641–656, 2014 © 2014 The American Academy of Psychoanalysis and Dynamic Psychiatry
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pies. Global mental health therefore comes in as many permutations as there are countries and cultures and treatment modalities. Currently, economic realities and pervasive stigma, among other potential factors, dictate that the practice of psychiatry in low resource settings typically comes down to deploying a narrow medication formulary to treat the most severely mentally ill in overcrowded, overlooked, and under-resourced psychiatric hospitals. It is therefore not surprising that a psychiatry fellow shared with one of the authors (CLK) a story of how her training director warned her of her need to make a choice when she disclosed that they had interests in both psychoanalysis and global health. People barely ever imagine how psychiatry can flourish in low and middle income countries and other low resource settings, let alone how psychotherapy and especially psychodynamic psychotherapy or psychoanalysis could. In fact, at a time when access to psychotherapy is being limited by economic considerations in the developed world, there is an increasing movement in the developing world to promulgate psychotherapy as cost-effective (Weissman, 2013). In this article, we address what Weissman calls the “psychotherapy paradox” by examining what is known about psychodynamic psychotherapy in the developing world. What follows is an overview of some areas of commentary and research in psychoanalysis and psychodynamic psychotherapy in low and middle income countries. It is not an exhaustive review of these or other psychotherapies in all resource-poor settings, as such a review would be beyond the scope of this article. Literature searches were conducted on PubMed using key words global psychoanalysis, global psychodynamic psychotherapy, global psychotherapy, Africa psychoanalysis, Africa psychodynamic psychotherapy, Africa psychotherapy, Asia psychoanalysis, Asia psychodynamic psychotherapy, India psychoanalysis, and India psychodynamic psychotherapy. Only full articles available in English were included. The discussion about psychotherapies other than psychoanalysis or psychodynamic psychotherapy will focus on research conducted in Africa, to narrow the focus somewhat. Finally, studies addressing public health outcomes beyond mental health were excluded. Examples of such studies include psychotherapies targeted toward increasing condom use or mosquito net use in Africa. Africa in the 20th Century Now and then a boat from the shore gave one a momentary contact with reality. It was paddled by black fellows. You could see from afar the white
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of their eyeballs glistening. They shouted, sang; their bodies streamed with perspiration; they had faces like grotesque masks—these chaps; but they had bone, muscle, a wild vitality, an intense energy of movement, that was natural and true as the surf along their coast. They wanted no excuse for being there. They were a great comfort to look at. For a time I would feel I belonged still to a world of straightforward facts; but the feeling would not last long. —Marlow, in Joseph Conrad, Heart of Darkness
Interest in global mental health goes back to the birth of psychoanalysis with Carl Jung’s trips to North Africa, East Africa, and North America in the 1920s. Jung spent a full five months in East Africa in 1925–1926 to establish a “psychic observation post” outside of the “European sphere of influence.” These trips were indeed taken at a time during which interest in exploring Africa was not uncommon, and Burleson (2008) describes Jung as having been a part of a movement called romantic primitivism, which involved an idealization of the pre-colonial, simple African lifestyle embodied in Marlow from Conrad’s Heart of Darkness (2010). Jung indeed described himself as wanting to connect with the primitive within himself by spending time with people who had not “lost their souls.” At the time, it was observation rather than treatment that was emphasized, and Jung and others taking expeditions at that time stressed the importance of preventing oneself from “going black” or “going native.” The interest in global psychiatry, in particular post-colonial Africa, continued extensively in the 1960s. The focus remained largely observational, and treatment recommendations were based on anthropological data. The core of the literature focused on describing mental illness in Africa and understanding traditional healing methods. The central question was whether Western-style psychological treatments could be applied to these dramatically different cultures, and, if so, what changes are required of the therapist. Baasher, in 1965, wrote about the recognition of somatization in psychiatric illness and focused on the little that was known about it at the time, both in Western and non-Western cultures. He argued that somatic representations of psychological ailments were particularly important in African culture and that Western doctors do not truly understand the cultural aspects of the mental lives of individuals in other cultures. He noted that traditional East African practice did not differentiate the somatic from the physical and that traditional healers were used for psychological ailments. He suggested that traditional healing practices were helpful in relieving tension and improving somatic complaints and speculated that although certain Western psychotherapies may be out of place in Africa, there is vast diversity among African tribes. He
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concluded that despite these differences and the potential irrelevance of Western psychotherapeutic techniques, regardless of the psychotherapy type, the most important factors in treatment remain the skill and personality of the therapist and the willingness of the patient to participate in the therapeutic process. A French couple, Marie-Cecile (psychologist) and Edmound (anthropologist) Ortigues, published an extensive report (L’Oedipe Africain) after spending four years (1962–1966) at the Fann Hospital in Dakar, Senegal. The University of Dakar was built by France in the post-colonial era, and with the university came the beginning of an academic dialogue on transcultural psychiatry. Similarly, in the 1960s, psychiatric journals were begun in both Senegal and Nigeria. As described by Bullard in 2005, the Ortigues pointed out several cultural differences that were important in treatment of psychological complaints in Africa, all of which were drawn from their observations during their time in Senegal. They noted that the family structure was quite different, and that polygamy, adoption, and gifting of children were all common. The definition of generations was also conceptualized differently, and any individual of a certain age could be referred to as “mother” or “father.” Intimate, one-on-one consultation tended to be anxiety provoking, but family consultation was complicated by fear of disrespecting or insulting elders. The posing of direct questions and expectation of direct answers violated social norms, as individuals feared that disclosure of daily or lifetime events invited witchcraft. In contrast to the lengthy consultation procedures performed by Western psychologists, traditional healers asked only when and where the evil illness began. Furthermore, the traditional culture identified three basic reasons for psychopathology; possession, persecution by witchcraft (usually a cannibalistic fear of being eaten by a witch), and magical cursing. The Ortigues also observed that the transference was strongly affected by the White therapist–Black patient relationship. Despite all these differences, they argued that the Oedipus complex is universal, and that the fundamental problems of life are triangulation of relationships and sexual differentiation, regardless of the setting. Their formulations of the oral, anal, and phallic stages do discuss what they believed to be cultural differences at these stages of development. Bullard, in describing L’Oedipe Africain in 2005, cited a conversation she had with a Senegalese psychiatrist, Dr. Momar Gueye. Dr. Gueye commented that part of the reason that there is no psychoanalytic presence in Senegal is that traditional healers carry out analogous treatments. In 1967, Sargant, in a paper describing many traditional healing practices he observed, noted a technique in Zambia that is, in many ways, analogous to Western psychoanalysis. In this practice, the witch
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doctor, or traditional healer, showed the patient a naked fetish doll with exaggerated sexual anatomy. He would tell the patient to go home and study the doll closely and return the next day to discuss the dreams the doll had evoked. The therapeutic process then used these dreams to inform the patient and doctor of the underlying anxieties causing the symptoms. However, Sargant also describes many traditional healing practices that are quite different from Western psychoanalysis. For example, traditional healers would often “smoke out” possessions causing anxieties with a method that combined over-breathing, trance, and dissociation. The patient was given a protective amulet at the end of the process to prevent relapse. Despite some similarities and many differences between Western and African culture as well as among different African cultures, Sargant argued that all of the apparently different mechanisms are really methods to induce abreaction; therefore, the rationale and end result for psychotherapy should be the same across cultures. From these examples, it becomes clear that early efforts to characterize African psychological distress and treatment focused on vast cultural differences, and it was often concluded that therapeutic techniques were adaptable to other cultures as long as differences were appropriately noted and attended to. However, there was little or no guidance as to how to change practice in order to best serve individuals of other cultures. In addition, there was no evidence that Western psychotherapeutic techniques were superior to traditional healing methods. Recent Reports from Africa and Beyond Current discussions of psychodynamic psychotherapy in other cultures remain observational and continue to be based on discussion of ideas and case reports rather than on randomized controlled trials. In addition, there is little consistency among different authors both in setting of care and country of care, making it difficult, as in the 1960s, to draw firm and evidence-based conclusions. In 1998, Englund wrote about Mozambican refugees in Malawi from an anthropological perspective, noting that there was little evidence to guide therapeutic practice. His paper focuses on the therapeutic relevance of funerals and exorcisms of spirits of war casualties to treat psychological symptoms, stating that practices requiring extensive verbalization are not congruent with the culture and may feel forced to this population. He argued that humanitarian projects should focus on assisting people in carrying out funeral rites and that Western style psychotherapy is really not culturally relevant.
