Monsieur D. arrives at the Centre Georges Devereux
Now, a year and a half after his arrival in France, Monsieur D. sits in the Centre Georges Devereux, an ethnopsychiatry clinic in Paris. Congregating around him, a group of professionals and student interns face the task of sorting out his past in order to assure his future. Observing this calm, dignified man from across the room, I have no inkling that our interactions will have such a profound impact on my understanding of psychotherapeutic intervention. His face and ears are heavily scarred, one eye is a deformed mess and the other barely able to perceive moving shadows, but he has fully regained his intellectual faculties and participates readily in the discussion. Meanwhile, his baby daughter gurgles and bounces energetically in the arms of her mother, who followed Monsieur D. to France when she could get no news of him and feared the worst.
As long as Monsieur D. needs acute medical treatment, the safety net provided by French social services will care for him; but his wife and child have no official status, and only charitable organizations help them struggle on from one day to the next. So after surviving two apparent attempts on his life, Monsieur D. and his family will remain in legal and material limbo unless they can attain permanent refugee status. Otherwise, they must return to Africa.
Given Monsieur D.'s utterly fantastic history, any forced return to Africa would constitute a death sentence. Unless, that is, the clinicians at the Centre Georges Devereux can help unravel his mysterious past, identify his invisible enemies, and activate the necessary forces of protection.
Monsieur D. eventually agrees with Marie, the Antillean psychologist leading the session, that his fall from the hospital window represents a logical continuation of the gunshot fired in Africa, both events the result of very powerful witchcraft. A tentative idea emerges in the clear, dignified voice of Christophe, a Catholic priest and trained psychologist from a nearby African country and one of the cultural mediators at the Centre. “Christophe gently hints that during the course of his Western education and rise in status, Monsieur D. has perhaps neglected to sufficiently honor his ancestors, who in turn allowed his enemies to attack him with impunity.” If so, he would need to mend his relationship with his ancestors as a first step in protecting against future attacks. Monsieur D. nods thoughtfully and rubs the scar that bulges behind his huge, thick eyeglasses.
This is not a case of the experts announcing a diagnosis and course of treatment to the trusting patient. Monsieur D. knows that the professionals at the Centre Georges Devereux have entered his territory and will negotiate on familiar terms. None has more expertise in the intricacies of his culture and world than he does, and he is being enlisted as a partner in this brainstorming session. Though nearly blind, powerless to provide for his family, and wracked by nightly terrors, in this place Monsieur D.'s impediments melt away. So, when he responds to Christophe's suggestion, the patient presents an alternate interpretation in measured, professorial tones: "Yes, you could look at it as a failing on my part that allowed such catastrophes to befall me. “On the other hand, it is equally possible that I actually survived the pernicious attacks thanks only to my powerful ancestral protection.”" A crucial distinction that, if true, would point to an entirely different course of action. With ancestral protection already intact, Monsieur D. would need to look elsewhere to bolster his defenses, perhaps in his twin sons, since twins often have special status and powers in his culture.
Three hours later, the point remains unresolved, but clinicians and client agree on some provisionary steps and work out various practical details of the couple's life, such as how to keep the baby fed during the coming month. After shaking hands with Monsieur and Madame and watching them disappear out into the hall, I look vaguely around the room and then follow in their footsteps to exit the building. Welcome to the Centre Georges Devereux, I think to myself! Monsieur D. will return in a month for a second consultation. I'll be back tomorrow morning.
Ethnopsychiatry: Treating cultural phenomena at face value
Despite their home away from home within Paris, African immigrants face many obstacles in the highly traditional French society. And when they run up against cultural barriers, there is one place in particular within the official French social service network where immigrant families can hope to be understood and taken seriously: the Centre Georges Devereux, housed in the University of Paris VIII. “It is there that a French social worker can bring a Moroccan man who refuses to support his wife, claiming she is possessed by a jinn”; there that a French judge can refer a Malian family with two delinquent kids who, alienated from both their parents' culture and the French mainstream, have forged an identity in a gang. The epicenter of research in the emerging field of ethnopsychiatry, this clinic focuses on developing new methods for treating people in psychological distress.1
The innovative theories and methodology at the Centre Georges Devereux ensure that it is not only a cultural island compared to the rest of French society, but also an ideological island compared to mainstream clinical psychology in France, which is rooted in the Freudian tradition. Rather than weekly therapy that may go on for years, clients at the Centre go only once a month for two to six months for an intensive three-hour group problem-solving session. Each consultation brings the client (or family) together with several clinical psychologists who come from all over the world, as well as with other specialists—anthropologists, linguists, lawyers, social workers, physicians—and various interns. The sessions are often conducted in the patient's native tongue, with the help of an interpreter/cultural mediator who shares the client's native culture and has studied its traditional therapeutic methods.
