The migration process is a phenomenon in which the stake of acculturation is right in the center of adaptation and/or integration problems.
Mental health being a concept that is far beyond the mental desease, therefore, it is necassary first to distinguish the psycho anthropological aspect of personnality organizations of a migrant from the psychopathological aspect when his strategies fail.
A long clinical experience in migrants’psychopathology allow us to say that it might be too quick to consider the mental pathology only on a pure nosographic basis, as it is apparently the case in France.
Also, a bibliographic research on migrants’ mental health allowed us to discover quite a number of fundamental points
1) There is no epidemiological research on migrants’mental health deseases for a number of reasons inherent to ethical health care and due to the statistical system technic.
2) Most of the researches are carried out on small samples not representative of a given population.
3) Most of the qualitative approaches are yet significant and allowed to spot different ways to use the health care system in France.
4) It emerges from a number of experiences (Françoise Minkowska Center, Comede, the Franco Muslim hospital in Paris, Health Care Center in Grenoble) that more and more the representation idea of mental health and mental desease is becoming unavoidable in the « doctor patient » interaction.
The difierent thinking movements in France ut, L’LaL cibpect generally embrace the medical anthropology with medical ethnology, psychoanalitical ethnology, cross cultura 1 psychology dimension and the transcultural psychiatry.
These different thinking movements are already within research strategies but we lack, at present, significant works and comparative studies between different migrating ethnics.
The main aspect I would like to give the greatest importance today, is that of the medical anthropology versus the crosscultural psychiatry in refereing to an Explanatory Model of A.KLEINMAN, which I consider with my modest experience in that field, as something very near to what is involved in the transcultural or endo cultural situation.
Straigtaway, I would like to make it clear that I will use the word endo cultural for the relationship between a native maghrebian therapist and a maghrebian patient. The word -cross cultural/transcultural when the patient and the medical doctor are not from the same cultural origine.
Before having a clinical talk, I would like to underline the extraordinary resistance of the care system as regards to the medical anthropology speech.
The idea that a patient could have an interiorized reference system that leans on tradition, religion and initiatic talks, makes it very difficult in the mentality of therapists accustomed to a rigorous nosographical speech. Number of collaborations we had with psychologists, psychoanalists, psychiatrists, non informed about the cross cultural field, brought about several attitudes which we can spot for the time being as such :
1) A total denial of culture with this conscious argument of mental desease universality whatever the expressing ways of it : everything can be easily spotted.
2) Use of bits of linguistic and cultural knowledge (more exotic than anthropological) to attempt to communicate, to make a diagnosis and decide a therapeutical modification.
3) Excessive culturalization of the patient with perverse effects,distorting a relationship which often topples over in a cultural capture of the patient to the detriment of a real interaction.
4) The therapist conscious that he is part of a health care system which does not give him a solution and, therefore, he has to seek for other possibilities somewhere else.
For instance, to ask for a linguistic and cultural interpreter ; to seek for some cultural inlights from a therapist belonging to the same culture of the patient ; to ask some structures which have developped technics allowing better communication and unuderstanding oi the symptoms.
Regarding the Maroccan migrating population in France (and this could be applied to the maghrebian population too), it is clear that mental health and mental desease do not respond to the same criteria than those used by the present nosography.
Classical notions such as possession, bewitchment, struggle against the evil eye, the use of ritual formula based on the Coran aiming at exorcizing anguish or « misfortune », all those are an integral part of the Ego integrity and must not be considered as archai c tools of a wild thought in the way Levy Brul defined it (before he changed his mind regarding this notion).
The comparaison between Maroccan communities in France (more specifically round Paris Ile de France ), in Belgium and mainly in Holland(EPPINKE A., … DIJK V.,..etc.1989)show that there is a stability in the representation modes through this migrating community, taking into account, of course, of the migration time, of the socio economic condition of the original town and the ethnic specificity.
At this stage of my speech, I would like to make a point
There is no dîsappearance of certain representations when the acculturation process is well advanced. It is fundamental not to think in terms of abandon and borrowing cultural items (as if it was a thermo dynamic process).
Psychee energy involved in personnality reorganization is more complex, as you already know, and I would like to propose a systemic approach close to the cybernetic one as formulated by a group of researchers and clinicans as Gregory Bateson, Paul Waltlawick, E.T. Hall and H.S. Sullivan.
There is neither point of departure nor point of arrival ; there Are only interactions in particular situations.
If the doctor patient interaction is reliable for the patient, he will be able to lean on any possibility te ucie metaphorical formula to express his pain and,it is only from that moment, that the doctor can hear a more reliable description of somaticcomplains or somatizations or psychosomatic disorders.
This is why KLEINMAN approach seems to me convenient as regards to my own clinical experience.
The psychiatrist anthropologist defines his Explanatory Model as ilthe notion about an episod of sickness and its treatments that are employed by all those engaged in the clinical process ».
