‘‘Talking is better than giving medicines’’:
Exploring Moroccan immigrant patients’
perceptions and experiences of
schizophrenia
and related mental health workers’
views and approaches
in The Netherlands
Universiteit van Amsterdam
Master in Medical Anthropology and Sociology
Thesis by: Estefanía Bravo Valentín
Supervisor: Walter Devillé
The Netherlands, 2014
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TABLE OF CONTENTS
CHAPTER 1
INTRODUCTION
1.1. PRESENTATION OF THE RESEARCH
1.2. THEORETICAL FRAMEWORK AND LITERATURE REVIEW
1.3. PROBLEM STATEMENT, RESEARCH QUESTIONS AND KEY CONCEPTS
CHAPTER 2
RESEARCH METHODOLOGY
CHAPTER 3
FINDINGS
3.1. MOROCCAN IMMIGRANT PATIENTS’ DESCRIBED PERCEPTIONS AND
EXPERIENCES OF WHAT IS CALLED SCHIZOPHRENIA
3.1.1. Definition of the problem, construction of schizophrenia and
experiences
3.1.2. Described feelings, expressed emotions and attitudes related to
the illness
3.1.3. Expressed perceptions of others, cultural differences and social
conditions
3.1.4. Narrated experiences and opinions about Dutch health services
3.2. MENTAL HEALTH WORKERS’ EXPRESSED PERCEPTIONS ABOUT
SCHIZOPHRENIA AND MOROCCAN IMMIGRANT PATIENTS
3.2.1. Mental health workers’ perceptions and opinions about
Moroccans’ understanding and experiences of schizophrenia
3.2.2. Mental health workers’ perceptions about their work
3.2.3. Mental health workers’ perceptions of Moroccan immigrant
patients’ attitudes
3.2.4. Recognition of the role of social and cultural conditions in
Moroccan patients’ experiences of schizophrenia
CHAPTER 4
CONCLUSIONS, DISCUSSION AND RECCOMENDATIONS
REFERENCES
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CHAPTER 1
INTRODUCTION
1.1. PRESENTATION OF THE RESEARCH
‘’And those who were seen dancing were thought to be insane by those who could not hear the music’’
Old proverb
Boundaries between sanity and insanity are imprecise and controversial. They change through history and across different societies. In this sense, behaviours, thoughts or feelings which were centuries ago considered symptoms of mental distress in Western societies, are no longer seen as pathologies, or certain mental problems which exist currently in some contexts, were not recognised in the past or are not identified in other societies. Even when certain mental illnesses have a long history or are observable in different cultures, the interpretations, explanations and meanings attributed to them are diverse and even sometimes contradictory. Psychological and psychiatric anthropology have made important contributions emphasizing the ways in which categories of ‘’madness’’ are culturally constructed and the influence of culture in the experience of mental illness. In addition to this, transcultural psychiatry approaches have widely tried to deal with the lack of a universal theory of psychopathology (Lock & Nguyen, 2010: 172, 173).
The influence of sociocultural, economic and politic aspects on health and illness processes has been widely argued and is the main point for Sickness’ approaches to health and in Critical Medical
Anthropology studies. Patients’ narratives with reference to illness episodes have also been explored in
many anthropological researches, aiming to reveal the ways in which subjects explain and signify illness experiences. However, regarding schizophrenia, still a lot remains unsaid about the conflicts between different perspectives and the role that socio-cultural conditions play in their construction.
In The Netherlands, prevalence of schizophrenia is higher in minority ethnic groups such as the Moroccan immigrant community, according to numerous studies (Selten et al. 2001). Despite this, little has been researched about the way in which schizophrenia is culturally perceived by immigrants and about the conflicts that can appear between non-Western ways of understanding the illness and the Dutch ways of approaching it from the medical services.
In a multicultural context such as The Netherlands, in which diverse conceptualizations about normality, reality, the mind, the body, etc. coexist, exploring sociocultural perspectives of schizophrenia (the ways in which its causes, effects and treatment are conceived and signified), as well as the social aspects which shape experience, appears to be an important question to be addressed, in order to contribute to culturally adequate, equal and fair mental health services and assistance.
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In this study, I tried to understand Moroccan immigrant patients’ explanations of what is called schizophrenia, as well as their thoughts and opinions about the care provided by Dutch health institutions. In addition to this, my aim was to look into mental health workers’ approaches, in order to comparatively analyse both perspectives and contextualize the clinical encounter.
This thesis is the result of my fieldwork. In the first chapter, I present a broad literature review and the main questions which led to the research. In the second one, a brief description of the methodology employed is included. In chapter three, Moroccan immigrant patients’ and health workers’ perceptions and perspectives about schizophrenia are presented and analysed. Finally, in the last chapter, I will draw some conclusions based on the comparison of these two different constructions, suggesting some recommendations related to the findings.
1.2. THEORETICAL FRAMEWORK AND LITERATURE REVIEW
According to the medical anthropologist Ángel Martínez (1998: 13), probably very few illnesses present nowadays such a degree of ambiguity and lack of definition as schizophrenia does. Perhaps due to the fact that still today the processes and causes of this disease remain undiscovered by the scientific community, or maybe because its name is culturally and historically overloaded with stigma and metaphors, schizophrenia in Western societies appears in these days associated with uncertainty, as this author has noted. Ángel Martínez has critically approached schizophrenia from three different perspectives (Disease, Illness and Sickness), terms used in medical anthropology to analyse respectively the biological, cultural and social dimensions of illnesses.
With reference to the Disease or biological perspective, he states that biological and psychiatric orientations consider schizophrenia a cerebral illness (result of dopaminergic pathways, lesions, virus or genes) and consider the arguments which situate its causes on social and subjective aspects erroneous. However, according to Martínez, a truly precise medical definition of schizophrenia is still lacking nowadays, as its classification and diagnosis rely on manifestations and expressions (signs, symptoms and course) rather than on irrefutable medical tests or physical localization of the disorder (Martínez, 1998: 17).
From the cultural or Illness interpretations, following Martinez, schizophrenia falls into a cultural determinism, as from these perspectives it is considered to be a mere social construction product of a particular culture and time (1998: 23). He criticizes these approaches, considering insanity not only a social construction or a symbol which reveals social contradictions and power structures, but also a way of suffering and a reality which exists beyond categorization and symbolization. Following Susan Sontag (1991), Martínez argues that despite illnesses can act as metaphors of the social order and ethos of a certain time, this does not mean they are only metaphors and cultural representations, but also biologic, economic and politic phenomena (1998: 25).
