Clinical Vignettes

Case one. "Carl" is a severely non-compliant young patient with schizophrenia. His family is gravely dysfunctional, showing an extreme level of expressed emotion. Carl's father is an observant Jew, born in Iraq but raised in Israel. His mother was born in Iran and grew up in Israel. She defined herself as "religious, but not as strict" as the father. Their interaction is marked by chronic marital discord.

The therapist focused on strengthening the relationship between Carl and his father, bearing in mind that religion could help him deal with noncompliance and rehabilitation. Furthermore, religious metaphors of experience could improve thought processes. Although Carl was in a closed ward, the therapist allowed for a couple of visits to a rabbi, who acted as a healer in the Iraqi community. The rabbi performed some healing and purification rituals.

Carl's condition improved for a short period. However, his mother complained to the medical director, disapproving of both the father and therapist. Finally, Carl's mental status deteriorated to a point warranting electroconvulsive therapy.

Commentary. The therapist was correct in the perception of the importance of religious metaphors in Carl's illness experience. Moreover, strengthening the attachment to the father was a legitimate therapeutic goal. However, the therapist failed to a certain extent to address both components of illness experience and disease process. Although the patient was taking antipsychotics, his mental condition was not stable when he went to the rabbi. This enabled his mother's complaints about what she perceived as an inadequate management.

In addition, the therapist failed to address the marital discord. In this particular context, a more useful approach would have been to deal with the traumatic histories of both parents, who shared traumatic experiences of uprooting and migration, as well as their different meaning of religious practices.

Case two. "Dara," a middle-aged woman born in Russia but living in Israel for 15 years complained of several somatic symptoms. Her husband, also born in Russia, joined her during the diagnostic interviews. The therapist himself is a grandson of Russian immigrants.

He diagnosed a depressive state and started antidepressant treatment. In addition, he started supportive psychotherapy, focusing not only on the experience of migration but also on the forced adaptation to Israeli life. Both Dara and her husband were able to recover the meaning of longing for Russia. They connected with reminiscences of their past. This took place in an interactive process, in which the therapist allowed himself to relate to his origins as well. The patient remarkably improved, and the somatic symptoms abated. At the end of the therapy, the husband traveled back to Russia for the first time since their migration.

Commentary. Through a comprehensive assessment based on the cultural formulation model, the therapist was able to handle both the biological and sociocultural aspects of the disorder. More specifically, he focused on the experience of migration and nostalgia and enabled the couple to work through anxieties linked to questions about continuity of life. Moreover, actively engaging Dara's husband in the therapeutic process proved to be a useful strategy because she was conveying shared anxieties and symbolic meanings through her somatic idiom of distress.

Concluding Thoughts

To sum up the implications of transcultural psychiatry for the clinical practice, I would like to think of an approach that will incorporate the existential dimension of human suffering (Kleinman et al., 1997). However, in doing so, psychiatry must develop better treatment strategies, engage minority patients according to appropriate standards of care and fight inequalities in the health care system.
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