Transcultural Psychiatry 48(3) 205–227 ! The Author(s) 2011
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Current developments in French
University of Paris 13
University of Bremen
Marie Rose Moro
University of Paris 5
French ethnopsychoanalytic approaches to therapy with immigrants combine the psy-
choanalytical interest in subjectivity with a specific concern for cultural factors and with
the role migration plays as a crucial life event. Recent approaches consider culture as
profoundly hybrid and use the notions of ‘‘me ´tissage’’ and ‘‘de ´centrage’’ as central
concepts. This article presents extracts from a qualitative study of ethnopsychoanalytic
therapies with immigrant families. The authors argue that the ethnopsychoanalytic
approach helps to open new ways of considering cultural hybridity and create a third
space where experiences ‘‘from the margins’’ may be verbalized.
cultural hybridity, ethnopsychoanalysis, transcultural psychotherapy
The therapeutic approaches we refer to collectively as ‘‘French ethnopsychoana-
lysis’’ combine a psychoanalytic perspective on the conscious and unconscious
dimensions of subjectivity with an exploration of the social and symbolic contexts
referred to by the patient. As Fassin and Rechtman have shown (2005), these
approaches emerged in the discursive context of French debates about the question
of ‘‘culture’’.1For the most part, two opposing positions can be distinguished in
these debates. On one side stand those who argue that reflection about culture and
its impact on human experience should be integrated into psychotherapeutic theory
Gesine Sturm, University of Paris 13, 74, rue Marcel Cachin, 93003 Bobigny Cedex, France.
and practice (Nathan, 1986, Moro, 1998); on the other side stand those who urge
extreme caution in using the notion of culture (or even argue that it be left out of
psychoanalysis altogether). They stress the risks of a stereotyped perception of the
cultural Other, which may be enhanced by static and holistic conceptions of culture
(Fassin, 2000; Rechtman, 1995, 2000). In the last twenty years, these sometimes
quite passionate debates have led to a number of interesting developments in
ethnopsychoanalysis on three levels: theory, discourse-analysis and innovation in
As has been well documented, psychiatry0s emergence during the colonial period
and its institutional relationship to the colonial project have had continued legacies
in the way that postcolonial psychiatry conceptualizes the cultural Other
(Collignon, 2006; Fassin, 2000; Fassin & Rechtman, 2005). This work clearly indi-
cates the need for critical reflection on the historical background of health care
practices involving migrants (see also Beneduce & Martelli, 2005).2Moreover, as
Fethi Benslamah has stressed, there are pitfalls in using the concept of ‘‘culture’’ in
a context where political and ideological claims are made in the name of ‘‘cultural
identity’’ (Benslamah, 2000, 2004). Benslamah proposes replacing the focus on
culture with reflection on the experience of migration as a re-location, a being
‘‘out of locality.’’ Simultaneously, in the arena of ethnopsychoanalysis, debates
about the misuse of the culture concept have led to the development of more
dynamic and multi-dimensional conceptualizations (Moro, 1998; Mestre, 2006).
In these approaches, the discussion of cultural issues is integrated into a complex
model, considering migration as a crucial life-event and the migration experience as
embedded into profoundly hybrid life-worlds (Sargent & Lachanche ´ , 2009).
In what follows, we describe the development and transformation of several eth-
nopsychoanalytic approaches in France.3
French ethnopsychoanalysis was strongly influenced by the work of Georges
Devereux (1967, 1972, 1980) and still refers to his fundamental distinction between
Culture as a universal dimension of human beings and culture as the very singular
way this dimension may be incarnated in the real life-world of a person. In the
1980s, Tobie Nathan proposed translating this principle into a strategy for thera-
peutic intervention (Nathan, 1986). According to Nathan, the only way to gain
access to universal dimensions of human beings was to understand the specific
culture into which a person was socialized. At that time Nathan introduced
some quite original ideas about cultural representations and their role in intra-
psychic processes. He suggested that cultural representations of sickness and suf-
fering, which he named ‘‘traditional etiologies,’’ should not only be considered
ideas which may help to explain suffering, but also dynamic representation systems
which may introduce positive change. Following this idea, he started to introduce
interpreters and cultural brokers to work within a multicultural team of therapists.
206 Transcultural Psychiatry 48(3)
The objective of these innovations was not only to better understand his clients, but
also to help them mobilize social and symbolic resources linked to their cultural
background. Thus, clients were invited to think about and to discuss their prob-
lems, referring to cultural representations with which they were familiar. They were
also encouraged to use the healing systems they knew and to which they felt
related. Through these innovations, Nathan departed from ‘‘universalist’’ positions
within the field of French psychiatry and psychoanalysis which left aside the ques-
tion of ‘‘culture’’ and the specific needs of migrants and minorities (Nathan, 2001).
In his early works Nathan (1986) referred to psychoanalytic theory and practice
but insisted on the need to understand the symbolic universes of a person in order
to enhance and understand his or her inner experiences.
We can identify Nathan’s idea of using ‘‘traditional’’ cultural representations
within a therapeutic setting as a strategy to contest the ethnocentrism of western
psychiatry. We may also link it to Obeyesekere’s conception of ‘‘reflexivity’’
within non-western representation systems. Obeyesekere (1981, 1990) argued
that the use of cultural practices and the reference to cultural representation
systems may provoke profound changes within the individual and his social
environment. Such changes may correlate with those brought about by success-
ful psychotherapy. They are conditioned on the one hand by the emotional
investment and appropriation of collective symbols by an individual (who trans-
forms them into personal symbols) and on the other hand, by the capacity of an
individual to use symbols in order to take some distance from his inner psychic
conflicts and to conceive of the latter within a larger symbolic context. In this
case, the individual may use cultural representations in order to sublimate inner
conflicts. They become progressive symbols (as opposed to regressive symbols
which are more akin to symptoms). Even if this process does not necessarily
imply an explicit reflection about one’s subjectivity in western terms, it may
provoke profound changes – in the individual and within his social environ-
ment. This is why Obeyesekere suggested that the western conception of insight
is simply one of a large number of possible ways to use cultural representation
systems in order to change what we would call social, familiar and intra-psychic
On the basis of similar reflections about the dynamic potential of cultural rep-
resentation systems, Nathan proposed some innovations to therapeutic practice.
