February 14, 2006 Volume 42 Issue 05
Out of their element
New to Canada but not necessarily to psychiatric illness,
immigrants need programs that are multicultural, multi-ethnic
Dr. Khalid Sohail
When I started practising psychiatry in Canada nearly 20
years ago, I became acutely aware there are vast differences
between the practices of psychiatry in the East and West.
Those differences are even more pronounced for psychotherapy
compared to traditional psychiatry, which focuses on
diagnosing mental illnesses and emotional problems, relying
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've looked after many South Asian
immigrants and their families who did not want to see Canadian
psychiatrists unaware of their language and culture.
The practice of psychotherapy has grown by leaps and bounds
in the capitalistic, secular and democratic societies of the
Western world in the 20th century. It became popular in
communities where the literacy rate was high and people became
preoccupied with issues of loneliness, existential isolation,
personal growth, self-actualization, and the quality of their
marital and family lives. The media played a major
roleódiscussions on radio and television, and articles in
newspapers helped people to share their problems publicly.
In many underprivileged countries of the Third World,
poverty, illiteracy, dictatorships and religious dogmatism
reign, and every day people die because of malaria,
tuberculosis and cholera. They suffer from anemia,
malnutrition and hunger. Where social and economic conditions
are extremely poor and people struggle with survival issues,
psychotherapy becomes a luxury that only a few privileged
people can afford. People are likely to go to holy shrines and
fortune-tellers to deal with physical and emotional
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 them. Ethnic communities
and mainstream health-care agencies are becoming aware that
both sides need to be educated to change their attitudes and
practices; immigrant families need to feel free to get help
when they need it and professionals need to be more sensitive
to the special needs of immigrants.
As an example, let me a present a case history of a
Pakistani family consisting of Sabir, an engineer who had been
sponsored by a Canadian computer company, his wife, Maryam,
and their daughters, Jameela and Saleema (names have been
During the first interview, I saw the older daughter,
Jameela, who had become 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 20s, casually dressed, mildly scared and
with no insight into her problems.
She had seen a psychiatrist in Pakistan who had diagnosed
her as suffering from schizophrenia and had 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 Jameela was not very talkative during the
interview, she felt comfortable enough that when I encouraged
her to start taking her medications again, she agreed. I
suggested to the parents they also needed psychotherapy to
understand and cope with Jameela's condition. They were quite
willing to co-operate.
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
jobs because they didn't yet have work visas or permanent
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 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 would get
up in the middle of the night to check on her daughters.
When the relationship between the sisters and their mother
deteriorated and the 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 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. The issues this new immigrant
family faced were not much different from other immigrant
families who struggle with serious emotional problems, such
1. Social isolation
The family had no social contacts and no support network.
During therapy the family was not only encouraged to join
their local ethnic community but were also referred to
mainstream health-care agencies in their area.
2. Language barriers
Although the family could speak English, they felt more
comfortable in Urdu so most of their sessions were conducted
in Urdu. Despite their initial conviction that an English
Canadian nurse would not understand their problems, they
consented to her home visits and she was able to introduce the
daughters to various Canadian programs and organizations.
3. Working with the healthiest member of the family.
I felt the father was the healthiest member of the family.
Whenever I had a meeting with the mother and daughters during
the day while the father was working, the mother's anxiety was
so overwhelming 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 the father held the power as head
of the family and he could implement the decisions we made in
our family sessions.
Over the months I helped the daughters become independent
of their mother. They learned the bus routes 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 overcame their sibling
rivalry and are getting along fine. The mother is far more
relaxed and the father is quite pleased with the progress of
Psychotherapy with immigrant patients and their families
does not only involve hospitalization and medications, but
also focuses on helping them socialize in a new country and
find ways to integrate into a new culture. It not only focuses
on the control of symptoms of mental illness and emotional
problems but also helps them improve their quality of
To help immigrant families we need programs that are
multicultural, multi-ethnic and multilingual, so that
immigrants can benefit from mainstream programs while 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
can respect each other's differences and live harmonious
lives. As the world is becoming a global village, we need to
create multicultural societies where immigrant and host
communities can work co-operatively and harmoniously. Mental
health professionals can play a significant role in building
such cultural and health-care bridges.
Dr. Khalid Sohail is a psychiatrist in Whitby,