Cross-Cultural Addiction Psychiatry: An Interview with Dr. Joseph Westermeyer, MD, PhD

One of the pleasurable discoveries within my explorations of the literature of addiction psychiatry has been the work of Joseph Westermeyer, MD, PhD. That discovery was made many years ago while first researching the history of addiction recovery within American Indian communities. Dr. Westermeyer’s studies were among the first to expose the “firewater myths” that had long pervaded the portrayal of alcohol problems among American Indians and were among the first to delve into cultural pathways of addiction recovery. His work exerted a profound influence on the book Alcohol Problems in Native America: The Untold Story of Resistance and Recovery (Coyhis & White, 2006). Since writing the book, I have become a student of his prolific body of contributions. I recently had the opportunity to interview Dr. Westermeyer about his life and work. Please join us in this engaging conversation.  

 

Early Career  

 

Bill White: Dr. Westermeyer, you completed your early medical education in the early 1960s. How would you describe medical education about addiction during that time period?

 

Dr. Westermeyer: During the first two years of basic science education, it was pretty minimal. We did learn about the metabolism of alcohol and how alcohol fit into the metabolic cycles. We learned about the physical pathologies associated with alcohol dependence and with drug abuse. We learned a fair amount in terms of the basic physiology and pathology. We didn’t learn much about the behavioral concomitants, the addiction sequences that occur. And there wasn’t much yet known back then about the neurotransmitter roots of addiction. By the same token, in the third and fourth years of medical school, we were exposed to a tremendous number of clinical experiences with people who were actively addicted to alcohol or other drugs. There was a marked discrepancy between the relatively focused and minimal information that we had during the first two years, probably adding up only to a few dozen hours, and the huge amounts of exposure we had to those conditions clinically, which would have amounted to hundreds of hours.

 

Bill White: Yeah. In the late 1960s, you returned to school to pursue degrees in specialty training in anthropology, public health, and psychiatry. What spurred your interest in those areas?

 

Dr. Westermeyer: This interest grew out of my experiences in medical school as well as in general practice. For example, my first patient when I was in medical school in my third year was an American Indian man who was a veteran of World War II of a notable battle in the Pacific (i.e., Tarawa). A schoolteacher, he was dying of cirrhosis of the liver. So, that event had an effect on me. While I was in general practice, I continued to see people with alcohol and drug problems. 

My general practice in St. Paul exposed me to three major communities. One was a combined French-American and American Indian community whose members had ties to reservations. The second was a Scandinavian group, who, unlike many Scandinavians, weren’t Lutherans. They were Baptists who had fled Scandinavia during pogroms against that group around 1900. The third community was Polish Catholic. The ways in which these different communities manifested their behavioral and family problems was of great interest to me and stimulated my taking anthropology courses on my afternoon off—a common custom during that time when medical practice involved being available 24/7. 

 

Bill White: If I recall, you were also involved in Southeast Asia during that period. Is that correct?

 

Dr. Westermeyer: Yes, that was after three years in general practice. I had completed my course credits for a master’s in anthropology, and I was interested in having a total cross-cultural experience. I looked at a variety of options and ended up going with the US Agency for International Development to Laos for two years as a primary care clinician. Part of my role involved public health programs and that got me interested in public health as a venue to improve people’s health.

 

Addiction Specialization  

 

Bill White: How did you move from that focus to the more specialized area of treating addiction?

 

Dr. Westermeyer: I entered a psychiatry residency at the conclusion of my two years in Laos. The program at the University of Minnesota fostered people working on a master’s degree while they did their residency program, which might vary from three to four years on average. I returned to the University of Minnesota as a graduate student in anthropology and also matriculated as a graduate student in public health. I finished my public health training toward the end of my residency.

 

Bill White: You were part of a vanguard of physicians and psychiatrists involved in NIDA and NIAAA’s Career Teacher Program. Could you describe that program from your perspective and its significance within the history of modern addiction medicine?