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From the social or Sickness perspective and in the studies carried out under this point of view, according to Martínez, schizophrenia has been widely related to low social class and socioeconomic position. In contrast to the biological deterministic currents, which consider that social descent and poverty are consequences rather than causes of the illness, these Sickness approaches understand schizophrenia as a result (or a highly determined product) of precarious labour conditions, economic cycles, social networks and institutional resources. In these studies, the prevalence of schizophrenia among certain subjects is not explained by biological aspects but by social inequalities (1998: 31).
Despite Martinez’s undeniable contribution to the deconstruction of schizophrenia, and his great job in revealing the ambiguity and paradoxes which underlay and intermingle in the Western understandings of this illness, he does not focus on the different cultural perceptions of schizophrenia, nor in the role that social inequalities play on its construction in certain disadvantaged groups. As the labelling of certain biological signs, behaviours or manifestations as a particular illness is a socio-cultural process of interpretation, dependent on cultural notions and conceptions (about normality/abnormality, health/illness, mind/body, etc.), the perception of schizophrenia and the way in which it is manifested, suffered and treated varies from one society or culture to another. The possible conflicts which can result from different understandings of schizophrenia in multicultural contexts is another aspect not treated here by Martínez and that still remains unattended in most social studies of schizophrenia. The medical anthropologist Arthur Kleinman coined the term Illness to take into consideration the personal perceptions and experiences of certain states which include but are not limited to the Disease, concept used to refer to biology and abnormalities in the structure or functioning of organs (in Young, 1982: 264). Kleinman defines Explanatory Models (EMs) as notions about an illness episode and its possible treatment employed by those involved in the clinical process, which reveal how subjects provide with sense and value the illness. Kleinman’s EMs and their semantic illness networks (which are its products) are attributed to individuals and not cultures, and are not homogeneous but variable over time and even in the same community (Young, 1982: 267). According to Young, Kleinman employs the idea of EMs to show how his informants produce their statements about sicknesses. Sometimes explicitly and sometimes tacitly, and usually about causes and effects, the EMs are useful to ‘’control and predict what is going to happen or to give moral significance to what has already happened’’ (Young, 1982: 267).
Much ethnographic work has been done under this perspective, even in the field of mental health, mainly focused on illness narratives. For instance, P. C. Alves and M. C. Rabelo analysed narratives of working class women who suffered from nerves and how their experiences and identities were discursively constructed (in Grimberg, 2009: 52). Similarly, Byron Good (1994) studied narrative representations of epilepsy in Turkey through interviews and life stories. Referring to illnesses as
syndromes of experiences and emotions, he considered them not only natural entities but also
socio-historic realities and symbols embedded in semantic networks, beliefs and values. Kleinman goes a step further, and in his research about the social course of epilepsy in China, not only studies the social experiences of the illness but also states that ‘’economic, moral and social institutional factors
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powerfully affect the lived experience (…), treatment and their social consequences’’ (Kleinman et. al 1995: 1328).
Using narratives of schizophrenia and homelessness, A. M. Lovell (1997) proposes an understanding of schizophrenic alterity constructed through spoken discourse. Although she recognises that complete understanding of the experience of the other is never possible (as an hermeneutic problem), she shows the role that narratives play in the constitution of a person’s subjectivity or self, and argues that the ability to give voice to someone’s story is a precondition to understanding his or her experience. Barker, Lavender and Morant (2001) have explored narratives used by clients and family members to explain the development of schizophrenia and its impacts on the client’s sense of self and social relationships, recognising how health professionals’ narratives also contribute to the sense making process. As well as this, the research carried out by Klausen, Haugsgjerd and Lorem (2013) has emphasized the importance of interpreting the experience of schizophrenic patients within health services. However, still cultural differences and social inequalities in the perception and experience of schizophrenia remain insufficiently addressed in these studies.
Other authors like Allan Young (1982) have criticized the Illness perspective in Medical Anthropology, considering that just as the biomedical approach, it takes the individual as object of study and does not give enough weigh to the social aspects in the analysis of illnesses, despite roughly considering them. He introduced the analytical concept of Sickness to describe the necessary process of socialization or contextualization of the Disease (biological signs) and Illness (personal experience and narratives). From the Anthropology of Sickness, according to Young, health, illness and care processes are considered cultural categories which vary from one specific socio-historic context to another, from which different meanings, senses and definitions are given to particular illnesses, and different practices and roles are shaped around them (A. Young, 1982: 270).
Great part of the approaches of the German social medicine of the 19th century already considered sicknesses a result of social conditions. This is the case of Virchow, who studied the social and economic dimensions of sicknesses focusing on the causes and treatments of diseases from a social and economic-politic perspective, including nonetheless other somatic and environmental aspects. This German doctor believed that certain life conditions or ways of living boosted the development of epidemic illnesses, and therefore the treatment had to be fundamentally social and reformist (Martínez, 2008: 123). As a result of the Sickness perspective just described above, the Critical Medical Anthropology and the Marxists and politic-economic viewpoints emerged in the field of Medical Anthropology during the 1980s. From these perspectives, diseases are understood as results of social inequalities and as products of exploitation relationships and accumulation of capital processes, consequences of hidden poverty and misery realities, acerbated by the decontextualization of socioeconomic factors and by the individualization of morbid processes (Martínez, 2008: 146). Authors included in this category denounce the coercive role of biomedicine in contemporary capitalistic societies, standing up for the study of the politic-economic conditions of sicknesses and defending a macrosocial analysis of health, illness and care processes. This point of view has been widely employed in the analysis of illnesses such as malaria
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or HIV/AIDS, with the ambition to reveal the socio-cultural, economic and politic determinants of illnesses and condemn the structural violence exercised against disadvantaged and vulnerable groups. In this sense, ethnographic studies as the ones carried out by J. Muela and S. Hausmann about malaria in Tanzania (2000, 2002, 2006, 2007) demonstrate that access to treatment and compliance are deeply influenced by aspects such as cultural beliefs and understandings of the illness, local interpretations of health messages and information, relationships between patients and health workers, environmental-related ways of living and social networks and gender inequalities. Similarly, A. Castro and P. Farmer (2003, 2005) in their research about AIDS in Haiti, mention repeatedly the role of structural violence in predisposing ''the human body to pathogenic vulnerability by shaping risk of infection and also rate of disease progression'' (2005: 55). Here, structural violence is defined by large-scale social forces which include social inequalities such as sexism, racism, political violence and poverty (2005: 54). This, according to the authors, is what ultimately determines access to diagnosis and therapy, as well as who suffers from AIDS stigma and discrimination. They criticize the fact that most anthropological and sociological studies and contributions overlook the broader social context, as they focus principally on individual perceptions and attitudes, disregarding the economic and political processes in which illnesses are embedded. In brief, apart from the personal experiences of patients, life stories and biographies (which were the main interests for Illness authors), other variables are included in their analysis, such as social forces.
