Reconsidering culture, attachment, and inequality in the treatment of a Puerto Rican migrant: Toward structural competence in psychotherapy

Abstract

Cultural competence refers to our ability to understand, engage, and treat patients from diverse backgrounds or belief systems different from our own. Although addressing culture and cultural difference as part of diversity is important, it is also critical to consider how systemic and economic forces influence the patient's presenting problem and clinical interactions. Summarizing research on cultural competence, attachment, and inequality, this paper reconsiders diversity considerations by discussing how structural inequities disrupt one's ability to trust others interpersonally and across cultural difference. Psychotherapy from this point of view is a relationship that attempts to address the effects of inequality at an individual level by repairing trust and using that trust to work toward change. To illustrate this perspective, the author presents a case of a Puerto Rican migrant whose developmental and family history was impacted by colonial, racial, cultural, and socioeconomic inequality. K E Y W O R D S cultural competency, cultural humility, inequality, Latinx, psychodynamic psychotherapy, Puerto Rico "Superiority? Inferiority? Why not the quite simple attempt to touch the other, to feel the other, to explain the other to myself? Was my freedom not given to me then in order to build the world of the You?" (Fanon, 1952/2008, p. 181) Frank (Pseudonym): Hi, Doctor… Gaztambide? [He pronounced it: "Gas-tum-bide"] DG: Hi, Frank? Yes, this is Daniel Gaztambide [I pronounced in Spanish: "Da-nielle Gaz-tam-bee-day"], returning your call. Frank: [In Spanish) But doctor… you're Puerto Rican? DG: [In Spanish) Yes, from San Juan. Frank: Ah, [Pause] de area metro./Oh, [Pause] from the metro area. Frank/DG: [Silence].Frank: [In Spanish] En ese caso, Francisco a la orden!/In that case, Francisco, at your service! Upon hearing my name pronounced over the phone with a distinct island-born Puerto Rican accent, there was a shift in "Frank's" tone. The weight of a strange, foreign name gave way to familiarity, inquiring with curiosity and warmth as to whether I was Puerto Rican. When I added I was from San Juan, the capital and center of the Area Metropolitana or "Metropolitan Area," this triggered another shift in Frank. A distance opened up, an "Ah" pregnant with suspicion and contempt. I noted this rapid oscillation in affect as silence punctuated the space between the said and the unsaid. Then, as if something slid out and then back into place, "Frank" became "Francisco," the distance between us morphing into a familiar and almost deferential tone-"at your service!"Once engaged in treatment, I would come to find out that Francisco was born and raised in a small town in what we called la isla-"the island" as shorthand for the Puerto Rican countryside. This would turn out to be an ambivalent appellation, signaling that the capital and broader metropolitan area were somehow separate and distinct from the rest of the island, which existed "out there" beyond the city limits. The metropolitan area served as the economic and po...

“What surprised me is that they try to humiliate me”: Conceptualizing the role of colonial power dynamics and logics in Puerto Rican postmigration experiences.

“…Together, embracing resistance and creating opportunities for group solidarity allows the community to envision new possibilities for living and formulate new strategies to rebalance power (Moane, 2003; Montero, 2009). For example, when describing his psychotherapeutic work with Puerto Ricans, Gaztambide (2019) describes how challenging colonial power dynamics and logics that lead to inequality, intergroup conflicts, and psychological distress in turn allows clients to experiment with new ways of thinking, reasoning, and behaving. Finally, the ethnopolitical psychology framework calls on psychologists to take part in political movements and actions (e.g., proposing legislation) that advances freedom for oppressed communities.…”

¿Pa ‘rriba o pa ’bajo? Upward mobility, anti‐Blackness, and the independence question among Puerto Ricans in NYC: A decolonial psychoanalytic study

“…We conceptualize this as a broader discourse that “speaks through” us, enacted through dissociated, conflicted self‐states existing side by side (Tummala‐Narra, 2016). Given the mental health impact of colonial mentality (Capielo Rosario, Schaefer et al., 2019), our psychotherapeutic recommendation is to attend to speech that enacts colonial self‐states and facilitate reflection upon them (Gaztambide, 2019b). Based on our observations in this study, a free associative process may likewise facilitate the emergence of these associations in treatment (see Gaztambide, 2024 ).…”

Working toward anti-racist perspectives in attachment theory, research, and practice

“…Many excellent ideas for anti-racist clinical practice have been proposed (see, e.g. Coard et al, 2004;Gaztambide, 2019Gaztambide, , 2021Kelly et al, 2020;Legha & Miranda, 2020;Maiter, 2009); further, a social justice framework is central to many models of counseling psychology (Hargons et al, 2017), social work (International Federation of Social Workers et al, 2012, and community psychology (Nelson & Prilleltensky, 2010). Here we highlight two themes of particular relevance to attachment-informed interventions.…”