Dr. Di Nicola presents Cultural Family Therapy (CFT), a synthesis of two approaches pioneered in the McGill University Dept. of Psychiatry where he trained: family therapy and transcultural psychiatry. Key influences include Maurizio Andolfi (1989) and Mara Selvini Palazzoli (1988) in family therapy and Raymond Prince (2010) and Henry Murphy (1982, 1986) in transcultural psychiatry. In numerous publications and international workshops over the last 30 years, Dr. Di Nicola has elaborated a model of CFT, beginning with a monograph published while he was a Fellow in Family Therapy at the Institute of Community and Family Psychiatry (Di Nicola, 1985) and a key article while he was Chief Resident at the AMI (Di Nicola, 1986). A model of CFT was presented in greater depth in his book, A Stranger in the Family: Culture, Families, and Therapy (1997) and updated in Letters to a Young Therapist (2011). CFT weaves together family stories that express their mental and relational predicaments and conceptual tools for conducting clinical work. CFT is an ongoing update of our notions of “family” and “therapy,” on one hand, and of “culture” and “psychiatry,” on the other. From the beginning, CFT was constructed to deal with threshold people undergoing rapid cultural change. Three basic principles and processes for CFT will be reviewed: 1) the deep parallels between the notions of “family” and “culture,” mean that “culture” supersedes the notion of family “system”; 2) each family is the bearer of the larger culture(s) in which it is embedded and creates a culture of its own, so the family is the vehicle for intergenerational cultural transmission, for maintaining culture (cultural coherence), and for generating its own small-scale cultural adaptations, yielding three yoked family functions: cultural transmission, cultural maintenance/coherence, and cultural adaptation; 3) at the heart of systemic family theory and sociocultural psychiatry is a relational psychology that inverses theorizing from self to society by redefining the notions of identity and belonging through relations. With its relational and sociocultural approach, CFT is exquisitely responsive to working with threshold people – families undergoing culture change within and across cultures. In a world with huge global flows of migrants and refugees instigated by conflict, disasters, or economic and social reasons, CFT offers clinical tools to understand and treat families experiencing severe stress due to rapid and massive culture change. CFT grew/unfolded by examining families in different cultures and in invisible or otherwise discounted/ignored social circumstances, from invisible minorities to undocumented migrants and refugees (Di Nicola, 1998, 2012a, 2016).

5. Multiples, Multiplicity & The Multitude
Dedication
Raymond H. Prince, MD, MSc
(1925 - 2012)
 Professor of Psychiatry
 Director, Division of Social and
Transcultural Psychiatry
 McGill University

6. Learning Objectives
At the conclusion of the presentation, the
participant should be able to:
 1. Understand families in cultural context
to learn to listen to family stories in
order to identify their mental and
relational predicaments as expressions
of their unique cultures.

7. Learning Objectives
At the conclusion of the presentation, the
participant should be able to:
 2. Define culture change and identify its
mental health impacts on families as a
cascade of consequences.

8. Multiples, Multiplicity & The MultitudeCommunities of Practice
Several communities of practice:
 Child and adolescent psychiatrist
 Social and cultural psychiatrist
 Psychotherapist and relational therapist
 Philosopher

9. Multiples, Multiplicity & The Multitude
Communities of Practice
 The solutions we seek are shaped by the
problems we address
 The problems that capture our attention are
shaped by our therapeutic temperaments
 Two therapeutic temperaments
 Refs: Di Nicola (1997, 2011)
Slavoj Zizek, The Parallax View (2009)

10. Multiples, Multiplicity & The Multitude
Communities of Practice
Two therapeutic temperaments
 Phenomenological temperament
 Technocratic temperament
 Refs: Di Nicola (1997, 2011)

13. Cultural Family Therapy
An integration of cultural psychiatry
 McGill social and transcultural psychiatry
 Later: elements of French ethnopsychiatry
and family therapy
 Milan systemic family therapy
 Later: Reflecting team, Dialogism,
“Face to face” encounter

