Topics in International Psychiatry: Bilingualism and Biculturalism in Psychiatry

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SECOND THOUGHTS

After a long and eventful summer break, I returned to my “Second Thoughts” column with a new charge. At the American Psychiatric Association Annual Meeting in Los Angeles in May, I presided as the newly-appointed Chair of APA’s Council on International Psychiatry and Global Health (CIPGH), following the successful tenure of Pamela Collins, MD, MPH, as immediate past chair. This position reflects my core commitments as a psychiatric physician with my involvement in the global mental health (GMH) movement, social and cultural psychiatry, and international medical graduates (IMGs).

In my last column, “America Is in the World, the World Is in America,” I offered an overview of the CIPGH and my goals for the work of the Council during my tenure as Chair. Now, I would like to turn to a very relevant but sadly neglected topic in international psychiatry.

Reflections on Bilingualism and Biculturalism in Psychiatry

When I was a member of the CIPGH in the past, I was invited to present on bilingualism and biculturalism in psychiatry, a subject that reflects my practice as an Italian Canadian working in the multicultural environment of Montreal. Here are the highlights of that talk which represents my focus as Caucus Chair on the challenges and contributions of the IMGs among us.¹

Are Bilingualism and Biculturalism Advantages or Hindrances?

There is a Spanish proverb that says that a person with 2 watches never knows the time. Is this also true of language and culture? Does having more than 1 linguistic and cultural base confuse, conduce to relativism, and undermine our values and verities? Or rather, does having 2 ways of measuring time or ways of talking and living in the world (which is what culture is) enrich us and expand our possibilities?

Of course, I can only speak for my experiences as a bicultural person and as a cultural psychiatrist. There are 2 maxims that I follow, each of which is true, and yet are at odds with each other:

• “Addition, not substraction,” by which I mean that I feel enriched rather than diminished by new experiences and possibilities.
• “For every door that opens, another one closes,” by which I mean that any real experience, real change—what philosopher Alain Badiou calls an “event”—involves recognition and naming of the event, and fidelity to that event, all of which require that we make choices and those open up new avenues but may shut down others.²

So, can we be radically open to new experiences and construe them as additions to our lives or, in living an event that gives structure and meaning to our lives, do we become more focused and selective?

Liminality, Threshold Being—“Limology”

There is no present in Montreal. Only the past claiming victories….

Each man speaks his father’s tongue.

– Leonard Cohen, The Favourite Game³

I am faced with these questions daily. In Leonard Cohen’s bildungsroman about a Jewish youth coming of age in Montreal, he described the echoes of long-ago wars of conquest between the English and the French on his present-day city. In Montreal, navigating between the 2 major linguistic and cultural communities of French and English, many of us dance a kind of “linguistic tango,” obliging us to identify ourselves and each other as anglophone or francophone. In our provincial jargon, I am neither or both: I am an “allophone.” In Canada, “allophone” is a term describing someone whose first language is neither English nor French.⁴ When it comes to language and identity in Canada, as the Facebook option for relationships declares, “It’s complicated!”

Another way of straddling cultures is through professional training. Along with many other psychiatrists in North America, I trained first in psychology then in psychiatry and have a keen interest in the relations between the 2 fields. Many colleagues also trained in other clinical professions, from nursing to pharmacy to social work. Can people with dual training (or more) ever wholly identity with one discipline or another? On the other hand, it helps to work in interdisciplinary teams if through our training we are accustomed to the value of dual or multiple perspectives.⁵

I want to cite a portrait of one of the most complex figures in the history of thought, the man we call “Spinoza.” In fact, and this already illustrates the issue, he went by many versions of his name—as Bento de Espinosa, the son of Portuguese Marrano parents who had migrated to Amsterdam, whose first name means “blessed” in Portuguese; as Baruch Spinoza in the Hebrew version of his first name, in the Sephardic Jewish community of Amsterdam; and finally, as Benedictus or Benedict de Spinoza in Latin, after his excommunication and expulsion from the Amsterdam Jewish community.⁶ In the history of thought, he is great enough to be known simply as “Spinoza.” What is special about Spinoza is that not only his thought but his life straddles cultures, so much so that we may see him as one of the first “modern” persons, whose life history and whose work reads like that of a contemporary citizen.¹

