Title: “Culture, Families & Psychosis: How the Culture of the Family Affects How It Deals with a Psychotic Member” Abstract Since the pioneering studies of Bateson and associates on their “double bind” hypothesis of schizophrenia, there has been a veritable industry of work on the family and schizophrenia. This included many family therapists as well as psychiatrists who were dissatisfied with the medical model of psychosis such as RD Laing. With the “expressed emotion” (EE) model of schizophrenia, which followed on the footsteps of sociological research by George Brown, Vaughan and Leff (1976) created a paradigm to examine the family, social and cultural context of psychosis. When EE was applied to immigrant families in London and exported to other cultures (see Di Nicola, 1988), for the first time a question was seriously posed about the interactions among three key variables: culture, families, and psychosis. One way of examining the relationships is to ask how the culture of the family affects how they deal with a psychotic member.

1. FAMILY & CULTURE SPECIAL INTEREST GROUP
Working with Families with Mental
Health Problems Across Cultures
Vincenzo Di Nicola &
Riyadh Al-Baldawi
World Congress of Cultural Psychiatry
Rotterdam, The Netherlands
Saturday, 17 September 2022

2. 6TH WORLD CONGRESS OF THE
WORLD ASSOCIATION OF
CULTURAL PSYCHIATRY
ROTTERDAM, THE NETHERLANDS
14 - 17 September 2022

3. Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, DLFAPA, DFCPA, FCAHS
E-mail: vincenzodinicola@gmail.com
Professor of Psychiatry
University of Montreal & The George Washington University
Honorary Chair & Professor of Social Psychiatry
Ambrosiana University
Founder & President, Canadian Association of Social Psychiatry
(CASP)
President-Elect, World Association of Social Psychiatry (WASP)

4. Conflicts of Interests
Neither of the presenters have any financial
conflicts of interest to declare

5. Family & Culture Special Interest Group
Co-chairs: V Di Nicola & R Al-Baldawi
The mission of the Family & Culture Special Interest
Group is:
To bring together mental health professionals and
scholars in cognate fields
With special interests in the family and culture, how
they relate to and enrich each other, and
How to study, investigate, and promote research,
teaching, practices, advocacy and policy-making to
advance the study of the family in a cultural context

6. Without a family approach, without culture …
something’s missing …

7. Culture, Families & Psychosis:
Does the culture of the family affect how
it deals with a psychotic member?

8. Learning Objectives
After this presentation, the participant will be able to:
1. Identify the evolution of how family therapy and
systems theory re-visioned psychosis as part of family
process
2. Appreciate the contributions and limitations of the
Expressed Emotion (EE) paradigm to understand the
interaction among family, social context, and psychosis
3. Understand how the culture of the family affects
how it deals with a psychotic member

9. Aims
1. Are How do culture, families, and psychosis
interact with each other?
2. Theories and models of family intervention
for psychosis.
3. Critique of the Expressed Emotion (EE)
paradigm for families with a psychotic
member.

10. Not a rhetorical question
The answer is not taken for granted
I want to emphasize that we can best address
it as an interface, an interaction
Lived experience of anything – anxiety,
depression, psychosis, trauma – is best
understood as taking place at the crossroads
of significant social contexts and cultural
processes
Culture, Families & Psychosis

11. Three Lenses
Psychosis
Families
Culture
Lived experience is at the crossroads

12. Methods
Literature review, including:
Early theories about the family and schizophrenia
Family therapy models of psychosis (Selvini, 1986;
Grácio, et al., 2015)
EE paradigm of social variables in in the family
experience of psychosis, leading to cross-cultural
studies (Vaughan & Leff, 1976)

13. Discussion
Research on interactions of culture, family and
psychosis question assumptions about their stability
“Psychosis” cannot be assumed as a stable concept
because family environment and cultural context
shape how it’s defined and experienced, which
explanatory models are privileged, and which
treatments are sanctioned
Just as culture shapes family experience as
demonstrated by cultural family therapy, culture and
the family shape the experience of psychosis as well
as its outcome in terms of illness or health

14. Salient history
Schizophrenia has been called the “sublime
object of psychiatry” (Woods, 2011)
Classification era: Kraepelin (1893), Bleuler
(1908), Jaspers (1913), Schneider (1939)
Social context era: Norman Cameron, Gregory
Bateson, RD Laing, Silvano Arieti
Family therapy era: Mara Selvini Palazzoli’s
“Road map to Schizo-land”
Culture, Families & Psychosis

16. Results
Selvini (1986) sought universal patterns of psychosis to
construct her “invariant prescription” in the family
treatment of psychosis
EE researchers tried to validate EE across cultures
rather than investigate the experience of psychosis in
other cultures (Di Nicola, 1988)
Difficulties exporting the phenomenology of psychosis
across cultures question the cross-cultural validity of
psychosis, echoing foundational work by Kraepelin, who
pioneered psychiatric classification and comparative
psychiatry

17. Norman Cameron
“paranoid pseudo-community” (1943, 1959)
Gregory Bateson
“double bind hypothesis” (1956)
RD Laing (1960, 1969)
“ontological insecurity”
“mystification,” “invalidation”
Silvano Arieti (1975)
“interpretation of schizophrenia”
“biopsychosocial approach”
Social Context Era

18. Three Lenses
Interaction of families and psychosis
Psychosis
Families
Culture

19. Mara Selvini Palazzoli (1978, 1989)
“Road map to Schizo-land” (Di Nicola, 1984)
Paradox and Counterparadox: A New Model in
the Therapy of the Family in Schizophrenic
Transaction (1978)
“counterparadoxical interventions”
Family Games: General Models of Psychotic
Processes in the Family (1989)
“universal prescription”
Family Therapy Era

20. Three Lenses
Interaction of culture and psychosis
Psychosis
Families
Culture

21. George Brown – sociologist (1972)
Julian Leff (1985) – social psychiatrist
Five components
Critical comments
Hostility
Emotional overinvolvement (EOI)
Warmth
Positive regard
Cultural critique – Di Nicola (1988)
Expressed Emotion (EE)

22. Family
I see humanity as a family
that has hardly met.
– Theodore Zeldin
An Intimate History of Humanity

23. Acknowledgements
WACP Officers
Dr. Roberto Lewis-Fernándo, WACP President
Dr. Riyadh Al-Baldawi,
SiG Co-chair
Image courtesy of Jaswant Guzder

24. References
Di Nicola V.F. Expressed emotion and schizophrenia in North India: An
essay-review. Transcultural Psychiatric Research Review, 1988, 25(3):
205-217.
Di Nicola, V.F. (1997). A Stranger in the Family: Culture, Families, and Therapy.
New York & London: W.W. Norton & Co. ISBN 0-393-70228-6. OCLC 36126477
Grácio J., Gonçalves-Pereira M., Leff J. What Do We Know about Family
Interventions for Psychosis at the Process Level? A Systematic Review. Fam
Process. 2016 Mar;55(1):79-90. doi:10.1111/famp.12155. Epub 2015 Apr 21.
PMID: 25900627.
Selvini, M.P. (1986), Towards a general model of psychotic family games.
J Marital and Fam Therapy, 12: 339-349.
doi.org/10.1111/j.1752-0606.1986.tb00665.x
Vaughn C.E., Leff J. The influence of family and social factors on the course of
psychiatric illness. Br J Psychol 1976;129:125-37.