Much of the work focuses on constructing an explanatory narrative, some coherent interpretation of (and then antidote to) the clients' experiences, which have often been invalidated or misunderstood by the various other professionals with whom they have had contact. As in the case of Monsieur D., many clients talk about ancestral spirits or witchcraft, phenomena that Western psychology generally finds itself unequipped to address (Are these people hallucinating? Are they psychotic?). At the Centre Georges Devereux such phenomena are accepted at face value, and the therapeutic methods of all practitioners—whether Western psychologists or folk healers and priests—are taken as clinical theories, all equally valid for study. Instead of diagnosing patients with a psychological or psychiatric disorder, the Centre tries to treat people using their own cultural references and, often, treatment methods. In this way, ethnopsychiatry has taken some bold steps to expand the field of psychology so that it might apply in a meaningful way to non-Western populations. What's more, marginalized by French society, the clients find that at the Centre Georges Devereux, their culture is taken seriously.
Founding of the Centre Georges Devereux in France
The university setting fosters this astonishing variety of research. At the same time, it provides an avenue for educating the community in ethnopsychiatry, alongside future clinicians and researchers. Many of the psychologists at the Centre Georges Devereux double as instructors at its host institution, the University of Paris VIII. They also give a year-long lecture series specially designed for professionals in various fields who work with immigrant populations. And the clinic itself is structured to host student interns, often Masters or doctoral candidates conducting research. Nearly as international a group as the staff, the interns during my time at the Centre included French, Italian, Argentinean, Rwandan, and Japanese students. “In researching the clinic itself rather than a specific thesis topic, I was a free-floating anomaly, and the staff often simply introduced me to clients as "our American."”
Thanks to the group structure and university setting, I enjoyed the opportunity of observing and even participating in intensive clinical consultations with patients. Of course, in reality the experienced clinicians and staff tended to direct the sessions, calling on the others' input under highly specific circumstances. I recall one session with a woman who complained of recurring nightmares in which her adolescent daughter was kidnapped and raped. Fatou, the Senegalese psychologist directing the session, aimed to discuss the client's onset of puberty in order to draw connections with her daughter; but the woman claimed to have forgotten the circumstances surrounding her first menstrual period. With her usual calm ingenuity, Fatou proceeded to ask each female in the room to recount the story of her first period. We had only gotten halfway around the circle when the patient broke in with her own story, and Fatou carried the discussion forward.
Then again, there were also times when the various experiences and perspectives in the room made truly independent contributions to the session, rather than merely serving as tools for the clinician directing the consultation. One memorable case involves a young girl who recently arrived all alone from the Ivory Coast and is inexplicably failing school. In a halting near-whisper, she insisted that French was her only mother tongue. The clinicians in the room seemed mystified, as they guessed that another language from her past has a hold on the child. Finally, a woman who had worked for years with the Parisian African population in another setting offered an explanation. According to her, the French spoken in the Ivory Coast differs greatly from the French spoken in France, more so than in many other areas of francophone Africa. Despite her reading and writing proficiency, the young girl was struggling to understand the classroom lessons and the teacher's instructions because of the unfamiliar dialect, but felt too ashamed to voice her difficulty. Without this crucial piece of information, the clinicians could not begin to work with the girl and the caseworker on ways to overcome this basic obstacle.
The group structure serves as more than a reflection of formal communal gatherings in Africa, then, and all the participants feel justified in their presence. When I happened to contribute a useful comment, I went home that day with the whole consultation thrilling through my chest, and the long subway ride home passed in just a short instant.
Between Two Worlds
In the evenings, I returned to the prestigious École Normale Supérieure (ENS) in the studenty, touristy Latin Quarter of Paris, where I immersed myself in an ancient but breathing symbol of French tradition. There I lived with the country's future academic and political leaders, a group with no more ethnic and socioeconomic diversity than Harvard had in the 19th century. I knew of one Arab student and no Africans, and even the considerable population of foreign exchange students come almost exclusively from the United States and Europe. Across disciplines, the array of seminars offered there covers the roots of Western civilization—from Greek to Roman to French—as it has for hundreds of years. Most people I told of my work at the Centre Georges Devereux responded with eyebrows raised in slightly bewildered surprise, as if I were working with exotic birds rather than a large population living in their own city. I learned quickly to keep the worlds separate and generally succeeded.