14. Raymond H. Prince, MD, MSc
(1925 – 2012)

15. Multiples, Multiplicity & The MultitudeRaymond Prince
Three ethnocentric Western assumptions
regarding psychotherapy:
 The importance accorded to the individual
 Personal independence as a therapeutic goal
 Introspection as a therapeutic method

16. Cartoon by Thomas Zummer

17. Implications
 Many of our therapies and professional
constructions are Western cultural products
 We could say that they form part of the folk
psychology of Western postindustrial,
postmodern societies
Cf. “Liquid modernity” (Zygmunt Bauman, Liquid
Modernity, 2000)
Multiples, Multiplicity & The Multitude

18. Mara Selvini
Palazzoli, MD
(1916-1999)

19. Multiples, Multiplicity & The Multitude
Mara Selvini Palazzoli
La terapia familiare è il punto di partenza
per lo studio di unità sociali sempre più ampié.
Family therapy is the starting point
for the study of ever wider social units.

20. Mara Selvini Palazzoli Maurizio Andolfi

22. Family Therapy
Family therapy is the space
that we open to explore
the possibilities of the family.

24. Family Therapy
What is the task of family therapy?
 To give structure and meaning to the
family’s predicament.
Multiples, Multiplicity & The Multitude

25. Family Therapy
 This exploration of the family is done in
therapy when it is not possible elsewhere
or otherwise.
Multiples, Multiplicity & The Multitude

26. Family Therapy
Family therapy provides guidelines
for research and instruments for
change

27. Soins partagés en pédopsychiatrieFamily Therapy Interventions
Family therapists do three simple things:
 Enhance uncertainty
 Introduce novelty
 Encourage diversity
Ref: Di Nicola, A Stranger in the Family (1997)

28. Cultural Family Therapy
CFT weaves together:
 family stories that express their mental
and relational predicaments, and
 conceptual tools for conducting clinical
work

29. Cultural Family Therapy
CFT is an ongoing update of our notions of:
 family and therapy
 culture and psychiatry

30. Cultural Family Therapy
CFT was constructed:
 to deal with threshold people
undergoing rapid cultural change

31. Multiples, Multiplicity & The MultitudeKey Features of CFT
 Recognizing families as unique cultures
 Immigrants as threshold people in
transitional states

32. Three Basic Principles and
Processes for CFT
 1. Parallels between the notions of “family”
and “culture”
 2. Each family is the bearer of the larger
culture
 3. Systemic family theory and
sociocultural psychiatry share a
relational psychology that inverses
theorizing from self to society

33. Key Words
“The Threshold”
 Cultural family therapy (CFT)
 Families as unique cultures
 Liminality versus community
 Threshold people and transitional states

34. Key Theme:
Liminality vs Community
Victor Turner – The Ritual Process (1969)
 Liminality – “betwixt and between”
Jean-Luc Nancy – La Communauté désœuvrée (1983) –
The Inoperative Community (1986)
 Community –
“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.”

35. Key Theme:
Liminality vs Community
 Giorgio Agamben – La comunità che viene (1990) –
The Coming Community (1993)
A philosopher of the threshold – he has written on
indeterminate being, infancy, potenza, potentiality

37. Culture of Origin
 Enculturation
Host Culture
 Acculturation

38.  Positive
 Negative

39. Negative and Positive Conceptions
of Cultural Encounters
Negative conceptions
 Shock
 Trauma
 Anxiety
 Mourning
Overall theme –
Dislocation and loss
Positive conceptions
 Surprise
 Learning
 Delight
 Celebration
Overall theme –
Discovery and growth

41. A STRANGER
IN THE
FAMILY
Culture, Families,
and Therapy
(NY: W.W. Norton, 1997)

42. Elements of CFT
 Milan Sytemic Positive connotation
Family Therapy
 Tom Andersen Reflecting team
 Tobie Nathan “Bombardement
sémantique”
 Mikhail Bakhtin Dialogism
 Emmanuel Levinas Face-to-face encounter