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Both Cooper in 2007 and Knight in 2013 used case reports to describe their experiences as White therapists treating Black patients in postApartheid South Africa. Both argued for the need for cultural sensitivity and awareness of the influence of severe historical racial discrimination on the psychotherapeutic process. In 2006, BenEzer described the importance of creating what he termed a “shared assumptive world” or “shared worldview” between patient and therapist. The therapist must remember that his usual tools of psychotherapy might not be relevant, and a world view must be created within the psychotherapy that is shared by both patient and therapist but not necessarily with either culture. BenEzer used his experience working in group psychotherapy with Ethiopian immigrants in Israel and made specific psychotherapeutic recommendations relevant to this group. For example, he noted that the therapist might need to be more active, as in Ethiopian culture there is a bias against sharing problems and emotions in public. The therapist must actively address issues of power within the psychotherapeutic relationship, as the patients often see the therapist as a teacher, or hierarchically superior. He notes that the Ethiopian “code of honor” dictates that it is inappropriate to say no to an authority figure, giving the example that many would refrain from telling the therapist that a particular appointment time is inconvenient, as it is culturally more polite to simply miss the scheduled session. While many discuss the need to be culturally sensitive, few give such specific examples regarding what culturally sensitive means. Masalha wrote about psychodynamic psychotherapy in an Arab village clinic in 1999, and his opinions differ significantly from those described above. He used a case study of a successful psychodynamic therapy as an illustration of his observations from his years in practice in the village. He noted that the general consensus had been that when treating other cultures, therapists must adapt their techniques to varying degrees. He fundamentally disagreed with the idea that practice should be changed. As an example, he pointed out that time is not measured precisely in Arab culture. Nevertheless, he used the same procedures when beginning psychotherapy, including importance of timeliness, as he does with Western patients. He argued that although individuality is not stressed in Arab culture, the role of the therapist is not to force patients into what he described as the continually repressive traditional Arab cultural framework, stating that he treats many psychosomatic and repressive symptoms that are reminiscent of Freud’s 19th century Vienna. The goal of the therapist is therefore to help people realize individuality while maintaining familial and community relationships. In his view, being culturally sensitive does not
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mean changing practice or disregarding the general principles and techniques of psychodynamic psychotherapy. Similarly, Draijer and Van Zon in 2012 describe a case report of successful treatment of a 24-year-old child soldier refugee from Sierra Leone using transference-focused psychotherapy, arguing for the use of traditional Western psychoanalytic techniques to be used without revision in the child soldier population. Clearly, there is great disagreement surrounding whether Western psychotherapeutic techniques need modification when treating patients from different cultures. While some authors advocate for culturally sensitive changes in technique, others argue that human nature is basically universal and therefore traditional Western psychotherapy is universally applicable. Increasing educational opportunities in countries that previously would have had no training in Western style psychotherapy has even further complicated the debate, as authors from within these cultures have also written opinion observational papers about psychotherapy within their home countries as delivered by members of those cultures. Kakar in 2003 discussed how Eastern meditative practices may relate to and be incorporated into psychoanalysis, focusing his discussion on the Indian teacher-healer’s empathic capacity through meditation. Javanbakht and Sanati provided a history of psychiatry in Iran in 2006, noting that although most treatments are biological, there is a psychoanalytic tradition in Iran. They point out that there are important differences between Western and Iranian psychotherapies. For example, group psychotherapy is conducted in same-sex groups, and they observed that Iranian psychotherapists tend to be more active than those in other cultures. Finally, Yang, in 2011, described the then 13-year-old Chinese psychoanalytic tradition, noting that psychoanalysis was introduced into China by Western teachers and taught in English. The author suggested that individualization is an important element in psychoanalysis, but in Chinese culture, collective interest and the interest of the family is more important than that of the individual. The individual is born to serve the collective, thus the emphasis on individual expression may need to be restructured when working with this population. Oras, Cancela de Ezpeleta, and Ahmad (2004) examined eye movement desensitization and reprocessing therapy (EMDR) in 13 refugee children with PTSD, ages 8–13, living in Sweden. These children were of different cultural backgrounds, and all were in the process of seeking refugee status in Sweden. They described their use of EMDR as having occurred in a psychodynamic context, meaning the therapy itself (outside of EMDR) was based on psychodynamic theory with objectrelations and family therapy approaches. EMDR itself involves a process of remembering while receiving different types of bilateral sensory
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stimuli. The authors note that effectiveness of the technique has been demonstrated in adults and that their clinical experience indicated effectiveness in children. The study allowed significant freedom on the part of the therapist to vary the treatment session content and length and the number of EMDR sessions, with the number of sessions ultimately ranging from 1–6. The authors note overall improvement in PTSD symptoms and depressive symptoms, with the caveat that family stability was an important indicator of treatment success and that a common clinical finding is that children’s symptoms often resolved when the family gained permanent residence. Van’t Hof, Cuijpers, Waheed, and Stein (2011) published a meta-analysis of studies examining psychotherapy in low and middle-income countries and included only one trial that involved psychodynamic psychotherapy. This study (Knijnik, Kapczinski, Chachamovich, Margis, & Eizirik, 2004), carried out in Brazil and published in Portuguese, examined a 12-session psychodynamic group therapy in social phobia and demonstrated effectiveness of this approach in their clinical sample. Other Psychotherapies Unlike psychodynamic psychotherapy, there is a growing literature of randomized controlled trials demonstrating effectiveness of other types of psychotherapy in low resource settings and diverse cultures. While the classic questions regarding cultural relevance of the psychotherapies remain, there are many new questions asked by these researchers. For example, is psychotherapy useful in the context of the ongoing trauma, poverty, and insecurity experienced by many of the individuals it tries to reach? To what extent can psychotherapy be implemented in resource-poor settings in terms of the ability of patients to attend and afford regular sessions? One example of such a psychotherapy is Narrative Exposure Therapy (NET), which was developed by Neuner and colleagues in 2002 for the treatment of PTSD for people in low-income countries, particularly in Africa. It is a standardized, short-term therapy based on cognitive behavioral therapy for PTSD, in which the patient is asked to talk extensively about the trauma while re-experiencing the event, ultimately leading to habituation. Because it is difficult to discern what the worst event has been in many individuals in resource-poor settings, NET also draws on testimony therapy, developed by Lira and Weinstein in 1993 to treat Chileans traumatized by the Pinochet regime. In testimony
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therapy, the patient creates a narrative of their entire life, focusing on a detailed report of their traumas. In 2004, Neuner, Karunakara, and Elbert published a study examining NET in Sudanese refugees living in Northern Uganda. There were three treatment groups in the study: a control group received one session of psychoeducation, an unstandardized treatment group received four counseling sessions, and a third group received four NET sessions. The majority of those screened agreed to enroll in the trial and there was a low dropout rate, demonstrating that this population was willing to accept psychological help. Forty-three participants were re-examined immediately following treatment, four months later, and one year later, and the NET group demonstrated lowest symptom burden after one year. However, the authors point out that many remained severely traumatized, raising the question of whether a four-session treatment is adequate for those who are continuously traumatized. The authors point out that the psychotherapy was carried out by highly trained European psychologists, which is a potential barrier to wide-scale implementation. Similarly, Onyut et al. (2005) used NET to treat six Somali children ages 8–17 living in a refugee camp in Uganda. In this small, uncontrolled study of 4 to 6 NET sessions, all completed therapy and all had symptom improvement immediately after and at nine-month followup, at which time four of the six children did not meet criteria for PTSD. Again, the authors point out that the psychotherapists in the study were highly trained experts. The question of implementation on a local level was addressed in subsequent studies. In 2008, Neuner et al. compared NET to unstructured counseling and a non-treatment control group. In this study, trained lay counselors carried out NET in a refugee settlement in Uganda with 277 individuals from Rwanda and Somalia. NET was equal to unstructured counseling and both were superior to control. At the end of this study, 70% of the NET group and 65% of the unstructured counseling group no longer met criteria for PTSD. Dropout rate was low; 4% in the NET group versus 21% in the counseling group. Ertl, Pfeiffer, Schauer, Elbert, and Neuner (2011) demonstrated again that NET carried out in eight sessions by lay counselors is effective, this time in a group of 85 former child soldiers with PTSD ages 12–25 living in Northern Uganda. Participants were randomized to NET, an academic catch-up program, or wait-list. PTSD, depression, and functional impairment were measured at treatment completion, three months, six months, and nine months. NET outperformed both the academic catchup and wait-list settings.
