Dancing naked on the bridge is a case study in first person, that acknowledges the intersection of vicarious trauma and culture shock.
Maller, D., Langsam, K., & Jerbian Fritchle, M. (2013). Praeger handbook of community mental heath practice. (Vol. 3, pp. 15-21). Santa Barbara, CA: Praeger.
Dancing Naked on the Bridge
The Bridge Between Two Cultures
Born and raised in India, I was lovingly nurtured by the melodious sounds of my middle class family switching freely between Hindi, Bengali, Tamil and English. I grew up in the modern urban India of the eighties and nineties, proud of our traditions yet curious about the rest of the world. Just as we code-switched between languages, we ate both biryani and pizza with equal gusto. We loved the freedom of wearing jeans to college and the feminine joys of dressing up in sarees for family gatherings, with jasmine garlands and henna scenting the air. While cable television beamed Western culture right into our living rooms, we loved Bollywood movies with the dramatic scenes of angry fathers disowning sons, love lost and regained, and of course, the dancing in the rain.
I was barely out of my teens when I moved to America, and reasons of the heart have held me here since. In the early years of my life in California, often, I had the feeling of walking a tightrope between two cultures. My authentic Indian self appeared needy and vulnerable to the friends I tried to make in this new context. My more laid-back California self with its shiny new accent sounded phony to me, but found greater acceptance and companionship. Slowly I began to feel as if there was a “me” in India circa 1997, and a different “me” in the US. As the years went by, I began to give up on the challenge of getting them to inhabit the same body at the same time. On my visits back to India, I continued to feel the joys of homecoming, combined with the challenges of balancing on this tightrope. The very accent that gave me greater credibility in America was teased and ridiculed, and I would find myself short of words to explain my life in a very different cultural context.
Over the past fifteen years, what seemed to be a tightrope has evolved into a wide four lane bridge that I freely traverse. I am a child of India whose professional identity has been shaped by a Western education. India is my homeland, my place of origin, the keeper of my childhood dreams and memories. India is the place I go when I walk down memory lane, when I want the comfort of my mother’s cooking, or to share much laughter over steaming cups of chai. India is where my roots are deeply planted, drawing nourishment and sustenance, while California is where the branches of my tree can spread in a multitude of directions. California has allowed me to choose an adult definition of myself that is malleable and evolving, where the ups and downs have allowed me to grow in ways that I never knew possible. It is in California that I define myself as a mental health professional, having worked in schools and clinics, and specializing in working with survivors of domestic violence.
In 2008 a chance meeting the Medical Director of the institution resulted in an invitation to visit and volunteer at the Amrita Institute of Medical Sciences and Research Center (AIMS) in Kochi, India. The AIMS Hospital is supported and funded by the Mata Amritanandamayi Math, a registered Public Charitable Trust founded to spread the message of spirituality, universal love and selfless service to humanity. Mata Amritanandmayi Devi, lovingly known as Amma, recognized that advanced medical care is beyond the reach of India’s majority who live well below the poverty line. Her vision led to the birth of a highly sophisticated, 1450–bed super-specialty teaching hospital where the poor could receive free advanced medical care, such as heart operations and kidney transplants, in an atmosphere of love and compassion. Approximately one–third of the treatments are free, a third are subsidized, and the rest are provided at the prevailing rate for those with adequate incomes. With over 50 clinical departments and spread over 125 acres of land, AIMS has grown to be a prominent academic institution and research hospital with an accredited degree program in medicine.
The Medical Director of AIMS was gracious in offering the possibility that I could help to formulate a Masters in Counseling program, the first of its kind in India. AIMS was ready to move beyond Psychiatry in exploring the realms of mental health. India has psychiatrists and psychologists, but Marriage and Family Therapy is a new realm and despite wordy explanations, clarifications and protests from me, many, in India, still see me as a psychologist. I was provided email introductions to the clinical psychologist in the Neurology department and to the psycho-oncologist in the Pain & Palliative department. They expressed enthusiasm for my arrival and assured me that there was much to be done when I arrived.
The Bridge Between Being and Doing
Excited as I was about the possibilities, I was equally overwhelmed by the scope of such a daunting task. I had been given such freedom to choose my time-line and goals that the plethora of possibilities made it difficult to find a focus. I approached this pre-departure anxiety by writing lists, creating master-plans and doing research. I spent hundreds of hours online and at the library creating a safety net of information around me. I decided that I would spend 4 months in India to start with and developed these short term and long term goals to guide my decision-making process.
Short Term Goals:
- Assess the mental health needs of the hospital patients and surrounding community, including prevailing clinical concerns and diagnoses with a focus on women. Surveys and semi-structured interviews were to be utilized.
- Evaluate space opportunities within the hospital and develop requirements for a clinic with therapy rooms appropriate for adult and children, assessment and consultation rooms and office space for administrative materials.
