Psychiatria din. 11: 90-95 (1978)
Conflicting Concepts of Mental Health in a Multi-Cultural Society1 Jafar Kareem London Borough of Haringey
Abstract. The paper challenges the claim that psychotherapy or any other form of treatment based solely on western concepts of mental health is applicable to patients whose basic concepts of life are non-western. Illustrations from actual case histories are given to show that some concepts of ‘mental well-being’, as seen in the western world, are totally meaningless in some other cultures. It especially draws attention to situations existing in parts of the U.K., which have a high proportion of inhabitants originating from other parts of the world, especially the eastern world, and suggests that any treatment for patients from different cultural backgrounds must take into account such differences; the treatment must have meaning and relevance to patients, especially in emotional terms. The paper implies a new reorientation for western-trained professionals who may be engaged in treating patients from varied cultural backgrounds.
Before discussing this subject I would like to make it clear that the com ments 1 shall make arise not out of any detailed research but out of my own life and work experience. My own personal analysis and training in psychotherapy first made me aware of my confusion as an Indian in accepting certain western concepts of psychoanalysis. I found I first had to understand my own childhood and life experience within the terms of reference of my eastern culture and then transpose them into the western culture, to make a meaningful link relevant to my present life. This was the beginning of my interest in studying the various concepts of mental health that exist in different cultures, and in questioning the validity of applying one concept of mental health universally. In the field of neurotic disorders for which nowadays psychotherapeutic help is widely used, can we say that one type of treatment can apply to all patients, irrespective of their concept of life? I think not, because I believe that man’s concept of being well or being
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
1 Paper presented at the International Congress on Transcultural Psychiatry, Bradford, England, July 27-31, 1976.
Conflicting Concepts of Mental Health in a Multi-Cultural Society
91
ill is tied to his self image, and the experiences he has had as a person. This in turn is related to the cultural patterns, ethics, rules, modes of behaviour, and, most important of all, the abstract concept of life and death with which he has grown up. Quite often a man’s concept of being normal or abnormal, misfit or maladjusted is dependent, not so much on how he himself feels about himself, but on how the rest of the community in which he lives and has grown up feel about him, and it is their concept of what he is that affects him most. As I started to work in this country, and also while working in Austria and Israel, 1 collected material and gathered experience from which I have formu lated some ideas. The purpose of this paper is to share some of these with you. At present I am working in the Child Guidance Service of the London Borough of Haringey, which is supposed to have one of the largest concen trations of non-indigenous population. This naturally brings me into close con tact with a great number of people who come from very different cultural backgrounds. Quite often I have to sit back and think about my approach towards them and wonder how my westernised training may hamper my under standing of their problem. To illustrate this 1 would like to quote some examples. The first example is of a situation where the host society feels that the person labelled as ‘patient’ is not a patient, i.e. the patient (in this case a child) is not showing any abnormal symptoms, but the relatives of the patient (in this case the parents) feel that the child is sick and should be removed for treatment. A Pakistani family was referred to the clinic at the insistence of the father of a four year old child who felt that his child w'as showing ‘abnormal’ (father’s word) symptoms. The family was seen by the psychiatrist and the social worker at the clinic, and it was felt that it would help if the family saw me as I spoke Urdu (Pakistani language). When I met the parents with the child, the father complained that the child was showing ‘abnormal’ symptoms, e.g. running around in the play group, throwing sand and water all over the place, and while at home was very clinging and would not allow the mother to go out to work. Mother, who said that she had a B.A. degree in English, remained quiet at first but suddenly burst out in Urdu saying that she was very lonely and wanted to go out to work but her child would not allow her. She felt very jealous of her Pakistani landlord’s wife, whose child conformed to her idea of the well behaved child. Both parents were very frustrated by the attitude of the nursery staff, who they felt were unsympathetic to the child’s ‘problems’, and in coming to the clinic they were seeking confirmation of their belief that the child was abnormal.
