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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 and multilingual

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 problems.

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 changed).

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 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 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 as:

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 the family.

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 life.

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, Ont.

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