When I started practising psychiatry in Canada nearly 20 years ago, I realized that it was practised very differently in the West. When it came to modern psychotherapy, as opposed to traditional psychiatry of the East, the differences were even more pronounced. Traditional psychiatry focused on emotional problems and relied heavily on the use of medication.
I wanted to focus more on education and counseling rather than on prescribing drugs. Being a Pakistani psychiatrist
practicing in Canada, I had to look after many South Asian immigrants and their families, as they did not want to see Canadian psychiatrists who did not know of their language and culture.
As I studied the subject of trans-cultural psychiatry, I learnt that the practice of psychotherapy had grown by leaps and bounds in the West during the twentieth century. The tradition of psychotherapy blossomed particularly in capitalistic, secular and democratic societies.
It became popular in communities where the literacy rate was high and people became pre-occupied with issues in loneliness, existential isolation, personal growth, self-actualization and the quality of their marital and family lives. The media played a major role, with discussions on radio and television and articles in newspapers helping people share their problems.
There has also been an increase in the number of psychiatry, psychology, social work, and marital and family therapy programmes in colleges and universities. All these changes are gradually turning psychotherapy into an integral part of the healthcare system in the Western world.
Although many traditional psychiatrists still focus on medication, more and more mental health professionals are becoming aware of the importance of psychotherapy. However, there still are underprivileged countries in the third world where poverty, illiteracy, dictatorships and religious dogmatism reign and everyday many people die of malaria, tuberculosis and cholera and many more suffer from anaemia, malnutrition and hunger.
Because of illiteracy and ignorance, people still go to fortune tellers to deal with their physical and emotional problems rather than seeking out qualified medical practitioners, psychiatrists and nurses. In such countries, people with emotional problems come under psychiatric care only when they have a psychotic breakdown or suffer from mania, severe depression, paranoia or schizophrenia and the family fails to handle them properly. Even in those circumstances in which patients get institutional care and receive medication, the role of psychotherapy is very limited.
In countries where social and economic conditions are extremely poor and people are struggling with survival issues, the practice of psychotherapy becomes a luxury which only a few privileged people can afford. As far as immigrants are concerned, when people from the third world countries immigrate to the first world they bring their philosophies of life with them.
In spite of the wide availability of mental healthcare services, many immigrants are reluctant to use the same. On one hand they feel nervous about privacy and on the other they wonder whether healthcare professionals growing up in a Western nuclear families would be able to understand the problems of an extended family system and appreciate their cultural conflicts.
It is not uncommon to see then that an immigrant family comes to the attention of the healthcare system only when one of its members suffers from a psychotic breakdown. Many immigrants feel embarrassed about seeking medical and psychiatric treatment and even when they do receive it, cultural barriers become an important issue for them.
In the last few decades, ethnic communities and mainstream healthcare agencies are becoming aware that both sides need to be educated in order to change their attitudes so that bridges of care could be built. Immigrant families need to feel free to seek help when they need it and professionals need to be trained to become more sensitive towards their special needs.
We need more workshops and seminars on healthcare issues so that immigrant families and mainstream healthcare professionals could have a dialogue and be able to resolve the conflicts. The time has come when both sides can learn from each other.
After working with many South Asian immigrant families, I have made a number of observations and drawn some conclusions. Let me present a case history and then give you my impressions.
In the last few decades, ethnic communities and mainstream healthcare agencies are becoming aware that both sides need to be educated in order to change their attitudes so that bridges of care could be built between them
This is the story of a Pakistani engineer and his family. Sabir was sponsored by a Canadian computer company and he came over to Canada with his wife Maryam and daughters Jameela and Saleema (names have been changed to respect their privacy). They applied for permanent residency in Canada.
During the first interview I saw the elder daughter, Jameela, who was often agitated and restless at home. Her parents were extremely concerned about her condition and worried that she might hurt her younger sister and mother during one of her “fits”.
When I saw the patient she appeared to be in her early twenties. She seemed mildly scared and had no insight into her problems.
Jameela had seen a psychiatrist in Pakistan, who had diagnosed her as suffering from schizophrenia and advised medication. No psychotherapy was offered to the family.
The patient had stopped taking her medicine during the move to Canada. I thought she was regressing and becoming psychotic again.
