Fitting In and Not Fitting In


In a lot of my life, I have felt like I didn’t fit in, yet it is a natural human impulse to fit in and be part of the group. In the cross-cultural psychology/anthropology class I took in college, much of it involved looking at how individualistic a person or culture was compared to how collectivist a person or culture was. The dimension of individualism valued individual achievement, accomplishment, separation from the group, and individual goals over collective or group goals or norms. The dimension of collectivism valued group cohesion, social norms, and a person’s sense of identity was achieved through the group rather than in separation from the group in the individual. I find myself thinking of these categories as we have been in New Zealand these past 3 months.

Maori culture definitely seems very collectivist in orientation. I have read some of Mason Durie’s books (a Maori psychiatrist) and he writes about how Maori people get there sense of identity from their whanau (family), as well as from their larger tribe, and even from their connection to ancestral land. The context of identity is the collective group and even the context of relationship to the land. New Zealand Europeans (as those born in New Zealand, but of European ancestry are called) are more individualistic, but seem more collectivist than people from the United States. Kiwi culture is much more group oriented and even socialist in orientation. New Zealand prides itself on being the first country to grant women the right to vote, they are also the first or one of the first countries to establish a modern social welfare system of health care, financial and medical support for those injured in accidents (ACC), and sickness, disability, unemployment, and retirement benefits. There is much more of an emphasis on collaboration and personal relationships in organisations and in decision making.

A dark side of this collectivist orientation in Kiwi culture is what is called the “tall poppy syndrome,” in which anyone who dares to stand out or stand above others is mercilessly cut back down to size. It is a sort of regression to the mean, which, from the outside, can seem like Kiwi’s value something other than excellence, or being the best at something (quite the contrast to the “we’re number one” collective mantra of Americans).


The logical outcome of someone from a more individualist country coming to a more collectivist country is a culture clash or culture shock. The individualist speaks up frequently, trying to constantly figure out ways to make the system better, whereas the collectivists are more concerned with fitting in, not making waves, getting by without making a big fuss. On the one hand the collectivist culture seems more laid back, but can also seem anti-progressive. I realize that these are generalizations and that cultures and individuals have multiple motivations and values.

I was recently in a small group discussion of local psychiatrists. In our group of 7 people, only one was a born in New Zealand and trained in the NZ medical system. The other 6 of us were from across the globe, Asia, Europe, North America. One of the topics that came up in the discussion was how those of us from other countries try to balance fitting in and not making waves with our own cultural and professional values. Someone said something that really resonated with me, that in trying to fit into the Kiwi medical system, a person could be fitting into a dysfunctional system.

This gets into an area that a lot of people declare off limits due to “political correctness” and “cultural sensitivity,” that there is no better or worse, just different, but I am really not sure this is a valid way of looking at things and it seems to shut down any conversation between cultures by avoiding stirring up any conflict. When two (or more) cultures come together, there is inevitably conflict. The issue is how the conflict is handled that is important rather than pretending there is no conflict. Conflict is when two people or groups come into communication with each other and they realize that they have different assumptions, perceptions, motivations, expectations, and goals than the other. The conflict is the sign that communication and interaction are occurring, albeit in an inharmonious way. The transformative issue is in how this conflict is managed, whether it goes into war, aggression, genocide, discrimination – or whether it is channeled into dialogue, conversation, attempts at understanding, and, most importantly, whether or not the two can develop a shared language or culture which holds together the interactions in a socially acceptable way.

I remember reading about a word, that I cannot now recall, that was used in the former Yugoslavian areas of Bosnia. It was a word that was a kind of glue that seemed to hold disparate people and groups together, even though there were generations of past conflict and genocide. This term spoke to a kind of social cohesion and acceptance of difference between a humane society. The fact that this society fell apart into genocide and war, does not negate the importance of this concept.

The medical system in New Zealand is now staffed by 40% international physicians. New Zealand, and particularly Auckland, are taking in people from all over the world, immigrants looking for a better way of life, professionals interested in something different for a brief stint of work, and refugees from many of the worlds conflicts. Auckland is the largest Polynesian city in the world. It is also a very diverse city with 30% of its residents having been born outside of New Zealand. The question of fitting in will be a big one for not just the medical system within New Zealand, but for all of New Zealand.