The second case I am going to refer to is of a situation where the host society (in this case the patient’s peer group, school etc.) felt that the patient was showing signs of emotional stress, but the patient and and his family did not think so. They actually felt that there was nothing wrong with the patient, and that he was behaving as was expected of him in their culture.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
John, a 15 year old West Indian, was referred to me because the school felt that since the boy’s mother had left home, he was losing interest in school activities, was becoming withdrawn and housebound, and not mixing very well with his peer group.
Kareem
92
When I saw John with his father, it transpired that he had hardly known his mother as she had left him in the West Indies and joined her husband in the UK. While John was still in the West Indies, his father had gone back several times to see him and his siblings. John had known his father better than his mother, and when she left home and father started living with his new girl friend, John began spending more time at home taking more interest in home and in his siblings and getting on much better with his father’s new girl friend. Father thought that was how things should be, as separation from his real mother was not such a traumatic thing as ‘people here’ (meaning school) made it out to be. John himself did not feel that he was in any way behaving in a peculiar fashion. He quite often recalled his life in the West Indies and told me how his cousins got on so well with their fathers’ girl friends. John also felt that he was giving up his school friends because his future would lie more with his father’s friends and friends of ‘his kind’.
The third case illustrates the situation where patient, relatives and host society all agree that the patient is ill but there is a difference of opinion as to what would constitute health in this situation.
In this case we clearly see that although all the involved people admitted the presence of the problem, they definitely had very different approaches to the solution. The process of treatment in such a case would obviously be very difficult, because one would constantly have to find bridges between concepts and feelings to which one might not necessarily subscribe, but which played a major role in the patient’s life. Psychoanalysis, psychotherapy, casework and group work are western
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
As she was showing general symptoms of depression, this 21 year old Asian girl went to see a doctor privately at the suggestion of her employer. She told him that her main problem was that her parents do not approve of her boyfriend (also Asian) and hence she had been feeling bad, had ‘choking pain in her chest’, and did not feel like going out at all. When asked if she was able to see her boyfriend at all, she replied that she only saw him when his parents were away and when she could sneak into his house, but that most of the time they met in cinemas. When asked to describe her relationship with her boyfriend, she replied that they were ‘intimate’, and at this point the doctor said he wanted to examine her to find out if she was pregnant as he felt that this might account for her depression. The girl felt very upset at this and said that she could not understand how she could be pregnant as she was still a virgin. She then left the doctor’s surgery in a huff and tears. The doctor felt concerned about her and referred her to me. When I saw her it transpired that the girl had been suffering from mild agrophobia since her teens and had been a shy, withdrawn girl for quite some time. She had had some medical treatment and had also had treatment from a ‘holy man’. She came from a big family of five brothers and one very domineering older sister. Recently she had formed a relationship with a young man whom her parents did not like because he belonged to a different religion. He also did not go out much and only wanted to listen to the radio. They had sometimes kissed and held hands in the cinema and she felt that this was ‘intimate’ enough. From my talk with the girl it was established: (1) that she herself admitted to suffering from depression and phobia, (2) that her family were well aware of her illness, but thought it could be cured by a traditional marriage to an arranged partner, and (3) that the the host society (i.e. her colleagues and peer group) also felt that the girl was ill and suggested psychotherapy.