Although the patient was quite reticent during the interview, towards the end of the session she felt comfortable enough to agree to resume her medication. I also advised psychotherapy so that her condition could be understood better. The parents were willing to cooperate.
During the interview I also discovered that the family had been in Canada for only a few months and lived in a three-bedroom apartment. They were socially isolated because they did not know anyone in their area. None of the women knew how to drive and they could not apply for a job because they neither had work visas nor a permanent residency status.
In the next few months, as Jameela got better, the younger daughter became ill to the point of being floridly psychotic. As I got to know the family better, I learnt that the mother was extremely nervous and had been reluctant to leave Pakistan. But she felt pressured by her husband who wanted a better professional future in Canada.
The mother was so worried about her daughters that rather than sleeping with her husband she slept in her daughters’ room. She used to get up in the middle of the night to check up on them.
Within a short period of time it became obvious to me that the daughters felt suffocated by the overprotective personality of their mother. The daughters wanted to be free from their mother’s controlling love and one way was to become psychotic!
When the relationship between the sisters and their mother deteriorated and the younger daughter’s condition didn’t respond to medication, I had to admit her to the hospital for a few weeks. During the next few months Saleema received a combination of therapy, comprising medication, education and individual psychotherapy and the family received family therapy.
Over the next few months the family recovered and felt reasonably settled. A year later, both sisters were doing well and were getting along better with each other and with their parents. I encouraged them to become independent and helped their mother respect her daughters’ choices, as they were adults.
Both parents were pleased with their progress and the mother became relaxed. While looking after this immigrant family with serious emotional problems, I became aware of a few issues in therapy which were not too different from those of the other immigrant families. These were:
Social isolation — The family had no social contacts and no support network. During therapy the family was not only encouraged to join the local ethnic community but was also referred to mainstream healthcare agencies in their area.
Secrecy — The mother was quite determined to keep her daughters’ illness a secret, as she was in the process of arranging marriages for them to two young Pakistani men. The mother felt strongly that her daughters would not get married if people knew that they were on medication.
I had to spend a lot of time educating her about accepting emotional problems and learning to cope with the stigma of mental illness in the community.
Speaking Urdu — Although the whole family could speak English, they felt more comfortable with Urdu. I left the choice to them. Most of my sessions with them were conducted in Urdu.
In the beginning the mother was reluctant to have a nurse visit them at home. She told me in Urdu that the nurse, being an English Canadian, would not understand her problems. But when I explained that the nurse was a professional and her home visits would ultimately help her daughters, she agreed. The nurse introduced the young ladies to different Canadian programmes and organizations.
The healthiest member — I felt that the father was the healthiest member of the family. Whenever I had a meeting with the mother and daughters during daytime, the mother was so anxious that her daughters could not concentrate on their therapy, as they felt controlled by her. She was over-protective and dominating.
When I changed the timing of the meetings to the evening, the sessions became more productive. I realized that the father held sway as the head of the family and the decisions we made in our family sessions were implemented far more easily. Over the months I helped the daughters become independent of their mother.
They learnt the bus route and started coming for their appointments on their own. They felt so much better that one of them went back to school and the other started doing volunteer work. They also made some Canadian and Asian friends.
The sisters have overcome their sibling rivalry and are getting along fine. The mother is far more relaxed and the father is quite pleased with the progress made by his family.
Mind you, psychotherapy with immigrant patients and their families does not just involve hospitalization and medication, but also focuses on helping them find ways to integrate into the new culture. It helps families in getting to know the new system from a social as well as a professional point of view so that they can live, work and socialize comfortably in both cultures.
It not only focuses on the control of symptoms of mental illnesses but also helps them improve their quality of life. I am of the opinion that to help immigrant families we need programmes that are multicultural, multi-ethnic and multi-lingual, so that immigrants can benefit from the same while staying in touch with their own cultures.
Psychotherapy with immigrants is an attempt to break down walls and to build bridges so that people from different cultures, rather than being prejudiced, can respect each other’s differences and lead a harmonious life.
As the world is turning into a global village, we need to create multi-cultural societies where immigrant and host communities may work cooperatively and harmoniously. I believe that mental health professionals can play a significant role in building such cultural and healthcare bridges.
The writer welcome@drsohail.com lives in Canada and practises psychiatry there
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