Therapists were invited to address cultural issues in a very active way, discussing
them with the client and with a culture broker or the members of the multicultural
team of therapists if necessary. Therapists were equally encouraged to make use of
the ‘‘inner logics’’ of cultural representations linked to sickness and suffering. For
example, they could take up a client’s idea that he was the victim of a sorcery attack
and discuss with him what he could do in order to protect himself. In this discus-
sion, allusions to ‘‘traditional’’ techniques, but also enquiries about the client’s
social network (to identify potential social support) would play an important
role. By integrating this kind of intervention into therapy, Nathan hoped to over-
come the inherent ethnocentrism of western approaches to therapy (Nathan, 1998).
Sturm et al. 207
Despite the innovative character of Nathan’s ideas, his approach has always
suffered from a lack of contextualization. Cultural representations were dis-
cussed as if they were fixed frames and there was no reflection about their
embeddedness in social, historical and political contexts. Caught up in his
combat with mainstream psychiatry, Nathan seems to have neglected to keep
up with current discussions about representation practices within cultural
anthropology (Clifford & Marcus, 1991) and medical anthropology (Auge ´ &
Herzlich, 1984; Kleinman & Good, 1985). He proposed an essentialist and
somewhat exoticizing conception of culture which has raised many theoretical
and practical issues (see Corin, 1997; Fassin, 2000; Rechtman, 1995). In the
heyday of radical ethnopsychiatry, Nathan introduced surprising innovations
such as the use of self-made ‘‘traditional’’ objects or the imitation of divination
practices during a therapy session (Nathan, 1995). Not surprisingly, this
approach provoked strong reactions within the community of psychotherapists,
and eventually Nathan’s approach became increasingly marginal within the field
of mental health care in France.
While some aspects of this radical approach in French ethnopsychiatry may
now seem historically distant, we should not forget that Nathan opened a
breach that led to more culture-sensitive approaches within French psychiatry.
Ironically enough, his failure to consider recent theory in cultural anthropol-
ogy pushed debates in France in a direction where cultural theory became
During the last twenty years, important developments have occurred within French
ethnopsychoanalytic theory and practice, and many of these innovations are linked
to the work of the child psychiatrist Marie Rose Moro and her team at the
Avicenne hospital (Baubet & Moro, 2003; Moro, 1998, 2002a, 2007; Moro, de la
Noe ¨ , & Mouchenik, 2006; Sturm, Heidenreich, & Moro, 2008). Moro’s and
Nathan’s approaches have important differences which are mainly linked to differ-
ent conceptions of ‘‘culture.’’ However, there is a continuity with Nathan’s work,
especially in regard to his early publications. Like Nathan, Moro focuses on the
exploration and discussion of cultural representations and the life-worlds to which
they are linked. While she continues to be interested in the cultural dimension of
therapies with migrants and minorities, she has introduced a more dynamic con-
ception of culture, and has shown specific interest in family dynamics, hybrid cul-
tural identities and work with children whose families have a migrant background.
In her work, culture is about the creation of intermediate spaces between different
cultures and representation systems. The objective of her work is not to reconstruct
cultural frames, but to create narratives, that establish bridges between different
life-worlds and cultural representation systems. This is why me´tissage and de´cent-
rage became key concepts within her theory.
208 Transcultural Psychiatry 48(3)
Moro’s conception of ‘‘Me ´tissage’’
In Moro’s writings (1994, 1998), the notion of me´tissage appears mostly as a very
positive term, an engaged commitment to diversity, and a request to acknowledge
the creative potential of transcultural encounters. At the same time, Moro tries to
understand the different ways of constructing and living cultural diversity. Even
though her notion of me ´ tissage still requires clarification (see Sargent &
Lachanche ´ , 2009), Moro’s work on bilingualism – which we will now examine –
indicates a shift in her conception of cultural diversity.
According to Moro, bilingualism may reflect quite dissimilar ways of integrating
different languages and symbolic systems (Moro, 1998, 2001; Rezzoug, De Plaen,
Bensekhar-Bennabi, & Moro, 2007; Sanson, Serre, & Moro, 2008). Children who
grow up with two or more languages may have good knowledge and capacities in
all of them, which can be identified by a rich vocabulary, the ability to use linking
words, developed capacities of association or an emotional investment in linguistic
expressions. This kind of bilingualism may help children to develop important
cognitive and emotional resources, going far beyond the simple fact of knowing
how to handle two or more languages (Bialystok, 1991; Bialystok, Craik, Klein, &
Viswanathan, 2004; Bijeljac-Babic, 2000). This pattern of language integration is
called additive bilingualism. But bilingual children may also learn a reduced version
of a language. In the worst case, poor language skills in the second language4are
built upon equally poor language skills in the mother tongue. When acquisition of
the first language is interrupted or restricted to weekends and the first language is
more or less replaced by the dominant language in the environment, children may
develop poor language skills in both languages. This scenario is called subtractive
Based on the first results of her research on bilingualism (1998), Moro tried to
define the factors favoring additive bilingualism and to describe risk factors asso-
ciated with the subtractive bilingualism pattern. One of the most interesting results
of her research on this topic is the observation that good language capacities in the
first language (mostly the parents’ mother tongue) seem to enhance good capacities
in other languages and to contribute to school achievement in general (Moro,
These research results led Moro to make some propositions for the evaluation of
linguistic capacities and the promotion of positive forms of bilingualism. First, she
proposed to investigate not only if children were bilingual, but also how they used
the different languages and which kind of capacities they developed in regard to
each of them. Second, she invited professionals to investigate the different contexts
of language apprenticeship: the specific history of a family, the role different lan-
guages played for each family member, the way institutions handled language
apprenticeship and so on. As good language skills in the first language seemed
to help children to develop better skills in the second language, Moro suggested
that parents should be encouraged to pass on their language, and invited to do so in
a way which helps to develop extensive language capacities – telling stories,
Sturm et al.209
building up a dialogue in the mother tongue with different persons of the extended
family network, learning about concepts that are anchored in this particular lan-
guage and so on.