With reference to mental illnesses within this perspective, A. Milne and J. Williams (2000) have particularly focused on gender inequalities and on the importance of making social changes in order to improve the living conditions of older women with dementia or depression. To prevent social injustices to perpetuate (as female major impoverishment and therefore major vulnerability to mental illnesses, for instance) they defend that a change must be me made in the UK economic policy, as well as in the care and service system. In addition to this, they claim that effective actions must include the involvement of older women, an increase of women's voices impact, and a reduction of inequalities as the key to prevention (Milne and Williams, 2000: 712).
Furthermore, B. D. Kelly (2005) emphasizes the impact of the social, economic and political aspects on mental illnesses and states that migration and poverty are associated with increased rates of schizophrenia, considering that structural violence amplifies the effects of this illness in the lives of patients. Previously but in the same direction, Hollingshead and Redlich (1958) observed how mental illnesses were much more frequent in disadvantaged classes, especially among non-qualified and semi-qualified workers. Based on their study in New Haven, they argued that there was a high association between schizophrenia prevalence and social inequities. Warner (1983, 1985), as Martínez notes (1998: 31), has pointed out that economic cycles, institutional resources and access to the labour market are linked to this illness, stating that during economic recessions and high unemployment rate periods in the EEUU, the number of registered cases of schizophrenia increased. In a similar way, other authors have related employment conditions (Link et al. 1986: 242; Maylath et al., 1989: 650) or indigence (Susser et al., 1989: 845; Susser & Stuening, 1990: 133) with schizophrenia (in Martínez, 1998: 32).
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Much has been written about schizophrenia and its causes from biomedical, psychological, sociological and anthropological viewpoints, with the purpose of identifying the reasons which lay behind it, explaining its prevalence among certain subjects and describing the experiences of the patients. Anthropological literature about the social construction of schizophrenia has mainly focused on illness narratives, overlooking broader sociocultural forces and processes from which it cannot be separated. The Sickness perspective in Medical Anthropology, which has been widely employed in the study of other illnesses, could help to contextualize these life stories and describe other cultural constructions of the disease. Even when this viewpoint has been used to address schizophrenia and social inequalities, still remains a lot unexplored about the role of cultural differences on its perception and the possible conflicts between the experiences of patients and health professionals.
The link between immigrant ethnic groups and schizophrenia has been also widely studied and asserted. For instance, Veiling et al. (2010), argue that in Western Europe, rates of schizophrenia in immigrants can be explained by social stress associated with ethnic minority status and perceptions of discrimination and exclusion, as ‘’belonging to an ethnic minority group subjected to discrimination and negative stereotyping (…) represents a threat to self-esteem and social identity’’ (2010: 1153). In addition to this, the authors state that the results of their case-control study are ‘’consistent with the hypothesis that identification with the own ethnic group, but not identification with the majority group, may protect form schizophrenia’’. Within the Netherlands, and comparing the prevalence and symptoms between natives and Moroccan immigrants, Veiling et al. (2007), suggest that not only incidence of schizophrenia is higher in minority groups due to social adversity (described as low socioeconomic status and high discrimination) but also that ‘’occurrence and content of psychotic symptoms may be influenced by cultural background’’ (Veiling et al., 2007).
Despite these studies do consider that there may be an influence of culture on the way schizophrenia is manifested and that social conditions play a crucial role on the development and experience of the illness, they fail to deepen and emphasize these aspects, which could help to explain why this higher incidence occurs only among certain ethnic groups (Moroccan, Turkish and Surinamese principally). Besides, they do not address illness narratives (as their results derive from statistical analysis) or the possible conflicts which can come from different classification and knowledge systems in multicultural contexts.
As Mezzich et al. (1999) have pointed out, culture is involved in psychiatric assessment and diagnosis. They consider individuals' sicknesses manifestations of larger social problems, stating that a diagnostic process exclusively based on individual pathology may work against a clinically (and morally adequate) response. ‘’Because the clinical encounter is often intercultural, the dynamics of cross-cultural work are crucial for understanding and refining diagnostic categories and practices’’ (Mezzich et al. 1999). According to these authors, the issues of gender and intracultural heterogeneity have also not been adequately addressed in DSM-IV, so they propose a revision of diagnostic systems.
Moreover, J. Warner and J. Gabe have analysed mental health worker’s perceptions of risk and their role in the classification of patients and assessment of treatment, highlighting some of the problems of
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policies and care systems which continue to reflect a medical model. ‘’Those service users whose behaviour was not easily attributable to either their personality or to their mental illness were seen by social workers as ‘liminal’ others (…) Such individuals were regarded as ‘difficult to place’ and were consequently often to be found ‘in-between’ places’’ (Warner & Gabe, 2004: 397). Furthermore, the authors point out to the influence of structural violence when stating that ‘’ those service users on the street who were black were seen as particularly dangerous. Being black and having a mental disorder represented two forms of ‘otherness’ which were mutually reinforcing’’.
Following Link et al.’s (1999) consideration that the opinions of the general public, patient's relatives and health professionals are extremely important because they may influence the detection of causes, psychosocial consequences and treatments for mental illnesses, A. Furnham and L. Wong (2007) have examined the cultural differences between British and Chinese beliefs about the aetiology and treatment of schizophrenia. According to their results, the Chinese hold more religious and superstitious beliefs about its causes and more negative attitudes, whereas the British emphasize on biological, psychological and sociological causes and treatments. Many other studies about the understanding of a particular mental illness have been carried out under the label of mental health literacy, as these authors have noted (Furnham & Wong, 2007: 123).
The understandings and attitudes towards schizophrenia of health professionals from different cultures have also been widely addressed. In a comparative research between British, British Pakistani and Native Pakistani medical students, Furnham et al. (2007) state that the beliefs about the manifestation, causes and cures of the illness differ considerably. According to these authors, Pakistanis perceived people with schizophrenia as dangerous and unpredictable and had the greatest tendency to use superstitious beliefs to explain its causes and symptoms.