Occasionally, I experienced a glitch in the transition, when the disconnect between my day at the Centre and my evening at the ENS sent shock waves through me until my brain froze with exhaustion. One day I arrived at the ENS breathless from the metro and ran straight to a rehearsal of my baroque chamber music ensemble. “I floated unconscious through the leader's explanation of the subtleties of grace notes in Couperin, my heart pounding, my throat aching, my mind unable to expel the grisly, heart-rending image of the walking skeleton I'd met that day.” I had never seen anyone dying of AIDS before, let alone a young woman, unidentifiable as such, who looked as if she had already died. The skin stretched taut and shiny with sweat over her huge eye sockets, and the wide mouth quivered, a shiver that spread to her whole emaciated body and wildly darting eyes while she listened to her seven-year-old daughter's estranged father, seated several chairs away. He wanted custody of the child and spoke in oily tones, drawing upon his royal West African heritage, while the mother's long, bony hag's hands trembled against each other in her lap in time with her only words, in a firm, ghostly whisper, "That's false. That's false."
Several times Marie paused the consultation to calm the mother, as her shaking grew more wildly uncontrolled, and in fear that she would fall down in a trance (or seizure, depending on your point of view). The child watched her mother worriedly from the corner, magic marker poised over untouched paper, while her father continued to wheedle unabashedly and display legal papers with such blatant callousness towards the mother's terrifying condition that I again shuddered with nausea as I raised my flute to my lips. No sound came out. Bach and Couperin had no more substance than a dream, but the AIDS-ravaged woman and her orphan-to-be proved ever more real in my dreams that night.
Healing Spirits
One of the first consultations I attend involved a family with a young boy who kept on falling. His most recent accident, a fall from a ladder, had landed him in the hospital for a month. I understood very little of the ensuing discussion, but I gathered in the end that the family somehow neglected to perform certain rituals at the burial site of a maternal ancestor. The completion of these rites would close the circle of ancestral protection, which had clearly suffered some punctures, allowing such ill fortune to befall the boy. Perhaps his repeated falls were actually occurring in order to remind the family of its neglected duties to its ancestral protectors. The parents and children left the session with many smiles and warm handshakes, highly satisfied and full of plans for follow-up after performing the rituals. I was enthralled and enthusiastic. And then, inevitably, the thought: But what happens the next time he falls? How could I wrap my mind around what seemed so obvious to the others, patients and professionals alike—that if they have correctly diagnosed the situation and prescribed the appropriate remedy, then the boy would not fall again? I could not, and still I tried.
Having since worked as a research coordinator in psychiatric genetics at a major U.S. hospital, I sometimes have trouble believing that, not long ago, I pondered the desires of ancestral spirits on a daily basis. But I certainly did, and with increasing ease. The discussions moved seamlessly from school performance or legal residency papers to honoring ancestors while remaining faithful to the Christian God . . . and back again! “The invisible and the spiritual inhabited the same plane as the utterly mundane.”
Eventually I learned to enter into this mindset, a way of thinking about the world that grew more and more familiar—but always as an outsider, sheepishly wearing another's clothes. I wondered uneasily whether I needed to feel sure of the existence of the phenomena we discussed in consultations for the work to be legitimate, whether it mattered as long as it functioned therapeutically, one way or another. It seemed all right to me as long as my place was mostly that of an observer, but what if I occupied the role of the psychologist directing the consultation? Although they would likely refute the idea, the legitimacy of the whole system seemed to me to rest in large part on the clinicians having cultural backgrounds comparable to those of their clients. When the Senegalese psychologist, Fatou, described how a patient should buy a small live chicken, feed it to her family, and then bring the contents of its stomach into the next consultation, she was not "playing" at something; she wore nobody's clothes but her own.
In this light, I came to understand ethnopsychiatry's disdain for the widely held idea that its therapeutic interventions work merely through "suggestion," influencing patients' psychologies for the better rather than actually affecting the supernatural forces under discussion. Although I myself have not resolved this issue in my mind, the idea of suggestion does seem patronizing. Setting it apart from much other cultural psychological theory and practice, which sometimes uses cultural sensitivity to facilitate essentially Western treatments, ethnopsychiatry takes the logic of intercultural respect quite seriously, audaciously, all the way to its conclusion. And I came to see why anything less—no matter how much more comfortable for the Western-trained intellect—falls short.
