Over the course of my conversations with the psychiatrists I interviewed last month, each practitioner explained that individuals mostly come to see them in search of la parole. Rather than a pill, in other words, patients consult a psychiatrist in private practice in the hopes of procuring a ‘talking cure.’
I found it interesting to hear that Moroccans – many of whom, according to my observations so far, seem very eager to solve an instance of bodily malaise with a quick pill – would prefer lengthy psychotherapy to pharmaceuticals. I found it surprising that there seems to be less stigma attached to counseling than there is to medication, as these psychotherapists claimed.
But what also struck me, and what I want to write about today, is the psychiatrists’ choice of the word ‘parole’. This French word can be translated as ‘speech’, or ‘spoken word’. Of course, ‘talking’ has been widely proven to be an effective form of psychiatric treatment. But what interests me here is the fact that ‘parole’ suggests such a strong emphasis on the linguistic dimensions of that activity. I don’t think that these psychiatrists ignore the myriad other dimensions of communication, but in general, I am getting the sense that Moroccan psychiatry focuses heavily on the issue of language.
Any time these psychiatrists spoke about establishing a sense of mutual understanding – and the importance of having a shared discourse on which to base that understanding – they would mention the importance of defining certain words, of ‘speaking the patient’s language’. In his writings about the history and practice of psychoanalysis in Morocco, Dr. Jalil Bennani even conceives of cultural beliefs as a kind of ‘language’. He suggests that a particular way of understanding and experiencing illness should be understood as a particular language, used to express feelings that are ultimately universal:
“Il convient d’accorder à la tradition magico-religieuse la place qui lui est due en interprétant celle-ci comme un effet de langage et non pas comme un effet ethnique. Il convient de reconnaître dans le discours magico-religieux du patient le signe d’un autre discours afin de réussir à dépasser la frontière stérile du magico-religieux et du rationnel et déplacer les conflits en vue de faire retrouver au sujet une capacité de liberté par rapport à sa propre parole."
Freely translated, he says the following: “we should see magico-religious tradition for what it is, conceiving of it as an effect of language, rather than an effect of ethnicity. We should recognize the patient’s magico-religious talk as marker of a different kind of speech,* so as to enable ourselves to transgress the sterile boundary between the magico-religious and the rational and to dissolve their conflict, so as to allow the subject to recover a capacity for liberty with regard to his own speech.”
I’ve noticed this psychiatric focus on language before – at the Clinic, for instance, when Dr. Rachidi lamented that with so few diagnostic tools available in Moroccan Arabic, doctors and patients forever risk getting stuck in a cycle of mistranslation. And this focus makes perfect sense, given the particulars of the Moroccan context.
Mutual understanding is always a crucial issue in psychotherapy. Doctor and patients may come from different (cultural, educational, economic) backgrounds, may ascribe to different ideologies, and may explain experience (and illness) in very different ways. Therapy is effective only if communication is; and in order to truly communicate, it is always important that these two participants understand the framework of assumptions and beliefs that the other is speaking from. In Morocco, where an incredible heterogeneity of beliefs characterizes not just society in general but most doctor-patient interactions as well, a difference in cultural background is often accompanied by a difference in language. Whereas the professional language of Moroccan psychiatry (and biomedicine) is French, the average patient who interprets his or her experiences as a form of spirit possession will not master this language, and will choose to explain said experiences in Moroccan Arabic – or in Tamazight, Tashelhit, or Tariffit.
Communication training manuals, or books about interviewing techniques, often emphasize the immense importance of understanding messages that are communicated nonverbally. The ‘indexical meaning’ of a message (Briggs, 1986) – facial expressions, gestures, tonal inflections, and so on – carry important clues about the ‘real’ meaning of whatever is expressed in words. But as much as it is true that we shouldn’t underestimate the necessity of heeding this more easily forgotten layer of communication, these Moroccan psychiatrists suggest that we should also not forget what’s right under our ears.