These studies on bilingualism reveal new dimensions in Moro’s conception of
cultural diversity. Starting from the positive assumption that diversity may open
new possibilities, she moved on to a more differentiated analysis of different forms
of diversity and the conditions that may help to construct powerful and creative
ways of ‘‘mixing cultures.’’ In her analysis, she also appraised the impact of insti-
tutional, socio-political and historical contexts on how migrants construct their
hybrid life-worlds. This reflection on institutional dynamics and the political and
social contexts appears even more clearly in Moro’s comments on racism and in her
statements about the impact of current immigration policies on the way clients may
live cultural diversity (Mestre & Moro, 2007; Moro, 2002b). At the same time,
Moro defends the specific psychoanalytic interest in intra-psychic and family
dynamics. When therapy focuses on the child’s language apprenticeship, therapists
are invited to determine the specific way a migrant family constructs their unique
life-world and the role different languages play within it. Specific attention is direc-
ted to the modes of language transmission and the creation of intergenerational
The second major concept in Moro’s work is that of de´centrage. This notion is
linked to what ethnopsychoanalytic therapists call cultural countertransference.
Cultural countertransference describes the emotional reactions and fantasies a
therapist may develop with regard to the ‘‘Otherness’’ of a client coming from a
different culture. As in countertransference in general, such reactions may be
quite disturbing if not reflected upon. Therapists may develop distorted percep-
tions of their clients if they are not aware of their own conscious and uncon-
scious reactions to the real or imagined ‘‘Otherness’’ with which they are
Making the assumption that most of these reactions are based on a lack of
knowledge of cultural diversity, Moro invites therapists to look actively for expe-
riences of intercultural encounters. Learning about cultural diversity, working in
different cultural contexts but also working in a multicultural team should help
therapists to take some distance from their own cultural position and to overcome
ethnocentric perceptions of the other. This process is what Moro calls decentering
or de´centrage (Moro, 1994).
But decentering also implies a certain degree of self-reflexivity. The encounter
with the ‘‘Otherness’’ of a client from a different culture is not only about concrete
cultural differences. It is also about the encounter with one’s own unconscious
images and with collective representations of the ‘‘Other’’ which may be mobilized
in a defensive way. Sometimes these representations may hide unconscious fanta-
sies linked to Freud’s concept of the uncanny: the seemingly strange encounter with
210 Transcultural Psychiatry 48(3)
familiar yet unconscious fears or desires. The collective representations of the
‘‘profoundly different Other’’ called upon in such an encounter are often ambiva-
lent, alternating between fascination and rejection (Hall, 1997). Supervision may be
very useful for therapists in order to become aware of the fantasies and collective
representations of the ‘‘Other’’ which may be mobilized during an encounter with a
client from a different cultural background. Therapists may become aware of the
defensive character of these fantasies by understanding what was so frightening
about this specific encounter. At the same time, they may also become more con-
scious of collective representations of the ‘‘frightening Other’’ which are part of
their own culture and history (Sturm, 2006; Sturm, Baubet, & Moro, 2007; Sturm,
Nadig, & Moro, 2010a).
Therapy in the ‘‘multicultural group setting’’: A case study
One of the most original practical innovations of French ethnopsychoanalysis is
called the ‘‘multicultural group setting’’. This involves several therapists of dif-
ferent cultural and linguistic backgrounds working together with one client or
family. Clearly, this quite costly arrangement, which requires the contribution of
several co-therapists, is not the standard therapy applied to all clients with a
migration background. These therapies are proposed in situations where a deep-
ening exploration of the cultural dimension and the history of the family’s
migration seem to be important.5In these therapeutic encounters, the construc-
tion of narratives about the family’s history and about events that occurred
prior to their migration plays a central role, and therapists take a particular
interest in the impact which migration and life in exile may have on the family
Even though therapies within the ‘‘multicultural group setting’’ are only offered
to a small percentage of clients with a migration background in France, this setting
has become paradigmatic for the ethnopsychoanalytic movement. Therapists use
this field of practice to develop specific ideas in transcultural communication. One
of the most important centers where this setting is used is the transcultural outpa-
tient clinic at Avicenne Hospital.6This specific setting is integrated into a multitude
of different therapeutic interventions which may be combined or used separately in
the course of the work carried out with a child or a family (De Plaen, Moro, Pinon
Rousseau, & Cisse ´ , 1998). Psychiatric consultations may be combined with psy-
choanalytic child therapies, group therapies such as psychodrama groups or with
techniques facilitating clients’ self-expression like the ‘‘bilingual group’’ or the
The following case study presents research conducted to study interactions
within the multicultural group setting (Sturm, 2005; Sturm, Nadig, & Moro,
2010). Key questions addressed by this research include how therapists and clients
construct ‘‘culture’’ during therapy. More precisely, we examined how difference
and cultural plurality were introduced, what value clients and therapists attached
to specific cultural representations, what meanings their enunciations had and how
Sturm et al. 211
this dialogue was integrated into a therapeutic process. The research was conducted
in the context of a binational PhD project.8Methodologically, the project com-
bined an ethnographic approach to the ‘‘space of interaction within therapy’’ with
grounded theory and with some elements of the ethnopsychoanalytic research tra-
dition tradition (see Nadig, 2000; Parin & Sturm, 2008). During one year, the
principle researcher attended more than 40 therapy sessions within the ‘‘multicul-
tural group setting.’’ Patients’ consent to participate in the research was obtained at
the beginning of each therapy session. In the presentation of the findings, any
information that could lead to identifying the patients has been removed. Field
notes taken during the sessions were completed by verbatim protocols taken by
trainees. The material was discussed in several interdisciplinary contexts: an inter-
pretation group consisting of researchers from the Cultural Studies Department at
the University of Bremen (Deutungswerkstatt), a psychoanalytic supervision and a
group of PhD students from the department of psychology at the University of
Paris 13 (Sturm, 2005). On the level of analysis and interpretation, a psychoanalytic
and ethnopsychoanalytic reflection on the dynamics appearing in the field (Nadig,
1997) was combined with theories from the disciplines of anthropology (Clifford &
Marcus, 1991; Geertz, 1973), cultural studies (Hall, 1997) and postcolonial studies
The material we discuss in this article concerns the beginning of a therapeutic
encounter with a five-year-old boy experiencing language acquisition difficulties
and his migrant family. While the problem which led the family to therapy is a
common one for therapies in the ‘‘multicultural group setting,’’ this particular
case was considered atypical by the therapists, because it was terminated by the
child’s parents after five sessions. Both parents told the therapists that they were
satisfied with the work and that there was no further need to meet. In fact,
there had been an improvement regarding the boy’s difficulties: he had started
to talk at school and to have more harmonious interactions with his peers. The
school doctor who also had attended the therapy sessions confirmed that
the therapy helped to strengthen communication between the school staff and
the family, making it more fluid and productive. However, the therapists were
not satisfied with the progress that had been achieved and remained skeptical in
regard to the stability of these results. They were under the impression that they
did not have the time to get to ‘‘real work’’ within therapy, which would have
included an elaboration of the family’s story and the difficulties the parents had
gone through. According to the therapists, the parents wanted to end the ther-
apy to avoid discussing too painful experiences.