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Another psychotherapy with a growing global literature is interpersonal psychotherapy (IPT), often carried out in a group setting. Bolton et al. (2003) studied 108 men and 116 women with depressive illness in single-gendered IPT groups. IPT groups were led by local people who had received two weeks of intensive training delivered by the authors of the paper. Treatment involved 16 weekly 90-minute sessions. A control group was not assigned to any structured psychotherapy, but individuals were allowed to seek local treatment as usual. IPT was found to be highly effective; as at the end of treatment 6.5% of the IPT group versus 54.7% of the control group met criteria for depression. Bass et al. (2006) interviewed this group six months after treatment and found that the benefits of IPT persisted. There are several other examples of IPT studies in Africa. Bolton et al. (2007) demonstrated IPT group therapy to be effective in female but not male adolescents aged 14–17 in two camps for the internally displaced in Northern Uganda. Peterson, Bhana, and Baillie (2012) demonstrated the effectiveness of group IPT delivered by supervised community healthcare workers in 60 participants in South Africa. In this study, IPT was effective compared to control at 12 and 24 weeks post-treatment. Peterson, Hancock, Bhana, and Govender (2014) demonstrated effectiveness in treating depression in a study of 34 HIV patients with IPT delivered by lay counselors in South Africa. There have even been studies comparing different types of psychotherapies. Schaal, Elbert, and Neuner (2009) compared NET to interpersonal therapy (IPT) in 26 Rwandan genocide orphans with PTSD. Each group had 4 weekly psychotherapy sessions carried out by doctoral level psychologists or graduate students. The authors report no significant treatment differences at post-test, but at six months, 25% of the NET group versus 71% of the IPT group met criteria for PTSD. Although the above discussion has focused on psychotherapy trials in Africa, it is important not to overlook completely that work has been done in other parts of the world. Patel et al. (2010) implemented a mental health care system to treat depression and anxiety disorders in a primary care setting in Goa, India. The writers developed what they called a collaborative stepped care intervention, which involved counseling by a trained lay counselor, antidepressant medication, and supervision by a mental health specialist in both private and public settings. Previously untrained lay counselors underwent a two-month training course and went on to act as case managers and psychoeducators to individuals enrolled in the study. Those individuals with moderate to severe illness or non-response to psychoeducation could either receive antidepressants from the primary care doctor or interpersonal psychotherapy from a lay counselor. The psychiatrist became involved in care
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when there was a high suicide risk, a non-response to other treatments, a diagnostic dilemma, significant alcohol dependence, significant comorbid medical disorders, or a consultation was requested from the primary care doctor. This stepped care approach was compared with what the authors called enhanced usual care, in which primary care doctors treated the disorder according to treatment manuals. The study detected improvement in outcomes in the public, but not private, settings, suggesting that patients already receive adequate care in the private setting. This trial is significant in that it not only demonstrates the usefulness of psychotherapy in a resource-poor setting, but it also demonstrates a system of care that incorporates psychotherapy as one arm of treatment can be both practical and useful. Many may wonder about the usefulness of psychotherapy in low and middle-income countries, positing that in the setting of extreme poverty, psychotherapy is a luxury that does not address the vast public health problems that plague these areas. Rahman, Malik, Sikander, Roberts, and Creed (2008) studied a group of depressed mothers in rural Pakistan, and used infant health as primary outcome measures and maternal mental health as a secondary outcome measure. In this study, married women ages 16–45 in their third trimester of pregnancy and with a diagnosis of depression were randomized to either cognitive behavioral therapy (intervention) or enhanced routine care (control). The intervention group received one psychotherapy session per week in the last four weeks of pregnancy, three sessions in the first postnatal month, then nine monthly sessions. The enhanced care group received the same number of unstructured visits. The psychotherapy was performed by local health workers trained in manualized therapy. Although one major primary outcome, infant height and weight, was not improved at the end of the study, the authors report decreased diarrhea and increased rates of immunization in the intervention group. Women in the intervention group were more likely to use contraception, which is an important finding in that birth spacing is a factor in infant mortality. Finally, the intervention group had significantly improved depression and less disability, and these gains were sustained at one-year follow-up. Interestingly, the trained health workers were also surveyed at the end of the study, and none considered the work or training an extra burden. Discussion The literature on psychodynamic and other psychotherapies suggests that individuals in resource-poor and low-income countries can
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accept and respond to Western-style psychotherapies. Psychotherapy has been found to be effective and practically deliverable both individually and in groups by trained lay counselors, a point which vastly improves the potential accessibility of these therapies. Still, where are we with psychodynamic psychotherapy? After much speculation, we do not really know whether it will be effective or culturally relevant in non-Western cultures, other than from observation and case reports. We do not know what, if any, changes in practice are necessary. A potential argument against the feasibility of psychodynamic psychotherapy is the length and breadth of training required of psychodynamic psychotherapists. Two papers suggest that there are ways to implement appropriate psychodynamic training in low and middle-income countries. Murray et al. (2011) have provided guidelines for training local psychotherapists drawn from ten years of experience. They stress the importance of supervision and feedback, as do Western psychotherapists. They present their “apprenticeship model,” which consists of three groups of therapists: (1) Trainers, who are experts in mental health but generally come from outside the community; (2) Supervisors, who are local individuals selected for an advanced role; and (3) Counselors, who provide the actual services. The authors feel that this model has been effective in implementing adequate psychotherapy training and supervision in low and middle-income countries. In this regard, Fishkin, Fishkin, Leli, Katz, and Snyder (2011) describe the China American Psychoanalytic Alliance (CAPA), which provides American-based supervision and training for Chinese psychotherapists via the Internet. Specifically, they use Skype, which uses a proprietary encryption protocol that makes third party interception impossible. CAPA has arranged psychoanalysis for about 40 and psychodynamic psychotherapy for about 30 individuals, mostly mental health professionals, noting that the limiting factor is generally access to high-speed Internet. The paper discusses several cultural barriers as well as challenges associated with Internet-based psychotherapy. However, the project has largely been successful in providing psychodynamic therapy and supervision to Chinese psychotherapists and suggests a platform for doing so elsewhere. Another concern is that lengthy treatment, potentially delivered multiple times per week, cannot be practical in resource-poor settings. This concern may be valid, yet we do not yet have evidence that this is the case. The existence of a still emerging evidence base has not deterred the use of psychodynamic therapy in the developed world, and
