Working with children and their families across cultures, especially during periods of cultural transition, is a complex and challenging task requiring knowledge of children’s normal growth and change under stable circumstances in their culture of origin and their host culture. While child specialists often express interest in families, differential rates of adaptation among the members of a family confound the perception and origins of children’s problems. Furthermore, the difficulties of adaptation during times of cultural transition are inadequately conceptualized, poorly documented, and often trivialized as transitional problems of adaptation or ignored altogether under the rubric of youthful resilience. In the vocabulary of psychology, psychiatry and other professional discourses, these problems can be summed up through three complex lenses: children (development), family (attachment, relationships, transmission) and culture (the context for the first enculturation and subsequent acculturations of children). The author examines several vignettes of children from Haitian families in Montreal experiencing serious mental health problems. The challenges of identifying patterns of cultural adaptation with these children are identified as are the requirements for an approach that is sensitive to all three crucial aspects of their predicaments—healthy growth, family relationships and cultural adaptation. The features of Cultural Family Therapy (CFT) are outlined to demonstrate its responsiveness to the complex task of working with children across cultures. The clinical tools of CFT are summarized to guide practitioners. Vignettes highlight children coping with psychosis and trauma. The presentation concludes with a summary of gaps in current thinking and practice in working with children across cultures and a call for more studies of children in cultural transition. Learning Objectives 1. To identify the challenges and rewards of working with Haitian children and families in cultural transition. 2. To present a model for conducting Cultural Family Therapy with families in cultural transition, adapting to living in Montreal. 3. To sensitize clinicians of the need for cultural understanding and review the clinical tools available to guide practitioners in their work across cultures. References Di Nicola, V. (1996). Ethnocultural aspects of PTSD and related stress disorders among children and adolescents. In A. J. Marsella, M. Friedman, E. Gerrity, & R. Scurfield (Eds.), Ethnocultural aspects of posttraumatic stress disorder: Issues, research, and clinical applications (pp. 389-414). Washington, DC: American Psychological Association Press. Di Nicola, V. (1997). A stranger in the family: Culture, families and therapy. New York, Norton. Di Nicola, V. (1998b). Children and families in cultural transition. In Clinical methods in transcultural psychiatry (S. O. Okpaku, ed.) (pp. 365-390). Washington, DC: America

1. Dèyè Chak Timoun 1
Rebâti Santé Mentale:
3rd Haitian Mental Health Summit
Collaborative Care for Mental Health
in Haiti and the Diaspora:
Culturally Sensitive Solutions for
Wellness Across the Lifespan

2. 2

3. Dèyè Chak Timoun 3
Rebâti Santé Mentale :
3ème Conférence sur la Santé Mentale
en Haïti
Soins collaboratifs en santé mentale
en Haïti et la diaspora :
Solutions adaptées à la réalité culturelle
pour le bien-être tout au long de la vie

4. 4
Jungle
Artiste:
Stéphane Senghor

5. Dèyè Chak Timoun 5
Dèyè Chak Timoun Gen Yon Fanmi e Yon Kilti
Behind Every Child Is A Family & A Culture:
Cultural Family Therapy
with Haitian Families
Vincenzo Di Nicola
Maisonneuve-Rosemont Hospital
University of Montreal

6. Dèyè Chak Timoun 6
Dèyè Chak Timoun Gen Yon Fanmi e Yon Kilti
Derrière chaque enfant on retrouve une famille et une culture :
La thérapie familiale culturelle
avec les familles haïtiennes
Vincenzo Di Nicola
Hôpital Maisonneuve-Rosemont
Université de Montréal

7. Dèyè Chak Timoun 7
Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, FAPA
Chef du Service de pédopsychiatrie, HMR
Chief of Child & Adolescent Psychiatry, HMR
Professeur titulaire de psychiatrie, Université de Montréal
Professor of Psychiatry, University of Montreal

8. 8

9. 9
Dèyè Chak Timoun
Learning Objectives
1. To identify the challenges and rewards of working with Haitian
children and families in cultural transition.
2. To present a model for conducting Cultural Family Therapy with
families in cultural transition, adapting to living in Montreal.
3. To sensitize clinicians of the need for cultural understanding and
review the clinical tools available to guide practitioners in their work
across cultures.

