Psychology

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    ‘Herr Frau Doctor’
    Interview with PD Dr med Schouler-Ocak

    Meryam Schouler-Ocak was born in Turkey in 1962. She came to Germany at the age of seven. She is a senior doctor at the Psychiatric University Clinic at St Hedwig’s Hospital in Berlin. The clinic belongs to the Charité, one of the largest university hospitals in Europe. Dr Schouler-Ocak is also director of the German-Turkish Society for Psychiatry, Psychotherapy, and Psychosocial Health (DTGPP). One of her main areas of research is transcultural psychiatry and psychotherapy.

    Alem Grabovac: Could you tell us about the psychotherapeutic care available to people with a Muslim background in Germany?

    Meryam Schouler-Ocak: There are far too few psychotherapists providing care for these people. Because of the cultural, linguistic, and perhaps even religious differences involved, it can take a person years to find a suitable psychotherapist. There is a massive shortage of care.

    How many Arab or Turkish psychotherapists are there in Germany?

    I only have figures for Berlin, but these in themselves are very revealing. There are between ten and twelve Turkish-speaking doctors in the field of psychiatry and psychotherapy in Berlin. Three psychiatrists have their own practices. But there are 180,000 people with a Turkish migrant background living in this city. Just calculate the ratio! There is a massive deficit in this area. Now look at this ratio from a gender perspective: for a women with a (Muslim) migrant background who would like to see a female therapist, the likelihood of her being able to find a female psychotherapist is smaller still.

    Are Muslims allowed to see a non-Muslim therapist?

    It depends on the interpretation, on the way someone interprets religion. In general, however, there is nothing to say that they are not allowed to. Strict Muslim women would go to neither a German psychiatrist nor a psychiatrist with a migrant background.

    Who helps these women?

    Friends, social environment, family and religion all play an important role in this respect. Many people find support, identity, and protection in religion; perhaps it even gives meaning to their lives. These people will go to a hodja, an Islamic religious scholar.

    Can traditional healing methods be integrated into psychiatric treatment?

    I always ask my patients whether they are undergoing any traditional forms of treatment. If someone reads the Koran and finds that helpful: well, then that’s great. If someone has rituals, that’s absolutely fine with me. That said, it must not be allowed to cross a certain line. As soon as I notice that traditional healers are interfering in the therapy or choice of medication, that’s where I draw the line.

    Are psychological illnesses a taboo issue for people with a Muslim migrant background?

    Certainly more so than they are for native Germans. An important factor here is the social milieu from which they come. It certainly makes a difference whether someone comes from a village in Anatolia where little importance is attached to education or from a Kemalist family in an urban environment where education is considered important. In Germany, people of Turkish origin are overrepresented in two milieus in particular. The first is the religiously-rooted milieu with archaic traditions: conservative, religious, strict and rigid ideals where the preservation of cultural identity, family honour, religious obligations, strict morals and iron discipline dominate. The second is the hedonistic, sub-cultural milieu, which describes the non-conformist second generation, whose identity and prospects are deficient. They want to have fun and refuse to conform to the expectations of the majority society. What is important here are values, participation, approval, money, success, consumption values, fun and action, leisure, ‘partying’, community/belonging to peer groups, subcultures. Unlike those who belong to the patriarchal-religious milieu, the people in this milieu are more open to the findings of modern psychotherapy.

    How do people with a Turkish or Arab migrant background describe their mental illnesses?

    Very frequently through physical complaints. Back pain, headaches, migraines, etc. occur more frequently among people with a migrant background than they do among native Germans. I think that the reason for this is that there is more tolerance of physical complaints than of mental complaints. It is easier for them to get support and sympathy if they are physically ill than if they say they are about to crack up. People who are physically ill are seen as being in need of protection, while those who are mentally ill – the ‘mental’ – don’t usually get such support. They also use more metaphors and paraphrase things more. For example, there are patients who say ‘I have a chill in my mind’, by which they mean that they are afraid of cracking up. There are also uncontrolled fits of crying and forms of behaviour that are seen as histrionic. All of these things are expressions of suffering. These descriptions and presentations of pain differ from those given by native Germans.

    So it is about understanding ciphers or body-related signals.

    In the Turkish context, for example, one can say: ‘My lungs are bursting’. That means: ‘I cannot withstand the pressure any more, I cannot breathe, I cannot fit anything else into my chest’.

    The art of interpretation

    Can German psychiatrists correctly interpret the mental illnesses of people with a Muslim migrant background? Do cultural differences not lead to diagnostic and therapeutic errors?

    The symptoms, the explanation of the illness, and the expectations regarding the treatment vary greatly from one cultural context to another. Depending on which cultural context I am in, I may not be able to understand the other person at all. Take, for example, the case of a female patient who might tell me that she wears lots of amulets because someone has bewitched her, put the evil eye on her, or cursed her. A Western psychologist, doctor, or psychiatrist might be misled into diagnosing something like a psychosis. Another example is patients who say that they hear the voices of their ancestors. This is immanent to their culture; as a psychiatrist, I have to know this, otherwise I cannot interpret it properly. In this case, a psychiatrist might incorrectly diagnose schizophrenia. In order to avoid such misinterpretations, I should as a psychiatrist hone my intercultural skills. In other words, I have to know what is considered normal, borderline, or pathological in the other culture.

