Read this article published on the Cercle Psy website.

Seeing a migrant patient in consultation means coming into contact with a foreign culture. What are the risks of interpreting migrants’ ailments using only our Western codes?

During a consultation, a little boy from an African family actively avoids the psychotherapist’s gaze.The psychotherapist immediately sees this as a suspicious sign of inhibition, relational awkwardness and withdrawal. But what if it’s just a sign of the child’s respect for the adult, in keeping with his parents’ culture?

« Migrant children are five times more likely than others to suffer from extra-familial mutism, i.e. they don’t speak when they cross the threshold of their home. Conversely, other psychopathologies, such as anorexia nervosa, occur less frequently in migrant children, although more are observed than before. I think that children end up adopting the ways of expressing the suffering of those around them. These are collective ways of saying individual things. « Marie Rose Moro, child and adolescent psychiatrist (1). What attitude should therapists adopt when dealing with migrant patients, given this risk of cultural misunderstanding?

« First, I try to understand his situation, through the way he explains it himself. I draw on his lay knowledge, and support him with what I know. To do this, we have to stay in our place and take account of our ignorance. It’s better to be two on the same road than to be alone, which is safer for him, and a little less so for me. « says Can Liem Luong, a doctor of psychology and psychiatrist at the Minkowska Center for the Health of Refugees and Migrants (2).

Transcultural consultations, which are highly specialized, generally welcome migrant patients at the request of professionals who are not in a position to manage and/or assess them. Two types of system can be set up: the classic consultation with interpreter, and the multidisciplinary group.

• The role of the interpreter

In the first case, the psychotherapist is accompanied only by an interpreter trained to translate the patient’s words, in a therapeutic context, sentence by sentence, word by word, as close as possible to his or her speech.  » The difficulty for the interpreter is knowing what to do with the untranslatables that occur in all languages, and how to translate word for word without the result appearing too chaotic for the therapist. Metaphors, on the other hand, are invaluable, as they are derived from the patient’s own language, and in many cases prove to be a real key to understanding the patient’s culture. « says psychiatrist and anthropologist Claire Mestre.

But what’s plan B if there’s no interpreter who speaks the migrant’s language, which is particularly rare?  » In this case, we find a language common to both the interpreter and the patient. For example, if no interpreter speaks Georgian, the exchanges will be in Russian. On one occasion, a young migrant spoke a particularly rare language that no interpreter had mastered. A translator crossed France to help us. « remembers Claire Mestre.

Contrary to popular belief, the interpreter’s role is far from limited to translation. « Over the years, we’ve come to realize that translators do a lot of good for migrants, but especially for their children. They identify with them, and often admire their ability to move from one language to another, from one culture to another, from one world to another. It has to be said that the mother tongue of these young people is not highly valued in France. Sometimes, it’s the translators themselves who heal them! So much so, in fact, that we have devoted a study to the specific function of the translator on children. « says Marie Rose Moro.

Depending on the patient’s needs, a multidisciplinary consultation can also be organized. The main therapist is accompanied by professionals with different but complementary backgrounds.

« The most classic scheme is one in which the main psychotherapist is accompanied by another psychologist and/or anthropologist and an interpreter. All are trained to work together, to hear and understand each other. At the start of the consultation, each of the co-therapists introduces himself/herself, after which the rules of shared confidentiality are explained to the patient « explains Claire Mestre. In such a collegial therapeutic context, how can we ensure a certain coherence between the words and ideas of all those involved?  » Speaking is highly coded: everything goes through the main therapist, and any face-to-face contact between the patient and the other co-therapists is avoided. In other words, if a co-therapist wishes to speak, he or she will address the main therapist, so that speaking is always mediated. Moreover, it is the main therapist who initiates and closes the consultation. « continues Claire Mestre.

What about consultations for the children of migrants?In this case, the whole family is invited, » says Marie Rose Moro. Children sit at a table in the middle of the group, where they can play and draw. Various possibilities are offered, depending on the child’s age. We then try to understand the child’s suffering through what the family has told us, while interpreting the child’s behavior during the consultation. We either receive the child with his family, or in co-therapy with a co-therapist, or in a small group with three co-therapists, or in a large group with a dozen polyglot co-therapists. « Generally speaking, whether young patients or not, a group consultation lasts about an hour and a half. This is followed by a summary meeting where professionals can exchange and compare their points of view. This practice, developed by Tobie Nathan (3) for the first generation, and by Marie Rose Moro for the second, is only organized for patients or families with complex symptoms. Whichever approach is chosen, the patient must be informed, consenting and accompanied during the consultation, if possible by a professional he or she knows, and very often by his or her family. « It’s important to prepare them well in advance, so they’re not surprised or uncomfortable by the nature of this device, » stresses Claire Mestre.

• Untraceable psychoses

The issue of migration is more topical than ever, stirring public opinion and sparking heated debate. Unfortunately, the field of education, health care and the human sciences is not immune.  » I think there’s a real contamination of the prevailing political discourse on the quality of reception of migrants by professionals. We therapists are inhospitable and unkind, which raises serious ethical questions. « says Marie Rose Moro. Whether they are aware of it or not, Western practitioners very often impose their way of thinking about ills and classifying mental illnesses, in an implicit acculturation process.  » We have a long tradition of all-powerful medicine, of a medical power that tries to make human manifestations its own. So, of course, migrants are no exception to the rule. « says Claire Mestre.

In individual fantasies, Western medicine holds the truth. A belief that can be observed above all within the institutions themselves, in the intimacy of the consulting rooms:  » Any therapist can make this confusion between the general and the universal, often to reassure himself. Because, I think, they fear any situation that is devoid of meaning. « notes Can Liem Luong.

A point confirmed by Claire Mestre: « Leaving one’s usual analytical grid can be complicated for the practitioner, because it calls so many things into question… ».Clinging to the beaten track of psychiatry, whatever the cost, is therefore commonplace for practitioners in industrialized countries… at the risk of making the wrong diagnosis.  » The therapist may induce his own conception of things, and fail to hear his patient. The patient may then feel guilty for not understanding, and intuitively obey the all-powerful practitioner’s injunctions. « says Can Liem Luong.

It’s a bit like trying to fit the patient into a box, » adds Claire Mestre. Practitioners know little about the migratory dimension. The classic mistake is to consider a psychosis where none exists. And unfortunately, this happens regularly!  » –

(1) Marie Rose Moro is also a psychoanalyst, professor of psychiatry at Paris Descartes University, researcher at Paris Descartes University and Inserm, and head of the Maison des Adolescents at Cochin Hospital AP-HP (Maison de Solenn).
(2) Can Liem Luong is also a lecturer at Paris 13 University, and President of the Association Scientifique Franco-Vietnamienne de psychiatrie et de psychologie médicale.
(3) See interview with Tobie Nathan, « Aux sources de l’ethnopsychiatrie »,Le Cercle Psy n° 8, March-April-May 2013.

To read…

Thierry Baudet, Marie Rose Moro,Psychopathologie transculturelle, Elsevier Masson, 2nd ed., 2013.