10. 10
Dèyè mon, gen mon.
Behind the mountain, there are mountains.
—Haitian proverb
Dèyè Chak Timoun

11. 11
Dèyè Chak Timoun
Short Abstract: “Dèyè Chak Timoun”
• Working with children and families across cultures during periods of
cultural transition is a complex and challenging task requiring
knowledge of children’s growth and change in their culture of origin
and their host culture.
• Vignettes of children from Haitian families in Montreal experiencing
mental health problems are presented.
• The features of the author’s model of Cultural Family Therapy (CFT)
are outlined to demonstrate its responsiveness to the task of working
with children across cultures.

12. 12
Dèyè Chak Timoun
I: “Looking Across at Growing Up”
• Working with children and their families across cultures,
especially during periods of cultural transition,
is a complex and challenging task
requiring knowledge of children’s normal growth and
change under stable circumstances in their culture of
origin and their host culture as well as their adapational
difficulties across cultures.

13. 13
Dèyè Chak Timoun
II: “A 3-Sided Puzzle” – Kids, Families, Culture
• While child specialists often express interest in families,
differential rates of cultural adaptation among the
members of a family confound the perception and origins
of children’s problems.

14. 14
Dèyè Chak Timoun
II: “A 3-Sided Puzzle” – Kids, Families, Culture
• Moreover, the difficulties of adaptation during times of
cultural transition are inadequately conceptualized, poorly
documented, and often trivialized as transitional problems
of adaptation or ignored altogether under the rubric of
youthful “resilience.”

15. 15
Dèyè Chak Timoun
II: “A 3-Sided Puzzle” – Kids, Families, Culture
• In the vocabulary of psychology, psychiatry and other health
care discourses, these problems can be summed up through
three complex lenses, a veritable 3-sided puzzle:
o children (development)
o family (attachment, relationships, transmission)
o culture (the context for the first enculturation and
subsequent acculturations of children)
• Remember that behind every child is a family and a culture!

16. Dèyè Chak Timoun 16

17. 17
III: Clinical Vignette –
Culturally Different, Crazy or Confused?
Dèyè Chak Timoun
• The author offers an overview of Haitian families in Montreal
experiencing serious mental health problems.
• A clinical vignette highlights a Haitian adolescent coping with psychosis
and trauma.
• The challenges of identifying patterns of cultural adaptation with these
children are identified as are the requirements for an approach that is
sensitive to all three crucial aspects of their predicaments—healthy
growth, family relationships and cultural adaptation.

18. 18
Key Theme: Liminality vs Community
• Victor Turner: The Ritual Process
Liminality – « betwixt and between »
• Jean-Luc Nancy – La Communauté désoeuvrée (1983) –
The Inoperative Community (1986)
"The community that becomes a single thing (body, mind, fatherland,
Leader) ... necessarily loses the in of being-in-common.
Or, it loses the with or the together that defines it. It yields its being-together
to a being of togetherness. The truth of community, on the
contrary, resides in the retreat of such a being."
Dèyè Chak Timoun

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Key Theme: Liminality vs Community
• Giorgio Agamben – La comunità che viene (1990) –
The Coming Community (1993)
La Communauté à venir (1990)
Dèyè Chak Timoun
A philosopher of the threshold – he has written on indeterminate being,
infancy, potenza, potentiality

20. Dèyè Chak Timoun 20
L’enfance est un
couteau planté dans la
gorge. On ne le retire
pas facilement.
- Wajdi Mouawad
dramaturge

21. 21
Maya: A Cultural Changeling
Behind every child
is a family and a culture.
Adolescent – 16 years
Ambiguous, ambivalent, fluctuating identity
Charming/attachante
Dèyè Chak Timoun

22. 22
Maya: A Cultural Changeling
Culture
• Haiti (parents)
• USA (born in Miami)
• Montreal (since age of 10)
Dèyè Chak Timoun