    What is transcultural psychiatry?

    It used to be the case that people tried to impose Western knowledge on other cultures. We prefer the term intercultural psychiatry, which means ‘between the cultures’. In principle, it is the theory of psychiatry in various cultural contexts.

    What distinguishes it from classical psychiatry?

    Intercultural psychiatry refers to the interaction between the cultures, for example migration psychiatry. People with a migrant background have other disorders and have to be treated differently because of their cultural context. There are codes, internationally recognised classification systems. However, some disorders that occur in some regions are not contained in these codes. For example, in some regions of South-East Asia there is a disorder whereby men are terrified that their penis will retract into their abdomen and they will die. Seized by panic, they grip their penis so that it cannot disappear. How can this disorder be classified in Western psychiatry? Is it an anxiety disorder? It doesn’t really fit neatly into any one category. The same can be said of a disorder that occurs in South America where a fright is believed to cause the soul to leave the body. Certain rituals are then used in an attempt to bring the soul back into the body. People living in an Oriental context have, for example, a different way of thinking that does not correspond to the Western dichotomy of the body-soul distinction. They believe that illness is holistic.

    What consequences does this have for therapy?

    Western medicine takes its lead from evidence-based medicine. One has to either verify it or prove that it is wrong. In contrast to this, there is also a medicine that is shaped by cultural influences. Here, entirely different aspects play a role. For example, the expectations regarding treatment can vary hugely. In Western psychiatry and psychotherapy, the aim is to teach people to be self-confident, to assume responsibility for themselves, and to be autonomous. They should be able to manage their lives themselves. This works very well in the individualistic concept that is shaped by Western ideas. However, you can’t do that with someone from the collectivist Oriental region. For example, if you use an individualistic concept such as this to remove a young women from her family and cultural structures – if, in other words, she loses the bond with her community and family, she could end up with even more problems. It is important to be very careful; this can really backfire.

    Do you mean that a German psychiatrist might see Islam as a problem in a case like this?

    Yes, they might. You have to integrate the cultural circumstances or values – and that includes religious circumstances and values too – instead of viewing them as problems. In an interview, Margarete Mitscherlich once said: ‘I believe that traditional Islam and psychoanalysis are like fire and water. Psychoanalysis, where you call everything into question and question motives, is not possible without enlightenment.’

    I subscribe fully to that opinion. With religion, rules are imposed and they cannot be questioned. Nevertheless, these people can be reached. After all, analysis is not the same thing as psychotherapy. In the case of behavioural therapy, for example, there are very clear structures for providing concrete assistance. The basic idea here is that bad behavioural patterns can be learned and unlearned again. The aim is to try and help the patient adopt more appropriate thought and behavioural patterns. Enlightenment is not necessarily essential for these therapeutic measures. However, people with a Muslim background who do not interpret the Koran in a dogmatic manner – and that, incidentally, means most of them – can of course be treated using psychotherapy.

    The language problem

    In psychotherapy or trauma therapy, absolutely everything is linked to language. In cases where the person being treated is not a native speaker of German, how can the treatment processes be guaranteed?

    Intercultural therapists have to be able to work with professional interpreters. Interpreting is a skill that has to be learned. There has to be a preliminary meeting with the interpreter to discuss the setting: the fact that the interpreter is bound to observe confidentiality, where the interpreter should sit, how the interpreter should interpret. The interpreter has to be made aware that everything has to be interpreted, nothing should be left out, nothing added, nothing read into what has been said. It is also always necessary to have a follow-up meeting with the interpreter. Could it be that this story is immanent to the culture? You also have to give the interpreter the chance to let go of the emotion, especially if the case is a traumatic one. And – and this is something I consider very important – you always have to work with professional interpreters. No children, relations, neighbours, partners, or friends. You never know what the relationship between the patients and the amateur interpreter is, what power structure, what kind of complex emotional structures exist. And you never know whether the question you have just asked has really been relayed to the person in therapy or whether what he or she has said is ever relayed back to you.

    Religion, tradition, and family: on the one hand, they help protect people from psychological illnesses; on the other, they can also trigger them.

    We know that religion and family are protective factors. But families can just as easily make someone ill, for example if they feel boxed in. I’m thinking here in particular of young women who have to adhere to specific traditions and values, but who live completely different values outside the family in their peer group and in their circle of friends. Many of them cannot manage this balancing act. Some female patients have told me that they feel like puppets in their families, that they are steered by others, and can never be themselves. That, of course, is problematic.

    Do women and men react differently to psychological illnesses?

    For men, the stigma is greater. They talk less, wait longer than women before seeking help, and are much less inclined to avail themselves of psychotherapy. Men in environments influenced by the Orient are still the lords and masters. Sexuality is also very often a taboo subject for them. They are much, much less willing to open up about it than women are, and certainly not to a woman doctor. In this respect, women are more courageous and even tend to speak more openly about their sexual problems than native German women.