On the other hand, transferring this logic from social/psychological to more biological/medical areas seemed to me problematic, from both a scientific and a humanitarian perspective. For example, in many parts of Africa, HIV/AIDS is generally viewed as the result of a witchcraft attack. And much as it makes me squirm, I can understand why one Western-trained African doctor I met (outside of the Centre Georges Devereux) regularly tells his African patients that the antiretroviral drugs serve as antidotes to witchcraft. The clinicians at the Centre Georges Devereux would certainly never use such methods. But who am I to decry this patronizing "ghost story" if it increases compliance with the treatment regimen and thereby prolongs lives? Interestingly, many HIV-positive Africans in France understand perfectly the way they physically contracted the virus as well as the biological course of their illness. And yet, simultaneously, they see a witchcraft attack as the underlying explanation for why they contracted the virus when and how they did. From this perspective, then, the antiretroviral drugs really do fight witchcraft, or at least the illness it causes (though strictly speaking they do not defend against further attacks). So while I never fully understood how ethnopsychiatry manages to integrate Western medical science with traditional etiologies and treatments, perhaps, there is ultimately no real conflict.
Bridging Troubled Waters
“The clinicians prove a wonderful resource for parsing out normal cultural practices from aberrant behaviors”, a particularly important distinction when making decisions about a child's future. One social worker's report of a mother's rough handling of her infant in the bathtub resulted in the baby's placement in foster care. The mother regained her child months later after a mediator at the Centre Georges Devereux explained to the social worker the cultural practice of firmly molding a baby's body to ensure its proper growth and development. Thus, as a constant undertone to whatever other therapeutic intervention they attempt, the clinicians work to improve communication and clear up misunderstandings between the social workers, judges, and educators on the one hand and their immigrant clients on the other. They succeed by using their mastery of both languages, literal and figurative, to bridge the two worlds.
Yet their work does not always consist of pure translation from one world to another. Sometimes it seemed to me that the Centre Georges Devereux created and worked with one multi-faceted language. True, the interpretation of a symptom sometimes varied depending on one's cultural viewpoint, determining whether someone was in a trance or having a seizure. But that was not always the case. For example, Dominique, a French psychologist and trauma specialist, runs special consultations for survivors of intentionally induced trauma.
Back to Monsieur D.
Importantly, the clinicians at the Centre also recognize when some symptoms are most easily classified in agreement with Western categories. A Haitian student intern reported to the group on her first attempt at a private mediation between a Haitian woman and the social services. The intern described to us how she explained the client's references to the Voodoo religion to the doctor and social worker present, so they might get a sense of the cultural framework behind her seemingly incomprehensible utterances. Then Marie, the psychologist who supervised the mediation, spoke to the intern: "You did a fine job explaining the various Voodoo figures and rituals the patient mentioned. “You neglected, however, to point out that the way the patient was talking about Voodoo actually made very little sense, and that the woman was on the verge of becoming totally delusional.”"
Whether or not in sync with Western categories, the professionals at the Centre are certainly well equipped to identify behaviors that are pathological within their cultural context. I recall too vividly the case of an eight-year-old boy accused of witchcraft by his aunt and uncle, his guardians in France. They had plenty of evidence according to traditional standards to convict the boy of trying to kill them slowly by witchcraft, probably by order of his grandmother. Among this Congolese people, I learned, a convicted witch is branded according to a traditional ritual in order to identify him/her, so that the witch can no longer go out at night to work destruction on innocent people. This small boy's uncle woke him up in the middle of the night and dangled him outside the open window for several minutes before bringing him back inside. He proceeded to bind the boy's hands and feet with rope before branding his shoulder with a hot iron. The child has an iron-shaped scar on his shoulder to this day.
I was horrified—not only that such horrendous abuse has occurred, but also by my frightening question, "Could this possibly be culturally normal? What then?" Apparently, the judge in charge of the uncle's hearing wondered the same thing, sending the boy to the Centre Georges Devereux to help herself as much as the traumatized child to make sense of the situation. There, the clinicians understood immediately that, whether or not the child was practicing witchcraft, the uncle certainly reacted abnormally. “He acted alone, outside of the codified, traditional system of communal witchcraft hearings, thereby transforming a ceremony with a preventive purpose into a form of private, vindictive torture.” What relief to discover that his act was pathological from any point of view! I can only guess at what precipitated the horrific branding: whether the craziness or evil of this individual or his displacement from a certain cultural/social context, or some combination of both. I know only that the judge could send the uncle to jail with a perfectly clear conscience.