The same was suggested in a recent article that appeared on CNN. It reported on a study conducted by medical journal The Lancet, which found that online psychotherapy may be as effective as actual, in-person counseling. A group of patients was given a remote form of psychotherapy: they communicated with their therapist online, through instant messaging. In comparison with a control group that received no form of counseling, this indirect form of therapy seemed to have as high a success rate as ‘traditional’ therapy does. This would suggest either that nonverbal cues may not be so necessary in establishing a therapeutically effective level of communication between doctor and patient, or that online therapy has a particular advantage that might make up for that lack. A therapist interviewed for the interview suggests that the lack of nonverbal communication may in fact be liberating for the patient. Through this indirect form of interaction, stripped of any social context, an individual might be less worried about the social repercussions of things he or she wishes to say. In his words I read the suggestion that a solely linguistic form of interaction – in which social norms, contextual factors, and other cues that alter the meaning of spoken words, do not come into play – may provide the patient with a therapeutic sense of agency, of power. Agency and power so often hide in the ability to be heard, and for one’s words to be accepted. If nonverbal aspects of an interaction make a patient feel as though his words are not openly accepted, even if a psychiatrists words do their best to convey that feeling, perhaps a strictly verbal interaction does create more openness.
So what does all this imply about the nature of communication? What does it imply about the way in which we connect to one another, and by extension about the nature of our interpersonal relationships? How important is listening, exactly, and how do listening (to verbal communication) and observation (of nonverbal messages) relate to one another in the process of (effective) communication? And, perhaps above all, how does each form of communication affect the power relationship between the two speakers? These are questions I would really like to explore further in my research. I want to examine the role of language in Moroccan psychotherapy: I’m interested in the importance of words in creating a sense of understanding or shared meaning. I hope to explore psychiatrists’ and patients’ conception of the role of language in communicating, in understanding, and more fundamentally in structuring personal experience. Most of all, I’m interested in the power of language – the role that linguistic (mis)communication plays in structuring power relationships between psychiatrist and patient within this Moroccan context, in which ideologies and accompanying languages constantly vie for dominance. I will need to study Jacques Lacan, the French psychoanalyst who used Ferdinand de Saussure’s structuralist theories of language to explain psychic structures and processes, and who has had a major impact on French – and thus Moroccan – psychoanalysis.
And I’ll need a methodology that creates room for the subtleties and conflicts of language. I’ll be using the format of person-centered interviews – a lengthy, open-ended and very unstructured genre of interviewing that, like Moroccan psychiatrists, assumes the power of words. It’s a psychodynamically oriented kind of interviewing, in which the point is not only to learn something from the interviewee about the cultural phenomenon you’re studying, but also to learn something about how the interviewee personally reflects on that phenomenon; what role it plays in his experience. The interviewee is thus not only informant, but also respondent, and person-centered interviews require heavy analysis of the meanings that do not lie immediately at the surface of the interaction. But aside from looking for nonverbal clues to those meanings, the trick is also to look for linguistic ones. Person-centered interviews encourage the respondent to structure the direction and content of the discussion, and to reflect on her experiences in her own words. The trick is to analyze the respondent’s choice of language, his “personally organized statements – clumping of themes, slips of the tongue, obvious defensive maneuvers, evidence of emotion, fantasy, and speculative thinking” (Levy 1973:xxii). Why did the respondent discuss that issue at this particular moment? Why did he choose that particular word, and the connotations it carries, to express that experience? What does all that suggest about the respondent’s feelings about the matter?
It is thus crucial for anyone hoping to carry out person-centered interviews to learn the language of her respondents. There is no way you will pick up on the subtleties of certain linguistic choices if your level of competence in that language is merely conversational. I have a lot of work ahead of me in that regard. I’m beginning to establish a kind of feeling for the subtleties in French (even if I myself haven’t actively mastered them yet), but I have a long way to go for Moroccan Arabic. I’m considering this post a re-dedication to that endeavor. I’ve created a bit of structure in my work life, and hope that this will create some time for renewed language study. And perhaps I’ll find some time for that psychoanalytic reading, as well…
* the French discours is not the same as the english discourse