By Dr. Khalid Sohail

Comments By Joe McALLISTER

When I started practising psychiatry in Canada nearly twenty years ago, I became acutely aware that there are vast differences between the practices of psychiatry in the East as compared to the West. Those differences were even more pronounced when it came to the practice of psychotherapy as compared to traditional psychiatry which focused on diagnosing mental illnesses and emotional problems and relied heavily on the use of medications. I wanted to focus more on education and counselling rather than just prescribing drugs. Being a Pakistani psychiatrist practising in Canada, I had to look after many South Asian Immigrants and their families, as they did not want to see Canadian psychiatrists who did not know their language and culture.

       As I studied the subject of trans-cultural psychiatry, I learned that the practice of psychotherapy has grown by leaps and bounds in the Western world in the twentieth century. The tradition of psychotherapy has blossomed in capitalistic, secular and democratic societies. It became popular in communities where the literacy rate was high and people became pre-occupied with issues of loneliness, existential isolation, personal growth, self-actualisation and the quality of their marital and family lives. The media played a major role—discussions on radio and television and articles in newspapers helped people to share their problems publicly. There has also been an increase in psychiatry, psychology, social work, and marital and family therapy programs in colleges and universities. All these changes are gradually making psychotherapy an integral part of the health care system of the Western world. Although many traditional psychiatrists still focus on prescribing medications, more and more mental health professionals are becoming aware of the importance of psychotherapy.

       On the other hand, there are still underprivileged countries of the “third world” where poverty, illiteracy, dictatorships and religious dogmatism reign and every day people die because of malaria, tuberculosis and cholera and suffer from anaemia, malnutrition and hunger. Because of illiteracy and ignorance people still go to holy shrines and fortune-tellers to deal with their physical and emotional problems rather than seeking out qualified medical doctors, psychiatrists and nurses. In those countries people with emotional problems come under psychiatric care only when they have a psychotic breakdown and suffer from mania, severe depression, paranoia or a schizophrenic breakdown and the family cannot handle them because of their losing control and causing severe disturbances. Even in those circumstances most patients get institutional care and receive medications. The role of psychotherapy in their care is very limited.

       Societies that have a religious base and judge people's behaviour on moral rather than psychological grounds have a tendency to consider emotionally disturbed people to be criminals or sinners and either jail them or send them to holy shrines to repent rather than to mental health professionals for treatment. In those communities, emotional problems are still considered to be “spiritual problems.” It is interesting that the word "psyche", which now means "mind", used to mean "soul" at one time, even in the Western world.

       In countries where social and economic conditions are extremely poor and people are struggling with survival issues, the practice of psychotherapy becomes a luxury that only a few privileged people can afford.

       As far as immigrants are concerned, when people from “third world” countries immigrate to the “first world” they bring their philosophies of life with them. In spite of the availability of mental health care services, many immigrants are reluctant to use those services. On one hand they feel nervous whether their privacy and confidentiality will be respected and on the other hand they wonder whether health care professionals who grew up in a nuclear family system and whose training was based on Western values would be able to understand the problems of an extended family system and appreciate their cultural conflicts. It is not uncommon that even living in the West, many immigrant families come to the attention of the healthcare system only when one of the members has a psychotic breakdown. Many immigrants feel very embarrassed about seeking medical and psychiatric treatment and even when they receive it, the language and cultural barriers become an issue for them in getting appropriate care.

       In the last few decades, ethnic communities and mainstream health care agencies are becoming aware that both sides need to be educated to change their attitudes and practices so that bridges of care can be built. Immigrant families need to feel free to get help when they need it and professionals need to be trained to become more sensitive to the special needs of immigrants. We need more workshops and seminars on health care issues so that immigrant families and mainstream health care professionals can have a dialogue about health care issues and be able to resolve their conflicts. The time has come when both sides can learn from each other.

          After working with many South Asian immigrant families I have made a number of observations and drawn some conclusions. In this essay let me a present a case history and then share my impressions. It is the story of a Pakistani family of an engineer, Sabir, who was sponsored by a Canadian computer company. He came with his wife Maryam and daughters Jameela and Saleema (names have been changed to respect their privacy) and applied for permanent residency status in Canada. During the first interview I saw the older daughter, Jameela who had been becoming very angry, agitated and restless at home. Her parents were extremely concerned about her and were worried that she might hurt her younger sister and mother in one of her “fits of rage.” When I saw the patient she appeared to be in her early twenties. She was casually dressed. She seemed mildly scared and had no insight into her problems. She had seen a psychiatrist in Pakistan who had diagnosed her as suffering from Schizophrenia and prescribed medications. There was no psychotherapy offered to the family. The patient had stopped taking her medications during the move to Canada. I thought she was regressing and becoming psychotic again. Although the patient was not very talkative during the interview, she felt comfortable enough with me that when at the end of the session I encouraged her to start taking her medications again, she agreed. I suggested to the parents that they needed psychotherapy also to understand her condition and learn to cope with it to improve the quality of their family life. They were quite willing to cooperate.

