Praxis der interkulturellen Psychiatrie und Psychotherapie
Migration und psychische Gesundheit.
Prof Wielant Machleidt
Prof Andreas Heinz
Urban & Fischer Elsevier, München, p. 612, 2011.
The expansion and maturation of the European Union over the past three decades has led to greater interaction and communication between the national populations that comprise the EU. It has also witnessed a much greater inflow of migrants from countries outside the EU. As the numbers of migrants from both European and other countries have increased, the national populations of many European countries have become steadily more culturally diverse. Migrants now comprise 10-20% of the national populations of many European countries. This new multiculturalism in European countries has opened up new fields of research and areas of clinical focus for psychiatry, psychotherapy and psychology in central Europe, as well as for sociology and ethnology.
This volume brings together major themes and findings of the resulting intercultural scientific research and experience from clinical practice, in the form of a textbook on the practice of cultural psychiatry and psychotherapy, edited by Wielant Machleidt and Andreas Heinz, that includes chapters by more than eighty experienced contributors to this burgeoning field. This is the first such comprehensive textbook on cultural psychiatry and psychotherapy published in continental Europe, and responds to the growing need over the past two decades for just such a comprehensive textbook.
The textbook contains 70 individual articles gathered together in eight chapters addressing the central themes of migration psychiatry and psychology, in addition to important but often 10 overlooked special topics. The text begins with a review of models of understanding of the phenomenon of migration. Section One, titled “Theoretical aspects” presents multi-dimensional approaches towards the understanding of migration including philosophical, ethnological, and ethno-psychiatric approaches, followed by a lively debate between the editors and individual authors on the strengths and weaknesses of the main theoretical positions in ethno-psychiatry. This theoretical section leads to a detailed review of the processes of migration, through discussion of the themes of integration, acculturation, identity and religiosity. The societal obstacles resulting from discrimination and racism are also analysed in depth. The section ends with an overview of the patterns of migration encountered in central Europe.
Under what conditions do migrants come into contact with the local population? Section Two, titled “General requirements for the care of migrants” includes contributions on this topic by researchers experienced in studies of migration to German-speaking countries and of people who themselves migrated to German-speaking countries as well: Turks, Russian Jews, Poles, Latin Americans, Chinese, and Japanese – as well as ethnic Germans who had been living for generations in areas of the former Soviet Union who have been re-settled in Germany during the past two decades. This section also addresses the complex issues of housing, educational and occupational opportunities made available to migrants, as well as health and mental health services offered to migrants by national and regional government agencies. The recommendations for psychiatric- psychotherapeutic treatment of migrants contained in the “Sonnenberger Guidelines” are ￼presented. In addition, this section deals with practical experience in language mediation, the development of multicultural clinical service teams, and acquisition of intercultural skills. This section also addresses the politically contentious basic requirements for naturalisation of aliens (asylum seekers), as well as methods of transcultural clinical assessment for courts.
Section Three focuses on “Diagnostics” from a three-fold perspective: cultural aspects of the clinical psychiatric exploration and examination – the cultural formulation; the objectifying of intercultural psychological test diagnostics on the basis of culturally sensitive and fair psychological test procedures; and a critical analysis of knowledge concerning the psychiatric vulnerability and risk of disease amongst people from other cultures – cultural epidemiology. It was a particular wish of the editors that Section Four deal with “migrant groups in special problem situations” – groups that are often not seen, but are in particular need of psychiatric/psychotherapeutic help. This includes groups that differ widely, such as adolescent migrants, unaccompanied underage refugees, women and girls from central and Eastern Europe who are victims of human trafficking, false imprisonment and sexual violence, illegal or ‘undocumented’ migrants, and elderly migrants.
Section Five, titled “Disease patterns”, makes it clear that both culturally comparative and migration specific perspectives are important for clinical diagnosis and treatment. All of the major psychiatric disease patterns are presented within the framework of the influence of their culturally- and migration-specific combinations of psychopathological symptoms. The section ends with a review of the “culture-bound syndromes”; 11 not only because they are often seen as ethnic “exotica” of transcultural psychiatry, but also because they are exemplary in repeatedly generating critical and useful controversy around the fundamental question of what constitutes psychiatric “disease entities”. What must be taken into account during psychotherapeutic treatment of patients from other cultures?
Section Six, “Intercultural and transcultural psychotherapy” approaches the question from two perspectives. One point of view deals with psychotherapy and rehabilitation of migrants from the perspective of depth psychology, behaviour therapy and systemic therapy, while the other compares psychotherapeutic methods and their effectiveness across cultural boundaries using the example of East African shamanism and traditional healing practices in Islamic culture. This section ends with a discussion of issues related to supervision of the treatment team in clinical practice.
At present the most intensive research activities in the psychiatric/psychotherapeutic treatment system involve the provision of culturally sensitive and competent “strategies for treatment and care” for migrants (Section Seven). Eleven contributions address in detail the important fields of care: clinical assessment and treatment of migrants in the emergency department; forensics; out-patient clinics; community psychiatry; prevention; intercultural pharmacology; as well as utilization of community mental health and clinical services by migrants. In addition the importance for the treatment environment of intercultural competence amongst nursing and social staff is considered. Finally concepts are presented that, as examples of “good practice”, can provide orientation for people wishing to expand their knowledge and clinical skills in this field.