93
methods of treatment based on western concepts of mental health. As such methods are now being used generally all over the world, and as people from very different cultural backgrounds are receiving training and treatment in such methods, I feel it is important now to try and make some serious evaluation of how effective these methods of treatment are for those who have not been brought up within the western culture. How can a patient, whose culture and society has no concept of what such terms as ‘oedipal complex’ mean, be treated by psychotherapy? For many well-educated Indians (and among this I include a number of doctors known to me personally), Freud’s ideas are ‘sinful’, ‘porno graphic’ and must not be considered for fear of contamination. Other Indians I have known may accept Freud’s concepts intellectually but have problems in reconciling these with their own faith in predestination and reincarnation, and consequently resort to drug treatments when these conflicts loom too large. (These comments are confined to Indians because of my own personal back ground.) It may seem to some that 1 am suggesting that all western methods of treatment are irrelevant to non-western people. My intention is definitely not that. What I do wish to suggest is that treatment of any kind, especially when it is based primarily on the non-use of drugs, must have some meaning and rele vance to the person to whom it is given. Any form of treatment that uses the ‘human relationship’ and its interpretation as its basic tool, must take into account that such a relationship is based on culture and there must be awareness of the different ideas and concepts of relationship within different cultures. In simple words, a therapeutic relationship must be honest to be effective and in order to achieve this honesty, the two persons relating to each other must take into consideration the various concepts of relationship that have formed the basic pattern of their individual lives. For exemple, the concept of the bound aries of close and helping relationships is very different in different cul tures. One can never find an absolute definition of mental health which can be equally acceptable in all situations and for all groups. On the contrary, I would suggest that any such attempt must be considered as essentially unhealthy. Similarly, one can never establish any one particular method of treatment not based on drugs that can be applied universally. This is perhaps the one reason why drugs are accepted and used so very widely, more as a means of communica tion and as a signal of treatment, rather than as actual treatment. I suggest that as there is no possibility of defining mental health in a universally acceptable way, it becomes all the more necessary to understand the differences in concepts and how and why they exist. 1 feel that it is in the understanding of differences of concepts, rather than in their uniformity that we may really find a basis on which we could build a communication pattern that will break the cultural barriers.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
Conflicting Concepts of Mental Health in a Multi-Cultural Society
94
One must try to become aware why and how a certain particular manifest behaviour is accepted as normal in a particular cultural pattern, whereas the same behaviour in another culture will be immediately considered as abnormal. To quote an example from my work in Israel with some North African teen agers: in this community it was quite acceptable behaviour for a young person, especially male, to pull out a knife in a heated argument - not necessarily to use it. It was not only acceptable, but in some cases it would definitely be con sidered as ‘abnormal’ not only by the peer group but by the family and the community, if the youngster did not flick out a knife, whereas in the west ernised Ashkenazi community such a gesture would immediately be considered a symptom of delinquent behaviour, and the youngster would be sent away for treatment. In such situations if one is not aware of the reason for the different attitude to the same type of behaviour, one cannot be forgiven for making a wrong diagnosis of the situation. However, having suggested that the therapeutic treatment technique should take into account cultural differences, I would now like to examine how far this is possible and even necessarily desirable in all situations. The need to find culturally based treatment techniques has arisen now because we find ourselves living in a multi-cultural society. In the present day the traffic has mostly been in one direction: more people have immigrated into westernised society than the other way round. Since such migration has taken place primarily for economic and political reasons, the immigrants had very little choice in the matter. Because of this it appears quite reasonable to expect that the host country should make and devise various means and techniques to meet the problems and demands of the immigrant population. However, if the situ ation were not so, and if some people in large numbers decided very deliberately to uproot themselves from one culture with a view to settling elsewhere, I feel that it should be equally reasonable to expect from the incoming population that they absorb, and ultimately accept the concepts and mode of life operating in the society in which they have chosen to settle. The point I am trying to make is that while we need to use treatment techniques which take into account cultural differences, we must not lean backwards to the extent that they lose their original value. The diversified concepts of mental health and the problems we face in dealing with them in a multi-cultural society must not lead us to reject the universality of the human being. Come what may, and whatever our cultural background, we are first of all human beings, before we are influenced by our respective cultures. Therefore we do not need to bend backwards to accommo date and understand another person from a different cultural background. We only need to be aware that we are open in ourselves, and not judgemental in our approach to others. I fundamentally believe that behind an alien from a different culture is a
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
Kareem
Conflicting Concepts of Mental Health in a Multi-Cultural Society
95
Jafar Kareem, 25 Dalmeny Road, London N 7 ODX (England)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
unique similarity of human emotions, which are almost universal. Pain is the same all over the world. Joy is the same all over the world. The difference is in their interpretation by somebody who has not had the same experiences and the same feelings. 1 repeat therefore that we must concentrate on understanding these differences of interpretation.
