Vol 9 #7

Summary by Pauline Pytka MD, FRCPC

Salman Akhtar OPA Psychotherapy Section Fall Conference October 17, 2020.

Salman Akhtar  is Professor of Psychiatry at Jefferson Medical College and a Training and Supervising Analyst at the Psychoanalytic Center of Philadelphia.  He has authored 300 publications  including 90 books and 12 collections of poetry.

Dr. Akhtar provided a fast-paced and rich presentation. In the first hour he discussed basic elements of the therapeutic relationship and the interface with ethno/cultural aspects. In this he addressed:

  1. The real relationship
  2. The therapeutic alliance –language that we use to enhance it –“let us see’ communicating with language that is a collaborative arrangement to develop a partnerships with the patient
  3. Transference

The older concept of transference as an unconscious repetition of early childhood experiences versus the newer concept (as evidenced by the British School) which emphasizes the role of transference as a search for a new developmental experience not simply a reenactment of the old.

  1. Countertransference

There is a need to recognize different elements of countertransference and the therapeutic relationship based on the cultural and ethnic roots of the analysts themselves. Historically the British Object Relations analysts  were more culturally secure and had confidence in their ability to assert themselves and their ideas. By contrast Freud was less assured because of his Jewish heritage and felt the need to ensure that psychoanalysis was not dismissed  as a ‘Jewish’ theory .

In our own times there are “new kinds of doctors and new kinds of patients”. For example therapists who have immigrated from the Middle East and India have made contributions based on their own cultures. Dr. Akhtar emphasized that psychiatrists and psychotherapists from different backgrounds should be made to feel  welcomed, accepted, and  empowered to utilize and present their therapeutic models and approaches.

We must be aware of whether the therapeutic dyad is homoethnic, homocultural versus heteroethnic  or heterocultural and recognize the different impacts of this on the therapeutic relationship.

Dr. Akhtar highlighted this ideas by the maxim “ When in Rome, do as the Romans do”. However in the  heterocultural therapeutic dyad which person is the “Roman,” the patient or the psychotherapist?  That is, should we defer to the patient’s cultural  customs and orientation  in such matters as greetings, levels of formality or to the dominant one?


Cultural Dimensions of the Dyad

Patients are not just “psychopathology” but  have healthy aspects of being.  They bring their healthy parts including their ethos (cultural parts). These cultural elements can affect all areas of the therapeutic relationship and recognition and respect are essential. It is important to be attuned to the following:


  • Ask the patient for the correct pronunciation of his or her name
  • Learn something about the culture, history, and geography of the persons country of origin. –
  • Do not assume a white patient from another country ( eg South African, Britain or Australia) does not have cultural issues to address.
  • Cultivate an openness to other cultures; see films, make friends from different backgrounds and be open.


In Western culture – time is experienced as a river. A river is always rushing forward towards some destination. In Eastern culture time is compared to a lake. A lake is calm, serene and connotes contemplation and connection.

Chronic lateness may be related to separation not resistance. It is a difficulty about leaving home. It is not a question of “arrival”.  If a patient is a few minutes late “forget about it”. Don’t interpret it. The Western concept of  time and structure is derived from industrialization: “time is money”. In other cultures time is related to connections, the arrival of loved ones – leaving and aloneness.


Sandor Ferenczi was the first to discuss the significance of mother tongues compared to secondary languages. J.A. Mehler in a seminal work on the subject, the Babel of the Unconscious, noted that our early language is related to basic bodily functions, and bodily parts are bound up with early emotional experiences.  The word and the thing are close in sound or even affect (e.g. penis, vagina). Obscene words in the mother tongue have different emotional valence.

Clinically this may be relevant for patients who are not speaking in their mother tongue. They may have more difficulty communicating certain deep affective experiences in their secondary language. In this circumstance it may be reasonable to request that a bilingual patient speak in the mother tongue – talk about crying, being upset, etc. Translations may be “linguistic sanitations”.

Taboo Topics

These vary in different cultures e.g. the topics of  sex and money. In American culture people flinch when talking about money – it is considered crude and rude. In other cultures the understanding of finances and sharing of information is accepted. Sex has become more open for discussion in Western cultures. In some other cultures you “wouldn’t dream” of discussing sex.


No culture is superior – some aspects may be better in some cultures than others but none is globally superior.

There are problems and needs in all worlds that are the same across cultures.

Some things are impossible( pre-oedipal); others are prohibited (oedipal).

Universal components of therapy across cultures:

  • Metapsychology
  • What the patient knows and can know
  • Dynamics,
  • Morality,
  • Sense of (psychodynamic) economics – too much, too little, too late, too early etc.,
  • Concept of (psychodynamic) genetics of today and yesterday
  • Adaptive – what is the worst thing the patient is avoiding?

We need a judicious accommodation to the therapeutic frame. We need to be open (flexible) to a different therapeutic frame. For example, we may need a translator from the family at times. While generally, this is not recommended sometimes a culturally sensitive interview with family is required because of an inability to find an appropriate therapist, or even in a culture where the gender of the therapist means the marital partner might need to be present.

A helpful recommendation was  how to do an interview with a translator (whether family or other). Instruct the patient to speak to the therapist. It is best if the patient and therapist look directly at each other and ‘speak to each other’ even when the patient is speaking in their mother tongue.

There is a need to validate the minority and cultural dislocation status. We must ask – how does it feel living in a country where you are a minority?  “I am white you are black. It may become an issue between us. If something comes between us – talk about it and listen and we can work together”.

We need to distinguish cultural conflicts from neurotic conflicts: a cultural conflict is the result of a clash between differing expectations or norms of one culture versus another. A neurotic conflict results from internal psychological dynamics.

Dr. Akhtar gave an example of two colleagues meeting. There was a small shared travel cost and tension on the part of the younger colleague about whether to offer to pay the cost, or contribute when the older colleague had offered payment. In American culture age is irrelevant, and offer of payment is considered polite. However in Indian culture this may be seen as disrespectful. This would be a potential cultural conflict.

Alternatively this scenario could be viewed as manifestations of a neurotic conflict. The tension of offering to pay or not can be related to ‘oedipal strivings’ in the relationship between the two men if one is experienced as a father figure.


4 The patient may also present a cultural rationalization to avoid addressing what is really a psychodynamic issue.

For instance, a person is grappling with living common law or getting married. This person was fully integrated into Western society, and had never previously expressed religious conflicts or concerns related to their or other people’s life choices. While exploring the tension surrounding this question, the patient suddenly retreated into religious explanations that were not in keeping with the patient’s life style or previously expressed beliefs. On deeper exploration these expressions of religious beliefs were actually a way of avoiding other issues related to trust and intimacy.


Dr. Akhtar was open about himself and engaging, making the presentation rich with illustrations. I have tried to summarize these ideas while respecting the personal nature of the presentation. Any examples given are my own syntheses and should not be construed to represent any specific persons.



Akhtar S. (2006) Technical Challenges Faced by the Immigrant Psychoanalyst, The Psychoanalytic Quarterly. 2006; 75:1, 21-43, DOI: 10.1002/j.2167-4086.2006.tb00031.x

Akhtar S. A third individuation: immigration, identity, and the psychoanalytic process. J Am Psychoanal Assoc. 1995;43(4):1051-84. doi:10.1177/000306519504300406

Mehler JA, Argentieri S, Canestri J, Jappe G. The Babel of the Unconscious: mother tongue and foreign languages in the psychoanalytic Dimension. Journal of the American Psychoanalytic Association. 1993;41(3):862-866. doi:10.1177/000306519304100325






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