43. Key Aspects
Cultural Family Therapy
 CFT is a cultural encounter
 CFT examines the presenting culture
 CFT generates a subjective perspective
 CFT adds cultural complexity to family therapy
 CFT deals with rapid culture change
 CFT is itelf a cultural product

44. Clinical Tools
Cultural Family Therapy
Tool
 Spirals
 Masks
 Roles
 Codes
 Cultural Strategies
 Bridges
 Stories
 Suture
Explanation
 Meeting strangers
 Cultural camouflage
 Insiders & outsiders
 Translation – Cultural & therapeutic
 Adaptation & acculturation
 Family life cycle in cultural context
 Narrative – the garden of forking paths
 CFT as story repaire

45. UM ESTRANHO
NA FAMÍLIA
Cultura, Famílias e Terapia
(Porto Alegre: ArtMed, 1998)

47. Taking Stock
To sum up, suturing a number of concepts and practices
together –
 The family as a storying culture where narrative (Bakhtin’s
dialogism) and culture (anthropology) are privileged
 liminality is acknowledged and threshold people in
transitional states (Victor Turner) become more visible and
more present to us
 in the face-to-face encounter (Levinas)
 where witnessing (Primo Levi, Agamben, Richard Mollica) is
possible for the re-signification of past experiences
(Freud/Lacan, Michael White)

51. Therapy as Translation
All therapy is a form of translation –
of language, of culture,
and of family process.
Ref: Beyond Babel: Family therapy as cultural translation.
Int J Fam Psychiatry, 1986, 7(2): 179-191.

52. Perdido na tradução: Tradutor da Google anuncia festival do clítoris
Lost in translation: Google translator announces clitoris festival

53. Therapy as Translation
Cultural Translation
Therapeutic Translation
Ref: Beyond Babel: Cultural and therapeutic translation.
In: A Stranger in the Family (1997)

54. Cultural Translation
 The elucidation of an individual’s or a family’s
idioms of distress,
explanatory models of illness, and
perceived predicaments
using:
family members, culture brokers,
and other informants,
including language translators,
in a collaborative effort.
Ref: Chapt 4: Beyond Babel: Cultural and therapeutic
translation. In: A Stranger in the Family (1997)

55. Therapeutic Translation
 Rendering an individual’s or a family’s
idioms of distress,
explanatory models of illness, and
perceived predicaments
into therapeutic idioms.
Ref: Chapt 4: Beyond Babel: Cultural and therapeutic
translation. In: A Stranger in the Family (1997)

56. Threshold Therapy
When applied to
 children and families undergoing
rapid culture change, and
 the study of liminal people and
transitional states,
 cultural family therapy may be called
threshold therapy.

57. Threshold Therapy
The objectives of studying liminal people and
transitional states are to:
1. Identify the conditions of culture change
2. Study its impact on children (“cultural
changelings ”) and the famly life cycle
3. Catalogue patterns of adaptation to culture
change
4. Recognize psychiatric disorders that emerge
from conditions of culture change
5. Construct models of identity formation and
culture change

59. Famiglie Immigrate e
Psicoterapia Transculturale (2004)

61. Transcultural
Issues
in
Child
Psychiatry
(1992)

62. “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.

63. 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.

64. “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.
Dèyè Chak Timoun

65. “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.”
Dèyè Chak Timoun

66. “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:
 children (development)
 family (attachment, relationships,
transmission)
 culture (the context for the first
enculturation and subsequent
acculturations of children)
Dèyè Chak Timoun

67. 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

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

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

70. Maya:
A Cultural Changeling
• 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)
 School, Social and Health Care Services
Dèyè Chak Timoun

71. 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

72. 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

73. 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

74. 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)

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

76. Maya: Predicament Dèyè Chak Timoun
“[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)
Therapeutic Translation

78. Mikhail Bakhtin
(1895-1975)
Philosopher
of dialogism
• Dialogism
• Heteroglossia
• Intertextuality
• Interior discourse
is social & historical

