El constructivismo tecnológico

Irene was a 46-year-old woman of Coast Salish Indian background. She had been treated primarily for arthritis and secondarily for depression by her general practitioner, who referred her to a Euro-Canadian psychiatrist. Irene had been twice widowed and was now married to her third husband, 10 years her junior, who pursued a “native” lifestyle; he was often away hunting and fishing with his friends. Irene had five children from previous marriages

and five with her present husband. They lived on a small Coast Salish Indian reservation in the Fraser River Valley of British Columbia, Canada. Irene was struggling to keep house for her large family in an overcrowded and dilapi-dated home.

Irene was a small woman; she looked older than her 46 years. Leaning heavily on a cane, she walked slowly with obvious pain. Sitting down in the psychiatrist’s office, she crossed her hands tensely over the cane handle. Her fingers were grossly deformed by arthritis. Her face had a fearful expression;

she hardly lifted her eyes from the floor, avoiding eye contact with the ther-apist. She did not speak spontaneously; she answered questions hesitatingly, with only a few words, in a low voice, nearly a whisper. In a moment of si-lence after questions, she began to cry.

The therapist knew that, for most Indian people in the area, contact with a psychiatrist is associated with fears, or even experiences, of being apprehended by police and sent to the mental hospital, and that psychiatric interviews are commonly likened to interrogations by police officers. To make the patient feel more comfortable, it was necessary to avoid appearing as an interrogator and to show a simple human reaction to her emotional pain by giving her time to get hold of herself.

Irene was left to cry for a while to show respect for her feelings and also to give the therapist time to think of a way of putting the patient at ease.

When Irene’s crying abated, she was asked whether the arthritis caused her much pain. Her attention turned away from the routine psychiatric enquiry to medical, and therefore emotionally less threatening, problems. Irene re-sponded that the physical pain often made her cry. This was accepted as a plausible explanation to avoid any embarrassment for the patient.

For a while, the dialogue was concentrated on her chronic arthritis: how long she had already suffered, what medication she was taking, and whether she had other physical symptoms. She now readily talked about how the ar-thritis made it difficult for her to do the necessary housework. She said that she often had headaches and had a hard time sleeping at night. The psychi-atrist indicated that her general physician would be contacted in order to discuss, and perhaps improve, the treatment regimen. When the psychiatrist touched Irene’s crippled fingers and expressed astonishment about how she was able to do her housework with them, the manifestation of empathy elic-ited a quick smile from the patient.

Now Irene’s apprehension was overcome, and she could be induced to talk about her daily life. With some encouragement, she shared her worries about the children. Some of the older teenagers used street drugs and were in trouble with the police, one of her teenage daughters was pregnant, and

another had dropped out of school—a sad picture often encountered among the young North American Indian generation in this and other areas. It was rare that the youngsters ever helped Irene in the house, but all expected to be fed and have their laundry done. Irene’s husband, rarely at home, had lit-tle authority over the youngsters. Sometimes Irene would be afraid of her big sons demanding things she could not provide; their anger would keep her in a state of anxious tension.

These revelations provided enough material for further enquiry and gave the therapist a first picture of Irene’s difficult life, illustrating again the common psy-chosocial stressors facing North American Indian people who live on poverty-stricken reservations. Communicating these problems to a therapist who was listening with interest and empathy allowed the patient to find some comfort in the interview situation.

Already in the second session, which started in a more relaxed atmo-sphere, Irene related an event that seemed to be of great importance to her.

One evening not long before, when driving home, she was stopped by police because of unsteady driving. She had perhaps taken too many painkillers, and when she stumbled out of the car, the officers, assuming she was under the influence of alcohol, arrested her and placed her in the “drunk tank.” No explanation or protest helped. Overwhelmed by shame, pain, and sorrow, Irene cried in her cell. When her crying turned into a strange sing-song, the officers thought she was mentally disturbed and expedited her to the mental hospital, where she was diagnosed to have a psychotic depression. Within 2 weeks, and after a few electroshock treatments, she was discharged home, feeling even more upset than before.

Having listened to Irene’s recent experience at the police station and the men-tal hospimen-tal, when she first felt stereotyped as a “drunken Indian” and then was taken for a “crazy person” in another humiliating encounter with “white” au-thority figures, the psychiatrist knew Irene would have to be helped to overcome the resistance she was bound to feel toward a non-Indian therapist. She would have to be encouraged to express her pent-up frustration and resentment and, in spite of her anger, to feel fully accepted as a person by the psychiatrist, before a meaningful therapeutic relationship could be established.

During the weekly sessions that followed, Irene became much more re-laxed. The sessions always began with the psychiatrist inquiring whether the prescribed antidepressant and anxiolytic medication had brought some re-lief. Such inquiries helped Irene to overcome her initial apprehension. Irene was then able to speak about her deep hurt and anger when she was unjustly accused of being drunk and taken into custody. She emphasized that she had never been drunk in her whole life, although she had been under pressure,

first by her mother, and then by her husbands, sons, and other relatives, to join drinking parties. Tearfully, Irene related that she had been unable to make the mental hospital staff understand that her singing in the police cell was not a sign of mental disturbance, but a “spirit song,” which had forced itself over her lips as an expression of her hurt. The electroshock treatment did not take away the spirit song as she actually had hoped: “That treatment made me forget nice things and left me with what I wanted to forget.” She therefore considered the treatment to be a kind of punishment.

The psychiatrist felt it was too early in therapy to take up the topic of the spirit song that Irene had indicated she rather wanted to get rid of. The patient’s full confidence would have to be won before an issue touching upon the secrets of Indian spirit power could be discussed. Even in the area of the Coast Salish In-dians, only a few non-Indian people are well informed about the winter spirit dances, which were the most important ceremonials of traditional aboriginal cul-ture. In the past, the Christian missionaries had actively discouraged, and the government had officially outlawed, these “pagan rituals” as incompatible with Christianity and “civilization.” The psychiatrist knew that if Irene were to ac-cept her spirit-song power, she would, according to native tradition, be expected to participate in the arduous process of being initiated into the revived traditional Salish winter spirit dances. In Irene’s case, this would be very difficult, not only because of her crippling arthritis but also because of the Western education and Christian teaching she had absorbed, and with it a general distaste of so-called

“primitive Indian ways.” In the following sessions, she was, therefore, encour-aged to tell her life story.