This author think that both patient and doctor have to bring through their Explanatory models, five illness aspects
1. The etiology of the condition
2. The timing and mode of onset of symptoms
3. The pathophysiological processes involved.
4. The natural history and severity of illness
5. The appropriate treatment for the condition
One should keep in mind that « Explanatory models are used by individuals to explain, organize and manage particular episodes of impaired well being and can only be understood by examining the specific circumstances in which they are employed » (1)
I can say that this fits also for comprehension of symptoms among Turkish population in France and also in Netherlands and in F.R.G.
The low economic status seems to be the common point between migrants from Morocco and from Turkey.
I had the possibility to work with these two ethnic minorities, and something strikes me in the references to tradition linked to Islam.Even though, we cannot generalize Islam to Turkish migrants, it seems that religious practice was drained off but all that is linked to tradition and to Islam reinforced initiatic process, kept its emphasis in onset of symptoms.
When a turkish patient complained about being victim of his cousin’s evil eye because he found an official position as a worker in France, he could give me more details when I asked him
« Why it happened ? »
Because, he said « It is logical that the evil eye came from the others’envy. It.is the way we harm someone if one is jealous ».
« Why is it happening now ? » I asked.
« Because my cousin took the opportunity of may success to express his old anger against me ».
Ouly at that moment, I could ask him
« What happened to you ?’
The listing of the somatic complains makes a new sens and this avoids me to abusively build a quick diagnosis.
We have to say that in France all this chapter of somatic complains, somatizations, psychosomatic disorders, hidden depression, is a real hard and mixed up classification.
Does this mean that I have a different classification than that of the DSM IIIR (or DSMIV) or CIDI, : NO. It is not, here, my purpose.
Faced to a migrant form south Morocco a Renault’s factory worker living with his wife and children, in Francewho consults because he is possessed by a female spirit (Jenia : she has magical and evil power), it was more than necessary to let him talk about his own questionnings concerning this mental disorder.
1)What has happened ?
2)Why has it happened ?
3)Why has it happened to me ?
4)Why now ?
It is interesting to see the way he replaces the joining of his wife and children in France in a confusing context (though the logic of welcoming system in France, this should have improved his living conditions).
This gave a particular tone to this traditional explanations and the diagnosis was nearer to « anguish neurosis » than to an acute psychosis.
Therefore, I could continue the consultin g/ asking him « what would happen if noting were done about it ? and What should he do about it ?
From that point, it is easier to understand that before using the official health system, the migrants , very often, refer to folk illnesses healers. (HELMANN)
« The folk illnesses(according to HELMANN)are syndroms from which members of a particular group claim to suffer and for which their culture provides an aetiology, a diagnosis, preventive majors and regimens of healing ».
For Maghreb, Turkey, it does exist a lot of people able to give folk answers to those who suffer from a mental disorder.
It is very truethat maghrebian patients can spot by themselves
• hole series of causes especially when they think they present
• weird behaviour for the group.
Also, when they have body injuries (work related) or a decrease in body resistance, or decrease in physical, mental, social or sexual powerfulness.
It is interesting to note that exorcism and endorcism technics are permanently present with secretions and ingested food.
Paradoxally, Nature is not very much incriminated because it is included in a fatalistic approach and, this one, gives emphasis to the social role (the others are responsable of the illness).
On the other hand, spirit ancestors and ancestors or supra natural Gods have a very limited role.
Except Allah’s power which remains the supreme decider, there are not many intermediary supra natural Gods. This does not mean that the patients do not refer to the cults of Saints (Marabout) that have the reputation to have therapeutic capacities.
CONCLUSION
As regards to this topic, I shall give some recommandations on
1) To train therapists to the idea that they do not have a complete knowledge of mental illnesses but just an explanatory model which brings out passionate conflicts.
2) To introduce the cross cultural knowledge in the educational system for psychiatrists, psychologists and social workers.
3) Promoting the skills in cross cultural communication with a. knowledge of the patient language b. the patient’s culture C. knowledge of acculturation process d. knowledge of non verbal language e. knowledge of the doctor’s own culture
4) Increasing collaboration between migrants, doctors, and autochton doctors, between psychiatrists, psychologists and antrhropologists.
5) To help the health caring staff to overcome ethnocentrism, racism, and mono disciplinarity.
6) To improve accessibility to the mental health care system for the migrants.
1 -EPPINK A. and K.A.A. MOUTHAAN Prelmary Report on evaluation research in 1988 on model projects of counselling Migrants with somatic Complains Hilversum 1989
2 DIJK V. and HOOLBOOM H. (1989) Ethnic youths and their problems, symposum on counselly and policy UTRECHT 1989
3 HELMAN C. Culture Health and Illness Ed. WRIGHT Bristol England 1985
4 – Nahit BADAOGLU Some Social and Psychiatric Aspects of Uprooting among Turkish Immigrants in West Germany in Uprooting ans Surviving Ed. by Richard C. Nann W.F.M.H . Priority Issues in Mental Health Volume 2 p. 111 118
5 ZOLA I.K. Path ways to the doctor from person to patient Soc. Sci. Med. 7, 677 689 1973
6 LITTLEWOOD R. and LIPSEDGE M+ (1982) Aliens and Alienist Harmonds worth : Pinguin
7 KLEINMAN A.