Despite this type of studies emphasize cultural differences on the perception and construction of schizophrenia, they do not use anthropological methodology and do not include ethnographic descriptions or analysis to support their results. The possible conflicts derived from the cultural and social differences between mental health professional and immigrant patients remain unattended. I. Al-Issa (1997) notes that clinical and anthropological data have related hallucinations to specific cultural factors, such as class, ethnicity, ecology, Westernization and acculturation (1997: 583). According to this author, one of the main problems in the study and research about hallucinations is its definition, to establish the criteria to differentiate psychotic or schizophrenic ones from other hallucinatory experiences and normal imagery. With reference to the role of sociocultural factors in hallucinations, he states that ‘’differences between Western and non-Western cultures in their concepts of hallucinations and reality are reflected in different attitudes towards hallucinations and the emotional reaction to them’’ (1995: 368). In fact, the author argues that cultural beliefs may affect the frequency of hallucinations. Many non-Western societies, in contrast to the psychological and psychiatric approaches to hallucinations, do not distinguish between hallucinations (in biomedicine related to schizophrenia) and other products of imagination (Al-Issa 1995: 369), being altered states of consciousness attributed to spirit possessions or trance. Furthermore, according to Al-Issa, individuals
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may also develop hallucinations clearly linked to culturally-based concepts of guilt related to the infraction of social rules.
The distinction between reality and imagination varies from one society to another, so the Western classification or categorization of experience into reality and fantasy can be problematic. According to Al-Issa (1995: 369), in many non-Western societies, ‘’ ‘’reality’’ is used to describe hallucinations, imagery and altered states of consciousness, and people react to these experiences not ‘’as if’’ they are real but ‘’as’’ real’’, and these experiences are positively valued, in contrast to the negative attitudes usually attached to them in Western societies. This ‘’negative attitudes may reduce the patients’ trust in others and make them unwilling to report their hallucinations for fear of the stigma of mental illness’’ (Al- Issa, 1995: 370). Furthermore, he believes that patients’ attempts to supress and control hallucinations seem also to be linked to the negative emotional responses towards their contents. Although Al-Issa’s research focuses on the problems that Western patients diagnosed with schizophrenia face and on the cultural reasons which may lay behind them, these arguments clearly point out to the possible problems which can come from intercultural clinical encounters. His ideas reveal the failure of schizophrenia therapies and care programs which do not consider the weight of cultural differences and social inequalities on the perception of the illness, the manifestation and interpretation of symptoms, the meanings of patients’ experiences and the different social values attached to them. ‘’Recognizing that there are multiple perspectives (…) on schizophrenia may enhance the quality and usefulness of the debate, illuminate the nature of their experiences and lead to improved clinical services’’ (Geekie, 2004: 159).
Other studies have also indicated the ethnic variability of symptom expression in schizophrenia spectrum disorders (Barrio et al., 2003) or the cross-ethnic differences in perception of emotion in schizophrenia (Brekke et al. 2005), following previous theories which have argued that cultures differ in expressed emotions and in how emotion is recognised. Although the obtained results claim for the consideration of cultural and social factors to fully understand schizophrenia, these studies still lack an anthropological perspective to explain these differences and the broader social forces in which they may be rooted.
As H. Fabrega has pointed out, the universalistic perspective in contemporary psychiatry (which states that schizophrenic behaviour not only looked the same but also tended to be judged similarly in different cultures) together with the ascendancy of neurobiology, has achieved dominance today. However, ‘’all systems of diagnosis in general medicine are complex, difficult to apply and ultimately based on statistical conventions of normality’’ (Fabrega, 1992: 100). Therefore, without denying the biological condition of mental illnesses, he criticizes the ethnocentricity of the biomedical categories and emphasizes the role of culture in mental health.
This point has also been more recently discussed by Martínez (2006) in his article about cultural psychiatry, in which he reviews the theoretical discussions and ethnographic studies about mental health services, cross-cultural comparative studies on psychiatric disorders, and the use of the cultural skills model with ethnographic minorities and refugees. He states that the cultural competency model,
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theoretically based on the comprehension and appreciation of the cultural differences and similarities between human groups, is problematic when put into practice and fails in many ways. For instance, little attention is paid to material conditions associated with cultural diversity (and vulnerable collectives such as immigrants) and culture is understood as a set of beliefs, instead of as a system which organises subjective experience, the explanatory context of the aetiology, symptomatology, course, development and treatment of mental disorders (Martínez, 2006: 2277).
1.3. PROBLEM STATEMENT, RESEARCH QUESTIONS AND KEY CONCEPTS
The aim of the research was to explore the ways in which schizophrenia is socially and culturally constructed (perceived, signified, explained and experienced) by Moroccan immigrants in The Netherlands, in comparison to the way in which it is understood and treated by mental health professionals of the Dutch service system, identifying the possible conflicts between the different views. The research questions were the following ones:
How do Moroccan immigrants diagnosed with schizophrenia in The Netherlands perceive and explain their own illness?
What symptoms and experiences do they suffer and describe? What are the causes they attribute to this illness?
What treatments or solutions do they culturally conceive as legitimate? Which social factors are operating in their personal experiences of the illness?
Are socio-cultural inequalities present and relevant in the experiences of these patients?
How is schizophrenia constructed by Dutch mental health workers dealing with this specific group of patients?
How are Moroccan immigrant patients perceived by related mental health workers?
What do mental health workers think about Moroccan immigrant patients’ way of perceiving schizophrenia?
Are there any conflicts or differences between Moroccan patients’ views and the ways in which this illness is addressed by the local health system?
Is the mental health service system failing to consider social and cultural aspects?
Could anthropology offer any alternatives to the way in which schizophrenia is being addressed in practice?
The key concepts used in this research are:
• Schizophrenia: There are many cultural understandings and interpretations of this mental illness and its symptoms. In this research, it will be understood from the Western biomedical perspective, as a mental disorder involving a range of cognitive and emotional dysfunctions that include perception, inferential thinking, language and communication, behavioural monitoring, affect, fluency and productivity of thought and speech, hedonic capacity, volition and drive, and attention (DSM IV). From
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the biomedical classification of mental illnesses, two or more of the following criteria must be present for a significant time per month in order to be diagnosed with schizophrenia: 1. Delusions, 2. Hallucinations, 3. Disorganized speech, such as frequent derailment or incoherence, 4. Disorganized or catatonic behaviour, 5. Negative symptoms, such as flattening, alogia or avolition.
