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Migration and mental suffering in healthcare and social assistance services: an experimental approach from an anthropological perspective

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Francesca Cacciatore Nadia Maranini Martino Ardigò

 

Francesca Cacciatore
Nadia Maranini


Although migration processes have been rooted in Italian territory for years they are still labelled as an "emerging social problem" and for this reason the policies and laws which are aimed at establishing the presence of foreign citizens are still oriented towards the temporary and urgent nature of this phenomenon. This is particularly apparent within healthcare and social assistance services where corporate structure and the current lack of resources have brought some existing difficulties to the fore. These concern the understanding and management of the suffering of a population which is still considered to be something of an unintegrated outsider.
Although, from the very first influxes, being an immigrant in Italy implied stringent limitations in terms of entitlement to full labour, economic and political rights, with serious repercussions in terms of health, to this day, the risk factors which expose foreign citizens to the onset of forms of suffering, in particular mental suffering, are still on the increase. In light of this, it is of paramount importance to close these gaps through the implementation of healthcare responses which serve to further examine these processes.
In 2009 an experimental project aimed at dealing with and reflecting on new ways of providing assistance for the migrant population was launched in the Bologna area (The East Lowlands District). The Centre for Cultural Consultation provides a multidisciplinary core of psychiatrists, public healthcare doctors, social workers and medical anthropologists with a view to offering advice and training to social and healthcare workers in particularly problematic cases. The aim is not to manage these cases but to provide guidance which also serves as a form of training for social and healthcare workers and which proves so effective as it can be immediately implemented in specific cases. This process must be accompanied by a scientific and research based approach, the aim of which is to identify the building blocks which would allow for the implementation of good practices and a deeper understanding of the matter at hand. In order to achieve this, a preventative analysis of the dynamics which characterise the relationship between the services offered and their users proved necessary. This was made possible by carrying out meetings and interviews with social and healthcare workers and by studying the current situation in the area.