This case illustrates divergent perceptions as regards to the quality of the
therapy, expressed by the different participants – the therapists, the school
doctor and the clients. We found this example quite interesting, and therefore
the primary researcher (GS) decided to submit the material associated with this
therapy to a detailed analysis, including supervision and discussion within the
group of researchers at Bremen. The work on this case led her to the conclusion
that important aspects of the therapeutic work (which actually produced
212 Transcultural Psychiatry 48(3)
positive results) had not been properly conceptualized by the therapists, leading
them to the perception that they could not properly carry out their work. While
therapists were conscious of these elements of therapy – which mostly concerned
processes of mediation and the development of an alliance with the clients –
they considered them peripheral or a prelude to the ‘‘real work’’ of therapy.
Nevertheless, these issues proved central to most of the situations analyzed in
Case study: Amadou9
Therapy with Amadou and his family was suggested by the staff of a public pre-
school situated in a multi-ethnic suburb of Paris. As usual, the situation was first
discussed with the child psychiatrist who was then in charge of the admissions for
the group setting. After discussing the issue with the school doctor, he invited the
family to a preliminary interview. During the interview (with Amadou’s mother), a
therapy in the group setting was proposed. Before the first therapy session, the
child psychiatrist presented the situation to the team.
Presentation by the child psychiatrist (from field notes and a summary
of the presentation)
Amadou is a five-year-old boy who has recently entered his second year in a public
preschool program. In school, he does not speak in French. His teachers comment
that he does not speak at all, even with his peers, and they observe that he is often
involved in quarrels in the schoolyard. Concerned about Amadou’s development, his
primary teacher asked the school psychologist his expert opinion on the young boy’s
emotional, intellectual and linguistic capacities. The school psychologist suggested
developmental problems on a cognitive and emotional level. At that time, teachers
had started to discuss Amadou’s difficulties with his mother. Unfortunately, commu-
nication was quite restricted by the absence of an interpreter. Amadou’s parents come
from Mali and his mother does not speak French very well; her native language is
Bambara. While Amadou’s mother understood that the school team was concerned
about her son’s development, this perception of Amadou seemed to surprise her. She
explained that he talked at home, using his mother tongue in a way which seemed
suitable for a boy of his age.
The school team was not reassured by these explanations, and even more con-
cerned. Did Amadou’s parents ignore the importance of early language apprentice-
ship? According to the idea that it would be necessary to talk to the ‘‘head of the
family,’’ a meeting with Amadou’s father was proposed. Amadou’s father agreed to
come, even though he seemed quite annoyed by the invitation. After listening to the
teacher’s explanations, he commented that his son could ‘‘stay at home if they did not
want him at school!’’ adding that he himself never attended school. The quite tense
Sturm et al. 213
interaction and Mr. Konate ´ ’s ‘‘threat’’ to take his son out of (non-compulsory) pre-
school provoked strong reactions among staff members at the school. The teachers felt
their worst doubts justified: the father seemed completely unaware of the importance
of French language apprenticeship and early formal education for the future of his
son. In the context of this quite conflict-laden situation, an ethnopsychoanalytic ther-
apy was proposed in order to ‘‘improve communication with the family’’ and to
‘‘evaluate Amadou’s difficulties.’’
First therapy session (field notes by the main researcher with extracts
of verbatim notes taken by a trainee)
After listening to the presentation made by the child psychiatrist, the main therapist
asks the co-therapists to ‘‘go slowly’’.
The family, the school doctor and the interpreter are invited to come in. (...)
Amadou arrives in company of his mother. She carries a baby in a papoose on her
back. Invited by the main therapist, she sits down and arranges the sleeping baby
comfortably on her lap. She tells her son to sit down on the tiny chair in the middle of
a circle composed of all the adults present in the session. Amadou seems lost in the
middle of this huge circle; he is sitting at a little table with pens and paper spread out
on the table but does not seem to be interested in using them. For the moment, he is
looking at all the therapists sitting around him and does not move at all.
(...) The primary therapist invites his colleagues to introduce themselves and each
presentation is translated by the interpreter. (...) After this short round of introduc-
tions, the school’s doctor is asked to describe the reason for the encounter.
School doctor: ‘‘Amadou is in his second year at preschool. Last year, he often
missed school. This year, he is aggressive and does not participate in group activities.
He also has rituals.’’
