Learning from strangers: ethnopsychiatry in practice

Introduction

When preparing this lecture ¹ , I kept starting over, not sure where to begin. I was disconcerted by the title of the keynote session in which I was invited to present—The Practice of group analysis: our clinical work—because I am not a practitioner of group analysis, nor even of psychodynamic therapy. My initial training as a psychotherapist was in systemic family therapy. I learned to focus on communication and interaction rather than the inner workings of the psyche. And then, for my PhD, I moved on to ethnopsychiatry as developed since the 1980s in France by Tobie Nathan, psychology professor and researcher, thinker, therapist, and writer. I carried out my doctoral research under his supervision on the unique problems of people born of intermarried Jewish–Christian parents, which also happens to be my case (Grandsard, 2005). The general title of the symposium, on the other hand—Crossing Borders—Social, cultural and clinical challenges—, sounded very relevant to me since my team’s clinical activities are mostly with first or second generation migrants in France. Our current work at the Georges Devereux Centre in Paris ² is mainly with the following people: unaccompanied foreign minors, foreign parents and their children (French-born or not), Holocaust survivors (former hidden children) and their families, and intermarried families.

Ethnopsychiatry

Ethnopsychiatry was first defined as a specific research area within anthropology by Georges Devereux (1908-1985), a Hungarian-born French ethnologist, who then became a psychoanalyst and later a Hellenist. Initially, ethnopsychiatry focused on the relationship between psychopathology and culture, and more specifically on the cultural modes of interpreting and treating disorders. Devereux (1961, 1963) argued that every human society prescribes normative behaviour to its members while also defining a culturally coded repertoire of deviancy. To put it more bluntly, according to culture, there are different ways of being ‘crazy’, of departing from the norm. Devereux defined these cultural repertoires of deviant behaviour and the specific related treatment methods as full-fledged ‘psychiatries’ worthy of interest as such. He specifically used the word ‘psychiatry’ in his writings to refer to this knowledge. He also referred to practitioners of cultural therapeutic methods, at least those recognized as healing experts within their respective societies, as ‘psychiatrists’. According to this way of thinking, medical psychiatry, psychoanalysis, systems therapy, cognitive behavioural therapy, these different approaches would also all qualify as ‘ethnopsychiatries’, healing practices related to specific worldviews, social groups and cultures (Gaines, 1992).

At the Georges Devereux Centre, we consider all healing experts as our potential colleagues from whom we can learn, mostly through the patients we often share (Nathan, 2001, Grandsard, 2006, Kaim, 2008). I will shortly present a case example to illustrate this first point. The centre is a research clinic founded (in 1993) and directed by Professor Tobie Nathan. Nathan was born in Egypt to a Jewish family that was exiled from its homeland, along with the entire Egyptian Jewish community, when Nasser came to power in 1956 (Nathan, 2012). He was eight years old at the time, and nine when his family settled in Paris. As a young clinical psychologist, Nathan trained as a Freudian psychoanalyst. He also attended Devereux’s weekly seminar and became his doctoral student and one of his closest collaborators (Nathan, 1999). His interest was in creating a clinical setting in which the findings of ethnopsychiatric research could be put to work, within which all healing methods, all therapies would be given equal attention, without being disqualified. This ultimately led him to abandon psychoanalysis as his main theoretical frame and to become interested in developing a general theory of therapeutic influence (Nathan 1994, Nathan and Stengers, 2018). A short case example taken from our recent clinical work will help in understanding more concretely this way of thinking.

Case example: Abdoulaye

When I met him, Abdoulaye was a 17-year old adolescent from Senegal ³ . He was brought to us by his caseworker after a violent fight with another young man in the foster home where he lived. My colleagues and I met with Abdoulaye four times over the next five months. The sessions typically lasted two hours. We were a group of four professionals from our team: two psychologists, a social worker and a translator/cultural mediator or ‘ethnoclinical mediator’ (Nathan, 1993, 2001). Abdoulaye was accompanied by his caseworker who also took part in the sessions. As the designated leader of the sessions, at the beginning of our first meeting, I asked the caseworker to tell us about Abdoulaye, in his presence. She told us Abdoulaye was a serious young man, trying to adapt as best he could to his circumstances as an unaccompanied foreign minor in France. He had arrived a year earlier and had never been violent before the incident with the other youth, also an unaccompanied minor, but from Afghanistan. When she asked him what had happened, Abdoulaye was not able to explain but he did tell her that he had trouble sleeping and mentioned the terrible boat trip he had experienced on his way to Europe. My colleague from Senegal, acting as ethnoclinical mediator in the sessions, translated into Abdoulaye’s native language, Soninke.