Therefore, in this study, schizophrenia patients will be those individuals diagnosed with this illness by the Dutch medical proffesionals who are receiving or received in the past assistance and/or treatment from the mental health services.
• Immigrant: with this concept I refer to first and second generation Moroccan immigrants, people who originally come from Morocco or whose family came to settle in The Netherlands. The selection of Moroccan immigrants was due to the practical access to respondents during the research.
• Mental health workers: This category refers to mental health professionals and employees of the Dutch medical services, dealing with schizophrenic patients. It includes nurses, caretakers and family assistants working with Moroccan immigrant patients in different ways and for different reasons. • Illness narratives: They will be understood as what A. Kleinman (in Young, 1982: 267) defined as
Explanatory Models, notions about an illness episode and its possible treatment employed by those
involved in the clinical process, which reveal how subjects value and signify illnesses. These illness narratives will be contextualized and analysed from the Sickness approach, taking into account broader socio-cultural factors and structural forces.
• Conflicts: In the study, conflicts will be understood as differences, oppositions or disagreements between the ideas, concepts, explanations, solutions and interests (related to schizophrenia and its causes, symptoms, treatments, consequences, implications, etc.) of two groups. Conflicts will also refer to misunderstandings and discrepancies about aspects and issues beyond schizophrenia but that significantly appear related to this illness. They were researched in patients’ and health workers’ relationships and narratives by determining the extent to which they explicitly appear in the informants’ discourses and recognising whether or not they appear implicitly in their narratives. These conflicts were also deduced by the comparison of different arguments and discourses.
• Structural forces: Following Castro and Farmer’s conceptualization (2005: 54) they could be described as large-scale social forces which include social inequalities such as sexism, racism, political violence and poverty. This concept is introduced in the study as a way of enabling the contextualization of the patient’s illness narratives and experience descriptions. Due to the difficulty to operationalize this concept, their identification would be reduced to patients’ discursive references to them in their autobiographical narratives.
• Social inequalities: They are understood as social unfairness, disparity, imbalance and inequity in opportunities, positions, statuses and access to material goods and services. Assuming they exist and are present between native Dutch and immigrant ethnic minorities, they will not be measured per se but the impact they have on immigrant patients’ experiences of schizophrenia. To take account of this impact (influence, importance, effect), it has been identified how often the informants refer to them in their life stories and narratives, due to the difficulty of operationalizing this concept.
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CHAPTER 2
RESEARCH METHODOLOGY
The research method that best suited to this study is descriptive qualitative research. The fieldwork period lasted from February to May 2014. During this period, as a suitable data collection technique for a descriptive qualitative research, I conducted individual in-depth and semi-structured interviews. Despite an interview guideline was designed, in the practice the questions were adapted to the particularity of each informant, since the profiles of respondents were different.This method allowed respondents to mention their concerns and raise important issues for them, within broadly defined research themes. The interviews to patients followed the basis of the Cultural Formulation, aiming to look beyond diagnosis typologies and to explore patient’s point of view about schizophrenia. The questions of these interviews related to the cultural identity of patients, their personal explanations of the illness and experiences and to the relationships with health care assistance or patients. The interviews with health workers aimed to explore their conception of schizophrenia and their perceptions of immigrant patients and encounters with them. Interviews to non-Moroccan patients were also conducted, although the information obtained is not the issue of this document and will not be presented. All the interviews were tape-recorded and completely transcribed in English, with the exception of one which was conducted to an English patient (due to time limitations). The data obtained from the interviews was analysed using a system of open coding, through which the information was classified into analytical categories. These categories were compared and contrasted between respondents to generate the themes which form the basis for analysis and discussion. Themes were identified through repetitions, similarities and differences between informants, and metaphors or analogies.
The informants that I was originally looking for were of two types: 1. Immigrants from non-European countries diagnosed with schizophrenia in Dutch mental health services, 2. Mental health workers from Dutch health services dealing with them. In practice, the appropriate research respondents were nominated by snowball method and the selection was mainly dependent on my practical access to them, which in the case of patients was conditioned by:
a) The permission fromorganisations, institutions, health professionals and their families or relatives. b) Their willingness to be interviewed.
c) Their level of English to be able to communicate with me. The respondents of this research were the following ones:
- Three male Moroccan immigrant patients aged 32, 26 and 36 (two born in The Netherlands, one born in Morocco). The three of them had been diagnosed by Dutch health services as schizophrenic and had experience with medical institutions in The Netherlands.
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-Two male Western patients who also work for a schizophrenia patient organization (Anoiksis). One of them is 76, originally English, studied Psychology and Philosophy and used to work as a publisher. The other one is 42, Dutch and graduated as a Cultural Anthropologist.
- A Dutch-Moroccan sociologist from the University of Amsterdam who had done research amongst Moroccans with schizophrenia in Utrecht and Rotterdam.
- A Moroccan jurist who works voluntarily as an interpreter in a home coaching project with Moroccan families of patients (Altrecht).
- A Dutch experienced family therapist with a son with schizophrenia who works informing and supporting patient families (Altrecht).
- A Dutch psychiatric nurse and cultural anthropologist working with the cultural interview in a psychiatric centre in Beilen.
The research was based on participants’ informed consent. The study was fully explained to the respondents before the interviews, as well as how it was going to be disseminated. Confidentiality has been assured by the anonymisation of the informants.
The research presented in this document is a small scale study and has limitations. However, the purpose of this research is not to be representative of all Moroccan immigrant patients’ and health workers’ experiences, neither to be generalizable. The aim of this research is to explore the ways in which Moroccan immigrant patient’s perceptions and experiences of schizophrenia might be understood and the ways in which Dutch mental health services are addressing the illness, identifying themes, variables and contrasts that may be of importance to understand the clinical encounter.
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CHAPTER 3 FINDINGS
The subsections of the following points in this chapter should not be understood as separated questions or issues, but as interrelated themes that overlap and intermingle one with another. The reasons of these divisions and the way in which the results are presented are practical.