 

Dr. Westermeyer: For me personally, that came at an excellent time in my career. I had finished my residency program three years earlier and had been a junior staff member in the Department of Psychiatry at the University of Minnesota. I had begun to do some research on my own, and had returned to Laos on three occasions by then. My career was just beginning to take root, and then the opportunity arose to join this consortium of people from around the country who were brought together by the National Institutes of Health. It was a boon to me personally because I got to meet people who were interested in addiction at a time when there were very few people at my own institution who shared this interest. We met about four times a year for a week at a time and, in the first year, spent about three months at one or another facility that was involved with addiction care. Through the Career Teacher Program we came to know one another and had our interests in addiction treatment supported. It was a tremendous opportunity for many of us as individuals, but it also was a great advantage for the country and for medical education at large. This was the beginning of formalizing many guilds or professional organizations that took root among these early “career addiction fellows.”

 

Bill White: It seems that the early roots of a professionalized field of addiction medicine date to this program and that period of time.  

 

Dr. Westermeyer: Yes, the first formal organization that came out of that Career Teacher Program was a group called the Association for Medical Educators and Researchers on Substance Abuse (AMERSA). That group continues today. It’s been in existence for over three decades. Two other groups influenced by the Career Teacher group were the American Association for Addiction Psychiatry, later rechristened the American Academy of Addiction Psychiatry and the American Medical Society for Alcoholism that later became the American Society for Addiction Medicine. From the beginning, the Career Teacher Program wasn’t focused just on psychiatrists; it also had family practice people, internists, pediatricians, psychologists, and basic scientists involved.

 

Cultural Psychiatry   

 

Bill White: You became interested in cultural psychiatry at a time psychiatry was evolving from psychoanalysis and psychotherapy to biological psychiatry and psychopharmacology. How did you swim upstream against this trend and develop a focus on cultural psychiatry?

 

Dr. Westermeyer: Initially, I found people at the University of Minnesota as a graduate student and as a resident, and later when I was in general practice and in Laos, who were willing to help and support me along the way. Two were psychiatrists, the chief of the service, and a psychopharmacology researcher (i.e., Drs. Donald Hastings and Bertrum Schiele), who eagerly supported my interests. And I’m not sure why, looking back on it. Neither of them had a background or even an interest in culture. One was an analyst and psychotherapist; the other was a psychopharmacologist. It may have been a time when academic psychiatrists were more willing to foster diverse explorations in the field, as compared to the more recent trend to help only those with one’s own special interests.

 

Three or four years out of my residency, mostly through the American Psychiatric Association, I found that there were other people like myself—young psychiatrists who had been in the Peace Corps or who had worked in ghetto settings or who had been in the Indian Health Service or who had themselves grown up in other societies around the world and immigrated to the United States. There were also those who grew up in minority neighborhoods, African-American, American Indian, Hispanic neighborhoods, or who had come to the United States as refugees, oftentimes during childhood. These people were writing and researching. We would submit our articles to the American Psychiatric Association for its annual meeting and we’d be put in the same symposium of a morning or an afternoon, so we came to know one another and to learn from one another. We started an organization, of which I was a founding member, called the Society for the Study of Psychiatry and Culture, which still exists.

 

Bill White: Did your focus on cultural psychiatry ever stand as an obstacle for you within the larger field of psychiatry?

 

Dr. Westermeyer: My first reaction is to say, “Absolutely not.” And I think that’s true on a local level where people knew me. I was the president of the Minnesota Psychiatric Association on a few different occasions and always got a lot of support. Never did anybody take my cultural interest as a thing against me. But on a national level, other psychiatrists have been suspicious not only of myself, but other psychiatrists with cultural interests. I think we have to find some way of coping with that. Many people in the Society for the Study of Psychiatry and Culture should be national leaders in psychiatry, but they’re not. There was a time when another cultural psychiatrist and I were put up for a national office in the American Psychiatric Association and a group of psychiatrists started a write-in ballot to make sure that neither of us was elected. I can’t help but think that our identity as cultural psychiatrists was offensive to them. For another example, I was the newsletter editor for the Addiction Psychiatry group for many years, and on one occasion, I wrote an editorial on statecraft in addiction, taking into account my years of experience with the World Health Organization and having seen countries either get deeper into addiction or dig themselves out of their severe addiction problems. In that newsletter article, I made observations about ways in which the United States had done both productive and unproductive things to address the problem. The Steering Committee saw that editorial as a political liability, and the following month, they asked me to step down. Cultural psychiatrists tend to take on issues that can make some of our peers in psychiatry uncomfortable.