In order to establish intercultural competence in daily practice in clinical settings, intercultural themes need to be included as a normal component of the learning environment and be embedded in the curricula of students (medicine, psychology, sociology, ethnology, etc.), as well as in higher and vocational education modules designed for all professional groups involved in psychiatry/psychosomatics and psychotherapy. Section Eight provides examples of how this may be applied in educational terms for a number of different professional groups.
In summary this textbook integrates the experience of well-known experts for application in intercultural practice. It is bound to the therapeutic requirement to treat people from other cultures with the same high professional standards of quality received by the native populations of Central Europe. The incidence of mental illness amongst migrant groups lacking an integrative infrastructure is known to be considerably higher. Conceptually, the objective of this textbook was to focus on two major topics; 1) the complexity of the migrant process and the host country acceptance of current migrants, and 2) the wellbeing of individuals and families of the different ethnic groups that constitute the current generation of migrants to central European countries.
Beyond this it is important for the editors to involve subject areas that are normally neglected. In the theoretical part of the book, for example, a debate is included concerning controversial standpoints in ethnopsychiatry (see the internet version), psychodynamic models of 12 migration are presented, and racist positions are delineated and discussed. What is the value of a book in which those affected do not have their say? The answer to this question is provided by articles, well worth reading, on the “subjective aspect of migration”, by people from very diverse cultures. Still more special topics are presented in the Section, “migrant groups in special problem situations”. This section deals with unaccompanied underage refugees, the situation of women and girls, “modern slavery”, east European women who are victims of human trafficking and prostitution, undocumented irregular migrants, and aged migrants. As explained, the interaction between psychotherapeutic methods from different cultures becomes productive only with the relativim of ones background and the analysis and exposure of the transcultural factors inherent in these procedures. The enrichment of a variety of psychotherapeutic procedures with impulses from other cultures is then not merely a vision, but can become, through further research and clinical experience, a concrete option with many uses in intercultural clinical practice. Many further themes that have been selected might be mentioned, but we will limit ourselves to two, the largely neglected prevention of mental illnesses, and the clear and inspiring concepts presented as models of “Exemplary Practice”.
This practical textbook will be a help to all those in the field of psychiatry, psychosomatics, and psychotherapy who wish to enrich and deepen their treatment of people from other cultures through increasing their intercultural competence. It is intended to all professional groups in these fields, including psychiatrists, psychotherapists, psychologists, general practitioners, sociologists, ethnologists, social workers, nursing staff, and those in closely related disciplines such as public policy, health administration, education, and legal services.
Hannover, January 2013
Wielant Machleidt and Andreas Heinz
PS: The editors thank Ron Wintrob for his help with the translation of the review.
Machleidt and Heinz
Praxis der interkulturellen Psychiatrie und Psychotherapie.
Migration und psychische Gesundheit.
By: Ronald Wintrob MD
The publication of the Textbook of Intercultural Psychiatry and Psychotherapy, edited by Machleidt and Heinz, represents another landmark in the rapid growth and maturation of both the academic and the clinical components of cultural psychiatry and its related disciplines in the German-speaking world.
A textbook has to serve multiple purposes and populations. It needs to be comprehensive in its scope, address current issues of theoretical importance in its field, offer practical guidelines for practicing clinicians and for investigators who come to the field of cultural psychiatry from a variety of academic and clinical backgrounds, and it needs to address the training of the next generation of clinicians and academics. Taking all this into account comprises a sobering task for the editors of any textbook.
In this instance, Machleidt and Heinz deserve congratulations for the comprehensiveness of the textbook they have generated. It is beyond the scope of this overview to elaborate on the content of specific chapters, but I would like to point out some of the unique features of the content of this textbook.
In the section on theoretical aspects, there are very welcome chapters on ‘psychodynamic models of migration’, ‘migration, culture and identity, and ‘acculturation’, as well as chapters on ‘stereotyping and discrimination’ and ‘racism’ in intercultural psychiatry and psychotherapy. These are all issues of fundamental importance to current-day cultural psychiatry that need to be given greater emphasis in articles and books addressing fundamental themes of cultural psychiatry in the years ahead.
Subsequent sections address the practical aspects of the treatment of specific immigrant groups in the German-speaking countries; Turks, Russians, Jews, Poles, Latin Americans, Chinese and Japanese. There are chapters on ‘multicultural teams’ and on ‘intercultural competence’, both issues of great current importance in cultural psychiatry and its related disciplines.
There is a chapter on the core theoretical and pragmatic issues of ‘cultural case formulation’. And there is a ground-breaking chapter on “modern slavery” that focuses on the tragic issue of the trafficking in women for the sex trade; in this case, women from eastern European countries. There is also a chapter on the burgeoning and often overlooked issue of undocumented (illegal) immigrants.
Machleidt and Heinz have shown very good judgment in including several chapters often overlooked in similar textbooks, on how to create a clinical ambience in hospitals that is sensitive to the needs of immigrants and ethnic minority populations.
The last section of this textbook focuses on training issues; that is, on culturally sensitive training of nurses, medical students, general physicians, social scientists, psychologists and psychiatrists; the future leaders of our field.
I am confident that this textbook will have a powerful impact on students, clinicians and scholars of cultural psychiatry and its related fields in the German-speaking world. It deserves the close attention of all those interested in the growth and development of the field of cultural psychiatry far beyond the German-speaking countries for whom this textbook is directed. The editors and authors deserve congratulations for what they have achieved. I hope the textbook will soon be published in languages that will extend its impact around the world.
Ronald Wintrob MD (E-Mail: firstname.lastname@example.org)