Thursday, July 2, 2009

A Psychiatric Tower of Babel

I was first introduced to the cultural dimension of healthcare and illness by a lecture at the Academic Medical Center in Amsterdam. It was 1999, I was a first year medical student, and I absolutely loved the curriculum. I listened with rapt attention at every lecture on biochemistry, microbiology and physiology, and I adored the anatomy lab sessions in which we explored a female body with scalpel and tweezers. But what really, truly awoke a passion was a single comment during a brief class on primary care medicine. The lecturing doctor mentioned that it is important to keep in mind that patients of immigrant backgrounds often have a tendency to explain their symptoms in ways that may be different from the ‘average’. That this is due to their cultural backgrounds – their ways of understanding illness, and the taboos that exist within their framework of reference. And that a Moroccan woman, for instance, may explain her gynecological symptoms to a male doctor as a stomachache – but that this should not be taken as a cue to start thinking about appendicitis.

This was the point when things changed for me. When I realized that medicine alone was not enough for me – that it was the socio-cultural side of medicine that I really had a passion for, and that I was missing a greater focus on this dimension in my medical education. I became a pre-med after my transatlantic move to Chicago, but drifted more and more toward the Division of Social Sciences, pulled in by classes with titles like “Mental Health and Healing Across Cultures.” A new world opened up before me as I realized that our American or Dutch way of conceptualizing illness is by no means ‘objective’. The fact that we imagine neurological issues as the short-circuiting of an electrical system – and a disorder of the urinary tract as a problem with our ‘plumbing’ – is as much culturally determined as someone’s belief that epileptic symptoms are the manifestation of spirit possession. Even the definition of ‘pathology’ is in a sense contrived: who determined that 200 mg/dL of cholesterol in your blood is the boundary between ‘normal’ and ‘risky’, and why is it not, say, 225, or 231? I was mesmerized by this disappearance of objective truth even from such a scientific discipline as medicine – and intrigued to no end by questions such as these: do illnesses like schizophrenia really occur in every corner of the world, and do they always manifest themselves in the same way? Does a different way of explaining illness just mean a different way of experiencing the same biological problem, or is the illness itself inherently different? If patient and doctor work with different models of explaining illness, how does that affect the course of treatment? How does the inherent inequality of power that characterizes the doctor-patient relationship (because the doctor is always the authority figure) affect treatment? To make a long story short, I quit the pre-med program and became a PhD candidate in medical anthropology.

The answer to the above questions, basically, is that of course all of these things affect medical treatment. Because what these issues all come down to is, in very basic terms, a barrier of communication. Simply put, doctors and patients are often each monolingual in their own language. Their tongues may sound similar – but deceptively so, because it only obscures the fact that translation is necessary. In any case, you can imagine how a resultant miscommunication might lead to problems: a wrong diagnosis, a misunderstanding about the dosage of medication, or a lack of trust in a doctor who just doesn’t seem to hear you, can all seriously hinder the success of treatment.

If most problems come down to barriers of communication, most research in this field aims at calling awareness to the need for translation – at developing dictionaries and universal languages to improve the effectiveness of patient-doctor dialogue.

This was the goal of a workshop that I attended this week at the Clinic.* Three psychologists from the University of Amsterdam had come to Morocco to speak with psychiatric residents and psychologists here about the development of an interview questionnaire that would be multiculturally valid. The rationale for this, as they explained, was their frequent work with teens of immigrant backgrounds in the Netherlands. They found that the existing self-report questionnaires that are used to assess teen functioning often didn’t produce useful results with this population, because these questionnaires work with scales of ‘normalcy’ that are based on very Dutch cultural assumptions.

The goal of this workshop was, then, to develop a self-report questionnaire that would work for teens of Moroccan origin in the Netherlands, as well as teens here in Morocco itself. It gave rise to a productive cooperative effort in which the Moroccan residents, as the Dutch researchers had hoped, actively participated. But although some great headway was thus made to bridge a communicative gap between Moroccan and Dutch cultural contexts, the workshop itself simultaneously brought to light two communicative barriers unique to the Moroccan context, that I think the researchers had not quite been aware of. One was cultural, the other linguistic.