80. Multiples, Multiplicity & The Multitude
Letters to a
Young Therapist
Relational Practices for the
Coming Community
(New York: Atropos, 2011)

81. Face à
face
La plénitude de l’amour
du prochain, c’est
simplement d’être
capable de lui demander :
« Quel est ton
tourment? »
- Simone Weil,
Attente de Dieu (1942)

84. The Event

85. Alain Badiou
(Born in Rabat, 1937)
Philosopher of
the Event
• L’Être et
l’événement (1988)
• Being and Event
(Trans, 1995)

86. Being and Event
Trauma and Event
• Radical disjuncture between being and event
• Radical disjuncture between trauma and event
The philosophy of the Event is
a theory of change

88. Trauma

89. L’enfance est un couteau
planté dans la gorge. On ne le
retire pas facilement.
– Wajdi Mouawad,
dramaturge

92. Multiples, Multiplicity & The MultitudeI see humanity as a family that has hardly met.
—Theodor Zeldin
 We are still strangers to each other.
 That is why the stranger at the gate, as
much as the neighbour and the friend, the
face of the other …continue to pose the
critical aporias for a relational psychology
and an evental psychiatry

93. Multiples, Multiplicity & The Multitude
ON THE THRESHOLD
Selected Papers of
Vincenzo Di Nicola, MD, PhD
Volume I:
Children, Families,
and Culture Change
Edited with an Introduction
by Armando Favazza, MD, MPH
Atropos Press
2016

94. Multiples, Multiplicity & The Multitude
ON THE THRESHOLD
Selected Papers of
Vincenzo Di Nicola, MD, PhD
Volume II:
The Body and
Culture Change
Edited with an Introduction
by Barton Blinder, MD, PhD
Atropos Press
(forthcoming)

95. Bibliography
 Di Nicola, V.F. Le Tiers-monde à notre porte : Les
immigrants et la thérapie familiale, Systèmes Humains,
1(3), 1985, pp. 39-54.
 Di Nicola, V.F. De l’enfant sauvage à l’enfant fou : A
prospectus for transcultural child psychiatry. In Grizenko,
N., et al. (ed.), Transcultural issues in child psychiatry.
Montréal, Éditions Douglas, 1992, pp. 7-53.
 Di Nicola, V.F. Ethnocultural aspects of PTSD and related
disorders among children and adolescents. In Marsella,
A.J., Friedman, M.J., Gerrity, E.T. & Scurrfield, R.M. (eds.),
Ethnocultural aspects of posttraumatic stress disorder:
Issues, research, and clinical applications. Washington, DC,
American Psychological Association, 1996, pp. 389-414.

96. Bibliography
 Di Nicola, V. A Stranger in the family : culture, families
and therapy. New York: W.W. Norton & Co., 1997.
 Di Nicola, V. Famiglie sulla soglia. Città invisibili,
identità invisibili. In: Andolfi, M. (ed.), Famiglie
immigrate e psicoterapia transculturale. Milano:
FrancoAngeli, 2004, p. 34-47.
 Di Nicola, V. Letters to a Young Therapist: Relational
Practices for the Coming Community. Foreword by
Maurizio Andolfi. NewYork: Atropos Press, 2011.

97. Bibliography
 Di Nicola, V. Family, psychosocial, and cultural
determinants of health. In: Sorel, Eliot, ed., 21st
Century Global Mental Health. Burlington, MA: Jones
& Bartlett Learning, 2012, pp. 119-150.
 Mollica, R.F. Healing Invisible Wounds: Paths to Hope
and Recovery in a Violent World. New York: Harcourt,
International, 2006.

98. Acknowledgements
Turku, Finland
 Dr. A.M Ghadirian
 Dr. Tewfik Said
Supervisors in Family Therapy:
 Dr. Gerry Wiviott
 Dr. Ronald Feldman
 Dr. Gaby Weiss
Mentors in Cultural Psychiatry:
 Dr. Laurence Kirmayer
 Dr. H.B.M. Murphy
 Dr. Raymond H. Prince