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the sparse literature regarding psychodynamic psychotherapy in the developing world should not necessarily lead to a presumption against its use or study in such settings. Furthermore, even if cultural and economic factors make longitudinal and intensive psychodynamic psychotherapy difficulty, this does not necessarily preclude the application of psychodynamic principles in supportive therapies or brief dynamic therapies. Regarding the vast cultural differences, available evidence from 1960s anthropological work suggests that traditional healers use psychodynamic principles as part of their repertory of healing techniques. In Africa, up to 80% of the population depends upon traditional healers; in India the figure is 70% (Bodeker, Ong, Grundy, Burford, & Shein, 2005). One study, for example, concluded that traditional healers provide a substantial portion of mental health care in South Africa (Sorsdahl et al., 2009). Another conducted in a West Indian village found that villagers were likely to consult both traditional healers and physicians for mental health complaints (Kapur, 1979). Western psychodynamically oriented psychotherapists could potentially learn a great deal about managing patients in both the developing and the developed world by partnering with local traditional healers. Marlow and Jung thought of the developing world as a place where the mind exists in its purest form. Today, Western doctors often think that considerations of the mind are the least relevant to peoples’ quality of life in situations plagued by extreme poverty, war, starvation, and disease. Both extremes are potentially narrow minded and deprecatory. Indeed, our own experience working in a number of low and middleincome countries is that one of the most common requests we receive from local mental health professionals is for help with addressing personality and other psychological issues with psychotherapy, with even more specific requests tending to focus on training in either CBT or psychodynamics. Ultimately, the psychodynamic stance involves open-mindedness about the unique history and characteristics that shape the minds of people, begetting the very compassionate and collaborative exploration of the remote corners of an individual’s experience that is psychodynamic psychotherapy. It seems there could not be a better stance with which to explore the world. As mental health professionals increasingly join the global health movement, there is abundant reason and emerging evidence to suggest that psychodynamic practice will be relevant and helpful.
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References Baasher, T. A. (1965). Treatment and prevention of psychosomatic disorders: Psychosomatic diseases in East Africa. American Journal of Psychiatry, 121, 1095-1102. Bass, J., Neugebauer, R., Clougherty, K. F., Verdeli, H., Wickramaratne, P., Ndogoni, L., Speelman, L., Weissman, M., & Bolton, P. (2006). Group interpersonal psychotherapy for depression in rural Uganda: 6-month outcomes: Randomized controlled trial. British Journal of Psychiatry, 188, 567-573. BenEzer, G. (2006). Group counseling and psychotherapy across the cultural divide: The case of Ethiopian Jewish immigrants in Israel. Transcultural Psychiatry, 43(2), 205-234. Bodeker, G., Ong, C. K., Grundy, C., Burford, G., & Shein, K. (2005). WHO global atlas of traditional, complementary, and alternative medicine, text volume. Kobe, Japan: World Health Organization. Bolton, P., Bass, J., Betancourt, T., Speelman, L., Onyango, G., Clougherty, K. F., Neugebauer, R., Murray, L., & Verdeli, H. (2007). Interventions for depression symptoms among adolescent survivors of war and displacement in Northern Uganda. Journal of the American Medical Association, 298(5), 519-527. Bolton, P., Bass, J., Neugebauer, R., Verdeli, H., Clougherty, K. F., Wickramaratne, P., Speelman, L., Ndogoni, L., & Weissman, M. (2003). Group interpersonal psychotherapy for depression in rural Uganda: A randomized controlled trial. Journal of the American Medical Association, 289(23), 3117-3124. Bullard, A. (2005). L’Oedipe Africain: A retrospective. Transcultural Psychiatry, 42(2), 171-203. Burleson, B. (2008). Jung in Africa: The historical record. Journal of Analytic Psychology, 53, 209-223. Conrad, J. (2010). Heart of darkness. New York: Harper Collins. Cooper, S. (2007). Psychotherapy in South Africa: The case of Mrs. A. Journal of Clinical Psychology, 63(8), 773-776. Draijer, N., & Van Zon, P. (2013). Transference-focused psychotherapy with former child soldiers: Meeting the murderous self. Journal of Trauma and Dissociation, 14, 170-183. Englund, H. (1998). Death, trauma, and ritual: Mozambican refugees in Malawi. Social Science and Medicine, 46(9), 1165-1174. Ertl, V., Pfeiffer, A., Schauer, E., Elbert, T., & Neuner, F. (2011). Community-implemented trauma therapy for former child soldiers in Northern Uganda: A randomized controlled trial. Journal of the American Medical Association, 306(5), 503-512. Fishkin, R., Fishkin, L., Leli, U., Katz, B., & Snyder, E. (2011). Psychodynamic treatment, training, and supervision using Internet-based technologies. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 39(1), 155-168. Javanbakht, A., & Sanati, M. (2006). Psychiatry and psychoanalysis in Iran. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 34(3), 405-414. Kakar, S. (2003). Psychoanalysis and Eastern spiritual healing traditions. Journal of Analytic Psychology, 48, 659-678. Kapur, R. (1979). The role of traditional healers in mental health care in rural India. Social Science and Medicine. Part B: Medical Anthropology, 13(1), 27-31.
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Knight, Z. G. (2013). Black client, white therapist: Working with race in psychoanalytic psychotherapy in South Africa. The International Journal of Psychoanalysis, 94, 17-31. Knijnik, D. Z., Kapczinski, F., Chachamovich, E., Margis, R., & Eizirik, C. L. (2004). Psychodynamic group treatment for generalized social phobia. Revista Brasilileira de Psiquiatria, 26(7), 77-81. Koplan, J. P., Bond, T. C., Merson, M. H., Reddy, K. S., Rodriguez, M. H., Sewankambo, N. K., & Wasserheit, J. N. (2009). Towards a common definition of global health. The Lancet, 373(9679), 1993-1995. Masalha, S. (1999). Psychodynamic psychotherapy as applied in an Arab village clinic. Clinical Psychology Review, 19(8), 987-997. Murray, L. K., Dorsey, S., Bolton, P., Jordans, M. J. D., Rahman, A., Bass, J., & Verdeli, H. (2011). Building capacity in mental health interventions in low resource countries: An apprenticeship model for training local providers. International Journal of Mental Health Systems, 5, 30. Neuner, F., Karunakara, U., & Elbert, T. (2004). A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement. Journal of Counseling and Clinical Psychology, 72(4), 579-587. Neuner, F., Onyut, P. L., Ertl, V., Odenwald, M., Schauer, E., & Elbert, T. (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(4), 686-694. Onyut, L. P., Neuner, F., Schauer, E., Ertl, V., Odenwald, M., Schauer, M., & Elbert, T. (2005). Narrative exposure therapy as a treatment for child war survivors with posttraumatic stress disorder: Two case reports and a pilot study in an African refugee settlement. BMC Psychiatry, 5, 7. Oras, R., Cancela de Ezpeleta, S., & Ahmad, A. (2004). Treatment of traumatized refugee children with eye movement desensitization and reprocessing in a psychodynamic context. Nordic Journal of Psychiatry, 58, 199-203. Patel, V., & Prince, M. (2010). Global mental health: A new global health field comes of age. Journal of the American Medical Association, 303(19), 1976-1977. Patel, V., Weiss, H., Chowdhary, N., Naik, S., Pednekar, S., Chatterjee, S., et al. (2010). Effectiveness of an intervention led by lay health counselors for depressive and anxiety disorders in primary care in Goa, India (MANAS): A cluster randomized controlled trial. The Lancet, 376, 2086-2095. Peterson, I., Bhana, A., & Baillie, K. (2012). The feasibility of adapted group-based interpersonal therapy (IPT) for the treatment of depression by community health workers within the context of task shifting in South Africa. Journal of Community Mental Health, 48, 336-341. Peterson, I., Hancock, J. H., Bhana, A., & Govender, K. (2014). A group-based counseling intervention for depression comorbid with HIV/AIDS using a task shifting approach in South Africa: A randomized controlled pilot study. Journal of Affective Disorders, 158, 78-84. Rahman, A., Malik, A., Sikander, S., Roberts, C., & Creed, F. (2008). Cognitive behavior therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: A cluster-randomized controlled trial. The Lancet, 372, 902-909.
