Wielant Machleidt & Andreas Heinz (Eds.),Praxis der interkulturellen Psychiatrie und Psychotherapie. Migration und psychische Gesundheit [ Practice of Intercultural Psychiatry and Psychotherapy. Migration and Mental Health ]

Reviewed by: Wolfgang Krahl, Isar-Amper-Klinikum München Ost, Germany

This volume is the most comprehensive handbook on cultural psychiatry and migration written in German. According to Tseng (2001) cultural psychiatry is primarily concerned with the cultural aspects of human behaviour, mental health, psychopathology, and treatment. At the clinical level, cultural psychiatry aims to promote culturally relevant mental health care for patients of diverse ethnic or cultural backgrounds. Machleidt and Heinz try to highlight these issues in their handbook. As culture and language are interwoven it makes sense that the book is written in German. About 100 million people live in German-speaking countries (Austria, Germany, Lichtenstein, and parts of Switzerland and Luxemburg). In today’s Germany about 20% of the population have a different cultural background than the autochthonous population. A strength of this volume lies in the fact that almost all of the over 80 contributors—who come from diverse cultural backgrounds themselves—are working in German-speaking countries, in the social and cultural environments they describe.

The first textbook on cultural psychiatry in Germany Transkulturelle Psychiatrie was published 1971 by Wolfgang Pfeiffer. It was a single-author book and dealt mainly with cultures in Africa, Asia, and Latin America; it did not focus on diverse ethnic groups within Germany. In the 1960s and 1970s Germany was still thought to be a rather homogenous society. Now that about one fifth of persons living in Germany have a diverse cultural background there are new demands on a book on cultural psychiatry. Machleidt and Heinz accept that challenging task and focus on the diverse cultural groups within German-speaking countries. The editors state in their preface their goal, which is that people from other cultures should receive the same high professional standards of quality of treatment and care as the native population. Culturally sensitive practice for the editors is a vital component of effective mental health care. To make this possible they gathered leading experts in the German-speaking world, clinicians as well as theorists in the field of cultural psychiatry to contribute to this volume. As Jablensky and Sartorius (1975) remarked, culture is often a blanket term to cover and obscure economic, political, social, biological, and physical environmental factors. That the editors are very well aware of this issue is reflected in the selection of the contributors who do not “culturalize” social, economic, and racist issues.

Patterns of ethnic diversity differ substantially in European countries. In France, the Netherlands, and the UK many immigrants come from their former colonies and that shapes the composition of the diverse ethnic groups in these countries. In Germany the largest number of migrants come from Turkey, the Balkans, the former Soviet Union, and from EU countries. What is common to all countries in the European Union (EU) is the fact that the expansion of the EU has led to greater interaction, communication, and migration within its members. In the last two decades German-speaking countries also witnessed a significant influx of migrants from Africa and Asia.

The Handbook is organized in eight sections with different topics, each section contains various chapters about the main topic. The 56 chapters are structured similarly: each chapter starts with a summary of learning objectives and ends with a take-home message. Important information is highlighted by short remarks under the heading “Notice.” These tools help the reader stay focused. Chapters that deal with clinical issues include useful case narratives that illustrate the importance of the discussed matters. It is a pleasure to read these well-written vignettes because they illustrate the complexity of diagnosis and treatment in real-life situations.

Section 1 starts with “Theoretical Aspects” and contains chapters on basic issues regarding migration and culture. The first chapter, written by Oskar Negt a respected social philosopher, engages the reader in a dialectical discourse on the topic of culture and migration. In subsequent chapters, an anthropologist gives her definition of culture, discusses in a critical way the term acculturation, and introduces the transnational perspective. Then follows a chapter that reflects the strengths and weaknesses of the main theoretical positions in ethno-psychiatry. The next chapters deal with the processes of migration and identity, the psychology of migration and acculturation. Another chapter deals with the important issue of stereotypes, prejudice, and discrimination which is followed by a profound chapter on race and racism. The chapter on religion and migration highlights these often underestimated topics and stresses both the positive and negative influences that religion can exert. The last chapter in this section gives an overview of the patterns of migration and the historical and political framework that accompanies global migration trends.

Section 2 deals with “General Requirements for the Care of Migrants.” Its first chapter is subdivided and contains several articles by different authors. It begins with an overview on the relationship of German and Turkish psychiatry that started in Heidelberg with Emil Kraepelin and Rasit Tahsin at the end of the 19th century and it goes on to describe today’s lively connections. The next article continues with a discussion on identity problems of ethnic Germans who lived for generations in areas of the former Soviet Union and who have resettled in Germany between 1950 and 2005. There are contributions on the migration of Russian Jews, Poles, Latin Americans, Chinese, and the very personal account of a Japanese psychiatrist who studied in Germany for 5 years. The next chapter elaborates the “Sonnenberger Guidelines” from 2002 (Machleidt & Sieberer, 2013), which are a landmark in German psychiatry giving recommendations on the requirements for appropriate psychiatric-psychotherapeutic treatment for migrants. The following three chapters deal with the challenges of how to mediate language and culture in a psychotherapeutic setting, how to develop multiprofessional and multicultural teams working in mental health, and the acquisition of intercultural skills. The next chapter discusses the different legal requirements in Germany, Switzerland, and Austria about immigration and naturalization as well as the legal options for asylum seekers. The last chapter discusses the skills and the methods needed for sound and competent cultural psychiatric assessment for courts.