We later asked Abdoulaye to give us a detailed account of what had happened to him during his trip to Europe. The eldest of five children, he told us he had left his hometown after his father’s death, telling his mother he was going to a larger town to find work and help support his siblings. He had spent a few months working in a coastal city to make money and then had managed to get on a boat overloaded with undocumented migrants headed for the Canary Islands, Spanish territory situated in the Atlantic Ocean, one hundred kilometres off the southern coast of Morocco. He had not told his mother about his overseas plans. During the trip, the motor broke down and the boat drifted for several days in very hot weather. Five people died from heatstroke and dehydration, young boys like Abdoulaye. Their bodies were thrown overboard. Finally, the motor was repaired and worked long enough for the survivors to reach Spanish waters where they were rescued. When we explored his symptoms, Abdoulaye reported that when he looked at himself in a mirror and saw the scars left by the salt water and the burning sun, the faces of the dead boys would appear before his eyes. He felt his personality had changed: he incessantly thought about death, kept wishing the five boys had been properly buried instead of thrown overboard; he had nightmares, and often felt depressed.

I asked my colleague if there was a word in Soninke to describe Abdoulaye’s symptoms. ‘Kany’, he replied, ‘it means fear, the kind of fear that dislodges a person’s soul’. Abdoulaye laughed when we mentioned the word in his native language, both surprised and relieved that we might be interested in a word familiar to him. ‘Who knows how to treat the effects of Kany?’ I further asked my colleague. ‘A Jaaranda’’, he replied, using the Soninke word referring to a healer or doctor.

Abdoulaye confirmed that his mother had in fact consulted a Jaaranda before he left. The man had told her that her son would travel very far and had carried out procedures to ensure he would be protected during the dangerous journey. Abdoulaye was convinced he had survived the ordeal thanks to his mother’s blessing and the Jaaranda’s intervention. Following this exchange, we later decided to contact Abdoulaye’s mother to ask her to return to the same Jaaranda and tell him it seemed to us her son suffered from Kany: he had experienced great fear, had seen people die, his personality had changed, he could not sleep and had bad dreams . . . She assured us she would do as we asked but in return she hoped her son could also be given medication to help him. In the weeks that followed, Abdoulaye was indeed given medication to treat his insomnia. A month later, at our next meeting, he felt greatly relieved and his symptoms had disappeared. When I asked him if he was still taking the sleeping pills, his answer, in French, was: ‘What for? Now that my mother went to the Jaaranda and he did what was necessary, I don’t need them anymore!’.

It was clear to Abdoulaye that the effective treatment of his ailment had not been the medication or the talking sessions with us but the healing methods of the Jaaranda back home. Not only did we, as a team, accept this as a fact, our entire therapeutic strategy had been precisely to reconnect Abdoulaye with the healing resources of his family and social group of origin. To do so, we first set out to define as precisely as possible the nature of his troubles. In psychological terms, his symptoms seemed clearly post-traumatic. But we also wanted to know if his experience had a name in his native language. We were interested in learning from his cultural group and from him how to make sense of his problems, not merely in our western psychological terms, but primarily in Soninke terms. We explored the concept of Kany, which means ‘to be afraid’ but also refers to a disorder or illness that can affect people who have experienced extreme fear (Nathan and Grandsard, 2006). We then turned to identifying who had the knowledge and the legitimacy to treat Kany. We deliberately restrained from trying to interpret the disorder in the light of our own psychological theories or from assuming that Abdoulaye’s psychological state would improve thanks to the opportunity to verbalize his problems in a clinical setting and/or to the adequate medical treatment to ease his anxiety (sleep medication). Instead, we accepted the notion that if Kany made sense of Abdoulaye’s experience, then it needed to be treated specifically by an expert in Kany: a Jaaranda colleague. And we accepted that such a treatment would be, or at least could be, very effective in relieving Abdoulaye of his ailment. This is what I mean by a clinical setting in which all healing methods, all therapies and their practitioners, can be given equal attention, without being disqualified. We were lucky in this case that Abdoulaye was in touch with his mother and agreed to let us contact her. Of course, none of this would have been possible without a Soninke interpreter and even more so, an experienced Soninke mediator, who knows how to present himself and our team to people in a way that promotes trust, who is perfectly fluent in the cultural ways of Soninke society and also has a deep understanding of French realities and institutions: these are the required qualities of an ethnoclinical mediator.

Including people’s ‘natural’ groups in our clinical setting

Following Tobie Nathan’s lead, working with foreigners has brought us, as psychologists, to completely rethink our conceptual tools as clinicians. Nathan (1994, 2001, 2012; Nathan and Stengers 2018; Nathan and Zajde, 2012) has written extensively about this switch and it would be useful and interesting to revisit in detail each step of his ongoing intellectual process. For lack of time, my goal here is to convey to you some of the key notions of our current approach to therapy. Perhaps the main premise we start from is the following: people belong to and are attached to ‘natural’ social groups and our principal methodological concern is to find ways that force us, as therapists, to include these ‘natural’ social groups in our clinical setting.