Spinoza is most contemporary as an exemplar of what Italian philosopher Giorgio Agamben calls the “state of exception”—a state in which one has no status as a citizen.⁷ Like countless asylees and refugees, the state of exception describes what has become the norm for millions of migrants around the world.⁸ Spinoza was, above all, a liminal person straddling cultures. As such, we see in him the courage to confront his liminality, on the threshold between one notion of being a Jew and a citizen and another, emerging view that is emblematic of today’s multilateral, pluralistic world. Here is how Israeli philosopher Yirmiyahu Yovel, captures Spinoza’s liminality in his authoritative study⁶:

It is not hard to understand how a man who is neither a Christian nor a Jew, but who is divided between the two or who possesses memories of one within the other, might be inclined to develop doubts about both, or even to question the foundations of religion altogether.

Spinoza is the model of the contemporary liminal person and represents a major human, cultural, political, and health care phenomenon: the figure of the migrant.⁹ American philosopher Thomas Nail^9,10 has a bold new way of looking at migration not as the exception, but as the rule in human history. He calls for limology, the study of those I have called “threshold people,”¹¹ and calls the study of the consequences of borders and migration kinopolitics, a political theory of movement.¹⁰

Training, Culture, and Comparative Perspectives

When we think about and practice psychiatry through more than one perspective, does this enrich our work? In his classic, Comparative Psychiatry, HBM Murphy¹² which he defined as “the international and intercultural distribution of mental illness,” does not talk about the culture of the psychiatrist and the comparison he documents is rather an epidemiology of psychopathology across cultures. This is a worthy goal in itself. So, while Murphy and others in the founding generation of social and transcultural psychiatry were interested in different social and cultural manifestations of mental illness, they still saw psychiatry through a universalist perspective which overlooks the psychiatrist as a person from a given culture with a specific and often very local perspective. Even the GMH movement^13,14 has not escaped this universalist assumption and consequently has been criticized.^15-17

We experience this dilemma from the beginning of our training. In psychology, psychiatry, and psychotherapy there was much talk during my training years first of the therapy wars (within psychoanalysis, among the psychotherapies, between individual psychotherapy and family or group therapies, not to mention psychotherapy vs behaviour therapy vs cognitive therapy, and all their offshoots), competing frameworks (psychodynamic psychiatry vs biological psychiatry vs community psychiatry vs neuroscience), then of eclectic approaches (“atheoretical” like DSM-III), and some bold souls attempted integrations (like cognitive behavioral therapy), and even overarching theoretical and clinical frameworks (eg, the biopsychosocial model,¹⁸ social neuroscience,¹⁹ GMH¹⁴). How do trainees, faced with these competing perspectives, manage to integrate them into a coherent framework and congruent practices? It often feels like we are talking different languages referencing different underlying cultural frameworks in psychiatry, leading to a cacophony with no consensus as to how we define persons (psychology, for the sake of argument), a theory of psychiatry, and a theory of change.²⁰

The Psychiatrist as a Model of Cultural Adaptation for Our Patients

• How are cultural encounters and cultural integration imagined? See my analysis of negative and positive conceptions of cultural encounters: “Shock, trauma, anxiety” vs “surprise, discovery, enchantment.”^21,22
• How do we think of culture change and cultural adaptation? See Canadian psychologist John Berry on acculturation^23-25; Di Nicola on culture change and cultural adaptation.^21,22
• What does culture mean for psychiatry today? See the cultural formulation and the cultural formulation interview, integrated into the DSM-5.²⁶

Implications for Bilingual and Bicultural Psychiatrists and IMGs

What happens when someone comes from a traditional or conservative culture to a culture that values more diversity and multiplicity of approaches?

Policy-Making and Advocacy

Does psychiatry have a political agenda? Should it? Why or why not?²⁷

One of the 4 major tasks of our field is health care policy and advocacy, along with clinical, academic and research tasks. One of the problems for bicultural people can be the dual loyalty charge which makes it difficult sometimes to advocate for policies when our own commitments are questioned.

Personal Narratives

Beyond my work as a child and adolescent psychiatrist, my own expertise is in cultural psychiatry and GMH. After my training in transcultural psychiatry at McGill, I have a career-long commitment to these issues in our field but personal issues are much less discussed. These include the person of the therapist, the controversial issue of self-disclosure, and the choice of theoretical framework and clinical models integrating both evidence-based²⁸ and values-based practice in health and social care.²⁹

Identity and Belonging

More profoundly than our professional training, these questions touch on issues of identity and belonging, on several levels: personal, cultural, and professional. Also, as part of the Freudian legacy of the analyst as a “blank screen,” there has been a tendency for the psychiatrists to suppress or keep from view their own identity and positions on matters from policy to politics, not to mention identity and integration.

