Thursday, November 12, 2009

Ethnography of a Psychiatric Ward: Addiction in Rabat

Mr. Abbas is a thin, clean-shaven man in his fifties. He is well-spoken, but restless as he meets with his treating physician, a young petite woman in her second year of psychiatric residency. Sitting on the edge of his seat, he keeps getting up and walks around the room, as though he is acting out the story he is telling. He is beating around the bush, and the resident repeatedly calls him on it: you’re not answering my question, she tells him.

He isn’t providing the resident with the information she is looking for. Neither is he speaking her language: while she poses her questions in Moroccan Arabic, he insists on answering in French, and utters not a word in dialect throughout the meeting. At first I think he may be doing this for the benefit of the observers in the room: two master’s students in clinical psychology, a psychiatrist from France, and myself. Our presence probably did have something to do with his conduct. But there was more to Mr. Abbas’ very performative behavior.

Mr. Abbas is an alcoholic, and he has checked himself into the Clinic in order to conquer his addiction. When his doctor introduces us, the observers, during this particular consultation, Mr. Abbas responds with a polite and pleasant enchanté, and proceeds to introduce himself with a quite elaborate story. He is a successful lawyer, he tells us, well-educated and fluent in French. Over the course of the consultation he talks about his practice, his nice car, his wife – none of which the resident asked about. After he leaves, his doctor tells us that Mr. Abbas hasn’t worked in three years. His wife has left; in fact, the life he just described to us has been destroyed by his addiction. What emerges at that point is the sad picture of a man dethroned; a man who has lost everything he thought to validate his existence; a man who desperately tries to maintain an image he knows he has already lost.

And it made me wonder. What does alcoholism mean for a Moroccan man? Alcoholism is destructive to anyone, but in this country, where alcohol is forbidden by religious decree, what does it mean to be an alcoholic? What does it do to Mr. Abbas’ sense of who he is? To his identity as a man, as a Moroccan, as a Muslim?

Mr. Abbas is but one of the patients I met during my week of observation on the service de toxicomanie, the Clinic’s addiction ward. It was the inaugural week of my research project; though I will not actually be able to do anything I mention in my research proposal until I obtain authorization from a local ethics board, the Clinic’s director has given me permission to kick-start my research with a period of general observation. Dr. Rachidi and I designed a schedule that would put me on a different ward each week, and as of last Monday, I spend every weekday morning looking around, shadowing doctors and nurses, and sitting in on meetings and rounds.

The service de toxicomanie has been running for a number of years, but recently moved into new housing: a newly built two-storey construction just inside the hospital grounds. Clearly the recipient of considerable funding, the service stands out from the rest of the hospital by virtue of its size and its modern and clean appearance.

But despite its large quarters, the service is small. Aside from Dr. Rachidi, who is the attending on this ward (here she is called professeur), the place is staffed by two residents (résidents) and about three nurses per shift. The number of patients, too, is small; I can count them on my two hands. All are male, and most are there because of their dependence on alcohol. From a poster that charts the service’s functioning over the past five years, I learn that this is the norm for the ward. The men range from late adolescence to late adulthood, and come from equally varied backgrounds. I see wedding rings on a few hands, and I wonder about their families, their friends. Who comes to visit them? I’ve already learned that the patients themselves are not allowed to communicate with the outside world; one of the first things I am shown is the therapeutic contract that each patient is asked to sign upon admission (all patients on this ward are admitted to the hospital voluntarily). This list of rights and obligations indicates that each patient is to surrender all means of communication. A total of two visiting hours are scheduled for the weekends. I wonder what this restriction of contact is like for a Moroccan family – togetherness is so important here, and I get the sense that that is especially true in times of sickness. The crowds of loved ones around each hospital bed left a lasting impression on me when I visited a public hospital in Fes, a few years ago.

The average length of stay is a month, though some stay longer. When I arrive with the doctors around 9.30 every morning, the men are usually grouped together in a small courtyard off the main corridor. This is the only place where they are allowed to smoke, and all of them make eager use of this right. They lounge on benches or hang around in the doorway, chatting with one another, occasionally requesting something from a doctor or nurse. The patients don’t seem to get much of this kind of down time, however. Their days are highly structured; a weekly timetable posted on the bulletin board in the main corridor allocates every hour of every day to a particular activity. An hour of every morning is scheduled for consultations with the médecin, the doctor, and each day devotes an additional hour or two to a particular form of therapy (group discussions, during which patients discuss a theme of their own choosing, but always related to addiction and substance abuse; motivational therapy; psycho-éducation, during which awareness is created about the negative impact of substance abuse; or relaxation therapy, for instance). Afternoons and evenings promise activities of a more recreational variety, such as television, reading, ping-pong, or cards. There is time for exercise, and even for music – I have already seen the well-equipped gym and music room upstairs. It is a full schedule and indeed, it seems that the patients and staff are always either coming from one activity, or about to start another.