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Sargant, W. (1967). Witch doctoring, zar and voodoo: Their relation to modern psychiatric treatments. Proceedings of the Royal Society of Medicine, 60, 47-52. Schaal, S., Elbert, T., & Neuner, R. (2009). Narrative exposure therapy versus interpersonal psychotherapy. Psychotherapy and Psychosomatics, 78, 298-306. Sorsdahl, K., Stein, D. J., Grimsrud, A., Seedat, S., Flisher, A. J., Williams, D. R., & Meyer, L. (2009). Traditional healers in the treatment of common mental disorders in South Africa. The Journal of Nervous and Mental Disease, 197(6), 434441. Van’t Hof, E., Cuijpers, P., Waheed, W., & Stein, D. J. (2011). Psychological treatments for depression and anxiety disorders in low- and middle-income countries: A meta-analysis. African Journal of Psychiatry, 14, 200-207. Weissman, M. (2013). Psychotherapy: A paradox. American Journal of Psychiatry, 170, 712-715. Yang, Y. (2011). The challenge of professional identity for Chinese clinicians in the process of learning and practicing psychoanalytic psychotherapy. International Journal of Psychoanalysis, 92, 733-743.
Craig L. Katz Director, Program in Global Mental Health Clinical Associate Professor of Psychiatry and Medical Education Icahn School of Medicine at Mount Sinai One Gustave L. Levy Place, Box 1257 New York, NY 10029 [email protected]
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Psychodynamic Psychotherapy and Global Health Rachel L. Moster and Craig L. Katz Abstract: This study surveys and examines the literature about psychodynamic psychotherapy in low and middle income countries. Although much has been written on this topic, the literature remains disjointed, unsystematic, and lacks randomized controlled trials. This trend is in stark contrast with a growing body of systematic literature and randomized controlled trials that exist in other types of psychotherapy used in low and middle income countries. While there is evidence that other types of psychotherapy are useful in these countries, questions remain regarding the implementation of psychodynamic psychotherapy. Is psychodynamic psychotherapy relevant to non-Western cultures? Are changes necessary to make it relevant? Is psychodynamic psychotherapy economically feasible in low and middle income countries? Although definitive answers to these questions do not yet exist, as psychodynamic psychotherapy is open-ended and client-centered, it is likely to be flexible across a wide range of cultures.
Global health embodies “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide” (Koplan et al., 2009, p. 1995). Global health is commonly equated with a focus on infectious diseases such as malaria and HIV. However, as efforts to eradicate these diseases achieve greater success, the field increasingly looks to address non-communicable diseases. The emerging field of global mental health applies the principles of global health to mental health and seeks to improve access to mental health throughout the world (Patel & Prince, 2010). The field of mental health embodies a wide range of therapeutic interventions spanning somatic treatments such as medications and electroconvulsive therapy to residential treatment to the psychotheraRachel L. Moster, M.D., Fellow in Public Psychiatry, New York State Psychiatric Institute at Columbia University Medical Center. Craig L. Katz, M.D., Director, Program in Global Mental Health, Clinical Associate Professor of Psychiatry and Medical Education. Psychodynamic Psychiatry, 42(4) 641–656, 2014 © 2014 The American Academy of Psychoanalysis and Dynamic Psychiatry
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pies. Global mental health therefore comes in as many permutations as there are countries and cultures and treatment modalities. Currently, economic realities and pervasive stigma, among other potential factors, dictate that the practice of psychiatry in low resource settings typically comes down to deploying a narrow medication formulary to treat the most severely mentally ill in overcrowded, overlooked, and under-resourced psychiatric hospitals. It is therefore not surprising that a psychiatry fellow shared with one of the authors (CLK) a story of how her training director warned her of her need to make a choice when she disclosed that they had interests in both psychoanalysis and global health. People barely ever imagine how psychiatry can flourish in low and middle income countries and other low resource settings, let alone how psychotherapy and especially psychodynamic psychotherapy or psychoanalysis could. In fact, at a time when access to psychotherapy is being limited by economic considerations in the developed world, there is an increasing movement in the developing world to promulgate psychotherapy as cost-effective (Weissman, 2013). In this article, we address what Weissman calls the “psychotherapy paradox” by examining what is known about psychodynamic psychotherapy in the developing world. What follows is an overview of some areas of commentary and research in psychoanalysis and psychodynamic psychotherapy in low and middle income countries. It is not an exhaustive review of these or other psychotherapies in all resource-poor settings, as such a review would be beyond the scope of this article. Literature searches were conducted on PubMed using key words global psychoanalysis, global psychodynamic psychotherapy, global psychotherapy, Africa psychoanalysis, Africa psychodynamic psychotherapy, Africa psychotherapy, Asia psychoanalysis, Asia psychodynamic psychotherapy, India psychoanalysis, and India psychodynamic psychotherapy. Only full articles available in English were included. The discussion about psychotherapies other than psychoanalysis or psychodynamic psychotherapy will focus on research conducted in Africa, to narrow the focus somewhat. Finally, studies addressing public health outcomes beyond mental health were excluded. Examples of such studies include psychotherapies targeted toward increasing condom use or mosquito net use in Africa. Africa in the 20th Century Now and then a boat from the shore gave one a momentary contact with reality. It was paddled by black fellows. You could see from afar the white
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of their eyeballs glistening. They shouted, sang; their bodies streamed with perspiration; they had faces like grotesque masks—these chaps; but they had bone, muscle, a wild vitality, an intense energy of movement, that was natural and true as the surf along their coast. They wanted no excuse for being there. They were a great comfort to look at. For a time I would feel I belonged still to a world of straightforward facts; but the feeling would not last long. —Marlow, in Joseph Conrad, Heart of Darkness