In other words, find ways that force us to refrain from automatically formulating and interpreting the people we work with and their problems based on our usual theories and to access the thinking of their ‘natural’ social group or groups. We strive to include our ‘patients’ in the process of selecting how their case will be formulated, which conceptual matrix will be called upon to do so. Going back to Abdoulaye, was he suffering from PTSD and depression or from Kany? What was the best course of treatment for him: medication and psychotherapy or sending his mother to consult a Jaaranda? Treatments are not necessarily mutually exclusive, of course, as we saw in this example. But the ontological rationale underlying the Jaaranda’s incantations and animal sacrifices—most probably a sheep and/or a chicken in this case—and the psychologist’s talking therapy or the medical doctor’s sleeping pills are predicated on completely different ideas. In a shrinking world, who gets to decide which of these is more valid than the other? At the Georges Devereux Centre, we are interested in understanding and even experiencing the validity and rationality of our colleague the Jaaranda’s approach to treating affliction. We have put aside the notion of belief and retained the idea that all therapeutic techniques contain thinking in action that can be studied and understood. We are also interested in involving the people that are referred to us in the process of selecting the conceptual context that will inform their therapy. For Abdoulaye, it was clearly the Soninke concept of Kany and its treatment that were most relevant, in other words restoring stability to his soul through actions aimed at placating forces of the invisible world to which he and his family are attached.

Acknowledging our ignorance

In order to work this way, the first step is to acknowledge our ignorance. Hence, we think of ourselves first and foremost as researchers and learners. Of course, over the years, we have acquired experience and can guide the people we engage with along certain paths but we always strive to put aside our psychological theories and concepts, to not interpret through the prism of our psychological beliefs what the people we work with tell us, their experiences, their fears, their anger, their problems (Nathan and Zajde, 2012; Grandsard and Nathan, 2011). When a woman trusts us enough to tell us she is married to a male spirit that she can describe, see and hear and that this spirit guided her in her choice of her human husband, the latter being fully aware that he shares her with the spirit, we put aside our shared beliefs as psychologists—that this woman may be suffering from a form of psychosis for instance—to explore her world: what does the spirit want? Is he the father of one of her children, a 13-year-old boy, a juvenile delinquent who is in great danger of spending his life in and out of prison? We are not interested, in our work with her, in psychodynamic ideas of transference and counter-transference, projection or other defence mechanisms, not interested in thought processes and their effect on behaviour nor in systemic ideas, etc. Rather, we are interested in identifying and learning about the specific social attachments that inform her life, behaviour and thinking. What is it like to be married to a spirit? What does the spirit want? What does he look like? Where does he come from? In this example, we discovered the woman’s father belonged to a lineage of Bambara healers in Mali who had recently abandoned their ancestral practices in order to conform to what their local Muslim leaders expected of them. The woman knew she had a calling to heal that her son had also inherited, but what could they do with such a calling in France? This is the formulation we spent many sessions discussing, with her, her husband and also her teenage son who had, up until then, always refused any form of treatment or educational help.

In other cases, we may be the ones who ask: could your problems or symptoms be caused by a special relationship with a spirit? When asked precisely that question, a young man from Morocco answered: ‘exactly! How do you know? Can you see her? Her face is always hidden by her very long hair’, he added. ‘My mother told me she’s been with me since I was a baby, she told me she was breast-feeding me one afternoon and felt a second child she could not see sucking on her other breast’.

Social attachments

When people cross borders, they bring with them their identities and attachments to languages, gods, cuisines, ways of doing things, etc. (Nathan, 2001, 2009). I refer here to the concept of attachment Nathan borrowed from the sociologist Bruno Latour (1999) who defines it as ‘that which makes one do or act’ (faire-faire) in certain ways ⁴ . Often, in their dealings with their host country, after a while, people who have migrated may try to hide their identities and attachments, in order to conform to what is expected of them, or simply choose not to mention them because they have had the experience of not being understood or worse, of being disqualified. As clinicians, true hospitality, as we see it, amounts to creating a therapeutic space in which foreigners are invited with their specific attachments. Sometimes these attachments are so alien to us, they clash with our own attachments: our values or laws. In such cases, that fact becomes a crucial part of the conversation.

Case example: a couple from the Indian subcontinent

Thus, for example, a young Muslim woman from the Indian subcontinent in her late 20s complained to her social worker, in very broken French, that her husband, also a Muslim from the same country, but in his mid-40s, had been forcing her to have sexual intercourse against her will. They shared a studio apartment with their four small children. This revelation led to an emergency intervention by child protection services: the four girls were removed from their home and placed in foster care. The case was referred to our Centre by the children’s judge. He had given the woman a choice: either to leave her husband taking her children with her or be separated from them. The judge was perplexed by the woman’s refusal to leave her husband and hoped we could help him better understand the family situation. When we met them, both parents were in shock.