23. 23
Maya: A Cultural Changeling
Culture: Identity vs Belonging
• Haiti
• USA
• Montreal
Dèyè Chak Timoun
“I’m American”
or
“I’m bisexual”
Maya lives an ongoing process of change,
adaptation, change …

24. 24
Maya: A Cultural Changeling
Family Culture
Dèyè Chak Timoun
• Haitienne/“American”/québecoise
• Mother: older, single parent, déracinée
• Evangelical Christian who reads the Bible daily
• Bible reading and prayer are sources of comfort and
healing

25. 25
Maya: A Cultural Changeling
School, Social and Health Care Services
• School:
Équipe ad hoc / “Ad hoc team” (en français)
• Social services:
CLSC team – SMJ – Santé mentale jeunes –
Youth Mental Health (en français, anglais et créole)
• Health care services:
Child & Adolescent Psychiatry (ER, Outpatient, Inpatient)
(en français, anglais, créole)
Dèyè Chak Timoun

26. 26
Collaborative Care
Collaborative mental health care refers to a family physician or other
primary care provider working together with a psychiatrist or other
mental health worker in a mutually supportive partnership.
The responsibilities of care are shared and apportioned according to the
respective skills of the providers and the (changing) treatment needs
of the patient.
– Nick Kates (2009)

27. 27
Maya: Psychiatric Diagnoses
Outpatient Psychiatry:
•Dx Deferred – no evidence of psychotic disorder or ODD
•Parent-child relationship problem
•Possible search for sexual identity
Inpatient Psychiatry:
•Schizophreniform Disorder
•Borderline intellectual functioning
Neuropsychology:
•Dyslexia,
•Language Acquisition Disorder
Speech Therapy:
•Severe language disorder
Dèyè Chak Timoun

28. 28
Maya: Psychiatric Diagnosis
Family
Narratives of suffering,
Beliefs, rituals
• “Psychiatric problems
belong in the asylum”
• Prayer and Bible reading
are healing
Culture
Explanatory models
• Haitian Creole culture
• Religion
Dèyè Chak Timoun

29. 29
Maya: Predicament
Family Culture
Cultural
translation
• Haiti (parents)
• Miami (birth)
• Montreal
(since age of 10)
Dèyè Chak Timoun
Therapeutic
Therapeutic
translation
• Parent-child
conflict
• Attribution re:
illness and
recovery
• Alien and alienating
symptoms
• Lack of insight in
psychosis:
• unawareness
• misattribution

30. 30
Maya: Predicament
Dèyè Chak Timoun
Therapeutic Translation
“The Kraepelinian paradigm encouraged an ‘us’ and ‘them’
distinction between the mad and the sane ... [yet] we are
mad to varying degrees, ... the boundaries of madness are
subject to negotiation, and ... some of us get on very well
despite being (in psychiatric terms) quite psychotic for much
of the time.”
– Richard Bentall, Madness Explained (2004, p. 496)

31. 31
Maya: Predicament
Dèyè Chak Timoun
Therapeutic Translation
There are two sources for this paradigm ...
• Emil Kraepelin’s categorical classification, and
• Karl Jaspers’ phenomenological psychiatry which
established psychosis as ununderstandable due to an
unbridgeable empathic chasm between psychiatrist and
psychotic patient

32. 32
Maya: Predicament
Dèyè Chak Timoun
Therapeutic Translation
“[T]he trouble is, you want to cure hallucinators, whereas I
want to liberate them. I think they are like homosexuals in
the 1950s – in need of liberation, not cure.”
“[W]hy not help some psychotic people just to accept that they
are different from the rest of us? Fear of madness may be a
much bigger problem than madness itself.”
– Richard Bentall, Madness Explained (2004, p. 511)

33. 33
Maya: Themes
Negative conceptions
• Shock
• Trauma
• Anxiety
• Grief
Theme:
Rupture and loss
Dèyè Chak Timoun
Positive conceptions
• Surprise
• Learning
• Enchantment
• Celebration
Theme:
Discovery and growth

34. Dèyè Chak Timoun 34

35. 35
IV: “Cultural Family Therapy”
Dèyè Chak Timoun
• The features of Cultural Family Therapy (CFT) are outlined to
demonstrate its responsiveness to the complex task of working with
children across cultures.
• Key clinical tools of CFT are summarized to guide practitioners.
• The presentation concludes with a summary of gaps in current
thinking and practice in working with children across cultures and a
call for more studies of children in cultural transition.