Interest in global mental health goes back to the birth of psychoanalysis with Carl Jung’s trips to North Africa, East Africa, and North America in the 1920s. Jung spent a full five months in East Africa in 1925–1926 to establish a “psychic observation post” outside of the “European sphere of influence.” These trips were indeed taken at a time during which interest in exploring Africa was not uncommon, and Burleson (2008) describes Jung as having been a part of a movement called romantic primitivism, which involved an idealization of the pre-colonial, simple African lifestyle embodied in Marlow from Conrad’s Heart of Darkness (2010). Jung indeed described himself as wanting to connect with the primitive within himself by spending time with people who had not “lost their souls.” At the time, it was observation rather than treatment that was emphasized, and Jung and others taking expeditions at that time stressed the importance of preventing oneself from “going black” or “going native.” The interest in global psychiatry, in particular post-colonial Africa, continued extensively in the 1960s. The focus remained largely observational, and treatment recommendations were based on anthropological data. The core of the literature focused on describing mental illness in Africa and understanding traditional healing methods. The central question was whether Western-style psychological treatments could be applied to these dramatically different cultures, and, if so, what changes are required of the therapist. Baasher, in 1965, wrote about the recognition of somatization in psychiatric illness and focused on the little that was known about it at the time, both in Western and non-Western cultures. He argued that somatic representations of psychological ailments were particularly important in African culture and that Western doctors do not truly understand the cultural aspects of the mental lives of individuals in other cultures. He noted that traditional East African practice did not differentiate the somatic from the physical and that traditional healers were used for psychological ailments. He suggested that traditional healing practices were helpful in relieving tension and improving somatic complaints and speculated that although certain Western psychotherapies may be out of place in Africa, there is vast diversity among African tribes. He
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concluded that despite these differences and the potential irrelevance of Western psychotherapeutic techniques, regardless of the psychotherapy type, the most important factors in treatment remain the skill and personality of the therapist and the willingness of the patient to participate in the therapeutic process. A French couple, Marie-Cecile (psychologist) and Edmound (anthropologist) Ortigues, published an extensive report (L’Oedipe Africain) after spending four years (1962–1966) at the Fann Hospital in Dakar, Senegal. The University of Dakar was built by France in the post-colonial era, and with the university came the beginning of an academic dialogue on transcultural psychiatry. Similarly, in the 1960s, psychiatric journals were begun in both Senegal and Nigeria. As described by Bullard in 2005, the Ortigues pointed out several cultural differences that were important in treatment of psychological complaints in Africa, all of which were drawn from their observations during their time in Senegal. They noted that the family structure was quite different, and that polygamy, adoption, and gifting of children were all common. The definition of generations was also conceptualized differently, and any individual of a certain age could be referred to as “mother” or “father.” Intimate, one-on-one consultation tended to be anxiety provoking, but family consultation was complicated by fear of disrespecting or insulting elders. The posing of direct questions and expectation of direct answers violated social norms, as individuals feared that disclosure of daily or lifetime events invited witchcraft. In contrast to the lengthy consultation procedures performed by Western psychologists, traditional healers asked only when and where the evil illness began. Furthermore, the traditional culture identified three basic reasons for psychopathology; possession, persecution by witchcraft (usually a cannibalistic fear of being eaten by a witch), and magical cursing. The Ortigues also observed that the transference was strongly affected by the White therapist–Black patient relationship. Despite all these differences, they argued that the Oedipus complex is universal, and that the fundamental problems of life are triangulation of relationships and sexual differentiation, regardless of the setting. Their formulations of the oral, anal, and phallic stages do discuss what they believed to be cultural differences at these stages of development. Bullard, in describing L’Oedipe Africain in 2005, cited a conversation she had with a Senegalese psychiatrist, Dr. Momar Gueye. Dr. Gueye commented that part of the reason that there is no psychoanalytic presence in Senegal is that traditional healers carry out analogous treatments. In 1967, Sargant, in a paper describing many traditional healing practices he observed, noted a technique in Zambia that is, in many ways, analogous to Western psychoanalysis. In this practice, the witch
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doctor, or traditional healer, showed the patient a naked fetish doll with exaggerated sexual anatomy. He would tell the patient to go home and study the doll closely and return the next day to discuss the dreams the doll had evoked. The therapeutic process then used these dreams to inform the patient and doctor of the underlying anxieties causing the symptoms. However, Sargant also describes many traditional healing practices that are quite different from Western psychoanalysis. For example, traditional healers would often “smoke out” possessions causing anxieties with a method that combined over-breathing, trance, and dissociation. The patient was given a protective amulet at the end of the process to prevent relapse. Despite some similarities and many differences between Western and African culture as well as among different African cultures, Sargant argued that all of the apparently different mechanisms are really methods to induce abreaction; therefore, the rationale and end result for psychotherapy should be the same across cultures. From these examples, it becomes clear that early efforts to characterize African psychological distress and treatment focused on vast cultural differences, and it was often concluded that therapeutic techniques were adaptable to other cultures as long as differences were appropriately noted and attended to. However, there was little or no guidance as to how to change practice in order to best serve individuals of other cultures. In addition, there was no evidence that Western psychotherapeutic techniques were superior to traditional healing methods. Recent Reports from Africa and Beyond Current discussions of psychodynamic psychotherapy in other cultures remain observational and continue to be based on discussion of ideas and case reports rather than on randomized controlled trials. In addition, there is little consistency among different authors both in setting of care and country of care, making it difficult, as in the 1960s, to draw firm and evidence-based conclusions. In 1998, Englund wrote about Mozambican refugees in Malawi from an anthropological perspective, noting that there was little evidence to guide therapeutic practice. His paper focuses on the therapeutic relevance of funerals and exorcisms of spirits of war casualties to treat psychological symptoms, stating that practices requiring extensive verbalization are not congruent with the culture and may feel forced to this population. He argued that humanitarian projects should focus on assisting people in carrying out funeral rites and that Western style psychotherapy is really not culturally relevant.