Diagnosis is the focus of Section 3. Diagnosis is a central concept in psychiatry and medicine, it establishes the patterns according to which clinicians observe, think, remember, and act. In the first chapter Calliess and Behrens sensitize the reader to the importance of being aware of their own cultural background and discuss thoroughly the cultural pitfalls in the formulation of a psychiatric diagnosis. They also stress that migration-related stressors have to be taken into account to come to a valid diagnosis. The following chapter deals with intercultural psychological test diagnostics. It becomes clear that in German-speaking countries there is a lack of reliable and validated test instruments for minorities. The authors warn about the uncritical use of standard test instruments and demand psychological test diagnostics on the basis of culturally sensitive and fair test procedures; to improve the situation they suggest concerted efforts through cooperation. The last chapter in this section is only indirectly connected with diagnosis; it gives an overview of psychiatric epidemiology concerning migrants. This chapter shows that there is no simple correlation between mental illness and migration.

Section 4 deals with “Migrant Groups in Special Problem Situations,” the editors have to be lauded for including challenging topics in their book that are missing in many other textbooks about cultural psychiatry. The following chapters focus on groups that are often neglected but that are in particular need of psychiatric/psychotherapeutic care. This includes groups such as adolescent migrants and unaccompanied minor refugees. One chapter concerns “modern slavery” and discusses the fate of women and girls especially from central and Eastern Europe who are victims of human trafficking and sexual violence. Another chapter highlights the plight of illegal or “undocumented” migrants and their mental health problems, which are usually unattended because these people have no health insurance. The last chapter on elderly migrants will be of utmost importance in the future as their number is increasing steadily and their former dream of returning home is often not possible. There is, however, one topic that is missing: a chapter on Sinti and Romas—an often forgotten minority. It is estimated that there are about 10 million Romas living in Europe. This omission is also true for other textbooks on cultural psychiatry no matter whether written in German or English. The next edition should include this important topic.

The chapters in Section 5 on “Disease Patterns” will be the ones most likely read by clinicians because they are relevant to daily practice. There are chapters on psychotic disorders and schizophrenia, anxiety disorders, posttraumatic stress disorder, depression, somatization, personality disorders, and addiction. All the chapters are written by clinicians who have wide experience in their field with German patients as well as with patients from diverse cultural backgrounds. The authors make it clear that both culture- and migration-specific perspectives are important for sound clinical assessment and treatment. Each chapter contains case vignettes, which illustrate the clinical problems in diagnosis and treatment. A chapter that I found missing in this section is one on bipolar affective disorders. In addition to psychiatric disorders, there are two additional chapters in this section on trance and possession states and culture-bound syndromes. Most clinical psychiatrists have no experience or sound knowledge of these topics and these chapters give a good introduction. Culture-bound syndromes are not seen in current psychiatric practice either in Europe or in the regions where they originally occurred. For many psychiatrists the culture-bound syndromes were associated with cultural psychiatry, one of the reasons why cultural psychiatry was seen as “exotic.” The authors give a critical account on the discourse on the culture-bound syndromes and demonstrate why it does not make sense to fit them into standard classifications.

Section 6 deals with cultural aspects of psychotherapy which is of particular interest for clinicians dealing with patients from diverse cultural backgrounds. In a series of stimulating chapters, experienced practitioners from psychodynamic, behavioural, and systemic psychotherapeutic schools give their views on cases from their different perspectives. This is followed by a chapter that gives examples of intercultural supervision, which is important especially if teams are multiprofessional and multicultural. The next chapter describes concepts of psychosomatic rehabilitation, an area where migrants in Germany are usually underrepresented. The last chapter of this section deals with nonwestern psychotherapeutic approaches, including shamanism, traditional healers in East Africa, and Islamic cultures.

Section 7 about strategies for treatment and care starts with a chapter about medical treatment of migrants in emergency departments that also addresses the social situation of migrants. A chapter on liaison psychiatry shows how important cultural competence is to help to come to a valid diagnosis and initiate appropriate treatment. The chapter on pharmacotherapy demonstrates that ethnicity and culture represent important factors in pharmacotherapeutic responses in psychiatric patients. Psychopharmacological research in different ethnic groups is almost absent in Germany but is needed. Since in Germany more than a quarter of patients in forensic units are from diverse cultural groups, the chapter on forensic psychiatry by Hoffmann is of great importance. Subsequent chapters are concerned with day-hospital and out-patient treatment; community psychiatry; cultural competence in psychiatric social work and in psychiatric nursing. An impressive example of preventive approaches regarding migrants and addiction describes the concept of “cultural key persons” who have access to the targeted migrant groups. The last chapter of this section demands and presents concepts of “good practice” in the field of cultural psychiatry.

The eighth and final section discusses how to establish cultural competence firmly in various academic curricula. This is seen as a crucial prerequisite to improve diagnostic and therapeutic procedures. So far cultural competence training in Germany is not included in the curriculum for medical students or residents. Suggestions are made on how to improve this situation not only in medicine but also in psychology, social work, and nursing.

This volume is successful in its effort to achieve breadth and comprehensiveness. The editors have tried to appeal to a wide audience including psychiatrists, psychologists, sociologists, anthropologists, social workers, nursing staff, and interested general medical staff, and the contributors of this volume are drawn from these fields. A strength of the book is the referencing of research done in Germany.

While in Germany 30 years ago cultural psychiatry was considered exotic by mainstream psychiatry, this view is changing. Since the German-speaking countries have become culturally more diverse, the importance of cultural psychiatry is increasingly recognized in everyday clinical practice. The Handbook by Machleidt and Heinz will support clinicians in their work. It also provides a source of reliable information for researchers and academic teachers. This handbook is highly recommended to anyone seeking to broaden their knowledge of culture, migration, and mental health and illness.