 

Bill White: What are some of the important lessons you’ve drawn from your cross-cultural explorations that would be important for front-line addiction counselors?

 

Dr. Westermeyer: I recommend Perti Pelto’s guideline to inundate yourself in the culture, particularly if it is an unfamiliar culture that you are entering. If it was your own culture, you have to inundate yourself in subgroups within that culture so that you weren’t blinded by your own idiosyncratic experiences. It’s virtually impossible for any one individual to be fully enculturated into any and all aspects of their own culture, particularly if that culture has any complexity to it. So, the first step is inundating yourself, spending a year or two in that culture, and going into it with a fairly open mind. Then, the second step would be to choose some topic or question of interest that you are willing to devote yourself to and learning more about it in the context of the culture. The third step in this scenario is to undertake research, using both qualitative and quantitative questions. The qualitative questions give you a skeleton and a foundation and the quantitative questions add flesh and muscle and nerves to whatever it is that you are studying.

 

Bill White: So you must enter work within these cultures as a student rather than as a teacher? 

 

Dr. Westermeyer: Exactly!

 

Bill White: One area of great interest to me is the collection of papers you’ve done on the history of alcohol problems among American Indians and particularly, the firewater myths that have pervaded that history. Could you recap some of those myths and what you’ve since learned about alcohol problems and their resolution in American Indian communities?

 

Dr. Westermeyer: The lessons were from American Indian communities here in the United States, but also in communities beset with opium addiction in Asia. Those interests grew out of my clinical experience. When I first began these explorations, there was the prevalent concept in American Indian communities as well as in communities in Southeast Asia that alcohol use in the former and opium use in the latter were not significant problems. They were portrayed as a resource that could help people relax, give them time out, and help them with recreation. Alcohol or opium relieved boredom or pain, and any problems related to such use were considered minimal—those were the prevailing viewpoints at the time. This notion of denial, first of all, held that there wasn’t a problem. Second, if you provided contrary information drawn from clinical experience or epidemiologic studies, this information would be minimized: “Yes, there is a problem, but it’s a small one.” These were the attitudes of the movers and the shakers of the society who were in a place to do something about it. Third, if you got them to turn the corner by showing them epidemiological data and said, “Yes, there is a pretty serious problem if ten percent of our people have this addiction,” then they would say, “Well, but this isn’t our problem; other people brought this poison to us,” or “This is not what we were like before this thing happened and now we’re changed. We didn’t do this to ourselves, somebody else is to blame. Somebody else has to solve the problem.” In sum, the early denial of a problem was followed by minimization, and then by projection of responsibility for the problem being somewhere else. Sometimes, a community leader might say, “Well, this is your problem as a clinician, but it isn’t my problem as a community leader.” Or a teacher would say, “It’s your problem as a doctor, not my problem as a teacher.” So, there are these three elements of denial, minimization, and projection that you have to recognize at a basic cultural level before you can do anything beyond what we can accomplish as clinicians.

 

Bill White: One of the firewater myths is that American Indians have a biological vulnerability that makes alcoholism almost inevitable. This is in sharp contrast to more recent analyses that place the roots of alcohol problems in Indian communities within historical or cultural influences. How have you reconciled these views? 

 

Dr. Westermeyer: Biological vulnerabilities do exist across individuals. Studies among American Indians and other groups show individual differences in metabolism and in vulnerability. However, the individual differences within any one culture greatly exceed the rather small differences that occur from one culture to the next. I don’t want to ignore biological influences, but to ascribe this complex behavior solely to biology is an oversight.

 

Cultural, social, psychological, and familial characteristics are the domineering factors at the root of these problems. Biological factors provide the instrumental means by which these conditions are made manifest. In societies with very low rates of addiction, those folks who lose contact with their cultural roots have rates of alcoholism as great, sometimes even greater, than people that have already high rates of alcoholism. Culture and society really have been neglected as being potent carriers of the etiologies of alcoholism. By the same token, addiction involves physical processes along with psychobehavioral and sociocultural processes. Genetic components likewise play a role, but sociocultural factors can facilitate addiction in those with minimal genetic predisposition, or prevent addiction in those with high genetic propensity to addiction. But we can say that about virtually all of the psychiatric disorders that we treat— depression, anxiety, and other physicopsychological conditions—vary tremendously from one society to the next because of the basic sociocultural-familial characteristics that trip them off and make them manifest.