School doctor: ‘‘He repeats words or sentences we do not understand. I met his
father. At home, they only speak their African mother tongue. The father never went
to school and he says that for him it is no problem if his son stays at home: he would
be like his father.’’
While listening to the translation of the school doctors’ presentation, Amadou’s
mother becomes visibly angry. She explains that the family does not have a problem
with having Amadou at home, and that he speaks his native language quite well.
The only reason he might be aggressive at school is that – lacking the necessary
214 Transcultural Psychiatry 48(3)
vocabulary in French – he has no other way to defend himself. In any case, she adds,
Amadou may stay at home if he is not wanted at school.
The beginning of this therapy session is marked by the collision of different concep-
tions of ‘‘the problem’’ requiring treatment. The school’s doctor ascribes ‘‘the prob-
lem’’ to Amadou and his family: the young boy is described as behaving
inappropriately and the family is presented in rather devaluating terms. The parents
are implicitly blamed for their son’s truancy, their language is depicted as second-
rate (‘‘they onlyspeak their African mother tongue at home’’) and Amadou’s incom-
prehensible utterances are associated with ‘‘rituals’’ – in a quite surprising way.
In response to this initial framing of ‘‘the problem’’ and its possible origins,
Amadou’s mother denies that there is any problem at all with her son. She ascribes
responsibility for the problem to the school: the staff does not accept her son as he
is and school seems to be a rather hostile environment for her son. If necessary, she
is ready to withdraw him from school in order to protect him.
As is usually the case in this therapeutic setting, these alternate understandings
of ‘‘the problem’’ are not discussed until the very end of the session. The entire
session will be used in order to come to know Amadou’s family, as well as the story
of his parents and their migration. It will also be used in order to prove to
Amadou’s mother that the school’s staff-members really want to understand her
position and to help her son.
After these initial exchanges, the primary therapist invites Mrs. Konate ´ to tell the
group more about their situation and the family’s story. This is a very standard pro-
cedure in the ethnopsychoanalytic group sessions. But this time, the exploration turns
out to be quite difficult. Mrs. Konate ´ is still angry and lets out an annoyed sigh. She
may be wondering whether the therapists are also trying to ‘‘place blame on’’ the
family for Amadou’s difficulties. The primary therapist explains: ‘‘We ask you these
questions because we are trying to understand.’’ She nods, yet she seems cautious and
tense. Amadou is sitting stuck to his chair following the conversation.
Gradually, the group learns some of the main events in the family’s story. Mrs.
Konate ´ migrated to France ten years ago, joining her husband who had arrived five
years earlier. They had married in Bamako and when she migrated, she left her first
child, a little daughter, at her mother’s place ‘‘as a consolation’’ for her own depar-
ture. In France, three more children were born. Amadou was their third child and first
son. The last sibling is little Kadjatou, who still sleeps on her mother’s lap. (...)
When she is asked her children’s ages, Mrs. Konate ´ becomes nervous – ‘‘How old was
the eldest one? 11 or 12 years?’’ ‘‘I don’t know, she is not with me, she is still in Mali!’’
she answers. Nervously she looks for something in her handbag. Finally she takes out
the vaccination cards of her children. Now she sits up and reads out the dates of birth
of all her children. I wonder how many times she has gone through this procedure
with the French administration.
Sturm et al.215
In this sequence, the primary therapist tries to obtain contextual information
which might help to understand the history and the dynamics of Amadou’s family.
But Mrs. Konate ´ is not convinced yet that the team may help the family – do
they understand and accept her perception of ‘‘the problem’’? Are they trying
to blame her? Does she have to prove that she is a good mother? Is their way
of proceeding appropriate for the situation? She still seems reserved and on the
Finally, Mrs. Konate ´ finds an indirect way of expressing her discomfort. Little
Kadjatou wakes up and starts crying. Mrs. Konate ´ explains: ‘‘she is afraid!’’ The
main therapist takes up this idea and adds ‘‘because there are so many people here!’’
Mrs. Konate ´ nods. She hides her daughter under the sheet that she had previously used
to carry her. ‘‘That is good, now she doesn’t see us any more!’’ comments the primary
therapist. The baby stops crying. Now Mrs. Konate ´ seems far more relaxed. Perhaps
she felt that the therapist understood not only her daughter’s cry, but also her own fear.
This brief interaction turns out to be a reversal point in the session. From that point
on, Mrs. Konate ´ appears more comfortable and open. Perhaps she feels understood
in her fear without feeling blamed. Now she speaks about the loneliness she has
return to Mali to see her mother or eldest daughter. She felt very lonely and often it
was Amadou who cheered her up. In fact, this boy is particularly close to her.
Now the therapists may understand that the relation of Amadou to his mother
was certainly influenced by her sadness and loneliness. One hypothesis the thera-
pists suggest after the session was that it could have been difficult for the boy to
invest in the apprenticeships at school because he had a hard time accepting sep-
aration from his mother. This difficulty could originate in the fear of letting her go
or even in an insecure attachment developed during the time his mother was too
sad to be emotionally available to her son.
A strategy that therapists often apply in this kind of situation is to create a
holding environment in order to disburden the mother and to show the child that
she is not in danger but that may be helped by adults. In this specific therapy
session, the therapists speak about the mother’s sadness, but they also indirectly
raise the issue of her fears related to Amadou’s leaving home for school.
One of the co-therapists proposes the idea that Mrs. Konate ´ entrusted her son to
school as she entrusted her eldest daughter to her own mother, with all the confidence
this implies. The co-therapist suggests that it is hard for her to hear the criticism of the
school team – had she not already shown how much she trusted them by accepting
that her son went to school?
Amadou’s mother tells the team now that she was always willing to maintain a
positive relationship with the school team, and she explains how much she felt hurt
when the school’s team ignored her openness to discussion. And how could they invite
216 Transcultural Psychiatry 48(3)
his father to a discussion with the team? – ‘‘He doesn’t care! [in French] The only thing
that is important to him is that Amadou speaks Bambara.’’
As we may see in this sequence, Mrs. Konate ´ needs to feel understood and
accepted before she can bring up the differences between her husband and herself.