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Both Cooper in 2007 and Knight in 2013 used case reports to describe their experiences as White therapists treating Black patients in postApartheid South Africa. Both argued for the need for cultural sensitivity and awareness of the influence of severe historical racial discrimination on the psychotherapeutic process. In 2006, BenEzer described the importance of creating what he termed a “shared assumptive world” or “shared worldview” between patient and therapist. The therapist must remember that his usual tools of psychotherapy might not be relevant, and a world view must be created within the psychotherapy that is shared by both patient and therapist but not necessarily with either culture. BenEzer used his experience working in group psychotherapy with Ethiopian immigrants in Israel and made specific psychotherapeutic recommendations relevant to this group. For example, he noted that the therapist might need to be more active, as in Ethiopian culture there is a bias against sharing problems and emotions in public. The therapist must actively address issues of power within the psychotherapeutic relationship, as the patients often see the therapist as a teacher, or hierarchically superior. He notes that the Ethiopian “code of honor” dictates that it is inappropriate to say no to an authority figure, giving the example that many would refrain from telling the therapist that a particular appointment time is inconvenient, as it is culturally more polite to simply miss the scheduled session. While many discuss the need to be culturally sensitive, few give such specific examples regarding what culturally sensitive means. Masalha wrote about psychodynamic psychotherapy in an Arab village clinic in 1999, and his opinions differ significantly from those described above. He used a case study of a successful psychodynamic therapy as an illustration of his observations from his years in practice in the village. He noted that the general consensus had been that when treating other cultures, therapists must adapt their techniques to varying degrees. He fundamentally disagreed with the idea that practice should be changed. As an example, he pointed out that time is not measured precisely in Arab culture. Nevertheless, he used the same procedures when beginning psychotherapy, including importance of timeliness, as he does with Western patients. He argued that although individuality is not stressed in Arab culture, the role of the therapist is not to force patients into what he described as the continually repressive traditional Arab cultural framework, stating that he treats many psychosomatic and repressive symptoms that are reminiscent of Freud’s 19th century Vienna. The goal of the therapist is therefore to help people realize individuality while maintaining familial and community relationships. In his view, being culturally sensitive does not
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mean changing practice or disregarding the general principles and techniques of psychodynamic psychotherapy. Similarly, Draijer and Van Zon in 2012 describe a case report of successful treatment of a 24-year-old child soldier refugee from Sierra Leone using transference-focused psychotherapy, arguing for the use of traditional Western psychoanalytic techniques to be used without revision in the child soldier population. Clearly, there is great disagreement surrounding whether Western psychotherapeutic techniques need modification when treating patients from different cultures. While some authors advocate for culturally sensitive changes in technique, others argue that human nature is basically universal and therefore traditional Western psychotherapy is universally applicable. Increasing educational opportunities in countries that previously would have had no training in Western style psychotherapy has even further complicated the debate, as authors from within these cultures have also written opinion observational papers about psychotherapy within their home countries as delivered by members of those cultures. Kakar in 2003 discussed how Eastern meditative practices may relate to and be incorporated into psychoanalysis, focusing his discussion on the Indian teacher-healer’s empathic capacity through meditation. Javanbakht and Sanati provided a history of psychiatry in Iran in 2006, noting that although most treatments are biological, there is a psychoanalytic tradition in Iran. They point out that there are important differences between Western and Iranian psychotherapies. For example, group psychotherapy is conducted in same-sex groups, and they observed that Iranian psychotherapists tend to be more active than those in other cultures. Finally, Yang, in 2011, described the then 13-year-old Chinese psychoanalytic tradition, noting that psychoanalysis was introduced into China by Western teachers and taught in English. The author suggested that individualization is an important element in psychoanalysis, but in Chinese culture, collective interest and the interest of the family is more important than that of the individual. The individual is born to serve the collective, thus the emphasis on individual expression may need to be restructured when working with this population. Oras, Cancela de Ezpeleta, and Ahmad (2004) examined eye movement desensitization and reprocessing therapy (EMDR) in 13 refugee children with PTSD, ages 8–13, living in Sweden. These children were of different cultural backgrounds, and all were in the process of seeking refugee status in Sweden. They described their use of EMDR as having occurred in a psychodynamic context, meaning the therapy itself (outside of EMDR) was based on psychodynamic theory with objectrelations and family therapy approaches. EMDR itself involves a process of remembering while receiving different types of bilateral sensory
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stimuli. The authors note that effectiveness of the technique has been demonstrated in adults and that their clinical experience indicated effectiveness in children. The study allowed significant freedom on the part of the therapist to vary the treatment session content and length and the number of EMDR sessions, with the number of sessions ultimately ranging from 1–6. The authors note overall improvement in PTSD symptoms and depressive symptoms, with the caveat that family stability was an important indicator of treatment success and that a common clinical finding is that children’s symptoms often resolved when the family gained permanent residence. Van’t Hof, Cuijpers, Waheed, and Stein (2011) published a meta-analysis of studies examining psychotherapy in low and middle-income countries and included only one trial that involved psychodynamic psychotherapy. This study (Knijnik, Kapczinski, Chachamovich, Margis, & Eizirik, 2004), carried out in Brazil and published in Portuguese, examined a 12-session psychodynamic group therapy in social phobia and demonstrated effectiveness of this approach in their clinical sample. Other Psychotherapies Unlike psychodynamic psychotherapy, there is a growing literature of randomized controlled trials demonstrating effectiveness of other types of psychotherapy in low resource settings and diverse cultures. While the classic questions regarding cultural relevance of the psychotherapies remain, there are many new questions asked by these researchers. For example, is psychotherapy useful in the context of the ongoing trauma, poverty, and insecurity experienced by many of the individuals it tries to reach? To what extent can psychotherapy be implemented in resource-poor settings in terms of the ability of patients to attend and afford regular sessions? One example of such a psychotherapy is Narrative Exposure Therapy (NET), which was developed by Neuner and colleagues in 2002 for the treatment of PTSD for people in low-income countries, particularly in Africa. It is a standardized, short-term therapy based on cognitive behavioral therapy for PTSD, in which the patient is asked to talk extensively about the trauma while re-experiencing the event, ultimately leading to habituation. Because it is difficult to discern what the worst event has been in many individuals in resource-poor settings, NET also draws on testimony therapy, developed by Lira and Weinstein in 1993 to treat Chileans traumatized by the Pinochet regime. In testimony
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therapy, the patient creates a narrative of their entire life, focusing on a detailed report of their traumas. In 2004, Neuner, Karunakara, and Elbert published a study examining NET in Sudanese refugees living in Northern Uganda. There were three treatment groups in the study: a control group received one session of psychoeducation, an unstandardized treatment group received four counseling sessions, and a third group received four NET sessions. The majority of those screened agreed to enroll in the trial and there was a low dropout rate, demonstrating that this population was willing to accept psychological help. Forty-three participants were re-examined immediately following treatment, four months later, and one year later, and the NET group demonstrated lowest symptom burden after one year. However, the authors point out that many remained severely traumatized, raising the question of whether a four-session treatment is adequate for those who are continuously traumatized. The authors point out that the psychotherapy was carried out by highly trained European psychologists, which is a potential barrier to wide-scale implementation. Similarly, Onyut et al. (2005) used NET to treat six Somali children ages 8–17 living in a refugee camp in Uganda. In this small, uncontrolled study of 4 to 6 NET sessions, all completed therapy and all had symptom improvement immediately after and at nine-month followup, at which time four of the six children did not meet criteria for PTSD. Again, the authors point out that the psychotherapists in the study were highly trained experts. The question of implementation on a local level was addressed in subsequent studies. In 2008, Neuner et al. compared NET to unstructured counseling and a non-treatment control group. In this study, trained lay counselors carried out NET in a refugee settlement in Uganda with 277 individuals from Rwanda and Somalia. NET was equal to unstructured counseling and both were superior to control. At the end of this study, 70% of the NET group and 65% of the unstructured counseling group no longer met criteria for PTSD. Dropout rate was low; 4% in the NET group versus 21% in the counseling group. Ertl, Pfeiffer, Schauer, Elbert, and Neuner (2011) demonstrated again that NET carried out in eight sessions by lay counselors is effective, this time in a group of 85 former child soldiers with PTSD ages 12–25 living in Northern Uganda. Participants were randomized to NET, an academic catch-up program, or wait-list. PTSD, depression, and functional impairment were measured at treatment completion, three months, six months, and nine months. NET outperformed both the academic catchup and wait-list settings.