    How do men and women differ when it comes to cases where there are several different mental illnesses involved?

    Women with a migrant background, and also those with a Muslim background, are twice as likely to suffer depression. The suicide rate in this group is also much higher than it is for men. There are several reasons for this; generally speaking, it is because of escalations in crises caused by the family or cultural context.

    Are migrants more likely to be depressed? And is their depression different to that experienced by others?

    Both. They are also more likely to suffer psychosomatic complaints than native Germans are. The problems that can arise in the course of the migration process – for example, the separation of family members, financial difficulties, the children not doing as well as the parents had hoped, the experience of being the subject of discrimination – all of these things are additional burdens to those experienced by native Germans and can promote depression.

    Can you give some exact figures on this?

    There are none. There are no epidemiological numbers on this for people with a migrant background in Germany. In the German national cohort, 200,000 people are regularly examined for psychological and somatic illnesses over the course of several decades. And what happened? Migrants with language difficulties, who might also have been illiterate, were excluded from the study because it was too expensive to collect this data. Millions are spent on this study, but there is not enough money for people with a migrant background. I think it is scandalous. We are missing a huge opportunity here.

    There are now 15 million people with a migrant background in Germany.

    This is exactly why, at the Charité, we have made it obligatory for students in the second semester to complete practical training on barrier-free access for migrants and introduced a lecture on migration and psychological health. In other words, every student has to complete this practical training. Our awareness of culture has to be heightened. What kind of culture-specific problems do people with a migrant background face? Where do they face discrimination? How can we increase their access opportunities at third level? In other universities, this option is unfortunately only an elective. That is regrettable.

    What, in your opinion, should be done?

    Many facilities say that they are in favour of intercultural opening. But they are just paying lip service. The necessary preconditions are just not being met. Staff are not interculturally open; they are not trained. They lack knowledge, willingness, and perhaps even the right attitude. Stigmatisation plays a major role in the health care system. We lack even basic things like information leaflets in a variety of languages. This hostile attitude to people from Turkey or the Arab world, for example, exists in medical circles as well. Some colleagues even admit this quite openly. They don’t really want anything to do with Turks.

    Women in positions of authority

    And what is the situation with German patients?

    There are patients who refuse point blank to see the woman with the Turkish name. On the other hand, there are also men with Turkish roots who refuse to see me or to be assessed by me because I am a woman. Some men with a Turkish migrant background have even addressed me during therapy as Herr Frau Doctor instead of just Frau Doctor. The woman disappeared behind the person of authority and became Herr Frau Doctor Schouler-Ocak, and then it was all right for them.

    How are people with a Muslim background dealt with in practice?

    There is still a lot to do. There are no prayer rooms for Muslims. There are Bibles on many wards. Why are there no Korans? Why is there no indication of the direction in which Mecca lies? It is important to ensure that no female carers are present when male patients with a Muslim background are being washed. And what about care for the terminally ill? We should also work with imams. Then there is the problem of the headscarf. I find it very problematic when people see religion or a symbol of oppression in everything. While I myself don’t wear a headscarf, I really do think that we could take a more relaxed attitude to it. There are still some facilities and institutions that do not hire women who wear a headscarf.

    When I look out the window of your office, I see a Christian cross. You work in a Catholic institution in co-operation with the Charité university clinic. Do they have Korans here? Are you allowed to leave Korans in the ward?

    We have never asked. However, we do inform our patients about pork products in medication, make sure that pork-free meals are available, explain to them that they do not have to observe the fast if they are ill during Ramadan. An intercultural hospital should observe all these things. Returning to medicine for a moment: low doses given to patients with Turkish roots can lead to considerable side effects. There are genetically-determined factors that influence the breakdown of an active ingredient. Depending on the genetic variants patients have, their metabolism can react slowly or quickly to certain substances. Some medication has to be given in small doses to people from some ethnic groups and in high doses to others. One in three Ethiopians, for example, is a super fast metaboliser.

    Does intercultural psychology exist in Turkey? For Syrian refugees, for example.

    Although Turkey is a country of immigration, there are no translation services and there is no awareness of the need for intercultural psychiatry. Unfortunately. Not yet.

    The Arab Spring and Gezi protests: were they both cases of people, young people, rising up against their patriarchal über-fathers?

    Well, I have my own political opinion on this which I would rather not express in public. I am speaking to you today as a doctor.

    Are you a practising Muslim?

    I am a Muslim, but I am not a strict practising Muslim; I respect the religious rituals of community and, naturally, the feelings of believers. However, I have no time for fanaticism.

    Would you go on a pilgrimage to Mecca?

    If I decided that I would be able and willing to follow the rituals associated with it on my return, then I would go. Those who go on a pilgrimage to Mecca accept a life philosophy that they must then adhere to afterwards. At the moment, I’m not sure that I could observe these guidelines: wearing a headscarf, for example, or many other different things. It’s about developing an internal attitude and then being able to live it.
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