Can transcultural psychiatry help us to understand the predicament of C-L psychiatry?☆

Transcultural psychiatry is mainly devoted to two complementary objectives. The first, theoretical and epistemological, is to differentiate in psychopathology what is universal and what is influenced by, or even peculiar to each culture. The second, pragmatic and operational, is to pay more attention to factors of vulnerability and pathological manifestations of minority ethnic groups or patients of foreign origin.

A classical issue for transcultural psychiatry is the worldwide distribution of somatic forms of depression. It is traditional to say that reporting somatic symptoms due to a psychological disorder, as well as denying the existence of psychological distress, is frequent in non-Western cultures. Likewise, it is suggested that somatic presentations of mental disorders are more frequent in the cultures where there is a stigma attached to mental illness. Results of an international study supported by the World Health Organization and carried out in 15 primary care centers indicate that the differences between the centers cannot be explained by a Western vs. non-Western countries gradient or by an opposition between high and low developed countries but, rather, by the organizational characteristics of the centers with regard to the available health care [1]. Higher rates of somatic complaints are observed in centers offering walk-in care, with no personalized doctor-patient relationship, than in those characterized by ongoing doctor–patient relationships, scheduled appointments and emphasis on the privacy of the visit [1]. Moreover, even if the overall prevalence of the depressive symptoms varied considerably between centers, the balance between psychological symptoms and physical symptoms was similar whatever the center: therefore, the tendency to disclose or deny psychological symptoms of depression was not related to the location of the center. These results suggest that reporting somatic symptoms does not reflect an unwillingness or inability of the patient to recognize his psychic distress. It is more likely that patients believe that somatic complaints are a better reason for seeking help from a primary care physician, a process which can be called “optional somatization” and corresponds to an “admission ticket” to the primary care clinic.

The initially somatic presentation of psychiatric symptoms that leads to medical hospitalization constitutes a classical reason for a referral to C-L psychiatrists. Among these patients, those of foreign origin occupy a particularly distinctive place, but even when the referral to the C-L psychiatrist concerns “comorbid patients,” who combine a general medical condition and a mental disorder, such patients, labeled as “psychiatric,” are frequently regarded as “foreigners” in the medical environment. Indeed, caregivers usually display in this case more embarrassment or confusion than intolerance towards the psychiatrically ill patient. Sometimes, this embarrassment may be due to an excess of empathy with regard to the psychic suffering of the patients resulting in difficulty to maintain a “distance” in the relationship with the patient; sometimes, it can be due to results in the caregivers' missing reference marks and tools that can give a meaning and help in succeeding to relieve such suffering.

All C-L psychiatrists know how much they may be perceived as being apart from the other doctors, although they are part of the medical profession. They may be considered as true foreigners in the medical services because of their specific theoretical knowledge and also because of the fantasies that being a psychiatrist convey. Not feeling at home in the medical environment, C-L psychiatrists sometimes also cannot feel totally at home in the traditional psychiatry departments, because their concerns, interests, and ways of thinking may have evolved and moved away from those of their colleagues who devote themselves only to mentally ill patients. Therefore, some C-L psychiatrists find themselves in the same position as some immigrant workers: foreigners in the host country but also foreigners in their native country, condemned to continued return journeys, and divided between loneliness and nostalgia.

Transcultural psychiatry can also be useful for understanding the traumatic component of some hospitalizations, consisting of a depersonalizing and derealizing immersion in a culture that is radically different from the daily life of many patients: the culture of hospital, white coats, sophisticated and mysterious technical investigations, both fascinating and worrying. Even if the patient does not come from a foreign culture, the violence of certain hospitalizations, the prospect of possible death, may be equivalent of an initiatory rite, a rite of passage, if not from childhood to adulthood, then at least from a time of relative unconcern to a time of lucidity, maturity, and accepted vulnerability. For many patients, this passage must be achieved without crying or at least without complaining about any psychological distress, but using, if necessary, the somatic language that is considered politically correct in a medical environment.

Could these reciprocal relationships between transcultural and C-L psychiatry enrich, in the future, our mutual practice and move forwards the boundaries of C-L psychiatry and psychosomatics?