          During my first interview I also discovered that the family had been in Canada for only a few months and lived in a three-bedroom apartment. They were socially isolated because they did not know anyone in that area. None of the women knew how to drive and they could not apply for a job because they didn’t yet have a work visa or permanent residency status.

          During the next few months as the older daughter got better, the younger daughter became ill, to the point of being floridly psychotic. As I got to know the family I realized that the mother was extremely nervous and had been reluctant to leave Pakistan but felt under pressure from her husband who wanted a better professional future in Canada. The mother was so worried about her daughters that rather than sleeping with her husband she slept in her daughters’ room. She used to get up in the middle of the night to check up on her daughters. Within a short time it became obvious to me that the daughters felt suffocated by the overprotective personality of their mother. There was a symbiotic relationship between mother and daughters. The daughters wanted to be free from their mother’s controlling love and one way was to become psychotic.

          When the relationship between the sisters and their mother deteriorated and younger daughter’s condition didn’t respond to medications, I had to admit her to the hospital for a few weeks. In the next few months the younger daughter Saleema received a combination of therapy consisting of medications, education and individual psychotherapy, and the family received family therapy to cope with the problems at home.

          Over the months the family recovered and felt reasonably settled. A year later, both sisters were doing well and were getting along better with each other and with their parents. I encouraged them to become independent and helped their mother to respect her daughters’ choices, as they were adults. Both parents were pleased with their progress and the mother was more relaxed and reassured. While looking after this new immigrant family with serious emotional problems, I became aware of a few issues in therapy with this family that were not much different from those of other immigrant families who struggle with serious emotional problems.

1.    Social isolation.

The family had no social contacts and no support network. During therapy the family were not only encouraged to join their local ethnic community but were also referred to mainstream health care agencies in their area.

2.    Keeping the Illness Secret

The mother was quite determined to keep her daughters’ illness a secret, as she was in the process of arranging marriages for them to two young Pakistani men. The mother felt strongly that her daughters could not be married if they were taking medications. I had to spend a lot of time educating her about accepting emotional problems and learning to cope with the stigma of mental illness in the community.

3.    Speaking Urdu

Although the whole family could speak English, they felt more comfortable in Urdu. I left the choice to them. Most of my sessions with them were conducted in Urdu. In the beginning the mother was reluctant to have a nurse visit them at home. She told me in Urdu that the nurse, being an English Canadian, would not understand her problem, but when I explained in Urdu that the nurse was a professional and her home visits would help her daughters, she agreed. The nurse introduced the young ladies to different Canadian programs and organizations.

4.    Working with the healthiest member of the family.

I felt that the father was the healthiest member of the family. Whenever I had a meeting with the mother and daughters during the daytime while the father was working, the anxiety of the mother was so overwhelming that the daughters could not concentrate on the therapy session, as they felt controlled by her. She was quite over-protective and dominating. When I changed the meetings to the evenings when the father could attend, the sessions became more productive. I realized that the father held the power as the head of the family and he could implement the decisions we made in our family sessions.

Over the months I helped the daughters to become independent of

their mother. They learnt the bus route and started coming for their appointments on their own. They felt so much better that one went back to school and the other started doing volunteer work. They also made some Canadian and Asian friends. The sisters have overcome their sibling rivalry and are getting along fine. The mother is far more relaxed and the father is quite pleased with the progress of the family.

Psychotherapy with immigrant patients and their families does not

only involve hospitalization and medications, but also focuses on helping them socialize in the new country and find ways to integrate into the new culture. It helps families get to know the Canadian system from a social as well as professional point of view so that they can live, work and socialize comfortably in both cultures. It not only focuses on the control of symptoms of mental illness and emotional problems but also helps them improve their quality of life.

I am of the opinion that to help immigrant families we need

programs that are multicultural, multi-ethnic and multi-lingual, so that immigrants can benefit from mainstream programs alongside staying in touch with their own cultures. Psychotherapy with immigrants is an attempt to break down walls and build bridges so that people from different cultures, rather than being prejudiced, can respect each other’s differences and live a harmonious life. As the world is becoming a global village, we need to create multi-cultural societies where immigrant and host communities can work cooperatively and harmoniously. I believe that mental health professionals can play a significant role in building such cultural and health care bridges.


Dr. Khalid Sohail