Friday, December 5, 2008

Back to the Clinic

This morning I had another meeting with Doctor Chikri at the psychiatric Clinic. I had planned this meeting primarily as a way to remind him of my existence, weeks after having given me research permission, but it was useful. Dr. Chikri introduced me to the hospital’s director of research, Dr. Rachidi, and together they discussed with me the hospital’s protocols for research conducted on its premises.

One thing I learned was that it is apparently illegal in Morocco for anyone without some kind of medical certification to be alone with patients. I believe I had heard that somewhere earlier, but clearly had forgotten it, because it is not something I had thought of as a possibility while designing my methodology. In any case, this means that all of my contact with patients, including the intensive interviews I want to conduct, will be supervised by a psychiatrist. Obviously this will affect the analysis in some way – having a third person in the room will affect what a patient chooses to tell me, what words he or she chooses to use; and most likely it will affect me and my engagement with the patient, as well. But I don’t necessarily think it will hurt the research in any way. Hopefully, the supervising clinician will be the patient’s actual treating physician. In that case I am hoping the patient will already have established such a rapport and relationship of openness with that clinician, that having him or her present during the interview will not necessarily make the patient keep certain things inside. If anything, the patient will probably be more likely to open up toward the psychiatrist than toward me – and in that case perhaps having the patient’s doctor there will create a kind of atmosphere of familiarity and comfort that will allow him or her to trust me more than they otherwise would…

It also answers any questions that the IRB board will have about issues such as crisis management, evaluation of patients’ capacity to understand my research and give consent for participation, and the potentially upsetting nature of certain questions. The only question I am left with now, is how to provide the same kinds of assurances for the clients of sha’ouada – popular, religious, or cultural healing practices. Obviously there is no such institutional framework there to make use of, so how do I satisfy the IRB? The best thing to do, probably, is to tell the IRB that this group is not actually mentally ill – to refer to them as ‘clients’ rather than ‘patients’. And in fact, this is a better way to frame my project, in general: because, after all, many of these clients have not been formally diagnosed with a psychiatric disorder, and many choose to visit a mousha‘ouada (traditional/popular/cultural healer) precisely because they reject the label of ‘mentally ill’. Hopefully, by avoiding the label of mental illness, questions of competence and such will not emerge. The only question then, is how to explain my use of the MINI – a diagnostic interview protocol that I plan to conduct with both ‘patients’ and ‘clients’. I’m using it only to establish some kind of baseline for comparison – even if it is an admittedly biased one because it makes use of psychiatric paradigms – but I need to find a way to justify the fact that I am submitting a population that either doesn’t consider itself mentally ill, or rejects that label to this diagnostic tool…

The difference between ‘patient’ and ‘client’ also came up briefly in the talk I had with Dr. Rachidi after leaving Dr. Chikri’s office. Telling her more in detail about my research project, she, too, volunteered her own thoughts about what makes people choose sha‘ouada over psychiatry. Like Ilyas, she also affirmed that this decision does not necessarily have anything to do with income level or even education. These two factors are certainly involved for many people, but there are interesting exceptions – the rich and educated who avoid psychiatrists as vehemently as a member of the lower class. What she also mentioned, as Ilyas had as well, was the distinction that is made between ‘illness’ and ‘culture’. A psychiatrist belongs in the domain of disease, of afflictions and of stigma. Going to a psychiatrist means being ‘crazy’. Sha‘ouada, on the other hand, belongs in the realm of culture. Visiting a fqih, a shouafa, or a saint’s tomb does not carry the stigma that a psychiatric consult does – and so many people resort to the latter to alleviate their malaise.

This argument I also found in one of the three theses I found in the Clinic’s library. Apparently all psychiatric residents write a “mémoire,” a kind of thesis, at the end of their program. All these theses are collected in the Clinic library, and Dr. Rachidi recalled at least three that discuss precisely the questions I am interested in: what makes people choose for either a psychiatrist or a mousha‘ouid (formulated by these psychiatrist more in the sense of ‘why do people wait so long to get real help?’). Dr. Rachidi introduced me to a woman who I think is the Clinic librarian, office manager, or something like that – a woman, at least, with a little command of French and a key to the library. With the authors’ names on a sheet of paper, she accompanied me there and sat me down on a chair while she searched and delivered me the three works. I looked around, already noticing there was no Xerox machine. How would I be able to make copies? I was about to ask this when she herself brought this up. Follow me, she said, and off we went – out of the library, off the hospital premises, and into the little surrounding streets, in search of a téléboutique.

Xeroxing is one of those other things in Morocco that is really easy to do – once you figure out where and how. You will not find a kinko’s here. But what you do find, and on every street corner in fact, is a téléboutique (a little parlor with payphones) or a cyber (internet café) that has a Xerox machine. The way it works is that you hand your material to the proprietor, who will then make your copies. If it’s a page or two you can wait while he or she takes care of your job, but if you have a lot – like my 180 pages – you will get an estimate. Or a flatout refusal. All three téléboutiques we stopped by in the Clinic’s neighborhood took one look at the stack of theses and shook their heads. Not enough paper, they said. After shop number three, the librarian told me to just take the theses with me, copy them on my own, and bring them back as soon as I could – which, with the upcoming eid, would be next week.

Back in my own neighborhood, I went to my favorite, albeit very slowly connected, internet café in the middle of the bustle of rue souika – it’s hidden behind a hole in the wall shop that sells lacy table cloths and place mats – and it has a Xerox machine. No refusal here, but clearly it was going to take some time: was Sunday early enough? This estimate made me a little nervous: the Clinic had made clear these were valuable possessions, and I didn’t feel comfortable leaving them unattended behind that old desk at that old internet café for an entire weekend. So I asked him, if he did just one of the three, how long would it take? With a weighty expression, he leafed through the work – upside down – and asked me, how many pages? Fifty-five, I said. He nodded, looked at the thesis again as though it was a carburetor, and told me: today, 6 PM? I agreed. And just as I was about to leave with the other two, he told me to leave them, and gave me a wink. A little hesitant but hopeful, I left him with the Clinic’s material.

When I came back at seven thirty, he had indeed managed to make copies of all three theses. With a big smile, he handed me the entire packet. It came down to 94 Dirhams ($10) for about 200 pages of material. Not bad.

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