3.1. MOROCCAN IMMIGRANT PATIENTS’ DESCRIBED PERCEPTIONS AND EXPERIENCES OF WHAT IS CALLED SCHIZOPHRENIA
The Moroccan immigrant patients who were interviewed during the fieldwork were the following ones: · Hassan, a 32 year old Moroccan immigrant who came to The Netherlands when he was around 6 years old. He was diagnosed with schizophrenia years ago and lives with his mother and two brothers (one of whom has some illness akin to Down syndrome) in South Rotterdam. He hears voices and is given injections every three weeks. He has written a book with poems about his experiences, (some in English, some in Dutch), which has been published by Anoiksis, a Dutch association for people with vulnerability for a psychosis. The same organization has also published a portrait of him in another book about the patients’ experiences of schizophrenia. I came in contact with Hassan through another member of Anoiksis, an English patient who works for the organisation and who told me about him. This English patient was present during our meeting in Hassan’s mother’s house. Hassan likes to write, draw, act and sing, and he wants to publish his book in America and record a rap song with the famous singer Shakira. · Ali (26), who was born in The Netherlands and lives in Diemen Zuid, with other people with mental problems. He comes from a Moroccan family and was forced by his father to leave home when he stepped out of religion. He denies having schizophrenia and argues that he was misdiagnosed. He says he had to accept the treatment because he was living in the street and had no home. I knew about him through a psychiatrist from the AMC who offered me to join the VIP programme to see if I could get to some informants. They gave me a list of eight patients. Ali was one of the only two who I could contact and the only one willing to talk to me.
· Mohamed (36), a second generation Moroccan immigrant born in The Netherlands, living in a psychiatric institution in the centre of Amsterdam. His father and his sister died, and his mother and his brothers (one of them also mentally sick) visit him sometimes. He can’t go outside because he panics. He has spent around 20 years in psychiatric hospitals. He has published a book about schizophrenia in which he narrates his story and his experiences. He is studying psychology at the moment. I knew of him through another member from Anoiksis, a Dutch cultural anthropologist who used to be patient himself too.
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3. 1.1. Definition of the problem, construction of schizophrenia and experiences
Two of the three Moroccan patients who were interviewed denied having schizophrenia (considering it a label put by someone else) and expressed disbelief or distrust in the diagnosis given by mental health workers. Both of them talked about depression when referring to their problem, closely relating it to schizophrenia, when not considering it the problem itself.
In this sense, when asked about his diagnosis, Hassan tells me ‘’I don’t believe, I don’t believe in that.
They put a number on somebody, if he is sick, they say ‘’Oh, he has schizophrenia’’ but it doesn’t always have to be like that. Maybe you’re sick, but not schizophrenia’’, and later in our conversations he adds ‘’It’s just depression. Depression, not schizophrenia. I don’t believe in schizophrenia. They say schizophrenia to different people, but I’m just one person.’’
Ali denies having schizophrenia too. He insists on the fact of never having mental problems and repeats over and over again that he was misdiagnosed, also referring to his problem as depression instead of schizophrenia: ’’What happened in my life is not that I have mental problems (…) I was in the past
depressed, you know? But I never had schizophrenia’’. However, despite he at first talks about depression rather schizophrenia, later in our conversation he identifies one with the other or strongly
compares both of them in his explanations:
‘’Schizophrenia is like people seeing things that are not the reality, hearing voices in their heads, you understand? You can call it depression also, you understand? It’s almost the same, but schizophrenia, the differences are they are scared, you understand? Scared of the people, scared of masa, they are upset, they cannot talk about their meaning, they don’t have their own meaning.’’ (Ali)
Furthermore, depression is not only considered the problem instead of schizophrenia by Hassan and Ali (and at the same time identified with schizophrenia by Ali, as just seen above), but it is also mentioned by the Moroccan patient who recognises having schizophrenia, considered a previous step or cause for the illness and simultaneously a consequence too, constructed through the verb become:
‘’In the Moroccan community, Turkish community also, the development of schizophrenia begins with you not liking people, you not liking the world, you not liking anything (…) you go into depression, when you are in depression you can fall deeper, you can fall deeper, when schizophrenia develops (…) In that depression, if you stay so long then you develop schizophrenia, you know?’’ (Mohamed)
‘’I developed also depression, I became depressive (…) so I said to my friends ‘’You mustn’t come every day because I can’t handle it, I’m very depressed and I can’t handle it.’’ ’’ (Mohamed)
In addition to this, apart from depression, the problem is considered to be also stress in Hassan’s narrative. When asked about his problem, he says: ’’Ahh…just stress, stress and thinking about a lot of
stuff’’.
While both Hassan and Ali deny having schizophrenia and consider it a label put on them by others, as we have seen, only Ali narratively expresses the perception of diagnosis as someone else’s mistake or
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error, a wrong decision made by experts due to the fact of not knowing and understanding him well. This is what apparently makes him not accept it:
‘’She said to me ‘’You go to the clinic’’, and I said to her ‘’What?! You’re sending me to the clinic?! I’m not aggressive or something, or have a mental problem, I think you’re making a wrong decision, you don’t know, you don’t understand my life, my situation, like who I am, who I really am, you’re choosing only that way, I don’t want that and no.’’ ‘’ (Ali)
Descriptions and comparisons with other people who Ali considers to really have mental problems are also frequent in his speech, used to deny his diagnosis. These comparisons enable him to discursively construct himself differently and in opposition to them, narratively legitimizing his position of denial. Although comparisons with other people are common in the speeches of the three Moroccan patients who were interviewed and comparisons with other patients appear in two of them, only in Ali’s case these comparisons are used in the way described above:
‘’I live with people there, they have really problems. Really mental problems. I have a girl there, ask her sometimes things, I asked to her ‘’What do you see? What do you feel, what is for you reality? What is the mystery [ ] how do you see?’’ She said ‘’I’m so upset, I don’t believe in myself anymore, I was in the past different from who I am now, now I say weird things to people, that’s not what I want’’ and everything. I was like ‘’Oh my god’’, you understand? Really a problem.’’ (Ali)
The fact of being crazy is often identified with having schizophrenia in the discourses of the three Moroccan patients interviewed. In Ali’s words, for instance, schizophrenia is negatively equated to having mental problems and this to being crazy, and not having schizophrenia or not being crazy is expressed as something you have to prove to others:
‘’I didn’t have any mental problems. She didn’t know that. I did nothing, you understand? (…) ‘’Let me read a book, that I’m not crazy’’, you understand? ‘’That other people see that I’m not crazy’’, she made the wrong decision. And I felt so bad at that time, you understand?’’ (Ali)
Similarly, when I ask Hassan to tell me how he deals with his voices, he tells me ‘’Yeah, just ignore them,
you know? Ignore them. Don’t give them chance to make me crazy’’. As it can been seen from his words,
through the verb make, craziness or being crazy is constructed as a non-permanent state, not as something you are but as something you can become. This construction can be noticed also in Mohamed’s discourse when talking about medication: ‘’Without pills I will go nuts’’.