Conflicting Concepts of Mental Health in a Multi-Cultural Society1 Jafar Kareem London Borough of Haringey
Abstract. The paper challenges the claim that psychotherapy or any other form of treatment based solely on western concepts of mental health is applicable to patients whose basic concepts of life are non-western. Illustrations from actual case histories are given to show that some concepts of ‘mental well-being’, as seen in the western world, are totally meaningless in some other cultures. It especially draws attention to situations existing in parts of the U.K., which have a high proportion of inhabitants originating from other parts of the world, especially the eastern world, and suggests that any treatment for patients from different cultural backgrounds must take into account such differences; the treatment must have meaning and relevance to patients, especially in emotional terms. The paper implies a new reorientation for western-trained professionals who may be engaged in treating patients from varied cultural backgrounds.
Before discussing this subject I would like to make it clear that the com ments 1 shall make arise not out of any detailed research but out of my own life and work experience. My own personal analysis and training in psychotherapy first made me aware of my confusion as an Indian in accepting certain western concepts of psychoanalysis. I found I first had to understand my own childhood and life experience within the terms of reference of my eastern culture and then transpose them into the western culture, to make a meaningful link relevant to my present life. This was the beginning of my interest in studying the various concepts of mental health that exist in different cultures, and in questioning the validity of applying one concept of mental health universally. In the field of neurotic disorders for which nowadays psychotherapeutic help is widely used, can we say that one type of treatment can apply to all patients, irrespective of their concept of life? I think not, because I believe that man’s concept of being well or being
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
1 Paper presented at the International Congress on Transcultural Psychiatry, Bradford, England, July 27-31, 1976.
Conflicting Concepts of Mental Health in a Multi-Cultural Society
91
ill is tied to his self image, and the experiences he has had as a person. This in turn is related to the cultural patterns, ethics, rules, modes of behaviour, and, most important of all, the abstract concept of life and death with which he has grown up. Quite often a man’s concept of being normal or abnormal, misfit or maladjusted is dependent, not so much on how he himself feels about himself, but on how the rest of the community in which he lives and has grown up feel about him, and it is their concept of what he is that affects him most. As I started to work in this country, and also while working in Austria and Israel, 1 collected material and gathered experience from which I have formu lated some ideas. The purpose of this paper is to share some of these with you. At present I am working in the Child Guidance Service of the London Borough of Haringey, which is supposed to have one of the largest concen trations of non-indigenous population. This naturally brings me into close con tact with a great number of people who come from very different cultural backgrounds. Quite often I have to sit back and think about my approach towards them and wonder how my westernised training may hamper my under standing of their problem. To illustrate this 1 would like to quote some examples. The first example is of a situation where the host society feels that the person labelled as ‘patient’ is not a patient, i.e. the patient (in this case a child) is not showing any abnormal symptoms, but the relatives of the patient (in this case the parents) feel that the child is sick and should be removed for treatment. A Pakistani family was referred to the clinic at the insistence of the father of a four year old child who felt that his child w'as showing ‘abnormal’ (father’s word) symptoms. The family was seen by the psychiatrist and the social worker at the clinic, and it was felt that it would help if the family saw me as I spoke Urdu (Pakistani language). When I met the parents with the child, the father complained that the child was showing ‘abnormal’ symptoms, e.g. running around in the play group, throwing sand and water all over the place, and while at home was very clinging and would not allow the mother to go out to work. Mother, who said that she had a B.A. degree in English, remained quiet at first but suddenly burst out in Urdu saying that she was very lonely and wanted to go out to work but her child would not allow her. She felt very jealous of her Pakistani landlord’s wife, whose child conformed to her idea of the well behaved child. Both parents were very frustrated by the attitude of the nursery staff, who they felt were unsympathetic to the child’s ‘problems’, and in coming to the clinic they were seeking confirmation of their belief that the child was abnormal.