However, these differences seem to be important. When the expression ‘‘Il s’en
fout!’’ (i.e., he doesn’t care) slips out of her mouth in French, she seems to look
for understanding by establishing direct contact with the group. It may even be that
she uses this expression of anger in French as a ‘‘rebellion’’ against the loneliness
and isolation of her familial role. Once she feels understood in her loneliness and
anger, she draws a different image of her son’s difficulties. She talks about the fact
that Amadou does not speak as well as his siblings at home, but she is sure that he
will be able to catch up with them.
At the end of the therapy session, the primary therapist invites Mrs. Konate ´ to discuss
with her husband what had been said and to tell him that the group would be happy to
work with both parents.
At the moment of closure, the primary therapist only indirectly answers Mrs.
Konate ´ ’s allusion to a potential conflict between the spouses. He proposes talking
to Mr. Konate ´ and including him in the therapy. After the session, the main ther-
apist comments that he had suspected important conflicts between Mr. and
Mrs. Konate ´ but that he found it too ‘‘risky’’ to approach them in a direct way.
The interpreter shares his impression and comments: ‘‘She is very sad and angry.
The Konate ´ ’s are like volcanoes, they are explosive.’’
In the discussion that follows this first session, the therapists propose the idea
that Amadou may be caught in a conflict of loyalty: if he starts to play and to learn
at school, he might ‘‘betray’’ his parents – his mother because he leaves her alone at
home, his father because he invests in a language associated with a hostile and
menacing environment. The therapists also explain to the school’s doctor that Mrs.
Konate ´ ’s role stands as the sole interlocutor for her children is not unusual for
families with West African origins. As Mrs. Konate ´ explained in the session, she
considers it her role to look after her children in their early years, while their father
should take a more active role when they are seven years and older. At the end of
the session the school’s doctor speaks about the family in more empathetic terms,
commenting that the school team should be more aware of the efforts Amadou’s
parents have already made.
Field notes of the second session (summary)
At the next session, Amadou is accompanied by his father. The session starts with the
usual group presentation, followed by translation into Bambara. The primary therapist
Sturm et al.217
is a psychologist and psychoanalyst with West African origins who does not speak
Bambara, but knows some words and phrases, and begins by addressing Mr. Konate ´
with greeting words in Bambara. After this presentation, he invites the school’s doctor
to speak. She reports the positive changes observed by the school staff-members.
on these observations, Mr. Konate ´ refers to the conflict that preceded the therapy. He
explains that he was very angry because ‘‘the school’’ had forbidden him to speak
Bambara at home. ‘‘That is why I wanted to take some distance from the school’’ he
adds. While Mr. Konate ´ is talking, the school’s doctor waves her hand to show that she
would like to comment on Mr. Konate ´ ’s version. ‘‘We never said that!’’ she states
without being invited to speak. The main therapist makes a gesture asking her not to
Feeling that the question of transmission and the construction of intergenerational,
extended family as well as ‘‘community’’ bonds were crucial to Mr. Konate ´ ’s experi-
ence, one of the co-therapists chooses to recount a story by Khalil Gibran, about a wise
being the last person with a sound mind. He alludes indirectly to Mr. Konate ´ ’s fear that
he (and his son) might be cut off from the others. In response to this story, Amadou’s
father expresses his fear that his son might not learn his native language and that he
could ‘‘be lost to the community’’ in Mali. (...) After a long discussion about his fears
and the proposal of stories and images referring to his struggle to maintain the connec-
tion to the extended family, Mr. Konate ´ becomes more open to dialogue. However,
when therapists start to talk about Mr. Konate ´ and his story in relation to the problems
Amadou is experiencing, he responds vigorously: ‘‘I came here to talk about Amadou,
not about myself!’’ Reassured that these limits will be accepted, he agrees to continue
the work. At the end of the session, the school doctor comments that she understands
Mr. Konate ´ ’s fears and adds that nobody intended to forbid him to speak Bambara
with his children at home. Teachers only suggested that he ‘‘speak French a little bit’’ at
home. Mr. Konate ´ nods and explains that the school doctor was very important to the
family, because she understood them and had helped to better their relationship with
the rest of the school’s staff.
In this session, family dynamics and topics linked to question of language-transmis-
sion take on new dimensions. Mr. Konate ´ explains how his seemingly rigid position
was based on his fear that he might not be able to assure the transmission of his
native language and affiliation to his son. We may imagine how frightening and
menacing the proposition to talk ‘‘a little bit of French at home’’ may have been
in this context.
Final sessions (summary based on field-notes)
In the third session, therapists hear that Amadou has begun to speak more French at
school. At the same time, Amadou’s father explains that he has allowed his children to
218 Transcultural Psychiatry 48(3)
speak French together at home. While the French environment seems to have become
less frightening, the family’s limits also became more permeable. It seems that the
conflict with the school team has been overcome. Two sessions later, Mr. Konate ´
states that the therapy can now stop as there is no more work to do. However, he
says they could continue to work with his wife. Therapists accept and suggest a new
appointment. Mrs. Konate ´ arrives with her son, but once again she seems defensive
and reserved. She explains that Amadou is doing fine and that there is no need to
continue. Finally the therapists agree to conclude the therapy, but they suggest the
school doctor contact the team if ever another session is necessary.
Comments on the case study
In young Amadou’s case the transcultural consultation was proposed in order to
understand and overcome his difficulties expressing himself in French. The team of
therapists understood these difficulties in the context of a strict separation between
the ‘‘inside’’ of the family – a space with restricted social contacts and exclusive use
of the Bambara language – and the ‘‘outside,’’ representing the French environ-
ment – a space perceived as strange and hostile.
The beginning of Amadou’s schooling represents his first steps into this envi-
ronment. Though his older sister also goes to school, he seems to be experiencing it
on his own. His parents are not familiar with the system and it is primarily his
mother who mainly deals with the school staff. However, her ability to communi-
cate with the teachers is restricted: she does not speak French well and the school
does not make any effort to provide an interpreter.