Mohamed, who acknowledges having schizophrenia unlike the other two Moroccan patients, distinguishes between two types of schizophrenia: innate (inborn) and acquired (developed):
‘’I have schizophrenia. We have two schizophrenia: one you’re born with, one you develop. The one you’re born with, that’s me. So I was born with it (…) I got schizophrenia and I didn’t know about that time I had schizophrenia, because it didn’t happen suddenly but it happened slowly, you know? It’s not like a broken arm but it goes very slowly’’ (Mohamed)
Mohamed says he was born with it, but describes his sickness as something that happened gradually (something that developed slowly), comparing it to the other type of schizophrenia he denies having. He
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tells me: ‘’I think most people don’t accept people who have developed schizophrenia, because it’s their
fault, you know? (…) They were not born with it, they did it’’. Arguing that he was born with the sickness
seems to be a way of enabling himself to narratively deny responsibility or guilt for having schizophrenia, due to the perception of it not being accepted by others. In other words, while Mohamed recognises having schizophrenia, he is at the same time denying a type of schizophrenia which he considers to be not accepted by people.
In addition to this, in Mohamed’s speech , schizophrenia is described as emptiness or being/feeling
empty, in contrast to normality:
‘’Schizophrenia is like an empty body (…) It’s like…it’s a whole new world… it’s like a [ ] transformation, you go in the process but it feels like… it feels like empty (…) that’s how I can describe it, it’s empty, your mind is empty, you’re spirit is empty, there’s not much to live for, there’s only you and all that living that I used to do when I was little… that is gone (…) Now, if you experience that emptiness I told you about, you must understand that everything you see is different and that and everything you think about yourself is different than normal.’’
(Mohamed)
Comparisons with others are not used in Mohamed’s case to deny his diagnosis (as happened in Ali’s explanations) but to accept it. He identifies himself with other patients and their experiences:
‘’When I went to the hospital I came in contact with other people who lived there, so we had a conversation ‘’What are you doing here? What is wrong with you?’’ and when I heard all these stories, then I though by myself ‘’Oh…’’ [ ] then I knew it. It was schizophrenia.’’ (Mohamed)
In his particular situation, and in contrast to Hassan’s and Ali’s stories, diagnosis was not given by a professional expert but was deduced or known through comparisons and identification with other patients. In this sense, diagnosis seems to come from his own conclusions instead of being a label imposed by others, and this could be interpreted as the reason why he acknowledges having schizophrenia. Something similar can be noticed in his speech when talking about the symptoms:
‘’Then they came, the voices (…) I thought that was paranormal, I thought I could talk to people on the street and talk to people with my mind (…) I thought myself I could talk to people in my mind, so that’s how it began. (…) And when I was in hospital and I heard the stories of people living there, then I knew I was having voices. I’m not paranormal, I’m having voices.’’
(Mohamed)
With reference to the perceived symptoms, the experience of hearing voices was mentioned by all of the three Moroccan patients who I talked to. Fear or being scared was recognised by two of them:
‘’Schizophrenia is like people seeing things that are not the reality, hearing voices in their heads, you understand? You can call it depression also, you understand? It’s almost the same, but schizophrenia, the differences are they are scared, you understand? Scared of the people, scared of masa, they are upset, they cannot talk about their meaning, they don’t have their own meaning’’ (Ali)
‘’I developed fear (…) I’m home, I’m talking to the voices, so the voices say to me ‘’Someone is going to get you’’ (…) So I developed fear, you know fear? (…) that’s the problem I really have,
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because if I get fear I’m scared with no reason. People get scared, I used to get scared when I was little, it’s not a problem. But now, if I experience fear I can panic, just like that, you know? (…) I can live with it, I can do my things, but if I have it to the big level then I panic and I must search for safety so I can rest (…) that’s the reason why I’m really in hospital’’ (Mohamed) ‘’Yeah, I hear voices. I hear voices and I get very stressed because I hear the voices, I get stressed (…) They are not nice, they yell at me and dirty voices. But it’s getting better, it’s getting better. I hear them now not always but sometimes’’ (Hassan)
Although Hassan and Ali deny having schizophrenia, they both recognise experiencing some of the symptoms established by biomedicine, describing them as improving (in Hassan’s case when talking about the voices) or trying to normalize them, considering them something common to everyone (in Ali’s case when talking about the voices too). This discursive aims to normalize the fact of hearing voices could reveal that Ali perceives that the voices are not being considered normal by others. The normalization is done by generalization to everyone:
’When I talk about voices… everybody in the world hears (…) and what I mean with voices, everybody has voices. Voices don’t like your rest [ ] disturb you’’ (Ali)
3.1.2. Described feelings, expressed emotions and attitudes related to the sickness
‘’You are never getting better or never getting really better’’ (Hassan).
A lack of expectation to completely recover was expressed by all of the three Moroccan immigrant patients. Hassan tells me ‘’I don’t think I’m going to get better than this. I don’t think I’m going to get all
rid of the voices, I don’t think so. It’s something that’s with me, I have an illness, you know?’’. However,
at the same time, patients seem to have a certain belief in improving, considering it a possibility. Flynn, an English patient who is present during my conversation with Hassan, says to him ‘’I don’t think you’ll
get rid of your voices, but I think they’ll might become more friendly’’, to which Hassan replies ‘’ I think also they’ll might become friendly, but I don’t know ‘’.
Acceptance or resignation to having the illness, and the aim of making the best of it as the only possible thing to be done (against the inability to change the situation), are also common expressed attitudes or ideas in the speeches of all the Moroccan patients who were interviewed. They appear throughout in our conversations:
‘’About schizophrenia, the voices or so, I can learn to go with it, I’ve learned it myself in a period of time (…) You make the best of it. You just make the best of it’’ (Mohamed)
‘’That’s the problem. There is nothing that makes the fear, the fear it comes from itself. There is no reason, if there was a reason you could do something about it. If you have a reason to sit in a room like that, then you can say ‘’OK, then you can sit in a room like this, no problem’’ ‘’
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‘’I can do nothing about it. You must accept it, how life is, accept it. You can’t change things if you want, as you expected, accept life how it is and live with it. Live with it. Life goes further, you know? (…) Life goes on’’ (Hassan).