The problematisation of currently available services
The first problems to be recognised within the social and healthcare system regarding mental health were, for the most part, related to compliance and the effectiveness of treatment. Due to these problems social and healthcare workers often define patients' treatment programmes within the social assistance and healthcare system as being inappropriate and discontinuous as well as being marred by communicative difficulties and a lack of reciprocal understanding. On the other hand, the very non-native patients who interact with doctors as well as social assistance and healthcare facilities tell of the difficulties associated with a system which is too inflexible and bureaucratic, at times even incomprehensible, in which they feel incapable of expressing themselves and of actively participating in the treatment process.
Indeed, what we can deduce from the treatment programmes of those belonging to this section of the population is a critical situation which can result in different and unfortunately inefficient outcomes; poor compliance or even abandonment of treatment programmes which hinders the full exercise of rights; being passively and iatrogenically subjected to the rationale behind healthcare and social assistance; a purely instrumental use of services, especially healthcare ones, in order to obtain social recognition. The latter assumes particular importance as the entitlement to healthcare is the only right to involve a wider range of guarantees which can, in turn, facilitate the activation of other types of resources. What seems clear is that one of the few opportunities for sociality stems from our existence as human creatures, from our mere biological and psychic existence, from illness and its treatment. Paradoxically it becomes desirable to be part of this form of sociality in order to assert one's presence,. It is a place where one can lay claim to something which is denied in other (legal, political, economic) fields. We are here referring to Rabinow's concept of biosociality: existing as a mere suffering body for which the healthcare system becomes the unwitting hideaway, where the stigma of the "parasitic migrant" and the relative communication and relational problems associated with it are reiterated.
Uncertainty and unmanageability are distinctive features of the cases which have come to the attention of the Centre of Cultural Consultation thus far: diagnostic uncertainty regarding the type of complaint, difficulties encountered in finding adequate resources, in developing effective treatment plans and in implementing successful social reintegration processes. Most cases are ones in which psychiatric treatment is always accompanied, or rather often preceded, by the immediate and urgent intervention of the social services. Psychiatric services take over in the acute phase of the case, when the care workers can no longer "connect" with or manage the patient. The psychiatrist is usually faced with the task of defining the "entity of the problem" which all other choices will subsequently depend on. Indeed, in many cases the Centre of Cultural Consultation is asked questions of diagnostic nature: how to carry out a psychiatric evaluation of the non-native patient? Which plan of action is most appropriate after so many others have failed? Why is the patient not complying?
The first attempts made by the healthcare services to examine and resolve such difficulties with non-native users pivoted on theoretical studies aimed at cultural diversity. Indeed, the network of cultural meanings which not only define and develop the experience of suffering but also influence treatment relations and therapeutic outcome, were among the first human and social science considerations to be made. The very basis for psychiatric diagnosis has been a bone of contention regarding what could be defined as the inappropriateness of ethnocentric classification in which the patient, having a different conception of the person and disorder, cannot always recognise himself.
If on the one hand, the way has been paved to make certain "matters" common knowledge, on the other hand, it is particularly problematic to contemplate these perspectives as part of practices whilst encompassing different approaches which explain the complexity of the processes. The pragmatic need to deal with an increasing number of non-native users has not led to a structured and coordinated process among the various services and competences involved However, some diversified and fragmented solutions imposed by current needs have been identified. Thus we can find dedicated services, linguistic and cultural mediation, ad hoc training on the multicultural perspectives of treatment for healthcare workers, without a self-contained plan behind them.
Whilst it is recognised that the Bologna experience has made some of the questions in this first approach to cultural competence "thinkable", it has also highlighted some obvious limitations which force us to reconsider this matter. Indeed, critical and intensifying impasses remain to be resolved in cases where it appears that not even cultural analysis can lead to better understanding and where the non-native patient maintains an aura of "intractability" and of non inclusion. All this represents a challenge for the principles of equity and participation in socio-medical programmes.
The matter of relations between patients and services is a rather delicate one as, in many cases, the defining and developing stages of treatment result in conflicting ideas regarding the very definition of and reason for the treatment itself. We are dealing with a divergence that appears to be due to the different aspects and processes which assume importance for the various parties involved. We are not here discussing a divergence associated with cultural difference or rather, not only. We are referring to an approach which sees the other as a reifying form of diversity in which both social and economic conditions, should they be granted deeper contemplation, become classifications and categorisations which are pigeonholed within economic ranges and bureaucratic requisites and alienate individual experiences. What we risk here is the overshadowing of political dimensions (the recognition of rights, inequalities, access to public resources) and of power relations concerning migration pathways not to mention the adaptation and dampening of patients' experiences in accordance with what the social assistance and healthcare system is able to offer.
Indeed, all too often the desired or anticipated outcome cannot even be achieved with the aid of cultural mediation since all that can be obtained is an incomplete collection of information which does nothing more than indicate where to place the user. It is often used as a tool whose only aim is to help the foreign citizen to understand the treatment prescribed by the doctor and/or social/healthcare worker.
After all, the thinking behind the corporatisation and restructuring of services, especially in terms of the economic crisis, means that there is a growing tendency to manage cases with a much reduced investment in relations and in the time needed treat a patient resulting in nothing more that his mere diagnosis. Indeed, it seems that practices are hinged both on a continuous state of emergency and on the predominance of technical aspects in a compromise between the most efficient and most cost- effective solution.
In the belief that hyperspecialisation is more efficient, the economic idea of productivity also leads to an increasingly specialised structuring of services. This also has repercussions on the socio-medical integration approach. Indeed, if the latter has proved to be the key to connecting the reciprocal influence between social dimensions and health, it must also be said that it is characterised by fragmented and highly specialised processes. The result is the loss of the ability to piece together patients' life experiences which are fundamental if we are to fully understand how to intervene efficiently. Consequently, one often witnesses the patient's estrangement from the appropriate treatment programmes as he feels the main objective of the service provided has been lost.
This represents yet another fundamental aspect as it too is involved in determining successful outcomes. Indeed, what is apparent from our observation of the services provided is basically the establishment of practices which define the doctor's expert opinion as the only legitimate means of discussing a patient's illness/suffering. These practices may assume different forms ranging from paternalistic rationale, which limits the patient the passive role of the inept party, to the concept of having every right to make one's own choices. In the latter practice the responsibility and expertise of the doctor make way for the principle of self-determination, allowing the patient to make his own decisions. Both approaches lack the patient's perspective of the illness.
Furthermore, in relation to other disciplines and fields of expertise the biomedical approach finds itself in a position of supremacy and for this reason different professional perspectives are overlooked and ill-equipped to guide practices.