- Author a plan for workshops and informational sessions to be offered to doctors and hospital staff, school and university staff, and students on a variety of mental health related topics, such as stress management, conflict-resolution, HIV awareness, pain management, domestic violence, depression, attention-deficit disorder, learning disorders, post-traumatic stress disorder, etc. The outreach goal was to reach out to women in the community with a specific focus on issues of self-esteem, HIV awareness, suicide prevention and domestic violence.
Long Term Goals:
- To set up a counseling clinic that would act as a model for community mental health services in other regions of India.
- To set up a Masters Program in Counseling in collaboration with a reputable US University. In this way, the students would benefit from the advanced academic structure of the West, while honing their clinical skills in the clinic to meet the practical needs of the community.
About six months after I first received the invitation, in early 2009, I returned to India confident that I was well prepared for my journey and the adventure ahead. I was humbled quite instantly. Much of what I had written in my goals had already been accomplished and some of what I had written was not realistic given the time-frame. More importantly, I had ignored an important component of my preparation – I was very poorly equipped in the language department. My Malayalam skills were quite basic and, at best, I could understand 60 – 75% of the conversations around me and a lot less when I was tired. I was definitely not equipped to provide therapy in Malayalam. The reality of the work looked nothing like the amazing project outline I had written in the comfort of my sunny California room. My urge to hit the ground running finally gave way to the intense heat, mosquitoes, and contextual reality, forcing me to slow down. And when I finally did, it sank in. First, I had to be and then I would learn what there was to do.
During my early months at the hospital, I was often reminded of a quote in Hermann Hesse’s book Siddhartha that exposes the folly of making plans and building upon assumptions.
“When someone is seeking,” said Siddhartha, “it happens quite easily that he only sees the thing that he is seeking; that he is unable to find anything, unable to absorb anything, because he is only thinking of the thing he is seeking, because he has a goal, because he is obsessed with his goal. Seeking means: to have a goal; but finding means: to be free, to be receptive, to have no goal.” (Hesse, 1922/1960, p. 112)
I realized that I had to stop seeking, and just be receptive to my new environment. I would have to learn to have no goal, but just to be. My colleagues in India were warm and welcoming. I was invited to sit in on as many sessions as I liked and I alternated between sessions in the Oncology and the Neurology departments. I had forgotten the casual flow of conversation in India. Initially, I had to mask my annoyance when rapport-building-conversations often included “Have you had lunch yet?” or “What did you have for breakfast today?” I had forgotten how important food is in India – food is a way of showing love, concern, affection; food is a way of connecting. I was re-learning cultural cues such as distinguishing socio-economic class from the material of a client’s saree or jewelry; of recognizing the cultural backgrounds from last names and the subtle nuances in the conversation. As I walked around the hospital, and met staff and patients, I was also trying to catch up to what India had made of herself in the past dozen years.
Initially, my colleagues and I began to work as co-therapists, with follow-up discussions about the differences between my training and theirs. We developed a healthy respect for the differences and this allowed us to learn from each other. At the end of the first month, I was (finally!) entrusted with some English speaking clients.
I was very excited about working with my first Indian client in India. However, the work was more challenging than I initially realized. Because my professional identity was so steeped in the American cultural dynamic, I struggled to learn how to work with a client from my own culture. Creating space for the Indian Rajani and the US trained Rajani to breathe the same air seemed, at the time, like an impossible task. Not only did the client and I not share the same discursive idiom, I did not have the context within which to ideally situate the therapeutic conversation. Where in the US, my status as a woman of color can help to reduce the power differential between me and the client; at the hospital, where “patients” not “clients” are referred to therapy, my status as a foreign educated professional instantly increased the power differential creating a highly unequal relationship. As a result, my clients were often uncomfortable and tongue-tied in my presence and my ability to make small-talk was limited by my command of Malayalam.
Working as a co-therapist with my Indian colleagues, on the other hand, was a much more successful endeavor. Their presence added to the clients’ comfort and my feedback was graciously sought and implemented both during and between sessions. As I began doing less and being more, letting go of projects and mental deadlines, being a curious observer and willing learner allowed things to unfold with greater ease.
Dancing at the Intersection of Culture Shock and Vicarious Trauma
By the end of the second month the frenetic pace of activity began to catch up with me. I realized that I needed to slow down but I didn’t know how to. I was not used to working a six-day week and I missed the comforts of home, my weekend rituals of curling up on the couch with a book, my favorite Thai restaurant, the ease of picking up the phone and chatting with friends. I needed detailed directions and vocabulary lessons whenever I ventured off the hospital grounds for even something as basic as buying an international voltage adaptor for my computer. I felt less independent than I was used to and it was hard to constantly ask for help.