36. 36
Family therapy is the starting point
for the study of ever wider social units.
—Mara Selvini Palazzoli (1974)
Dèyè Chak Timoun
Family Therapy

37. 37
Family Therapy
Dèyè Chak Timoun
• Family therapy is the space that we open
to explore the possibilities of the family

38. 38
Family Therapy Interventions
Family therapists do three simple things:
• enhance uncertainty
• introduce novelty, and
• encourage diversity
(Di Nicola, 1997)
Dèyè Chak Timoun

39. 39
Cultural Family Therapy (CFT)
An integration of cultural psychiatry
(McGill social and transcultural psychiatry
with elements of French ethnopsychiatry)
and family therapy
Dèyè Chak Timoun
(Milan systemic family therapy with Bakhtin’s dialogism and
Andersen’s reflecting team)

40. Soins partagés en pédopsychiatrie 40
Key Features of CFT
• Recognizing families as unique cultures
• Immigrants as threshold people in transitional states

41. 41
Elements of CFT
Milan family therapy: Positive connotation
Andersen: Reflecting team
Nathan: Bombardement sémantique
Bakhtin: Dialogism
Lévinas: Face-to-face encounter
Dèyè Chak Timoun

42. Dèyè Chak Timoun 42

43. Dèyè Chak Timoun 43

44. 44
Transcultural child psychiatry –
What “changelings” can teach us
• “Changelings” – Defining transcultural child psychiatry
• “Cultural blindspots” – Gaps in current thinking and practice in
working with children across cultures
• “On the threshold” – A call for more studies of
children in cultural transition.
Dèyè Chak Timoun

45. 45
“Cultural Blindspots”
Dèyè Chak Timoun
“Cultural blindspots” – Gaps in current thinking and practice in working
with children across cultures
• “Scotomata” –
Minimizing/denying/misunderstanding cultural differences
• “Cultural camouflage” –
Attributing to culture what is better explained by individual or family
levels of functioning

46. 46
“On the Threshold”
Dèyè Chak Timoun
“On the threshold” – A call for more studies of children in cultural
transition
• Culture change means a change of language, values, routines and
recipes for living, including how problems are experienced,
understood and communicated and what solutions are socially
sanctioned and culturally acceptable
• Children are especially vulnerable to such changes because they
rarely make the choice to change culture and are dependent on their
families whose members experience their own adaptational
challenges

47. 47
Conclusion: Après-coup
• Nachträglich - deferred action – Freud
• Après-coup – Jacques Lacan
Dèyè Chak Timoun
A chronologically anterior event as supplement to a
posterior one

48. 48
Conclusion: Après-coup
• Après-coup – Jacques Lacan
Dèyè Chak Timoun
A chronologically anterior event as supplement to a posterior one
What has always troubled me about “King Lear” is that Shakespeare
gives his characters no past. In “Ran,” I have tried to give Lear a
history.
—Akira Kurosawa
Examples: Film or novel “prequels” that fill in the backstory of the
characters

49. 49
Conclusion: Therapy as Après-coup
• CFT can be understood as “après-coup”
Dèyè Chak Timoun
Understanding cultural context, which means going
into the “backstory” of persons to elucidate their
predicaments, creates this paradox – what happened
“before” is a supplement to what is happening now.