 

Bill White: Did your work in American Indian communities and in Laos inform your later interest in addiction problems among immigrants and migrants?

 

Dr. Westermeyer: I’ve been interested in how some groups have been able to reduce their substance disorders with migration or immigration, while other groups have the problems continue or worsen. Following immigration, some ethnic groups have developed alcohol problems in just the way that alcoholism developed among many American Indian tribal groups. Opium-smoking developed among some but not all cultures in Southeast Asia following immigration to the United States.

 

Evolution of Addiction Treatment  

 

Bill White: You’ve worked for more than four decades in that field of addiction treatment.  What do you think are some of the most important historical milestones within addiction treatment over the course of your career?

 

Dr. Westermeyer: Perhaps, the most momentous thing I’ve seen take place is how national, state, and community leaders outside of clinical medicine have begun to pay attention to addiction. The involvement of community leaders, religious leaders, educational leaders, police departments, and the judiciary have created a social redefinition of the problem. Now we have drug courts. Instead of sending all criminal addicts away to prison, drug courts work with them to try and reverse their addiction. Many American Indian tribal leaders now will readily say addiction is one of their biggest problems. A few decades ago, the American Indian leaders in Alaska, for example, decried a clinical investigator who called attention to the widespread alcohol abuse in Alaska. And now, I don’t think you’d find a leader in Alaska who would deny that this is a major problem that he or she would have to address in their role as a community leader. Many religious leaders have picked this up. Educational disinterest is one weakness that remains, especially the college addiction problem. Many colleges around the United States have huge problems with alcohol abuse that unfortunately are not being resolved because educational leaders don’t feel empowered or imbued with the notion that they can and need to do something about it. Or they minimize the problem by simply hiring a counselor to take care of this, but don’t see it as something that their entire faculty, in all of their courses, and all of their students need to take to heart.

 

Bill White: What are your thoughts about the past, present or future role of psychiatry in the treatment of addictions?

 

Dr. Westermeyer: We’ve been trying to share this problem with more and more people and I think we’ve succeeded. The American Society for Addiction Medicine (ASAM) outnumbers the American Academy of Addiction Psychiatry (AAAP) by about three times. By the same token, there’s plenty left for psychiatrists to do. We must avoid treating people with addictive medications that can expand their miseries rather than ameliorate them. Many people with addictive disorders who didn’t have psychiatric problems prior to addiction do have psychiatric problems after addiction. It may be due to the drug itself, particularly the stimulants; cocaine and stimulant drugs that can precipitate psychosis or cause small strokes. Those folks can be changed irreversibly by their drug abuse. Traumatic brain injury is common in those with addictions. There’s going to be ongoing need for us to be of help to addicted people with a wide variety of problems.

 

Bill White: Through your work, you’ve emphasized the role of community and culture in addiction recovery, but you’ve also examined the role of medications in recovery initiation and maintenance. How do you see the future integration of medication with those broader psychosocial and community supports?

 

Dr. Westermeyer: I see it gradually changing over time. Initially, when I got into this field, we would be treating a patient with one of these medications and then refer them to a mutual help group, only to have the mutual help group start working on them to discontinue the medication. So that has been a problem, but sometimes it’s been a help. I have a patient right now who has an unlimited supply of prescribed benzodiazepines and the group has been leaning on him to stop using benzodiazepines. Their intent for people not to abuse their medication has been wonderful. In addition, their leaning on people who are benefitting from the medication has definitely cut back from what it once was. 

 

Some dilemmas do exist with certain medications. For example, Antabuse (disulfiram) can be a great help if it’s monitored. If you just give the patient a prescription for three months and ask them to come back, I wouldn’t even bother doing that. By the same token, we have a lot of patients who are on monitored Antabuse (e.g., their continued involvement at a job or the family providing shelter for them hinges on their taking Antabuse) and that’s been greatly effective.  The use of contingency contracting with some of these medications has great potential.

 

Bill White: What do you see as the future of medications such as methadone and buprenorphine?