Letting Amadou out of the inner space of the family is particularly difficult for
both parents. His mother feels comforted by Amadou in her solitude and sadness;
his father worries that Amadou’s ties to the family in Mali could be endangered by
the French environment. He fears that Amadou will give up learning Bambara if
the French environment becomes too dominant.
This dynamic is intensified by the way the school staff members organize
their dialogue with the family, a style which should be seen in the light of
French school politics and the role played by language apprenticeship within
it (Giraud, 2003, 2006). Within the school system, French is considered the
most important language, and no effort is made to tell the family that
Amadou’s school achievement could be improved if he learned both French
We do not have any evaluation of Amadou’s capacities in Bambara, apart from
his mother’s assertion that his abilities are normal for his age, even though he
started to speak late compared to other children. His apprenticeship may have
been slowed down by the isolation of the family and the fact that his main inter-
locutor (his mother) seems to have been isolated and depressed for years.
An evaluation of his development should certainly have included checking his
knowledge of Bambara.
Sturm et al.219
Strategies of intervention proposed by the team of therapists
During the five therapy sessions, the therapists mainly proposed interventions that
intended to promote movement out of the gridlocked family dynamics described
above. As a second objective, they tried to improve communication between the
family and the school staff. The therapists tried to understand the family’s history
and the individual positions of each parent from a psychoanalytic perspective.
At times cultural mediation was used in order to situate and contextualize the
narratives of the parents and to show them that therapists understood them
(e.g., when the primary therapist said that Mrs. Konate ´ left her daughter with
her mother in Mali ‘‘as a consolation’’).
When working with Mrs. Konate ´ , the therapists showed her that they recognize
her sadness and offered empathy and understanding. They helped her verbalize
emotions (through interactions with the baby), invited her to talk about her story,
and offered images that linked the current situation to the time before migration
(e.g., the idea that Mrs. Konate ´ entrusted her son to school as she had entrusted
her eldest daughter to her own mother). This gave her a way to describe her situ-
ation, her loneliness and her specific relationship with Amadou.
However, some topics were avoided in the conversation with Mrs. Konate ´ ,
especially her anger towards her husband. No one took up this subject, for fear
that this could intensify the conflict between the spouses. The therapists do help her
articulate her sadness, but they silence her anger. This may explain why Mrs.
Konate ´ loses interest in the therapy after a while. Indeed, she does not come
along with her husband and seems to be quite reserved during the last therapy
In the sessions with Mr. Konate ´ , the therapists proposed the same type of
work, this time focusing on his fear of failing to pass on his native language
and build inter-generational bonds with Amadou. In these sessions, the thera-
pists’ interventions aimed to approve Mr. Konate ´ ’s concern for his son’s
apprenticeship of Bambara, and to valorize the Bambara language (e.g., the
main therapist greeted Mr. Konate ´ in Bambara). The therapists wanted to
work more with Mr. Konate ´ ’s own filiations and the story of his migration,
but he made it clear that he did not come for this kind of work. While the
therapists did not insist, they felt disoriented, as they were bereft of their usual
The second aspect of the therapy was the work on mediation. Though not per-
formed in a very explicit way, this represented a crucial aspect of the team’s work.
Three types of interventions can be identified: the construction of narratives by the
parents in the presence of the school’s doctor, the inversion of usual roles, and the
contextualization of the parents’ narratives or opinions.
The first part of the technique proved to be very effective in this therapy.
Listening to the parents’ narratives changed the school doctor’s attitude. She
became much more empathic and eventually was a mediator between the family
and the rest of the school team – as someone who knew important aspects of their
220 Transcultural Psychiatry 48(3)
inside perspective. There were also real moments of inversion with regard to the
situations migrant families usually experience with French institutions. For exam-
ple, Bambara became the primary language used in the sessions within a hospital,
the primary therapist was of African-origin and the school doctor was asked to
‘‘wait and to listen’’ to the family’s point of view.
Finally, the therapy also included cultural mediation in the sense of contextu-
alization of cultural representations or practices. For instance, the therapists
explained to the school doctor that when children are young it is quite common
for West African mothers to be in charge of the relationship with their teachers. In
this case, cultural mediation was used to invite the school team to question their
ideas about ‘‘normal’’ family organization and to invite professionals to create a
dialogue with the family about their conception of parental roles.
This case study illustrates how mediation practice may play a central role in trans-
cultural therapy. Mediation can be defined both as conflict mediation and as cul-
tural mediation within a field of unequal power relations (Rousseau, 2003; Verrept,
2008). In what follows, we compare this practice with notions of cultural hybridity
recently elaborated by several cultural theorists. We would like to determine how
the ethnopsychoanalytic approach deals with diversity, which aspects of diversity
are represented and which other aspects may be faded out and silenced. Our argu-
ment is mainly based on the ideas of Bhabha (1994), Spivak (1993, 1996) and Hall
In The location of culture (1994), Homi Bhabha showed that the confronta-
tion with the cultural Other in colonial times was characterized by two simul-
taneousand seemingly contradictory
themselves submitted to stereotypes and devaluing representations within colo-
nial discourse. These representations were created in ‘‘the center’’ of the colonies
in order to justify the colonial enterprise. But finally they were also adopted ‘‘at
the margins’’ by the new elites who had been established by the Colonizers.
These representations were needed to justify the colonial order and to protect
the position of the elites. The imitation of colonial discourse by the Colonized –
the process of mimicry – led to new differences within the colonized population,
but also to growing ambivalence on the side of the Colonizer. The colonized
elite became almost alike though different, partly accepted and deeply feared.
They incarnated the possibility of a reversal of the colonial order. The elites
from the colonies reproduced stereotypes, but they also questioned them. New
challenging representations appeared within a new space, a space which Bhabha
defined as third space.