50. 50
Defining Transcultural Child Psychiatry
At the crossroads of 3 domains:
• Mental health
• Developmental studies
• Social and cultural sciences
Dèyè Chak Timoun

51. 51
Defining Transcultural Child Psychiatry
Domains
• Psychiatry
• Developmental studies
• Social and cultural
sciences
Discipline
Child Psychiatry
Dèyè Chak Timoun

52. 52
Defining Transcultural Child Psychiatry
Domains
• Psychiatry
• Developmental studies
• Social and cultural
sciences
Dèyè Chak Timoun
Discipline
Social and Transcultural
Psychiatry
McGill University – 1950s and
1960s

53. 53
Defining Transcultural Child Psychiatry
Domains
• Psychiatry
• Developmental studies
• Social and cultural
sciences
Discipline
Culture-inclusive
developmental
psychology
Dèyè Chak Timoun
Jaan Valsiner (1987, 1989)

54. 54
Defining Transcultural Child Psychiatry
Domain
• Psychiatry
• Developmental studies
• Social and cultural
sciences
Dèyè Chak Timoun
Discipline
Transcultural Child
Psychiatry
McGill Conference – 1991
Di Nicola (1992)

55. 55
Defining Transcultural Child Psychiatry
TCP is a field of study
that poses developmental questions
about child and adolescent mental health
in the context of culture
– Di Nicola (1992)
Dèyè Chak Timoun

56. 56
Contact
Vincenzo Di Nicola
VincenzoDiNicola@gmail.com
Dèyè Chak Timoun

57. 57
References / Bibliographie
Culture, Families and Therapy
• Di Nicola, V.F. Le Tiers-monde à notre porte : Les immigrants et la
thérapie familiale, Systèmes Humains, 1(3), 1985, p. 39-54.
• Di Nicola, V.F. (1992). De l’enfant sauvage à l’enfant fou : A
prospectus for transcultural child psychiatry. In Grizenko, N., et al.
(éd.), Transcultural issues in child psychiatry (pp.. 7-53). Montréal,
Éditions Douglas.
• Di Nicola, V. (1996). Ethnocultural aspects of PTSD and related stress
disorders among children and adolescents. In A. J. Marsella, M.
Friedman, E. Gerrity, & R. Scurfield (Eds.), Ethnocultural aspects of
posttraumatic stress disorder: Issues, research, and clinical
applications (pp. 389-414). Washington, DC: APA Press.

58. 58
References / Bibliographie
• Di Nicola, V. (1997). A stranger in the family: Culture, families and
therapy. New York, NY and London, UK: W.W. Norton & Co.
• Di Nicola, V. (1998b). Children and families in cultural transition. In S.
O. Okpaku, ed., Clinical methods in transcultural psychiatry (pp. 365-
390). Washington, DC: American Psychiatric Press.
• Di Nicola, V. (2004). Famiglie sulla soglia. Città invisibili, identità
invisibili. In Maurizio Andolfi (ed.), Famiglie immigrate e psicoteraopia
transculturale (pp. 34-47). Milano: FrancoAngeli.

59. 59
References / Bibliographie
• Di Nicola, V. (2011). Letters to a young therapist: Relational practices
for the coming community. New York and Dresden: Atropos Press.
• Di Nicola, V. (2012). Family, psychosocial, and cultural determinants of
health. In Sorel, Eliot, ed., 21st Century global mental health (pp. 119-
150). Burlington, MA: Jones & Bartlett Learning.

60. 60
References / Bibliographie
Collaborative Care
• Craven M, Bland R. Better practices in collaborative mental health
care: an analysis of the evidence base. Can J Psychiatry. 2006; 51(6) :
S7-S72.
• Doherty W. The why’s and levels of collaborative family health care.
Family Systems Medicine. 1995; 13(3-4) : 275-81.
• Kates N. Shared/collaborative mental health care. In JS Leverette, GS
Hnatko & E Persad, eds., Approaches to Postgraduate Education in
Psychiatry in Canada: What Educators and Residents Need to Know.
Ottawa: Canadian Psychiatric Association, 2009, pp. 183-197.
• Kates N, Craven M, Bishop J, et al. Shared mental health care in
Canada: the way ahead. Can J Psychiatry. 1997; 42(8) : 809-812.

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