 

Dr. Westermeyer: I’ve been involved with methadone programs for over three decades, going on four, and I do have a certificate to prescribe suboxone. I have patients on suboxone, and I’m a medical director of a methadone program. I’m in favor of these medications, but I’m not in favor of the way that these medications have been leaking out into the illicit supply route. Casual attitudes among some programs and some physicians about what happens to the medication and an overexpectation that the medication alone will provide a stable lifestyle are problems.  Governmental agencies should be monitoring diversion. The overwhelming ease with which physicians, dentists, licensed nurse practitioners, and pharmacists were willing to foster people being on huge amounts of opiates, or diverting opiates for profit into the illicit channel, fueled the iatrogenic opioid epidemic. A lot of work needs to be done to put suboxone and methadone back in their proper place. If that isn’t done, society will take it away from the patients who benefit from it, as well as taking it away from clinicians like me who feel that it’s a very useful aspect of our armamentarium to help addicted people.

 

Career-to-Date Reflections  

 

Bill White: You have been such a prolific writer throughout your career. How have you been able to integrate that into your administrative, teaching, clinical, and research activities?

 

Dr. Westermeyer: From childhood, I never got involved in watching TV. That void freed up most of my evenings for reading and writing. That habit was confirmed during my two years in Laos (1965–7), where there was no TV and evenings were given to reading, writing, and studying Lao or Hmong languages. I like music, and often have music in the background when I’m reading or writing.  

 

Upon returning to the US, I started residency. My days were given to clinical work, supervision, and frequent seminars, with evenings devoted to reading and writing. My wife started grad school, so her evenings continued along the same lines. And our children went to schools where homework was required. We’d take a study break each evening to play Ping-Pong, darts or make popcorn. So it became a family tradition. I’d also write on Saturday mornings if I didn’t have hospital rounds, Saturday afternoon for chores, and Saturday evening for a party or dinner out.  Sunday was for time-out with the family (church in the morning, skiing, swimming, and other activities later in the day), but often reading or writing in the evening. On vacations, reading or writing in the evening was relaxing and enjoyable for me, and still is.

 

Bill White: What have you liked most about working in this field now for these past four decades?

 

Dr. Westermeyer: Wow, that’s a big question. I would say one of the things I’ve enjoyed is the opportunity to be involved in a societal issue much bigger than myself. I didn’t think this through when I was a young man, but looking back on my own life and the life of my patients and my peers, I see a larger picture. Deciding early on goals that are bigger than one’s self and that serve a larger social body is conducive to good mental health and getting through the vicissitudes of life. It’s good to not just live for successes alone, but to realize that you’ve identified yourself with an important social need.  

 

Certainly, the improvement that I’ve seen in many of my patients has been a great support through my life. Even the reversals goad me on to keep involved. On a very personal level, my teaching and mentoring, as well as my research have provided many rewards in my lifetime.

 

Bill White: What do you hope will be the most important legacy you leave the field?

 

Dr. Westermeyer: Probably the biggest thing would be the people that I’ve mentored over time and the future contributions that they will make. I already see a number of them launching ahead in ways that overwhelm me with their insights and their motivations.

 

To a lesser extent, I hope some of the research that I’ve done has helped us move forward, like bricks in a wall. There is a wall of progress that requires many people to build. This approach is more evolutionary than revolutionary. They aren’t the kind of thing that an Einstein provided in the way of a leap, but I certainly feel good about having added bricks to the wall. In time, some of those bricks get worn out and are replaced by newer people adding their newer bricks and that’s just fine. I have no difficulty with that. 

 

And I think the lives of many of the patients that I’ve touched are a form of legacy. I don’t think I could have accomplished what many have accomplished in overcoming their addictions and rebuilding their lives. That gives me strength even when I’m facing challenges that try me. It gives me faith in the human condition that whatever challenge I am faced with can change with time.

 

Bill White: Dr. Westermeyer, thank you for this interview and thank you for all you’ve done for the field and the people we serve.

 

Dr. Westermeyer: Thanks so much for inviting me to share these reflections.    

 

Acknowledgements: Support for this interview series is provided by the Great Lakes Addiction Technology Transfer Center (ATTC) through a cooperative agreement from the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT). The opinions expressed herein are the view of the authors and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA or CSAT.