On a more personal level, I find myself re-visiting this question of to fit in or not fit in. I have always been comfortable gravitating toward the fringe in different ways, whether it was punk/new wave music, mysticism, spirituality, the philosophical problem of nihilism, psychiatry, trauma studies, holistic medicine, or energy healing, many of my interests are often not valued or are actively disdained by the larger cultural group. Physicians tell psychiatrists they are not “real” doctors. Many main stream physicians say that holistic physicians are not true scientists or “real” doctors. To study trauma and to treat people who have been traumatized is often not popular. Even amongst holistic doctors, energy healing is often seen as a fringe field. You would think by now I would be comfortable with an outsider role, but here I am finding myself desperately wanting to fit in and to be accepted. Yet this is problematic because I am a restless, outspoken American who has high levels of professionalism and ethics, who believes that holistic medicine means looking at not just the holistic dimensions of a particular patient, but also the social context and the context of the health care delivery system. Additionally, it seems almost impossible for me to shut off the part of me that wants to make things better when I come across a problem. (I suppose the cultural critique of this last issue could be that I go around looking for problems instead of seeing the strengths in a given system.)

I guess this desire to fit in is always a part of me. In some ways, this experience of moving to New Zealand and practising psychiatry reminds me a little bit of that strange cultural soup of high school, where kids were continually forming, remaking, and revising identities and social structures. I can remember desperately wanting to fit in while at the same time rejecting and disdaining many of the shared cultural values of a small high school.

I guess I’ll close this blog with a few queries. How important is it to be accepted by a group? How important is it to be true to your inner self and your personal ideals and ethics? How does one balance the rules of the group with the drives of the individual? How does one find a place in the collective world, while at the same time following their own unique path? How does one come to terms with the fear that they may not fit in anywhere in the world? Is it possible to be one’s self without becoming isolated? Is it possible to fit in without blindly conforming? Is being an individual and being an accepted part of a group a tension that can be transformative as well as potentially destructive


The Benefits of Being Lost

The Benefits of Being Lost
I just finished reading Rebecca Solnit’s book, A Field Guide To Getting Lost, and it deals with some themes I have been thinking about lately. Her book is a series of loose meditations on different aspects of becoming lost and of what a person can find out about themselves in the process. Whether it is about getting lost in the wilderness, being an immigrant, losing oneself in a time or place, losing oneself in sex, drugs, and rock and roll, suicide, or about various species of animal going extinct or coming back from the edge of extinction, the book explores the inevitability, costs, and consequences of becoming lost.

What I have been thinking about, and probably why I was drawn to the book, is about choosing to move to a new country for the experience of it and then finding the experience really challenging.

On the one hand I am daily excited and really enthused by the clinical work I am doing. New Zealand, Auckland, at least, is a place of immigrants and immigrants all have stories of leaving, losing, and finding.

This week, I met with a client from Central Africa, and another from North Africa. I had a Maori client who felt that one of his medications, the one that he said worked the best for his psychosis was also associated with a curse that caused him to “stargaze.” I met with a Pacific Island woman and her family and looked at the reasons why she had stopped most of her medication, what the medications were supposed to do, and how we might come up with some compromise of medications that would treat her psychosis, but would have acceptable side effects. I met with a New Zealand European client and her family and discussed her reasons for stopping her medication, that she felt the medications controlled her (and she was on a combination of sedating medications that I never would put someone on) and how she felt she couldn’t travel like her friends were doing, because of the restrictions of being on medication (sedation, need to be on it or become psychotic, the logistics of trying to get prescriptions abroad). With her, we looked at how sometimes when you accept your limitations, they actually limit you in your life less. That is quite a paradox. With the woman from Central Africa, she came from a lifetime of war and lawlessness and it will be quite a challenge to figure out if her paranoia, which has at times crossed over into psychosis, is really a reaction to her past trauma and her recent relocation to a country in which she doesn’t speak the language, or if she is really developing a psychotic mental illness. Another client spoke about how they would be alone here in New Zealand, or they would be alone if they moved to the country where their spouse was working, and they would be alone if they moved back to their country of origin.

On the other the hand, I realized that this is the worst job I have worked in as I look back at the seven jobs I have previously had since graduating residency. The orientation has been terrible. The mismatch between my expectations & the jobs expectations and how the structure of the job seems to do everything it can to frustrate meeting expectations. I feel like I am working hard all day long, but that I am pulled in so many different directions that at the end of the day I am exhausted and feel like I haven’t hardly done anything.


The Benefits of Being Lost


I understand, logically, that wanting to do something completely different means that I will not be doing the same old, comfortable thing. But sometimes, this all seems a bit ridiculous and I long for the good old days when I had some control over my professional life and I could feel good about getting some work done in a day.