Spivak (1993) also discussed practices of representation and the impact of a
dominant discourse on the subjectivity of the subjugated people. Using a decon-
structivist approach inspired by Deleuze and Foucault, she argues that there is no
Sturm et al. 221
subjectivity outside discourse – on the contrary, she states that discourse creates
subjectivity. Starting from this idea, she raises the question whether there could be
such a thing as a ‘‘voice of the subaltern.’’ She argues that those who are considered
exclusively as objects within colonial discourse cannot be heard, as dominant dis-
cursive patterns do not allow any ‘‘authentic’’ expression of subaltern subjectivity.
Nevertheless, this compelling theoretical argument does not mean that Spivak
would be against an attempt to make ‘‘the silenced voices heard,’’ for instance
through reconstructions of the perspective of the Colonized in history. She
argues that there may even be a political need to do as if these voices could be
re-constructed, a need she refers to as strategic essentialism. We should try to make
the silenced voices heard, even if we know that the reconstruction (or translation)
of these voices will always be caught up in the possibilities of essentializing and
silencing colonial (or postcolonial) discourses.10
We find a similar idea in the work of Stuart Hall (1992, 1997) who argues
that representation is profoundly intertwined with power. In an essay about
practices of self-representation in marginalized communities, Hall suggests that
it may be sometimes necessary to go through a period where the Marginalized
join forces in order to construct new – seemingly essentializing – representations
of themselves (as in the practice of re-interpretation of the notion of ‘‘Black’’ in
order to name, blame and fight racist discourses and practices). At the same
time, these homogenizing representations necessarily mask internal diversity and
always do damage to ‘‘the powerless’’ within marginalized communities.
Discussing internal diversity and inequality and deconstructing homogenizing
images should therefore be considered essential by activists who strive for
more equality within society.
Comparing our example of transcultural therapy to these theories, we may say
that there were many indications of an opening towards a ‘‘third space,’’ where
existing representations of the cultural Other may be questioned and confronted by
new narratives co-constructed by the therapist along with the migrant families.
Receiving migrants within a team that mainly consists of therapists with migration
experiences may be considered a symbolic act that questions practices of exclusion
and non-representation of minorities. The introduction of culture-specific logics,
the use and valorization of non-western languages are important symbolic acts,
showing a degree of interest in and acceptance of ‘‘Otherness’’ which clients do not
encounter in their daily confrontation with French institutions. In this sense, these
therapies are not only profoundly creative, but also subversive.
However, this subversion has limits. We did not find any open criticism of
dominant discourses in the school system. Power relations between the family
and institutions or within the family were not discussed and the issue of racism
was never raised. We also found limits in the therapeutic team’s capacity to
accept the expression of difference and conflict within the family. This silenced
important aspects of Mrs. Konate ´ ’s experience as a ‘‘twofold Other’’ who was
subjected to both (post-) colonial and patriarchal discourses (Peterson &
222 Transcultural Psychiatry 48(3)
These limits are certainly not only linked to a lack of consciousness on the part
of the therapists but are the consequence of a struggle with the constraints of
existing discursive practices. They may indicate that French transcultural psychia-
try is just entering the second period mentioned in Stuart Hall’s essay: a period
where inner diversity and even conflict within marginalized groups may be
acknowledged without undermining the recognition of shared experiences.
This research received no specific grant from any funding agency in the public, commercial
or not-for-profit sectors.
1. On one side, this field is characterized by the Republican ideal of equality, which sup-
ports a conception of Universalism incompatible with notions of cultural difference. On
the other side, perhaps as a reaction to this dominant model, we find pragmatic arrange-
ments within the health care system, which give space to ‘‘culture-oriented’’ approaches.
French ethnopsychoanalysis may be considered as a part of this latter movement.
2. More recently, Fassin and Rechtman (2007) have applied a technique of contextualiza-
tion and de-construction of discursive practices on the field of humanitarian interven-
tions and therapies with traumatized persons, proposing a very critical position with
regards to the social and political effects of a decontextualized focus on trauma and its
effects (see also Watters, 2007).
3. These innovations may be seen in the context of recent developments in other European
countries where a critical discussion over ethnopsychoanalytic ideas also led to the
development of new approaches. See Beneduce and Martelli (2005) and Giordano
(2008) for Italy and Wohlfahrt, Hodzic, and O¨zbek (2006) for Germany.
4. In France, many bilingual children learn French as their second language.
5. For a detailed description of the indications, see Moro, 1998.
6. Service de psychologie transculturelle de l’enfant, de la famille et de la psychiatrie
ge ´ ne ´ rale. Ho ˆ pital Avicenne, 129, rue de Stalingrad, F-93003 Bobigny, Cedex.
7. Therapy groups with children (bilingual group) and adolescents (slam group) where
creative techniques and the production of spoken and written texts play an important
8. The research was realized within a binational PhD research setting at the cultural studies
department of the University of Bremen, Germany and the psychology department at
Paris 13. It was co-directed by Professor Nadig (University of Bremen) and Professor
Moro (University of Paris 13).
9. The name of the patient and family has been changed to protect anonymity.
10. See also the brilliant article by Giordano (2008), in which she shows these processes at
work in her analysis of the discursive practices directed towards female migrants obtain-
ing residency as ‘‘victims of trafficking’’ in Italy.
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226Transcultural Psychiatry 48(3)
Gesine Sturm is Lecturer at the Department of Psychology at the University of Download full-text
Paris 13 and member of the Institute of Cultural Studies at the University of
Bremen (bik) in Germany. Her research and teaching concern transcultural ther-
apies, cultural brokering in the field of social and mental health care, and ethno-
psychoanalytic research methods.
Maya Nadig is Professor of European Ethnology at the Department of Cultural
Studies at the University of Bremen in Germany. Her teaching and research are
focused on ethnopsychoanalytic methods and theories, postcolonial cultural theo-
ries, migration, transculturality and identities in the context of globalization.
Marie Rose Moro is Professor of Child and Adolescent Psychiatry at the University
of Paris 5. Her teaching and research concern transcultural psychiatry, psychopa-
thology and intergenerational relations in the context of migration and
Sturm et al. 227