Personal and Professional Integration

And yet we know that many countries, certainly the US and Canada, have received many immigrants who came as children and subsequently trained here or came as already trained medical specialists. How these people negotiated their entry into the mainstream culture and how they establish their credentials and their practices is something we can profitably discuss now.

Training and Working Abroad, Coming Home

There is also the variant where someone is native-born in our countries but pursues studies elsewhere for advanced training or later, to do international consulting. The cultural and political problems of NGOs are discussed by French physician-anthropologist Didier Fassin in his critique of Humanitarian Reason.³⁰ In this case, the challenge is to integrate the knowledge and skill-set from another health care system and culture and for the psychiatrist to reintegrate into their culture of origin.³¹

Concluding Thoughts

A 2015 editorial noted that, “It is estimated that by the year 2050, Latinos will make up half of the nation’s population.”³² If for no other reason, as the editorial observed, “the wave of immigrants over the last decade has resulted in a greater need for bilingualism and biculturalism in the clinical setting.” For communication, for empathic understanding, for nuanced cultural formulations, and for better service delivery, we must study and promote bilingualism and biculturalism for all the cultural communities that we serve.

Resources

• APA Council on International Psychiatry and Global Health. https://www.psychiatry.org/about-apa/meet-our-organization/councils/international-psychiatry
• More information on the Council on International Psychiatry and Global Health (CIPGH) is available by contacting Ricardo Juarez at rjuarez@psych.org.

Select Bibliography on Bilingualism and Biculturalism

• Arnett JJ. The psychology of globalization. Am Psychol. 2002;57(10):774-783.
• Augustin J. Biculturalism: its implications for the family system. Mako: NSU Undergraduate Student Journal. 2012;4(1).
• Bhugra D, Mastrogianni A. Globalisation and mental disorders. Overview with relation to depression. Br J Psychiatry. 2004;184:10-20.
• Castro J, Rudmin FW. Multinational bibliography on acculturation (1808-2020), with URL links to abstracts or full-text. Online Readings in Psychology and Culture. 2020;8(1).
• Eytan A. Globalisation and biculturalism. Br J Psychiatry. 2004;184(4):362-363.
• Grosjean F. How cultures combine and blend in a person. Bilinguals who are also bicultural. Psychology Today. May 9, 2011. Accessed September 15, 2025. https://www.psychologytoday.com/blog/life-bilingual/201105/how-cultures-combine-and-blend-in-person
• Grosjean F. Advantages of being bicultural. Biculturals show greater creativity and professional success. Psychology Today. April 19, 2013. Accessed September 15, 2025. https://www.psychologytoday.com/blog/life-bilingual/201304/advantages-being-bicultural
• LaFromboise T, Coleman HLK, Gerton J. Psychological impact of biculturalism: evidence and theory. Psychol Bull. 1993;114(3):395-412.
• Paradis M. Bilingualism and neuropsychiatric disorders. J Neurolinguistics. 2008;21(3):199-230.
• Rivera-Sinclair EA. Acculturation/biculturalism and its relationship to adjustment in Cuban-Americans. Int J Intercult Relat. 1997;21(3):379-391.
• Tadmor CT, Galinsky AD, Maddux WM. Getting the most out of living abroad: biculturalism and integrative complexity as key drivers of creative and professional success. J PersSoc Psychol. 2012;103(3):520-542.
• Yamada A-M, Singelis TM. Biculturalism and self-construal. Int J Intercult Relat. 1999;23(5):697-709.

Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry & addictology at the University of Montreal. He is also clinical professor of psychiatry & behavioral health at The George Washington University and president of the World Association of Social Psychiatry (WASP). Dr Di Nicola has received numerous national and international awards, honorary professorships, and fellowships. Of note, Dr Di Nicola was elected a Fellow of the Canadian Academy of Health Sciences (FCAHS), given the Distinguished Service Award of the American Psychiatric Association (APA), and is a Fellow of the American College of Psychiatrists (FACPsych) and Fellow of the Royal Society of Canada (FRSC). His work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s publications include: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021).

