And there they were, the Moroccan daughter and her mother, in a Toronto
hospital emergency room. The daughter was suicidal. Could it be because she
was possessed by a malevolent spirit—a "djinn"? The mother
thought so. Then the daughter admitted that she had done something terribly
wrong. "Have you disgraced our family?" the mother asked.
Laurence Kirmayer, M.D.: The more psychiatrists know about the
circumstances of where immigrants come from, the better they can help
immigrants redefine themselves.
Marie-Eve Cotton, M.D., a Quebec psychiatrist, has worked with the Inuit
peoples for six years.
This scene was play-acted by two psychiatrists at the annual meeting of the
Canadian Psychiatric Association (CPA) in Montreal in October to provoke a
discussion of how psychiatrists should handle such situations.
The scene is also an example of the cross-cultural challenges facing
Canadian psychiatrists for several reasons—Canada is composed of peoples
from numerous backgrounds, immigrants are settling in more areas of the
country, psychiatrists are seeing more patients who have been tortured in
their home country, and Canada is one of the world's largest
immigrant-receiving countries. Some 150 languages are spoken in Toronto
"I call it hyperdiversity," Laurence Kirmayer, M.D., director
of transcultural psychiatry at McGill University, declared at the CPA meeting,
whose theme was culture and mental health. "It is
Also extraordinary is the plethora of challenges Canadian psychiatrists
face if they want to understand patients from different backgrounds and to
help them, several speakers noted.
Certainly language is a daunting problem. Lisa Andermann, M.D., a
postdoctoral fellow at the University of Toronto, said she sometimes uses an
interpreter, but even so, the interpreter and patient may get so involved
talking to each other that they forget the psychiatrist is there. Interpreters
cannot always give a psychiatrist the context of what is going on with a
patient, Dennis Kussin, M.D., a psychiatrist at Toronto Western Hospital,
Patients may not be able to read the labels on medications because the
labels are not in their native language, said Jose Silveira, M.D., also of
Toronto Western Hospital, whose mental health clinic serves about 280,000
Patients from other cultures may have unconventional ideas about the causes
of mental illnesses. One Inuit (Eskimo) patient with schizophrenia told Quebec
psychiatrist Marie-Eve Cotton, M.D., that he wondered whether his"
voices" meant that he was an Inuit shaman—that is, had the
power to heal. Some Christian Inuits believe that mental illness is due to
possession by the devil and that exorcism can heal it.
Not a few ethnic patients are troubled by identity, a concept that has to
do with where they come from and where they are going, their social position,
experiences that have affected their lives, and their perspective on the
world. Trying to help ethnic patients redefine themselves is not easy,
Nor is it easy to help patients from other cultures deal with their social
predicaments. Sometimes people of various ethnic backgrounds make an
appointment with Andermann not because they are mentally ill, but because they
have a social need, such as housing, and hope that she will provide them with
a letter of recommendation.
Migration has not been found to be a risk per se for mental illness, but
some factors associated with migration, such as a drop in socioeconomic
status, are. "It is not unusual in Toronto to find physicians driving
cabs," said Kussin. One can't help but wonder how they're faring
mentally, he said.
Morton Beiser, M.D., a professor of psychiatry at the University of
Toronto, and his colleagues studied Southeast-Asian refugees who were admitted
to Vancouver from 1979 to 1981. The researchers found that unemployment in
this group could lead to depression, as well as that depression could lead to
In contrast, many people in this group were not depressed, purportedly
because they concentrated on the present and repressed many aspects of their
lives in their home country. Thus, repressing the past may be one way that
refugees cope with their precarious situation and are able to find their way
in their new country.
One reason to think that this is the case is that when Beiser and his team
followed the fate of the Vancouver refugees from 1981 to 1991, they found that
the refugees had lower rates of depression and anxiety than Canadians in
general, that the refugees had done "exceptionally well" regarding
employment, and that the refugees' stories were "generally happy
Some ways in which Canadian psychiatrists can help people of various
cultures achieve "happy endings" were also discussed at the CPA
One is to conduct a good cross-cultural patient interview. Adam Quastel,
M.D., a University of Toronto psychiatrist who works with peoples who were in
Canada before the arrival of European settlers, determines what language or
languages patients speak and whether an interpreter is needed. He then asks
patients what brought them to see him and why (this way he constructs their
stories and also demonstrates that he is interested in them) and asks what
their current cultural identification is (which helps him decide how he is
going to treat them).
Psychiatrists can also assist immigrants in establishing a new identity.
The more you know about the circumstances of where they come from, the better
you can help them redefine themselves, Kirmayer advised.
One consideration is the cytochrome P450 enzymes, which are crucial for
metabolizing psychotropic drugs and can vary dramatically among ethnic groups.
There are now labs in both Canada and the United States that test for
differences in the genes that make these enzymes, and such tests can reveal
whether the patient can metabolize a particular drug, Joseph Sadek, M.D., a
Dalhousie University psychiatrist and psychopharmacologist, reported."
This is a new direction in psychopharmacology service," he added.
He and his colleagues have also "used the tests successfully" in
their clinics, he told Psychiatric News.
A psychiatrist's being open and nonjudgmental about unconventional
treatments may benefit patients from certain cultures. If Inuit patients want
to talk about shamanism to understand the voices they hear, Cotton is open to
it. But if they want to talk with her about serotonin, that is fine, too."
That is their choice, and the healing factor," she said. She also
tells them about the medications she can offer them, but adds that if they
want to go to a shaman or a priest for help, she will not be angry at them for
In fact, unconventional treatments may help such patients. Cotton had an
Inuit patient who had been sexually abused and who sought exorcism as a means
of healing psychologically. After the exorcism she got better and has remained
well for three years. "It left me quite speechless," Cotton
All in all, Canada is a country not just of incredible diversity, but of
considerable tolerance. Thus, if any psychiatrists can offer some good
suggestions on how to be culturally competent, it is probably Canadian
psychiatrists. "We are uniquely positioned to make a contribution
globally," Kirmayer contended. ▪