CCPR: Welcome, Dr. Pumariega. Please tell us about your work.
Dr. Pumariega: I have been examining the impact of culture on mental health my entire career. My early work involved clinical practice, literature review, and my own studies to operationalize culturally competent services, leading to the Cultural Competence Standards for Four Racial Ethnic Populations out of the Centers for Mental Health Services in 1999. More recently, my group authored the practice parameter for cultural competence out of the American Academy of Child and Adolescent Psychiatry (www.tinyurl.com/t3uwza4; Pumariega AJ et al, J Am Acad Child Adolesc Psychiatry 2013;52(10):1101–1115).

CCPR: Can you outline from your perspective as Chief of Child Psychiatry at University of Florida, Gainesville, the deficits in our knowledge of respectful care in culture and identity?
Dr. Pumariega: Today’s workforce is diverse, with many from immigrant families or underserved minority groups. They’ve been through that process of acculturation. But they don’t connect their personal experience and professional practice. Their experiences are so personal that they have a hard time talking about them.

CCPR: How does your own experience come into this?
Dr. Pumariega: I was born in Cuba and immigrated at 9 years old. My acculturation process had two stages, growing up in the ethnic enclave of Miami and then after medical school when I left Miami. I saw different populations, learning from patients, families, and their communities. Two things are important: First, humility—not seeing your perspective on values and beliefs as the only one, and not only accepting but also learning from the perspectives of people around you. The second thing is that you need to learn enough about the background of your patients—the population they came from and their personal experience. From here, you make adaptations to care to engage people who are different than you, translating interventions within the context that makes sense to your patients.

CCPR: Can you give us an example?
Dr. Pumariega: A simple example is separation and individuation. We have 30-year-olds living in their parents’ basement due to socioeconomic change. But in many cultures, the idea of a totally separate individual identity doesn’t even compute. It is a collective identity. In South Asian families, living under their parents’ roof or nearby in their 40s and 50s has been the norm. Immigration has imposed a lot of change to traditional cultures—you now have kids living in the US experiencing physical distance and sometimes emotional distance. Is marriage arranged or something you pursue yourself? Are relationships approved by the family? (Rothe E and Pumariega AJ. Immigration, Cultural Identity, and Mental Health. New York: Oxford Press; 2020)

CCPR: I see that with Middle Eastern populations. Is there a set of general themes we want clinicians to pay attention to?
Dr. Pumariega: Look at cultural norms around emotional expression. In some cultures, emotional expressiveness is very muted. Other cultures are intense, bordering on the high emotional expressiveness side, and perceived erroneously as psychopathology (Pumariega AJ et al, 2013). A classic example of this was the crash of a plane in Long Island that was headed to the Dominican Republic, shortly after 9/11. The scene at the airport in Santo Domingo was pandemonium, with multiple instances of dissociation, but all within culturally normal expressions of grief, close to ataques de nervios (a culture-bound syndrome seen among Caribbean Hispanics and Puerto Ricans, Dominicans, and Cubans). It’s the most emotionally intense scene you ever witnessed. Other people might just put on black, have quiet tearfulness and sadness, but not be so voluble.

CCPR: Right, we do not want to over-pathologize culturally typical emotional expressions and contribute to the mistrust of health care providers by minority populations. This reminds me of my Indonesian colleague whose emotional expression is very subtle, and contrasts with my very vocal Hungarian family members.
Dr. Pumariega: You need to know the normative emotional expression of someone’s cultural background as well as the stressors they’re dealing with, including immigration, acculturation, and the trauma of those transitions. Also, learn the strengths they bring, such as unique positive cultural values that reinforce resilience, normative defenses, and coping skills like humor or intellectualization. Have some familiarity and be able to identify those in people you serve.

CCPR: What about the stigma of mental illness?
Dr. Pumariega: US culture suffers from stigma around mental illness—our biopsychosocial model is not the norm. However, in some cultures, mental illness has a spiritual element or an interpersonal and spiritual element, like ascribing it to somebody putting a hex on the affected person. Or in some cases, mental illness is so shameful that you certainly wouldn’t share it with family or with people close to you, or even wouldn’t be able to marry as a result. In many minority communities in the US, it’s something that people are guarded about. For example, African Americans have been oppressed for centuries and don’t want the added burden of mental illness. It leads to double discrimination (Pumariega AJ et al, 2013).

CCPR: We have Latino families told to be structured in how they interact with their autistic kids, but that isn’t how they relate to their kids. And we’ve got families from Japan who politely cancel services after people visit their home and leave their shoes on, which is a serious cultural taboo.
Dr. Pumariega: Exactly. We have to adapt our methods.

CCPR: How can clinicians organize their approach to culture?
Dr. Pumariega: I see two levels of learning that are important. First, read up on the typical presentations of mental illness, traditions, and normative expressions for that group. You won’t know everything, but due diligence is important. Use reading materials, colleagues or friends, and cultural consultants—fellow professionals or somebody in the community that you trust. A helpful reference is a textbook titled Ethnicity and Family Therapy, Third Edition (McGoldrick M, Giordano J, and Garcia-Preto N, eds. New York: Guilford Press; 1996). Second, remember that cultures are not stereotypes—each person lives their culture differently, so listen for that in the clinical encounter. Ask how they experience key aspects of the culture that may bear on the interpretation and expression of the clinical problem.

Ed note: In San Diego, we are doing research on using promotoras, cultural brokers who are trusted community members with experience in the treating system, to bridge the connection between patient/family and provider, foster trust, and provide bidirectional understanding.