The Centre for Cultural Consultation and the anthropological contribution
Within the Centre for Cultural Consultation we have made a conscious effort to experiment with an intervention method which allows for an operational approach when confronted with the complex and multifaceted experiences that characterise migration and illness. If these cannot be dealt with through a sectoralised and specialist approach, at least not at the expense of inefficient outcomes, then it is necessary to consider interdisciplinary tools as well as ones which can re-orientate services.
Unlike the other experiences gained in recent years, whose main focus was on patient management, the Centre for Cultural Consultation does not directly address the user, but is defined as a consultation service for clinics and healthcare workers who find themselves having to deal with the difficulties which arise where treatment, society and culture converge. The decision not to provide a service with specific competences to dedicate to a particular part of society is based on numerous questions and considerations. First and foremost, there is a feeling that the difficulties associated with relating to the foreign citizen have broader implications within the population as a whole. Indeed, more often than not, as we have already mentioned, the difficulties which arise between patients and service providers involve social questions including rights of citizenship, the distribution of resources and equity in terms of access to services which involve the most vulnerable members of the population, only some of whom are migrants.
Cultural difference is therefore, a mere amplifier of broader social questions which cannot simply be tackled through cultural competence within a service whose expertise lies in migration if not in the broad sense we have discussed thus far. This also means breaking away from the principle according to which certain forms of suffering concern immigrants as such, in an almost ontological sense. This principle fails to highlight the etiopathogenesis which can be found both in social organisation and in that of services. To this we must add the relentless stigmatising and exclusionary effects which can be generated by the way in which dedicated services are structured.
What, therefore, emerges is the need to train social and healthcare workers and professionals to have a complex vision of illness which can only be treated by reconsidering the way in which the service is currently structured and by encouraging dialogue among the various professions involved.
For this reason it is believed that if social and healthcare workers are to be supplied with the multitude of determinants and implications of an illness, this must necessarily involve a multidisciplinary approach. After all, the role of the individual disciplines involved is to provide expertise which is open to dialogue and hybridisation with different forms of knowledge. The process is aimed at providing the referring body with the ensemble of implicit and explicit relations, on either micro or macro levels, which are present in every story of suffering. This is an attempt not to reproduce the sectorisation which characterises current approaches but rather to provide perspectives which are open and encourage negotiation.
For this reason, in the rationale of services where there is a tendency to limit suffering to the definition of a symptom, where diagnostic certainty seems to be the catalyst for all questions. Very often, the challenge is to work together with social and healthcare workers to redefine the questions we need to ask ourselves in relation to the different ways of considering suffering. This is an attempt to work both with the patient and around the patient to re-establish the interplay of power relations which influence life experiences and define the sufferer in relation to his illness, with a view to finding a way for the patient to express his ability to take action.
If we reflect on what medical anthropology has to contribute, its role must be to go beyond that of the mere "cultural" decoder and place cultural variables in a broader analysis which focuses on the historic and political processes provided by the various actors involved. By doing this, anthropology suggests a constant focus not only on the dynamics and processes which concern "the other", but also a constant self-reflection approach of the various disciplines involved which makes it possible to take a critical look at outcomes and at the social product of medical and institutional practices. At the same time, the theoretical and still rather academic "nature" of anthropology requires constant dialogue and restructuring with the help of psychiatric, medical and social expertise which make anthropological perspectives more "feasible".
Furthermore, we are dealing with a form of medical anthropology which attempts to tackle health matters in a way which is profoundly interconnected with questions of citizenship and social equity principles. It must however be said that this perspective is deeply rooted in the individual and specific meanings these matters assume. It is once more important not to limit the macro dimension of deeply personal processes. For this reason the patient becomes a fundamental interlocutor who is just as important as other experts.
This also serves to encourage a constant practice which forces us to carry out an in-depth analysis of the responsibility services have in uncovering instances of malpractice which are subtly concealed in treatment programmes, the opportunities the patient is actually given to fully express himself and the implications and consequences of choosing one type of treatment over another.
In this way, the team at the Centre for Cultural Consultation has raised some rather pragmatic questions which have provoked changes. It has forced social and healthcare workers to discuss a number of critical matters and led to the reconsideration of the "thinkability" of certain vital issues relating to treatment: the time dedicated to understanding life experiences, anchoring to diagnostic certainty, the need for greater disciplinary and professional integration, the absence of the patient's perspective.
It is indeed worth dedicating more time to the last aspect mentioned as it also allows us to investigate other matters. In fact, as is highlighted above, we have found that services offer patients little opportunity for self-definition, this leads to the patient progressively distancing himself from his own experience. In this way, when suffering is limited to a simple diagnosis it leads to preconceived suggestions and "solutions" which are determined by what is presumed to be the course and progression of the illness.