The second case I am going to refer to is of a situation where the host society (in this case the patient’s peer group, school etc.) felt that the patient was showing signs of emotional stress, but the patient and and his family did not think so. They actually felt that there was nothing wrong with the patient, and that he was behaving as was expected of him in their culture.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
John, a 15 year old West Indian, was referred to me because the school felt that since the boy’s mother had left home, he was losing interest in school activities, was becoming withdrawn and housebound, and not mixing very well with his peer group.
Kareem
92
When I saw John with his father, it transpired that he had hardly known his mother as she had left him in the West Indies and joined her husband in the UK. While John was still in the West Indies, his father had gone back several times to see him and his siblings. John had known his father better than his mother, and when she left home and father started living with his new girl friend, John began spending more time at home taking more interest in home and in his siblings and getting on much better with his father’s new girl friend. Father thought that was how things should be, as separation from his real mother was not such a traumatic thing as ‘people here’ (meaning school) made it out to be. John himself did not feel that he was in any way behaving in a peculiar fashion. He quite often recalled his life in the West Indies and told me how his cousins got on so well with their fathers’ girl friends. John also felt that he was giving up his school friends because his future would lie more with his father’s friends and friends of ‘his kind’.
The third case illustrates the situation where patient, relatives and host society all agree that the patient is ill but there is a difference of opinion as to what would constitute health in this situation.
In this case we clearly see that although all the involved people admitted the presence of the problem, they definitely had very different approaches to the solution. The process of treatment in such a case would obviously be very difficult, because one would constantly have to find bridges between concepts and feelings to which one might not necessarily subscribe, but which played a major role in the patient’s life. Psychoanalysis, psychotherapy, casework and group work are western
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
As she was showing general symptoms of depression, this 21 year old Asian girl went to see a doctor privately at the suggestion of her employer. She told him that her main problem was that her parents do not approve of her boyfriend (also Asian) and hence she had been feeling bad, had ‘choking pain in her chest’, and did not feel like going out at all. When asked if she was able to see her boyfriend at all, she replied that she only saw him when his parents were away and when she could sneak into his house, but that most of the time they met in cinemas. When asked to describe her relationship with her boyfriend, she replied that they were ‘intimate’, and at this point the doctor said he wanted to examine her to find out if she was pregnant as he felt that this might account for her depression. The girl felt very upset at this and said that she could not understand how she could be pregnant as she was still a virgin. She then left the doctor’s surgery in a huff and tears. The doctor felt concerned about her and referred her to me. When I saw her it transpired that the girl had been suffering from mild agrophobia since her teens and had been a shy, withdrawn girl for quite some time. She had had some medical treatment and had also had treatment from a ‘holy man’. She came from a big family of five brothers and one very domineering older sister. Recently she had formed a relationship with a young man whom her parents did not like because he belonged to a different religion. He also did not go out much and only wanted to listen to the radio. They had sometimes kissed and held hands in the cinema and she felt that this was ‘intimate’ enough. From my talk with the girl it was established: (1) that she herself admitted to suffering from depression and phobia, (2) that her family were well aware of her illness, but thought it could be cured by a traditional marriage to an arranged partner, and (3) that the the host society (i.e. her colleagues and peer group) also felt that the girl was ill and suggested psychotherapy.