CCPR: So would it be appropriate to say something like, “So, my understanding is that families from where you come from tend to make decisions together, rather than expecting individuals to make their own decisions. Is that how it works in your family?”
Dr. Pumariega: Yes, either in the family they grew up with or in their current family now. There’s a wonderful book from the 1970s by a former president of the American Psychiatric Association, John Spiegel, called Transactions. He looked at the impact of premature assimilation on European immigrants. Spiegel pointed out how this made for conflict in marital and work relationships when value systems clashed between couples from different backgrounds, though they had submerged their identities of origin. It includes beautiful case examples, all about diversity for folks of European origin (Spiegel J. Transactions: The Interplay Between Individual, Family, and Society. Science House; 1983).

CCPR: We have microcultures in San Diego, including a surfer beach community, an inland community that is agricultural, and several others. And then there’s the wide variety of infant rearing practices—some where parents avoid looking at their infants, others where children are carried on the backs of their parents for about 18 months.
Dr. Pumariega: Modes of interaction have a history in the rate of survival of infants for different populations, and so it has shaped infant-parent interaction. Parents from populations who had high historic infant mortality rates have traditionally avoided making the emotional investment for fear of painful loss.

CCPR: What does the research in this area look like?
Dr. Pumariega: There are randomized controlled trials of culturally adapted interventions for particular populations, and a number that relate to language and communication of emotions. There’s also a new line of neurobiological research, looking at neural representations of theory of mind that relate to culture. One study looked at Chinese college students in China, Chinese American college students, and then Chinese students who came to the US and stayed on and assimilated here. They looked at how the brain lit up when students thought about themselves and their mothers. The Western-raised, multigenerational Chinese American students lit up one area for themselves and a different one for their mother. The Chinese students in China had only one area of the brain that lit up when they thought of themselves or of their mother. When those Chinese students come over to the US and assimilate, it becomes like the pattern of those raised in the US (Pumariega AJ and Joshi SV, Child Adolesc Psychiatr Clin N Am 2010;19(4):661–680).

CCPR: Can you give me an example of a culturally adapted intervention that might come up in everyday practice?
Dr. Pumariega: Psychologists in Puerto Rico adapted a CBT manual for depression for youth. This is the same manualized therapy, with fidelity to what the original intervention is supposed to do, but they used more interpersonal concepts and conceptualized more of the examples within family interactions or peer interactions. And they changed idiomatic expressions, even using folk sayings that were different. Instead of “You can please some of the people some of the time, but you can’t please all of the people all of the time,” the Puerto Ricans say “I’m not a hundred-dollar bill,” which means “I can’t make everybody happy.” And the coping skills they teach fit the culture. For example, they emphasize humor over intellectualization.

CCPR: Do you have any other examples of interventions?
Dr. Pumariega: Yes, brief strategic family therapy (BSFT), which is a NIDA-supported, evidence-based intervention for adolescent substance use. It was developed at University of Miami to work with Latino kids on parent-child acculturation differences, such as when traditional parents are in conflict with their kids who are learning the language, customs, and peer culture. Kids want independence from their parents, who are then reacting to this, so the focus of family therapy is the generational cultural divide and bridging both ways. BSFT is supposed to be culturally specific but is very translatable; it also works with African American kids and Caucasian kids (Santisteban D et al, J Comm Psych 1997;25:453–471).

CCPR: That’s really interesting.
Dr. Pumariega: Another example involves yoga-based meditation therapies. That’s about as traditional as you get, as the literature in Sanskrit goes back a couple of thousand years.

CCPR: We have a backlash among some families worried that yoga is connected with a foreign, alien religion.
Dr. Pumariega: Right. They see yoga subverting what they’ve taught their kids, the values that their culture or religion teaches. Sometimes you have to not only adapt the approach, but also bridge the explanatory model of how the therapy works back to their belief system.

CCPR: This thinking generalizes to other situations. Some people don’t accept psychosis treatment, or they don’t believe in Western medicine—or gender transition.
Dr. Pumariega: Many traditional cultures don’t deal with gay, lesbian, or transgender identities very well and have incredible bias and stigma, which sometimes leads to incredible alienation between youth and their families in the midst of acculturation. That takes so much more bridging work—minority LGBT kids have some of the highest risk for suicide because of that disconnection (Hatzenbuehler ML et al, Pediatr Clin North Am 2016;63(6):985–997).

CCPR: What about native peoples?
Dr. Pumariega: Be open to using traditional healing methods. This is not incompatible with pharmacotherapy, and there are psychological interventions that utilize native rituals for native youth. Many Indian Health Service psychiatric units have ceremony rooms. Pedro Ruiz, former president of the American Psychiatric Association, the World Psychiatric Association, and many others, started out practicing in New York City. He recognized that many Latino patients were being siphoned off from his partial hospital program by folk healers meeting in church basements practicing Santería rituals (Afro-Cuban or Afro-Caribbean religion). Pedro visited the healers and invited them to collaborate with him on cross-referral, with mutual participation in their respective programs, asking for their support with medication—combining forces.

CCPR: Any final thoughts?
Dr. Pumariega: Culture matters in mental health. It’s not mysterious. If we stay humble, check our biases, learn about the culture and some adaptations in how we talk to the patient and relate to their belief system, we can be particularly effective.

CCPR: Thank you for your time, Dr. Pumariega.