The researchers had come prepared for the Moroccan-Dutch linguistic barrier. Although two of them spoke only English, the third spoke a beautiful French and translated the others’ presentations. Even this interpretation became a cooperative affair, as she asked her audience for assistance with the translation of technical psychological terms; a request the residents eagerly obliged. But as they did so, they brought to light another linguistic barrier that might problematize their use of this questionnaire with Moroccan patients. Like most other standardized questionnaires that are used at the Clinic, this one was to be composed in French. French is the language in which psychiatrists are educated, and it is the tongue in which they and other highly educated Moroccans converse comfortably – it may even be the language they prefer, when they talk about their work. However, statistically speaking the majority of Moroccans are not as highly educated as a doctor, and thus are far more comfortable explaining their symptoms in Moroccan Arabic.** The already difficult task of reducing your complex experience of symptoms into words that correspond to some kind of diagnostic standard is thus made even more difficult by requiring you simultaneously to translate that reduction into a foreign language.

I later asked Dr. Rachidi about this, and she confirmed: this barrier between French and Arabic is a constant issue in the communication with and treatment of patients. Only about 10% of their patients, she told me, speak French well enough to work with one of these questionnaires. A Moroccan psychiatrist is perfectly able to speak with a patient in Moroccan Arabic. However, without the convenience of a biological test for mental illness, linguistic assessment must be substituted for blood work or an MRI; and the only diagnostic tools a Moroccan psychiatrist has at her disposal are in French. Somewhere, a translation has to be made – but whether it be the psychiatrist or the patient who makes that effort, there is always the risk of mistranslation. And as all literature lovers know, a translation is never quite the same as the original…

The other barrier that became apparent is cultural. One thing the Dutch researchers may not have been entirely aware of is the infinite cultural heterogeneity within Morocco itself. Without even mentioning the different cultural practices of Arabs, Berbers, and Jews, and without even trying to parse out which cultural elements come from sub-Saharan Africa and which originated in the Middle East, there is a particular duality that seems lately to preoccupy the collective Moroccan mind – and it was brought out spontaneously and quickly by the Moroccan residents. When the researchers asked the group of residents to itemize typical characteristics of parental behavior in Morocco (this was to be the main topic of the questionnaire), they produced two separate lists. One applied to the “old generation,” while the other characterized the “new.” There are two different value systems in Morocco, the residents explained, pointing to items that presented these two generation of parents as polar opposites of one another. Where the old generation valued the family (“c’est vraiment de la vénération des parents,” one resident explained), the new strove for individualism. And where traditional parents enforced a strict authoritarianism, modern ones actually listened to their children.

The contrast between ‘tradition’ and ‘modernity’ seems to be on everyone’s mind in Morocco, and it resonates through nearly every dimension of public and private life imaginable. It’s a big issue also in Moroccan psychiatry: for one, their allegiance to modernity is psychiatrists’ way of distancing themselves from what they see as the dangerous practices of ‘traditional’ healing. My own research actually deals very directly with the question of how this duality of modernity and tradition (or a seeming duality, because I think the Moroccan verdict on their compatibility isn’t in yet) affects the way in which people think about mental illness and different forms of treatment. And so I was intrigued, when the residents suggested that the questionnaire under construction may not be universally applicable at all. And if they were right that there was such a great difference between these two generations, they were right that certain questions would have very different meanings for each. Each question represented a statement, and respondents would be asked to indicate on a scale of 1 to 5 to what extent they think the action in that statement is important. A ‘traditional’ parent would score “giving more allowance to a boy than to a girl” as very important. However, a ‘modern’ family wouldn’t know what to do with this question. They would completely disagree with this discriminatory practice, the residents hypothesized – but filling in “not important” is very different in value from indicating that you disagree with the statement. Well, one of the Dutch researchers suggested pragmatically, couldn’t we change the wording of the phrase to something more neutral that applies equally to both old and new generation?

Moving on to the next problematic item on the questionnaire, the residents never responded.

Is there even an answer to this question? I’m tempted to wonder if complete universality is ever actually possible in medicine – and I’m tempted to say no. But why should there be? The beauty of life may very well be that there is no objective truth, and thus that nothing is universally valid. So why doesn’t medicine do what anthropology tries to do, and celebrate the diversity in human experience? Because a lack of objective truth by no means suggests that everything is untrue. To the contrary: it means that all different views on life are equally true. All we need to do is be aware of the fact that we don’t all speak the same language, and enjoy the process of learning others’ foreign tongues.

* It’s been a while since I last mentioned this place, but the Clinic is the (pseudonym for the) psychiatric treatment facility where I will be doing half of my research.
** Not to mention the universal truth that the less fortunate among the population are always more likely to get sick and need a doctor (read Paul Farmer for more on this), meaning that the percentage of low-educated, non-francophone individuals should be even higher among patients at the Clinic than it is in society overall.

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