This immediately brings to the fore another important matter regarding the power of diagnosis which is designated to be the only criteria which seems to assist healthcare services in establishing a treatment programme by basing diagnosis on the predictability of the progression of an illness. This also serves to highlight the importance of reconsidering the central importance of the patient's life experiences within the treatment programme. Diagnostic inflexibility does in fact run the risk of underestimating the importance of life experiences in which the social and cultural dimensions of suffering indicate those specific personal trajectories which cannot be traced back to the illness but which involve social responsibilities.
On the other hand, the approach suggested by the Centre for Cultural Consultation highlights the need for a place where the experience of being ill can be expressed. It contemplates the numerous factors which combine to form this experience and views the patient as someone who, if provided with the right conditions, is able to interact with the world in a competent self-determinant manner. Therefore, part of our response is dedicated to meeting with the patient in order to ascertain his perspective, planning ability and the implications of his condition both as a sick person and as a patient. What is more, in keeping with the idea that illness is not characterised by an individual dimension but that it is something which is produced and shared collectively, we believe that it is also important to involve family members and the patient's social networks.
Acknowledging the importance of the numerous factors involved is therefore the first step towards redefining patient management and treatment. It is in this way that the thinking behind the service offered can be reconsidered so as to leave space for the central role of the person and not just the illness. This is indeed, perhaps even more so than the others, the most important transformation to make: for as long as we consider the illness in isolation as a mere pathological phenomenon and not the person, we will keep harking back to the very relational and power processes in which the patient is lost and in which other professional figures will always be overshadowed by the medical perspective.
There is no doubt that considering the patient as another person with "expertise" who is capable of co-constructing the meaning and dynamics of suffering can also lead to an organisational redefinition of the services provided: much more time dedicated to listening to the patient, more humane meetings and an increased investment in relations. Although this may not immediately reflect the criterion associated with the economic efficiency of services it does represent greater efficiency and satisfaction for both patients and healthcare workers, not to mention a reduction in long-term treatment costs.
It would be impossible to present this anthropological analysis of a new experimental service without mentioning the difficulties associated with the very role of medical anthropology when compared with other disciplines. Integrating a discipline which has for decades been relegated to cultural "exoticism" within "discussions" on mental health and related healthcare services represents the first step towards a new phase of self-reflection within socio-medical mechanisms. If in many cases the mere presence of an anthropological approach assumes a symbolic value of considerable importance, it goes without saying that its often antithetic role in relation to current thinking, makes its anchoring in the heart of social and health care services problematic.
Indeed, the perspectives aimed at reducing suffering and the corporatisation of services tend to crush other approaches. For this reason anthropology struggles to assert itself as a respected discipline when it comes to biomedical matters and western society. If on the one hand, some social and healthcare workers see reductionist practices as a problem it is, on the other hand, the very sense of powerlessness and the feeling that a different way of thinking within the organisation of services is impossible which generates frustration and the need to find alternative ways of implementing practices.
Therefore, what we also want to achieve through the Centre for Cultural Consultation is a sort of engine for the anchoring of integrated approaches within the complex nature of suffering in which the above-mentioned difficulties become a sort of common ground in where social and healthcare professionals can come together and share ideas.
Different and in many cases highly specialist languages often become an arena for conflicting viewpoints. However, this very process can actually lead to a new and necessary rethinking process which starts with the reformulation of a new and shared language. We are therefore dealing with a field of work which is not based on specific theories but which attempts to reconfigure itself through different practices whilst awaiting the creation of a common theory.
In this sense, the function of this experimental activity is to act as a transitional phase with a view to providing different solutions and practices which can be adopted and renegotiated both by and within healthcare and social assistance services.

 

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Center for urban suffering

The study centre wishes to study the phenomenon of urban suffering, in other words the suffering that is specific to the great metropolises. Urban Suffering is a category that describes the meeting of individual suffering with the social fabric that they inhabit. The description, the understanding and the transformation of the psychological and social dynamics that develop from the meeting of ...

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The Urban Suffering Studies Center - SOUQ - arises from Milan, a place of complexity and economic and social contradictions belonged to global world.Tightly linked to Casa della Carità Foundation, which provides assistance and care to unserved populations in Milan (such as immigrants legal and illegal, homeless, vulnerable minorities), the Urban Suffering Studies Center puts attention on ...

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