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November 27, 2011

Mental health of immigrants

The Canadian Charger

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Providing mental health services to immigrants and refugees is a particular challenge because of the need to understand and deal appropriately with cultural factors different from the Western Judaeo-Christian cultures that Western psychiatry is familiar with. But that is not all. According to Dr. G. Eric Jarvis, a psychiatry professor at McGill, "The patient may be influenced by more than one culture. There is the culture from before immigration as well as the culture which he is more or less integrating into in his new home."

Jarvis was speaking at a conference arranged by Healthcare Conferences Canada, at St. Paul University in Ottawa on November 18.  With Canada’s increasing cultural diversity, adding newcomers from around the world to the Aboriginal presence, the consideration of cultural factors in the treatment of mental illness is important.  When does a behavior by someone from a different culture or religion suggest the possibility of mental illness?

Jarvis set forth a short list of warning signals regarding religion: “A religious experience is more intense than is usual in the reference community; an experience is terrifying to the individual; an experience is prolonged; an experience is associated with deterioration of social skills or personal hygiene; an experience involves special messages from religious figures.”  As with religion, culture more broadly is a factor that plays a role, which the mental health practitioner must tease out.  Does the behavior deviate from that accepted as normal in the culture of the person?

He gave an example of a woman who was singing in the waiting room.  The tip-off came after an initial meeting, when she was returned to the waiting room.  She again began to sing, and her husband, who was with her, was clearly embarrassed.

The roles of the therapist and of the cultural interpreter are two important factors in provision of cross-cultural mental health services. How does the patient/client see the helping person?  Is he seen as an authority figure, as an antagonist, as a friendly helper?  The age of the therapist may be an issue–too young to have such an important role?  Is it a woman, who may have to bridge cultural prejudices around gender to fill the role?  These are all issues that the therapist may have to deal with.

The cultural interpreter, who translates and puts the situation into a cultural context, presents a different set of problems.  In a small ethnic community, the person may fear that the interpreter will gossip.  While Jarvis did not mention it, an interpreter may come from a hostile group.  For example, if the language is Serbo-Croat and the person is a Croat, the presence of a cultural interpreter who is a Serb could present a difficulty.  As well, cultural interpreters bring their own baggage with them.

Jarvis gave an example of an analysis of a situation by a cultural interpreter that raised some danger flags: “Some girls by nature are stubborn, some refuse to obey their husbands if they bring a fat dowry, or some educated girls also refuse to listen if their husbands are less educated.”

In spite of the potential problems, most patients/clients, according to Jarvis, “are relieved” to have an interpreter present.  Yet, the caveats need to be kept in mind.  Who said that being a psychiatrist or other mental health professional was going to be easy?

Professor Joseph Chandrakanthan, from the University of Toronto, looked at the same problems with a slightly different focus.  How does the culture define illness?  Thus, a diagnosis of cancer may, in many cultural milieu, be seen as a death sentence.  And mental illness often carries stigma and fear. In many languages there is no single word that corresponds, for example, with dementia.

He stated that a person has a right to know about his condition.  At times, those translating, especially family members, hide the bad news.  In one example, where family were translating information to a Chinese woman who was facing imminent death, after the doctor was done explaining the situation, the woman asked how soon she could return to her sewing machine. 

Chandrakanthan put the following questions about care: “Whether to seek care, where to seek care, trusting medications, consenting to treatment, and who decides.”  In terms of the “where”, he pointed out that the first person one goes to will likely be family or a friend, then a religious leader.  Trusting the diagnosis and agreeing to treatment are issues.

Treatment regimen may be tailored to the culture. In a situation that Dr. Chandrakanthan did not mention, in the U.S. Southwest, with the Spanish-American population, if a doctor feels that the patient needs to drink something hot, the recommendation might be for oregano tea, a traditional medicine. 

Another implication of Dr. Chandrakanthan’s comments is the importance of increasing mental health knowledge among religious leaders.

In many cultures, the family makes all decisions together, he noted.  Hence, family treatment may be the preferred mode.  An Australian study found that family therapy was more effective than individual treatment with Arab immigrants, whether Muslim or Christian.

He raised some cautions about looking at cultural factors in treatment.  One is that cultures are complex and that there is a tendency to oversimplify.  As well, there are other factors that play an important role with immigrants and refugees, for example, “trauma due to war, violence, political repression.”  Then there is the matter of generational differences.  These are only some of the complicating factors.

How, then, to deal with the complexities and avoid oversimplification?  “Focus on the person, not on problems.”

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