References

1. Di Nicola V. “Reflections on bilingualism and biculturalism in psychiatry.”Council on International Psychiatry, American Psychiatric Association, Washington, DC, September 15, 2017.
2. Badiou A. Being and Event. Feltham L, trans. Continuum; 2005.
3. Cohen L. The Favourite Game. Secker & Warburg; 1963.
4. Noakes T. Allophone. The Canadian Encyclopedia. Historica Canada. January 22, 2020. Accessed September 15, 2025. https://thecanadianencyclopedia.ca/en/article/allophon
5. Lomax JW, Kripal JJ, Pargament KI. Perspective on “sacred moments” in psychotherapy. Am J Psychiatry. 2011;168(1):12-18.
6. Yovel Y. Spinoza and Other Heretics. Volume I: The Marrano of Reason. Princeton University Press; 1989.
7. Agamben G. State of Exception. Homo Sacer II. Attell K, trans. University of ChicagoPress; 2005.
8. Di Nicola V. States of exception, states of dissociation—cyranoids, zombies and liminal people: an essay on the threshold between the human and the inhuman. In: Letters to a Young Therapist. Atropos Press; 2011:149-162.
9. Nail T. The Figure of the Migrant. Stanford University Press; 2015.
10. Nail T. Theory of the Border. Oxford University Press; 2016.
11. Di Nicola VF. A Stranger in the Family: Culture, Families, and Therapy. W.W. Norton & Co; 1997.
12. Murphy HBM. Comparative Psychiatry: The International and Intercultural Distribution of Mental Illness. Springer-Verlag; 1982.
13. Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet. 2007;370(9590):859-877.
14. Patel V, Prince M. Global mental health: a new global health field comes of age. JAMA. 2010;303(19):1976-1977.
15. Mills C. Decolonizing Global Mental Health: The Psychiatrization of the Majority World. Routledge; 2013.
16. Mills C. From ‘invisible problem’ to global priority: the inclusion of mental health in the sustainable development goals. Dev Change. 2018;49(3):843-866.
17. Watters E. Crazy Like Us: The Globalization of the American Psyche. Free Press; 2010.
18. Ghaemi SN. The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry. The Johns Hopkins University Press; 2009
19. Cacioppo JT. Social neuroscience: understanding the pieces fosters understanding the whole and vice versa. Am Psychol. 2002;57(11):819-831.
20. Di Nicola V, Stoyanov D. Psychiatry in Crisis: At Crossroads of Social Sciences, the Humanities and Neuroscience. Springer Nature; 2021.
21. Di Nicola VF. A Stranger in the Family: Culture, Families, and Therapy. W.W. Norton & Co; 1997.
22. Di Nicola V. Family, psychosocial, and cultural determinants of health. In: E Sorel, ed. 21^st Century Global Mental Health. Jones & Bartlett Learning; 2012:119-150.
23. Berry JW. Immigration, acculturation, and adaptation. Applied Psychology. 1997;46(1):5-34.
24. Berry JW. Psychology of acculturation. In: JJ Berman JJ, ed. Nebraska Symposium on Motivation, 1989: Cross-cultural Perspectives. Current Theory and Research in Motivation, Vol. 37. University of Nebraska Press; 1990:201-234.
25. Berry JW, Kim U, Minde T, Mok D. Comparative studies of acculturative stress. International Migration Review. 1987;21(3):491-511.
26. Aggarwal NK, Lewis-Fernández R. An introduction to the cultural formulation interview. Focus (Am Psychiatr Publ). 2020;18(1):77-82.
27. Di Nicola V. “Do Social and Transcultural Psychiatry Have a Political Agenda? Should They?” Culture & Mental Health Research Unit Meeting, Division of Social & Transcultural Psychiatry, McGill University, Montréal, QC, February 20, 2020.
28. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312(7023):71-72.
29. Fulford KWM, Peile E, Carroll H. Essential Values-Based Practice: Clinical Stories Linking Science with People. Cambridge University Press; 2012.
30. Fassin D. Humanitarian Reason: A Moral History of the Present. University of California Press; 2011.
31. Prince R. Mental health workers should be trained at home: some implications of transcultural psychiatric research. Afr J Psychiatry. 1972;2:277-282.
32. Carreon I. Editorial: Bilingualism and biculturalism in the clinical setting. International Journal of Mental Health and Psychiatry. 2015;1:1-2.