A Delicate Balancing Act
One Algerian client we saw exemplified this challenge. She had turned her husband out of the house, but still felt conflicted and allowed him to return to see the children. She reported that he destroyed things in the house and even hit her when she intervened as he disciplined the kids. As I listened to their story, I held my breath as the tone of the consultation became almost accusatory, with comments on how the woman had reduced her husband to less than a man. Finally, she rose abruptly and crossed the room with tears in her eyes. The clinicians were trying to jolt the patient into recognition that she still wanted and needed her husband, if only because she had fallen very ill since his departure and could not care for the children alone. They wanted her to agree to bring her husband to the next consultation, because their family would only continue to fall apart until she reconnected with her place as wife and mother. Practically speaking, they were probably right. Her brazenness had left her in an untenable situation, utterly isolated from both family and the larger community. In another culture, she might have had an opportunity to end an unhappy marriage and rebuild her life. But the world she was born into holds no place for a divorced woman. Still, I sat there sweating uncomfortably at the scene, acutely aware that this woman's brave resistance went unvalidated in this setting. The individualistic voice in my head cried out, Does she not have the right to disagree with the logic of her own culture?
And what about the clinicians? Did they have the right to disagree with the logic of their client's culture? This seemed even thornier a problem. I wonder how far to go in accepting the patients' culture at face value when some normal practices might run contrary to certain moral principles. If I believe that women are oppressed in certain parts of Africa, by tacitly accepting such cultural elements when working with the people, was I promoting intercultural understanding or perpetuating the oppression? Does the very presence of this question in my discomfited mind merely reflect my own ignorance and cultural biases? I cannot say for certain either way.
To add to my confusion, the power structure at the Centre Georges Devereux appeared extremely egalitarian—a far cry from my later experience (ironically, in the land that championed feminism) working at a U.S. hospital among many female research coordinators quietly waiting on almost exclusively male doctors. In contrast, female professionals at the Centre had equal voices, which they did not hesitate to use, and an equal share of power at all levels of the loose hierarchy. These independent, empowered women must have somehow reconciled their multiple university degrees and packed professional lives with their daily defense of the traditional values and practices of their cultures of origin. I never understood exactly how they did it, unless I vastly misunderstood those traditional values and practices. How could a female clinician legitimately press a client from a similar cultural background to stop resisting a traditional role, when the clinician had refused that role herself?
Perhaps, unable to sidestep my feminist perspective, I was failing to grasp the actual nature of the therapeutic interventions. I sensed, but could never articulate, the nuances in ethnopsychiatry's delicate balancing act. “Like a spider suspended in a doorway, thanks to the tension in its fine-spun web, the Centre Georges Devereux fosters the creation of a space between the extremes of cultural isolationism and total assimilation; a space where Africans can stay African while sustaining life in France.”
An Inconclusive End
My arrival at the Centre Georges Devereux felt like a leap into freezing water: I grew accustomed to it quickly, but I never forgot that I would feel cold again the moment I set foot on dry land. My discovery of ethnopsychiatry has certainly modified my educational and professional future; in fact, it has transformed me, or perhaps it has rather transformed the world for me. And now I must return to my previous world, alone, carrying the weight of an experience that is incomprehensible or merely of exotic interest to the inhabitants of that world. To my knowledge, ethnopsychiatry as defined at the Centre Georges Devereux does not exist in the United States. And yet, I would like to find a way to integrate what I have learned over the course of this year into my future studies and work. But attempting to "do" ethnopsychiatry on my own would not only be crazy and pretentious, it would also run counter to the fundamental principles of its practice. I would of course need a group. But how can I explain to others ideas and practices that I have not myself mastered, especially with the theoretical literature almost entirely inaccessible to non-French speakers? How can I avoid one of the risks of transplantation, in which the techniques and terminology become inactive, empty husks, having lost along with their roots the underlying depth of thought and their therapeutic powers? I do not know how to resolve these problems, among so many others. But I will search for a way.
And I am searching. I came to the Centre Georges Devereux to try to understand ethnopsychiatry: whether it works, how it works, why it works. After a year of attending consultations, I still have no clear idea how to answer those three questions. There was no introduction to the start of my time there and certainly no conclusion at the end; yet I have gleaned bits and pieces that will stay with me, even if I have not figured out how they all fit together. Most of all, I have gained another pair of eyes. Because ultimately, the Centre Georges Devereux works at the cusp of vastly different cultures in order to shake up the kaleidoscope through which we view the world, to offer the field of psychology a different, perhaps broader and more inclusive, and certainly a more varied and colorful perspective. In my desire to help foster that vision, I know only one way to begin. And so I offer my own story.
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