The hospital had express rules restricting personal emails, and so I had sporadic after-hours internet access with not enough bandwidth for a Skype or real time interaction. The twelve and a half hour time difference made for a very narrow window of opportunity with regard to phone calls to friends in California. I found myself awkward and the conversation stilted when we did connect. How could I possibly begin to talk about the intensity of working and living on a hospital campus 24/7? How could I convey the depth of the pain that I saw in the faces I met each day? What words could possibly convey my feeling of sheer helplessness at the daunting task of being a helping professional in such a different environment? As a result, I was starting to get really lonely. The friends I had grown up with in India had their own lives across the span of the subcontinent and we had gotten so used to rapidly scribbled birthday cards and phone calls that we didn’t have so much to say to each other anymore. More importantly, when I said “I’m homesick.” they responded with uncharacteristic vehemence berating me for considering America my home. Even as someone who can describe the phenomenon, I missed the signs that I was experiencing “re-entry culture shock”.
I woke up one morning feeling a wave of nausea wash over me. The loneliness was overwhelming, and I just wanted to crawl under the sheets and stay there. Wearily, I got out of bed, frustrated with the noise, the heat, the dust, the smells, and the monotony of the routine. I was tired of doing my laundry in a little bucket, I hated having to walk to the mess for a meal that I ate alone surrounded by hundreds, I was tired of the curious stares I still attracted, and I had no one to talk to about how I was feeling. In addition, I couldn’t track my progress because things were so fluid. In that moment, I was ready to just give up on this project and head back to California. The only thing that held me back was that I couldn’t honestly say ‘I’ve given it my very best shot”. So I started another day at the hospital, making the four minute walk from the guest house building to the Neurology department which housed the clinical psychologists.
The day seemed to drag on and I found myself annoyed by an “enmeshed” parent-child dyad as soon as they entered the therapy room. I struggled to remind myself that their behavior was culturally appropriate, notwithstanding my American cultural bias. Next came the couple where the husband spoke for his wife, adding to my frustration about living in a male dominated society. Then came the client who was so poor that she hadn’t any sandals, but still wore gold bangles and ear-rings. It was taxing for me to wrap my head around a cultural context that was familiar to me from a long time ago and different because I saw it from a new perspective, a lens so thoroughly shaped by my American education. I found the chatter in my mind getting louder and my veneer of professionalism growing thinner. The day wore on. I could hardly wait to say goodbye to my colleagues, while simultaneously dreading the lonely evening that awaited me in my sterile guest room, while they returned home to a meal surrounded by family. I unlocked the door to my room finding a fine layer of construction dust on everything. All of a sudden it was more than I could take; the relentless heat and mosquitoes, the sameness of each meal in the hospital dining room, the covert glances and whispers as I walked by, the inability to communicate with ease, the names, faces and stories of clients, the long 6 day work weeks, followed by lonely Sundays when it seemed like I was the only one on campus. And most of all, it was the image of the patient who had died suddenly, blood pouring out of every orifice. I began to cry with a ferocity I hadn’t known I had in me. I cried myself to sleep in the dark, waking up to a new calm, a new understanding. I was standing at the crossroads where culture shock and vicarious trauma intersect, and I felt more alone than I had ever been in my life.
I was at a secret destination that had much to teach me. Recognizing the co-ordinates for the crossroad helped to organize a strategy around healing. I began to explore the physical, psychological, relational, behavioral and spiritual dimensions of well-being and paid more attention to my own needs. I started a mid-morning coffee-break routine with a colleague. I went on some weekend trips to visit family and friends. My colleagues suggested a yoga class and I began my meditation practice with a renewed interested. I began to make the time to climb to the roof of the tallest building to watch the sunset each evening. I bought a sketch pad and started creating colorful drawings. I had to re-learn how to experience awe and wonder, joy and delight, whimsy and creativity in the new environment that was both familiarand foreign.
Dancing Naked on the Bridge
My experience in India was a lesson in humility, in recognizing that some lessons are worth learning over and over again. These are some of the lessons that bear repeating for me.
First, you have to be before you can do.
Second, Self care, Self care, Self care.
Third, use all the supervision, collaboration and co-therapy you can get, recognizing them as tremendous opportunities for growth. Ask questions, ask for help, and be honest with yourself.
Fourth, acknowledge your mistakes, this is the only way to get comfortable with your authentic self.
Two months after I returned to California, I received an email inviting me to the official inauguration of the Clinical Psychology Department and its Mental Health Clinic. I also received emails from my colleagues in India acknowledging and thanking me for my efforts and support in this endeavor. By March of 2010, a proposal for a Master of Science program in Clinical Psychology was approved and the students began their coursework in August 2010. There are ongoing discussions about initiating a 1 year post-Masters certificate program in Marriage and Family Therapy to begin in 2013. That sound you hear faintly on the wind is the sound of me dancing and singing naked on the bridge!
Hesse, H. (1960). Siddhartha. (H. Rosner, Trans.). New Delhi, India: Rupa & Co. (Original work published 1922).