Abstract
Since the early 1970s, the French public health system has been accorded considerable responsibility for immigrants identified by the educational, judicial or social service authorities as psychologically distressed or socially disruptive. In this paper we discuss three models of healing embedded in constructs of “cultural difference” and addressed at specialized mental health-care centers catering to immigrants in Paris: “cultural mediation,” transcultural psychiatry/ethnopsychiatry and clinical medical anthropology. Based on observations and interviews at three specialized mental health centers in Paris, we explore how these clinical approaches address migrant wellbeing and seek to resolve crises in migrant families, especially those of West African origin. We suggest that the prevalent approaches to therapy creatively blend concepts and practices of anthropology, psychiatry and psychology but, at the same time, confront challenges inherent in the use of a generic “African” healing modality. Cases studies demonstrate that in order for such interventions to be perceived as effective by patients, “cultural difference” must be acknowledged but also situated in broader social, political and economic contexts.
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Notes
The much cited law of 1901 allowed two or more individuals to constitute an association eligible to receive state funding for nonprofit objectives. This law was amended on 9 October 1981 to extend the right to “foreigners,” or those without French nationality. The mouvement associatif has both supplemented the provision of state social services and initiated social service and legal aid interventions, particularly those targeting migrant populations (Belhadj 2001, p. 3).
Preamble to the Constitution of 27 October 1946 (Préambule de la Constitution du 27 octobre 1946):
Au lendemain de la victoire remportée par les peuples libres sur les régimes qui ont tenté d’asservir et de dégrader la personne humaine, le peuple français proclame à nouveau que tout être humain, sans distinction de race, de religion ni de croyance, possède des droits inaliénables et sacrés. Il réaffirme solennellement les droits et les libertés de l’homme et du citoyen consacrés par la Déclaration des Droits de 1789 et les principes fondamentaux reconnus par les lois de la République. Il proclame, en outre, comme particulièrement nécessaires à notre temps, les principes politiques, économiques et sociaux ci-après…:
La Nation assure à l’individu et à la famille les conditions nécessaires à leur développement.
Elle garantit à tous, notamment à l’enfant, à la mère et aux vieux travailleurs, la protection de la santé, la sécurité matérielle, le repos et les loisirs. Tout être humain qui, en raison de son âge, de son état physique ou mental, de la situation économique, se trouve dans l’incapacité de travailler a le droit d’obtenir de la collectivité des moyens convenables d’existence (Emphasis added).
The data reported here were collected as part of research on reproduction and representations of family among Malians in Paris, conducted in collaboration with Dennis Cordell, Department of History, Southern Methodist University; Samba Yatera, Research Sociologist, Groupe de Recherche et de Realisation pour le Developpement du Tiers-Monde, Paris; and Ismael Maiga, Professor of Sociolinguistics, University of Paris VIII. Both Dr. Yatera and Dr. Maiga provided important insights regarding diverse issues facing Malian migrants in France.
For her, mediation poses ethical risks such as bearing false witness, opposed in the Koran and in the Bible. It is easy to abuse mediation (and translation) if you change the message you are asked to convey. For example, in order to be culturally appropriate, she would not say to a West African woman, “Stop having babies, take the pill” (as stated by a social worker or midwife). Instead she would say, “The social worker said I should tell you that, given your housing and financial problems, wouldn’t it be a good idea to take the pill?” She joked that her role is to make the message “hearable.”
Bintou offered insight into the history of mediation in West Africa and, thus, why clients find this approach congenial. In Africa, conflicts are customarily addressed by mediation. Men mainly serve as mediators, but women may mediate among women. In the Senegal River Valley region, from which many of the migrants to France originate, mediators are drawn from particular “castes” (nyamakala), including blacksmiths, praise-singers and leather-workers. Some mediators became renowned for telling the truth, being impartial and not disclosing secrets. Even in Paris, one can look for a nyamakala: to intercede with relatives on each side in a marital dispute, for instance. But this is less and less common, because now women go to their social worker and ask for autonomous support (such as an abused wife, a mother of children at risk or a victim of forced marriage).