The husband is a political refugee and has been in France for over 15 years, but he barely speaks a word of French. The wife, who is much younger than her husband, was sent to France by her family eight years ago to marry him. When she complained to the social worker, she had no idea her words would lead to the removal of her children. She expected her husband would be taken to the hospital and properly treated. Her husband agreed he was mentally ill. In his words, translated by our ethnoclinical mediator, he explained that his head had started ‘to heat up’ after the death of their first child, a boy who died in utero, six months into his wife’s pregnancy. He felt responsible for the death of this baby because they had missed a doctor’s appointment a couple of days before the catastrophe on account of his busy work schedule. He had not seen the dead baby and had not been able to perform proper burial and mourning rituals for him. After the tragedy, the husband became obsessed by the necessity of having another son: this would be the only way to restore order and meaning to his life. After two early miscarriages, his wife gave birth to a premature daughter who needed medical attention. Her husband became terrified that they would also lose this child. She is six years old today, a beautiful, healthy and lively little girl, the apple of her father’s eye. But he still desperately needed a son. Two more miscarriages followed and then, his wife gave birth to three more baby girls, each born one year apart from one another.

The couple agrees that after the loss of their first baby, the husband’s physical and mental health started deteriorating. With each new daughter, his problems became worse. Today, he is unable to work and receives disability payments. He loves his little girls and wants them back. In the hope of achieving this, he went back to the hospital for the third time since the birth of his first daughter and is very regular in taking his psychiatric medication. His psychiatrist, who had first treated him for what he thought was post-traumatic depression, recently revised his diagnosis, after inviting an interpreter to his sessions. He now thinks his patient suffers from a form of chronic psychosis and has changed his medication accordingly. The patient, on the other hand, remains convinced that only the birth of a son could have healed him, even though today, he says he has given up on having more children.

Evidently, this couple was referred to us in a state of deep crisis. They were desperate to be reunited with their children and were trying to do everything that was expected of them in order for the children’s judge to be placated. But it was also clear that neither had any understanding whatsoever of why their children were no longer with them nor why the judge had suggested divorce. They were bewildered and frightened.

Thanks to the social workers assigned to their case, the couple now have a larger apartment and, after seven months, the judge ruled, much to his own surprise, that the four girls could go home provided their parents would continue their therapy with us and that caseworkers would visit them regularly at home. Given the reasons that had led to the judge’s first decision, and his experience in such matters, he typically expected the girls would be separated from their parents for a much longer period of time. But all the professionals involved with the family, ourselves included, had observed the couple’s competence as parents as well as the four children’s very satisfactory psycho-social development. The children showed no fear or awkwardness towards either of their parents and kept asking when they could go home. Hence the judge, a little reluctantly, decided they could be reunited with their parents.

My point, in presenting this ongoing case, is that in order to make some sense of this situation, in order to arrive at an informed recommendation to the children’s judge regarding the reunification or not of this family, we set out to learn from the couple what their specific attachments might be (Zajde and Grandsard, 2010). We were interested in their political histories, both families belonging to different parties in their home country. We were also interested in the history of their marriage and how—and by whom—it had been decided. Arranged marriages are still the norm in many parts of the Indian subcontinent, and especially in the couple’s home district. It became very clear that the wife had come to France only to be married to this man she barely knew, and start a family with him. To divorce him, especially with him in such poor health—mentally and physically—would be frowned upon by her family back home as well as his: no one would accept that she live alone with her children and if she did, her reputation—and her daughters’ as well—would be ruined forever. Besides, as isolated foreigners, both husband and wife relied almost exclusively on each other for companionship and also shared very strong religious attachments. The father clearly expects his daughters to wear head covering when they reach puberty and the mother does not like them to wear short dresses without leggings underneath to cover their legs. Indeed, both parents expect their girls to grow up as they did, hoping they will have a better education than they ever had, but nonetheless that they will become good wives and mothers in the traditional sense, dedicated to their families. At this stage in their lives, neither has any notion that their kids are growing up like little French girls. And of course, we are very interested in the father’s illness and the specific attachments that may inform it. So far, the couple has repeatedly assured us that they believe only in God and in scientific medicine. Yet, thanks to our ethnocultural mediator, we know they come from a region in their home country where popular beliefs connected to spirits and witchcraft are very widespread. Perhaps they do not trust us enough yet to share deeper convictions about the illness and all they have been through with their children. This is a possibility we plan to explore in future sessions.

Concluding remarks

As therapists, psychologists and caseworkers, in an ever-changing world where individuals and families travel far away from their base while keeping close contact through modern communication technologies, working with people who come from strange and foreign lands is a formidable learning opportunity, provided we are prepared to take the risk of putting aside our certainties and of accepting to engage in a collaborative search for creative solutions to new and previously unknown problems.