The doctors (and I) begin their mornings at the Clinic-wide staff meeting, where they discuss new admissions. The presentation of patients is formalized; it is formulaic and ritualistic. In contrast, on-ward communication between doctors, nurses, and patients is informal and easy. After the doctors’ arrival on the ward, the staff briefly gathers to exchange pertinent information from the past night or weekend. They meet in one of the recreational areas off the main corridor or in the nurses’ station, a round space enclosed by glass at the end of the corridor. This room is furnished with a desk and a few bookcases that hold all records, files, prescription pads, and other necessities. The station makes me think of a Foucaultian watchtower; as particular patients are discussed, I notice doctors and nurses glancing at the man in question through the glass, sometimes even pointing as they review his behavior last night.

While the Clinic-wide staff meetings are held exclusively in French, the conversation between doctors and nurses is an even mix of French and Arabic. When speaking the latter, everyone addresses one another with the familiar tu. There are jokes and laughter, and everyone speaks at once. No one wears a name tag, and only the two residents walk around in white coats. There are no pagers; just cell phones. Dr. Rachidi is warm and approachable toward everyone; while she does not hesitate to point out flaws in her residents’ approach to their prise en charge (care), her criticism is always constructive. “You’re supposed to make mistakes,” she even tells them during one particular meeting, “you’re residents, you’re here to learn, not to do everything perfectly at once.”

Both residents on this ward are female. This reflects a general Clinic-wide gender-balance: of the 22 residents being trained here, sixteen are women. Likewise, there are three women among the six professors of psychiatry that teach and practice at the Clinic. In contrast, most of the nursing staff is male. The French psychiatrist, who began a six month fellowship here during the same week that I began my observation, tells me this is common at psychiatric wards throughout the world; a big strong man is often better able to deal with aggressive patients than a woman, she explained. Nevertheless, this particular gender balance provides an interesting contrast with traditional notions of professional roles within the world of healthcare, where men are in charge as doctors, and women are nurturing nurses. It’s a contrast also with traditional Arab conceptions of masculinity and femininity – conceptions that are very much alive here in Morocco. I very much wonder what this inversion of traditional roles does to the balance of power on the Clinic’s wards – especially on a service such as this one, where the patients are so predominantly male. For patients such as Mr. Abbas, who feel so dethroned, I wonder what it’s like to be treated by a female doctor. I’m curious to see how this plays out on other wards, and it could be an interesting angle for my research.

This week, I've moved on to a different service (more ethnographic sketches to come…). Toxicomanie is not the ward where I will be doing my research. Nevertheless, I was reticent to leave – not only because I found everything about the place so interesting, or because I would like a chance to answer the questions this week has brought up. I’m also reluctant because I was finally beginning to feel a bit more comfortable with my presence there. I had become familiar with the doctors, the nurses, the patients, the languages. I was losing some of my reticence about bothering busy doctors with my questions, or disturbing a patient with an inappropriate question. I am more of a wait-and-see person than a go-get-‘em-girl, preferring the slow, subtle approach to the direct and bold one. This can work well in anthropology, but not necessarily during the set-up phase of research; I often have to push myself to be assertive and ask the questions I want an answer to.

But I’ll do as much pushing as I have to. This week has proven, I think, that it pays to be direct, to stop worrying about things like bothering people, or misunderstanding them, or worse – not being able to make myself understood. For the first two days on the service de toxicomanie, I was incredibly anxious about issues of communication. I worried that I wouldn’t understand everything; my exhaustion at the end of each day reminded me how much energy it takes me to follow a conversation in medical French or Arabic. I panicked every time I realized I’d been dozing off and had missed a crucial turn in the discussion – something that tended to happen particularly at those moments that I spent worrying. I was even more nervous not being able to make myself understood: of tripping over words or, worse, not being able to think of any. I spent those mornings’ rounds in fear that I’d be asked to explain my research, to explain why I chose Morocco. But on day three I began to realize that, despite exhaustion, I had actually been understanding enough to have a good sense of what’s going on. And later that day, I suddenly found myself in various conversations, perfectly able to describe what I was doing there, even receiving a compliment on my French. And so I moved on to the next ward, perhaps not fearlessly, but at least with a good dose of faith that maybe, just maybe, this project of mine will be doable, after all…

1 comment:

Anonymous said...

Thank you for sharing. This is a very informative. It is important to know that there is help for those struggling with addiction and that they are never alone.

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