In addition to the term ethnopsychiatry, ethnopsychology and transcultural psychiatry are also referenced as approaches that attend to cultural difference and the cross-cultural “encounter” as being central to migrant health.
Not until the work of Georges Devereux was a methodology for a complementarity between psychiatry and anthropology in the clinical context articulated. It was argued that Devereux provided “a vast synthesizing effort between Freudian theories, American anthropology’s debate on the relationship between individual and society/psyche and culture, and finally the French school (Durkheim, Mauss, Levi-Strauss)’s dialogue with psychoanalysis” (Andoche 2001, p. 283). Devereux argued that it is impossible to dissociate the study of culture from that of the psyche, because both are concepts that—although distinct—are complementary to one another. Culture and psyche should be considered as two facets of the same reality, presupposing one another reciprocally, both functionally and methodologically. Hence the need for a complementarity between psychoanalysis and ethnology (Andoche 2001). Devereux’s seminar in Paris influenced the creation of transcultural psychiatric care sites and the development of psychoanalysis, along with a clinic of migration and exile (Mouchenick 2006, p. 59).
Devereux’s concept of complementarity is not theoretical but, rather, methodological. It prescribes that references to anthropology and ethnopsychoanalysis be considered distinctly, not simultaneously, so as to avoid confusion between their respective analyses (Mouchenick 2006, p. 59). It postulates a distinction between Culture in itself (a universal human phenomenon—psychic universality) and individual expressions of culture (cultural specificity and human diversity). It argues that the use of cultural material in psychotherapy could be used as a transitory therapeutic lever, but warned that the use of such cultural levers should not constitute a therapeutic object in itself (Moro 2006, p. 162). Devereux also notes that, in fact, the use of culture could potentially become an obstacle to therapy and, therefore, should be used cautiously (Moro 2006, p. 164). Thus, according to Devereux, therapists must cease to perceive patients as the “site of an illness”—providing them with investigations and all sorts of benefits—and, instead, must accept patients as persons belonging to the human condition, trying to give meaning to their suffering and a sense to their lives. In this perspective, the knowledge of patients’ original cultural milieu can be used toward therapeutic ends. But it must be employed neither as a possible means of readaptation to that milieu nor as a conditioning method to the healer’s culture (Andoche 2001, p. 289).
This is a partial presentation of a case that involved multiple consultations over a lengthy period. Some details have been modified to preserve confidentiality while allowing the therapeutic process to be portrayed.
As the attending anthropologist, Sargent observed that the father was visibly reassured by the ritual, but asked after the last session what would happen to the children. The two principal therapists said that, when school started in the fall, the case would need to be revisited.
She prefers the term transcultural psychiatry to ethnopsychiatry, although conceptually they do not differ, in her understanding, because it has more applicability in international psychiatry (and also lacks the controversial history of the term ethnopsychiatry in France).
Although it may not immediately be apparent why this approach is an example of a clinical medical anthropology, its practitioners have formalized their model and apply it in teaching at the university level, as well as in clinical discourse among staff. It appears that the medical anthropological components of significance are the concepts of illness, disease and sickness, the recourse to the concept of culture (where relevant) and the reference to “universality” as encompassing peoples of all ethnic/national/religious origins.
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Acknowledgments
This research was generously funded by the National Science Foundation (BCS 0105192) and by the Wenner-Gren Foundation, and it benefited from the insights of Didier Fassin, Professor of Anthropology, EHESS, and Yves Charbit, Professor, Inter-Pop, University of Paris 5. We also gratefully acknowledge the invaluable assistance of Dr. Rachid Bennegadi and the Centre Minkowska, Dr. Marie-Rose Moro, Hopital Avicenne, and Professor Mahamet Timera, University of Paris 7.
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Sargent, C., Larchanché, S. The Construction of “Cultural Difference” and Its Therapeutic Significance in Immigrant Mental Health Services in France. Cult Med Psychiatry 33, 2–20 (2009). https://doi.org/10.1007/s11013-008-9115-1
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DOI: https://doi.org/10.1007/s11013-008-9115-1