93
methods of treatment based on western concepts of mental health. As such methods are now being used generally all over the world, and as people from very different cultural backgrounds are receiving training and treatment in such methods, I feel it is important now to try and make some serious evaluation of how effective these methods of treatment are for those who have not been brought up within the western culture. How can a patient, whose culture and society has no concept of what such terms as ‘oedipal complex’ mean, be treated by psychotherapy? For many well-educated Indians (and among this I include a number of doctors known to me personally), Freud’s ideas are ‘sinful’, ‘porno graphic’ and must not be considered for fear of contamination. Other Indians I have known may accept Freud’s concepts intellectually but have problems in reconciling these with their own faith in predestination and reincarnation, and consequently resort to drug treatments when these conflicts loom too large. (These comments are confined to Indians because of my own personal back ground.) It may seem to some that 1 am suggesting that all western methods of treatment are irrelevant to non-western people. My intention is definitely not that. What I do wish to suggest is that treatment of any kind, especially when it is based primarily on the non-use of drugs, must have some meaning and rele vance to the person to whom it is given. Any form of treatment that uses the ‘human relationship’ and its interpretation as its basic tool, must take into account that such a relationship is based on culture and there must be awareness of the different ideas and concepts of relationship within different cultures. In simple words, a therapeutic relationship must be honest to be effective and in order to achieve this honesty, the two persons relating to each other must take into consideration the various concepts of relationship that have formed the basic pattern of their individual lives. For exemple, the concept of the bound aries of close and helping relationships is very different in different cul tures. One can never find an absolute definition of mental health which can be equally acceptable in all situations and for all groups. On the contrary, I would suggest that any such attempt must be considered as essentially unhealthy. Similarly, one can never establish any one particular method of treatment not based on drugs that can be applied universally. This is perhaps the one reason why drugs are accepted and used so very widely, more as a means of communica tion and as a signal of treatment, rather than as actual treatment. I suggest that as there is no possibility of defining mental health in a universally acceptable way, it becomes all the more necessary to understand the differences in concepts and how and why they exist. 1 feel that it is in the understanding of differences of concepts, rather than in their uniformity that we may really find a basis on which we could build a communication pattern that will break the cultural barriers.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
Conflicting Concepts of Mental Health in a Multi-Cultural Society
94
One must try to become aware why and how a certain particular manifest behaviour is accepted as normal in a particular cultural pattern, whereas the same behaviour in another culture will be immediately considered as abnormal. To quote an example from my work in Israel with some North African teen agers: in this community it was quite acceptable behaviour for a young person, especially male, to pull out a knife in a heated argument - not necessarily to use it. It was not only acceptable, but in some cases it would definitely be con sidered as ‘abnormal’ not only by the peer group but by the family and the community, if the youngster did not flick out a knife, whereas in the west ernised Ashkenazi community such a gesture would immediately be considered a symptom of delinquent behaviour, and the youngster would be sent away for treatment. In such situations if one is not aware of the reason for the different attitude to the same type of behaviour, one cannot be forgiven for making a wrong diagnosis of the situation. However, having suggested that the therapeutic treatment technique should take into account cultural differences, I would now like to examine how far this is possible and even necessarily desirable in all situations. The need to find culturally based treatment techniques has arisen now because we find ourselves living in a multi-cultural society. In the present day the traffic has mostly been in one direction: more people have immigrated into westernised society than the other way round. Since such migration has taken place primarily for economic and political reasons, the immigrants had very little choice in the matter. Because of this it appears quite reasonable to expect that the host country should make and devise various means and techniques to meet the problems and demands of the immigrant population. However, if the situ ation were not so, and if some people in large numbers decided very deliberately to uproot themselves from one culture with a view to settling elsewhere, I feel that it should be equally reasonable to expect from the incoming population that they absorb, and ultimately accept the concepts and mode of life operating in the society in which they have chosen to settle. The point I am trying to make is that while we need to use treatment techniques which take into account cultural differences, we must not lean backwards to the extent that they lose their original value. The diversified concepts of mental health and the problems we face in dealing with them in a multi-cultural society must not lead us to reject the universality of the human being. Come what may, and whatever our cultural background, we are first of all human beings, before we are influenced by our respective cultures. Therefore we do not need to bend backwards to accommo date and understand another person from a different cultural background. We only need to be aware that we are open in ourselves, and not judgemental in our approach to others. I fundamentally believe that behind an alien from a different culture is a
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
Kareem
Conflicting Concepts of Mental Health in a Multi-Cultural Society
95
Jafar Kareem, 25 Dalmeny Road, London N 7 ODX (England)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 9:42:18 PM
unique similarity of human emotions, which are almost universal. Pain is the same all over the world. Joy is the same all over the world. The difference is in their interpretation by somebody who has not had the same experiences and the same feelings. 1 repeat therefore that we must concentrate on understanding these differences of interpretation.