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Another psychotherapy with a growing global literature is interpersonal psychotherapy (IPT), often carried out in a group setting. Bolton et al. (2003) studied 108 men and 116 women with depressive illness in single-gendered IPT groups. IPT groups were led by local people who had received two weeks of intensive training delivered by the authors of the paper. Treatment involved 16 weekly 90-minute sessions. A control group was not assigned to any structured psychotherapy, but individuals were allowed to seek local treatment as usual. IPT was found to be highly effective; as at the end of treatment 6.5% of the IPT group versus 54.7% of the control group met criteria for depression. Bass et al. (2006) interviewed this group six months after treatment and found that the benefits of IPT persisted. There are several other examples of IPT studies in Africa. Bolton et al. (2007) demonstrated IPT group therapy to be effective in female but not male adolescents aged 14–17 in two camps for the internally displaced in Northern Uganda. Peterson, Bhana, and Baillie (2012) demonstrated the effectiveness of group IPT delivered by supervised community healthcare workers in 60 participants in South Africa. In this study, IPT was effective compared to control at 12 and 24 weeks post-treatment. Peterson, Hancock, Bhana, and Govender (2014) demonstrated effectiveness in treating depression in a study of 34 HIV patients with IPT delivered by lay counselors in South Africa. There have even been studies comparing different types of psychotherapies. Schaal, Elbert, and Neuner (2009) compared NET to interpersonal therapy (IPT) in 26 Rwandan genocide orphans with PTSD. Each group had 4 weekly psychotherapy sessions carried out by doctoral level psychologists or graduate students. The authors report no significant treatment differences at post-test, but at six months, 25% of the NET group versus 71% of the IPT group met criteria for PTSD. Although the above discussion has focused on psychotherapy trials in Africa, it is important not to overlook completely that work has been done in other parts of the world. Patel et al. (2010) implemented a mental health care system to treat depression and anxiety disorders in a primary care setting in Goa, India. The writers developed what they called a collaborative stepped care intervention, which involved counseling by a trained lay counselor, antidepressant medication, and supervision by a mental health specialist in both private and public settings. Previously untrained lay counselors underwent a two-month training course and went on to act as case managers and psychoeducators to individuals enrolled in the study. Those individuals with moderate to severe illness or non-response to psychoeducation could either receive antidepressants from the primary care doctor or interpersonal psychotherapy from a lay counselor. The psychiatrist became involved in care
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when there was a high suicide risk, a non-response to other treatments, a diagnostic dilemma, significant alcohol dependence, significant comorbid medical disorders, or a consultation was requested from the primary care doctor. This stepped care approach was compared with what the authors called enhanced usual care, in which primary care doctors treated the disorder according to treatment manuals. The study detected improvement in outcomes in the public, but not private, settings, suggesting that patients already receive adequate care in the private setting. This trial is significant in that it not only demonstrates the usefulness of psychotherapy in a resource-poor setting, but it also demonstrates a system of care that incorporates psychotherapy as one arm of treatment can be both practical and useful. Many may wonder about the usefulness of psychotherapy in low and middle-income countries, positing that in the setting of extreme poverty, psychotherapy is a luxury that does not address the vast public health problems that plague these areas. Rahman, Malik, Sikander, Roberts, and Creed (2008) studied a group of depressed mothers in rural Pakistan, and used infant health as primary outcome measures and maternal mental health as a secondary outcome measure. In this study, married women ages 16–45 in their third trimester of pregnancy and with a diagnosis of depression were randomized to either cognitive behavioral therapy (intervention) or enhanced routine care (control). The intervention group received one psychotherapy session per week in the last four weeks of pregnancy, three sessions in the first postnatal month, then nine monthly sessions. The enhanced care group received the same number of unstructured visits. The psychotherapy was performed by local health workers trained in manualized therapy. Although one major primary outcome, infant height and weight, was not improved at the end of the study, the authors report decreased diarrhea and increased rates of immunization in the intervention group. Women in the intervention group were more likely to use contraception, which is an important finding in that birth spacing is a factor in infant mortality. Finally, the intervention group had significantly improved depression and less disability, and these gains were sustained at one-year follow-up. Interestingly, the trained health workers were also surveyed at the end of the study, and none considered the work or training an extra burden. Discussion The literature on psychodynamic and other psychotherapies suggests that individuals in resource-poor and low-income countries can
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accept and respond to Western-style psychotherapies. Psychotherapy has been found to be effective and practically deliverable both individually and in groups by trained lay counselors, a point which vastly improves the potential accessibility of these therapies. Still, where are we with psychodynamic psychotherapy? After much speculation, we do not really know whether it will be effective or culturally relevant in non-Western cultures, other than from observation and case reports. We do not know what, if any, changes in practice are necessary. A potential argument against the feasibility of psychodynamic psychotherapy is the length and breadth of training required of psychodynamic psychotherapists. Two papers suggest that there are ways to implement appropriate psychodynamic training in low and middle-income countries. Murray et al. (2011) have provided guidelines for training local psychotherapists drawn from ten years of experience. They stress the importance of supervision and feedback, as do Western psychotherapists. They present their “apprenticeship model,” which consists of three groups of therapists: (1) Trainers, who are experts in mental health but generally come from outside the community; (2) Supervisors, who are local individuals selected for an advanced role; and (3) Counselors, who provide the actual services. The authors feel that this model has been effective in implementing adequate psychotherapy training and supervision in low and middle-income countries. In this regard, Fishkin, Fishkin, Leli, Katz, and Snyder (2011) describe the China American Psychoanalytic Alliance (CAPA), which provides American-based supervision and training for Chinese psychotherapists via the Internet. Specifically, they use Skype, which uses a proprietary encryption protocol that makes third party interception impossible. CAPA has arranged psychoanalysis for about 40 and psychodynamic psychotherapy for about 30 individuals, mostly mental health professionals, noting that the limiting factor is generally access to high-speed Internet. The paper discusses several cultural barriers as well as challenges associated with Internet-based psychotherapy. However, the project has largely been successful in providing psychodynamic therapy and supervision to Chinese psychotherapists and suggests a platform for doing so elsewhere. Another concern is that lengthy treatment, potentially delivered multiple times per week, cannot be practical in resource-poor settings. This concern may be valid, yet we do not yet have evidence that this is the case. The existence of a still emerging evidence base has not deterred the use of psychodynamic therapy in the developed world, and
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the sparse literature regarding psychodynamic psychotherapy in the developing world should not necessarily lead to a presumption against its use or study in such settings. Furthermore, even if cultural and economic factors make longitudinal and intensive psychodynamic psychotherapy difficulty, this does not necessarily preclude the application of psychodynamic principles in supportive therapies or brief dynamic therapies. Regarding the vast cultural differences, available evidence from 1960s anthropological work suggests that traditional healers use psychodynamic principles as part of their repertory of healing techniques. In Africa, up to 80% of the population depends upon traditional healers; in India the figure is 70% (Bodeker, Ong, Grundy, Burford, & Shein, 2005). One study, for example, concluded that traditional healers provide a substantial portion of mental health care in South Africa (Sorsdahl et al., 2009). Another conducted in a West Indian village found that villagers were likely to consult both traditional healers and physicians for mental health complaints (Kapur, 1979). Western psychodynamically oriented psychotherapists could potentially learn a great deal about managing patients in both the developing and the developed world by partnering with local traditional healers. Marlow and Jung thought of the developing world as a place where the mind exists in its purest form. Today, Western doctors often think that considerations of the mind are the least relevant to peoples’ quality of life in situations plagued by extreme poverty, war, starvation, and disease. Both extremes are potentially narrow minded and deprecatory. Indeed, our own experience working in a number of low and middleincome countries is that one of the most common requests we receive from local mental health professionals is for help with addressing personality and other psychological issues with psychotherapy, with even more specific requests tending to focus on training in either CBT or psychodynamics. Ultimately, the psychodynamic stance involves open-mindedness about the unique history and characteristics that shape the minds of people, begetting the very compassionate and collaborative exploration of the remote corners of an individual’s experience that is psychodynamic psychotherapy. It seems there could not be a better stance with which to explore the world. As mental health professionals increasingly join the global health movement, there is abundant reason and emerging evidence to suggest that psychodynamic practice will be relevant and helpful.
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Craig L. Katz Director, Program in Global Mental Health Clinical Associate Professor of Psychiatry and Medical Education Icahn School of Medicine at Mount Sinai One Gustave L. Levy Place, Box 1257 New York, NY 10029 [email protected]
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