I haven’t made the case yet for the necessity of becoming lost at times throughout one’s life, the need for that seems pretty obvious, at least to me. I understand the saying, that if nothing is lost, nothing is gained. However, many of the above clinical stories show some of the dangers of becoming lost and staying lost. I suppose psychosis, from a psychological perspective, is another way of becoming lost, losing touch with reality and getting stuck in a self-referential world in which one’s fears become self-fulfilling prophecies.

What Solnit’s book helped me to see is a deeper understanding of the double-edged sword of getting lost. I don’t think she really looks so much at the reasons why getting lost is necessary in life. It just seems like a given in the book. What the book does look at is the hard work and energy that goes into becoming lost in the first place and then in making sense of it in the second place. It is a serious book, but not a hopeless one. The book seems to honor the need and the process and the benefits of being lost without becoming too Pollyannaish or “therapeutic.”

Solnit mentions the early 1980s post-punk band from Manchester, England, Joy Division. There is a page or two devoted to the band, the environment their music grew out of, and the atmosphere that the music created. This last week, I went to see the bass player from Joy Division, Peter Hook, and a new band of young punks, recreate the album Unknown Pleasures, for its 30th anniversary. The other two original band members weren’t there. I wasn’t sure what to expect of the show. On one hand, I didn’t want to have an experience that lessened the original album and band, but on the other hand, I was really curious to hear what it would be like and to experience that music, that I had listened to over and over as a teenager, performed live. The technical sound of the music was incredible, it had the old effect I remember from the past of a dangerous and powerful current and how it has the effect of opening up strange, wonderful, and unsettling places within myself. (Although I think Cries and Whispers, honestly, at least in my memory, did better covers of Interzone and Day of the Lords). Listening to this music born in Manchester, that I had lost myself in while in my basement room in the Midwest of the United States, performed in Auckland, New Zealand, was amazing and unsettling.

Solnit writes in her book about book that she had conceptualized but had never written. It reminded me of the writing I had done on Joy Division, as well as other topics, for a book I had planned. The idea for the book was to look at the lives and work of people who had experienced some form of trauma in their lives and then addressed trauma in some way in their creative work. The chapter on Joy Division was to be called, “Trauma and Transformation in Punk Rock.” As I was recently thinking about this, I realized that I was working with some of the same themes about the dangers and benefits of becoming lost. I realize that the work I had done was not lost, because I am still working on the themes. I remember a Carl Jung quote that said something like, people don’t work on many themes in their lives, rather, they work on one theme from different perspectives.

The ways in which I currently feel lost are that I am having trouble seeing how I fit into the larger system of health care in New Zealand. The clinical work is challenging and rewarding, but how the community mental health centre I am working in will come through its own transition and what role I will play there is a big question. I have never had this much difficulty adjusting to a job. Many days I feel like the structure and system of the job is designed to prevent me from doing the clinical work that I know how to do.

I realize that the place I am working is in chaos and transition, but the overall New Zealand health system also seems lost in a way. Of the 50 spots for psychiatric trainees in the country, only 10 spots were filled last year. This year, the district health board I work for only has one new psychiatric trainee starting for the year, out of 10 positions. 40% of all physicians in New Zealand are from overseas. New Zealand is experiencing a steady brain drain of physicians going to Australia where they easily make 30% more for the same work which is probably not in a setting of continual strain and loss of staff. Even if my specific job sorted out, I would be unsettled by these larger trends. I knew of some of these issues before I arrived here, but I had no idea how dire the situation was. It seemed like this would also be an opportunity for creative ways of working and providing care, but the system seems incredibly apathetic and has incredible inertia that seems difficult to shift.

This reminds me, in a way of the US financial crisis, in which the people who seem least able to solve the crisis are the people in charge, because they are the ones who are the architects of the crisis. As Einstein said, you can’t solve a problem using the same tools you used to create the problem. You have to lose the old tools and step into the unknown of developing new tools. To an outsider, the situation the New Zealand health care system is in looks critical. While people get upset about little things with the system, no one seems to be revamping the whole system.

One thing that I am frustrated to have lost is the canvas on which to work – in my private practice, I could change things and develop new things as the need or mood would arise. Now, I have to ask permission from a system that is often apathetic and unresponsive. I have had a few experiences of putting a lot of energy into something that either goes nowhere, or the plug is pulled on. I am used to being a creative, hard-working, and conscientious person and sometimes these things seem to be either not culturally appropriate, or at least not supported within the local system. These are things that I know I can’t change or ignore within myself. The current system where I am working seems to require a tremendous amount of energy to function and in its functioning it seems to put energy into trying to make the system not function. I often feel like I am spinning my wheels and putting in a lot of energy with very little to show for it at the end of the day. I am also spending a tremendous amount of energy trying to figure out what is the local culture of the mental health centre (which almost everyone in and out of it admits is not functioning well) and what is the culture of the larger New Zealand health care system.

My observation about a dimensional difference between the United States and New Zealand is that in the United States, work is often very systematized and there are policies, procedures, and protocols. This is something that I have seen the dark side of in that the humanness of the individual physician and patient is often lost to the needs of the functioning of the system. Scientific, “evidence-based” medicine, also plays into this dehumanization and overly technical systematization of the doctor-patient relationship. The good thing in the United States is that things get done effectively and efficiently. The question is whether the things that are getting done are doing any good.

In New Zealand, there seems to be more of an Old World who you know instead of what you know. The “system” seems to function on the basis of individual relationships more than on policy and protocol. I have tried to banish the 4 P’s from my vocabulary: policy, procedure, protocol, and process. Things seem to be done the way they are done or the way they have been done and if there is a deviation from this, there is often a sense of floundering in the abyss, rather than an organized approach to system development and change. There is a manual that I see on a shelf at work entitled, CAOS. I fantasize that it is the English spelling of the word, “chaos,” but I haven’t worked up the nerve to look at the manual to see if it is for creating chaos or managing chaos.


The Benefits of Being Lost


New Zealanders really seem to despise anything negative being said about their country. There is the phenomenon of the “tall poppy” and “cultural cringe,” here. The “tall poppy” refers to New Zealanders trying to tear down anyone who dares to do something out of the ordinary or to stand above the crowd. Presumably this comes from a culture that is very collectivist and group oriented. The effect is a culture that creates mediocrity rather than fosters individual self-expression and creativity. I was reading an interview with Jemaine from Flight of the Conchords, and he was talking about “cultural cringe,” which is similar phenomenon, in which anyone who becomes popular or does better than others at something evokes a cringe and negative reaction from the culture. For instance, he says his popularity in the United States is dismissed as “Americans are idiots, so he can’t be that good.” I wonder if I am running into some of this attitude here as well. I know that there is a stereotype of Americans being clueless, self-centered know-it-alls, and I try to be sensitive to this, but I also know that it won’t work for me to try to be apathetic and mediocre.

In some ways, New Zealand seems like a culture that has lost its external referents, but hasn’t found itself. There is an official policy of Bi-culturalism here, based on the Treaty of Waitangi, which recognizes the countries responsibility to maintain Maori culture, the people who were the first human beings to colonize New Zealand. However, I have come across some comments that the New Zealand Europeans either don’t have a culture, or that their cultural identity is still with the UK more than with themselves. There have been debates in the newspaper whether or not New Zealand should become a republic after the current Queen of England is gone. Many of the arguments for keeping the monarchy over New Zealand seem to arise from a desire to be defined from someone and someplace else.

A friend of mine was talking about when her ancestors came to New Zealand in the mid-1800s and how her identity and much of New Zealand’s identity is still from the UK. I found it interesting that her relatives had come to New Zealand decades before many of my relatives, and yet I had a more of an identity as an American than she did as a New Zealander.

The Benefits of Being Lost


There are many ways that cultures work through being thrown in contact with each other. History shows that cultural interaction tends to enrich a culture more than any drive toward cultural purity or superiority does. The enriching interactions of different peoples and different ideas seem to be far more leavening than a lot of a single ingredient. (In fact genocide or discrimination seems to be how many of the single ingredient recipes work out). People seem to have different attitudes towards difference. Some don’t want one food to touch another on their plate, whereas others find mixing everything up to be more enjoyable.

The mixing of peoples and cultures is one form of change and this change is an inevitability. New Zealand is importing 40% of its physicians and that will change the culture of the medical system here. New Zealand, maybe more than any other place colonized by Europeans, is founded on a contract and treaty, that is still living, between two very different cultures, the Maori and the European colonists. Now New Zealand is opening up to refugees from all over the world and also many immigrants from Asia and the Pacific Islands. There are now more Pacific Islanders in Auckland than on some of the original islands. The United States went through the typical colonial exploitation of native peoples and is now struggling to make sense of the influx of Latino immigrants and Latino culture.

How this mixing, in New Zealand and the United States, and intermingling is handled will determine what is lost and what is gained. You cannot go to another country without losing something and gaining something. Similarly, a country cannot have an influx of new immigrants without changing in some way, and all change entails loss and gain. Maybe it is each individual’s and culture’s attitudes toward loss that determines the outcome of cultural interactions and the change that inevitably comes from it. On an individual level, maybe one’s attitudes toward loss and being lost determine what will eventually be found.


The Benefits of Being Lost