‘’Life is good, you know? You have to accept things, go further with your life, don’t think ‘’I’m sick, I’m stressed, I’m this, I’m that’’, you have to go further with your life and make things better for yourself’’ (Hassan).
‘’You need to accept yourself, who you are, and believe in yourself’’ (Ali).
‘’The toughest experience I will always have is the fear, you want to do things (…) but you can’t. So you must accept that you cannot do that. Sometimes it’s very hard. My sister who died was in hospital and I was not OK. So they told me ‘’Your sister is at hospital, you want to go?’’ But you can’t. Because if you go outside that moment you’re panicking. So I haven’t seen my sister in hospital, that’s hard. If something happens to my brother… you can’t, you can’t. So that’s tough.’’ (Mohamed)
In addition to this, two of the three Moroccan patients expressed the feeling of being considered
different, sick or crazy by others. In Ali’s speech, this last idea came linked to mental health professionals
and to diagnosis, as we have already discussed above. In a similar way, Hassan tells me: ‘’When you’re
sick, you know, then the people say ‘’Oh, you are sick’’, they look different at you, you know? They think you are crazy, different than them’’. These two patients also talk about discrimination and feeling
discriminated by others, but while Ali attributes it to mental health proffesionals (as we will see further on), Hassan relates it to friends:
‘’I think when I was getting sick they though ‘’Oh…he’s getting sick, good for him’’ because they were jealous of me, you know? I had nice clothes, I had money, lots of money… people get jealous, you know? That’s the way life is. And that’s why I say they discriminate me because I’m sick. They put a number on me because I’m sick, ‘’Oh, he’s crazy, da, da, da’’ (…) They are not my friends, you know? Not anymore. I thought, I thought they were my friends but I was wrong, they aren’t my friends.’’ (Hassan)
‘’A couple of years before I used to have many friends, you know? Many friends I had, but when I got sick they didn’t come to me, they didn’t help me, they disappeared, you know? Real friends… you can’t have real friends at this time. In the early days, there were friends and you could always depend on your friends, but at this time it’s difficult to have good friends because everyone thinks about money, material things… all those things. People don’t have time for friends. Yeah. I think I don’t believe in friends (…) If you can count on people it’s very nice. But when you’re sick nobody wants to help you, they say ‘’Oh, he’s sick’’. You have to get everything yourself, you know?’’
Hassan and Ali also expressed discouragement, disappointment and loneliness as a consequence of having the sickness. Ali describes people with schizophrenia in this way: ‘’ They are disappointed in their
lives, they think that all the people hate them’’. But these ideas are especially present in Hassan’s
discourse:
‘’I feel sometimes lonely. But yeah… what are you going to do about it? You can’t change the world. You can’t change the things that happen every day…you can’t change that (…) You have
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to make your life better, you can only do that yourself, you know? Nobody’s going to do it for you. No-one is going to make life better for you, you have to do it yourself’’ (Hassan)
Moreover, the feeling of being alone is generalized to other patients in Hassan’s speech. Loneliness seems to be described both as an external result (consequence of others’ reactions and attitudes towards the sick person) and as a personal decision (when expressed as isolation):
‘’If you’re sick it’s even more difficult to have friends. I experienced it, because I used to go to a lot of places when I was sick, and I saw other people who were also sick, I saw they didn’t have many friends, how do you say it? Isolated. Isolated themselves.’’ (Hassan)
It is common in all Moroccan patients’ discourses the expressed perception of not being listened to or understood and the consideration of it as something negative that makes them feel bad. This idea will be specially mentioned when describing their perceptions and opinions about mental health professionals and assistance later on, and has already appeared in Ali’s explanations about diagnosis quoted previously. With reference to relatives and close people, Hassan and Mohamed express it in these ways:
‘’ I know the imam [ ] of the mosque, I know him. I used to go to him, but he’s always telling me ‘’Oh, I don’t have time, maybe another time’’, I didn’t go back anymore. If you’re a good Muslim, you must help me. He said to me ‘’Next time, another time’’, that’s not good’’ (Hassan) ‘’My mother (…) she doesn’t understand, she doesn’t know, she knows about fear, but she doesn’t know what schizophrenia is or anything. [ ] When I was in hospital she told me ‘’Go outside, do things’’ because she doesn’t understand, that’s very hard in the beginning, eh? The beginning was very tough when she did that’’ (Mohamed)
3.1.3. Expressed perceptions of others, cultural differences and social conditions
When talking about other Moroccan people, the three Moroccan immigrant patients referred to them in third person, always using the pronoun they, distinguishing themselves from them, as can be noticed in the quotes that follow. Descriptions and generalizations of Moroccan personalities are also common in Moroccan immigrant patients’ explanations and discourses when talking about themselves. Ali constructs Moroccans as closed, scared or afraid, and strongly linked to religion:
‘’I believe more this is the paradise, now, you understand? I don’t know what will come later, you know? I don’t look further, you understand? That is more what I believe. Moroccan people with Islam and these things are living more in the past and they are scared about dying and that shit (…) what people are thinking about them, you understand? They want also to prove people, to make people think ‘’Oh, this is the best, you must like me’’, you understand? It’s like that. They don’t talk about their feelings, it’s like a shame (…) and this is why for them is not normal to be open, talking about everything, you understand? It’s only one room, one look, one judge, nothing else. But I believe there’s more.’’ (Ali)
‘’Moroccan people (…) when they have a problem, they don’t talk about the problem, they keep it. It’s not like sharing, it’s more like closed personality, you understand? They don’t know how
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to tell their emotions, when they tell their emotions they think ‘’Oh, I’ve said the wrong thing, I’ll go to hell’’ (…)They live in fear. Afraid about things. Very afraid to go or not to hell, to do good things, to prove to others, you understand? (…) But all the cultures where they don’t have Islam religion are more open, they are more open-minded. Moroccan people not.’’ (Ali)
As has been indicated above, Moroccan immigrant patients construct Moroccans as a group they are not part of, to which they don’t belong. Moroccans are perceived as others, but this happens also when talking about Dutch. The three of the Moroccan immigrant patients interviewed referred to them also with the pronoun they (and also made generalizations about their personality). Despite recognising cultural differences with Moroccans, Hassan describes negatively Dutch with expressions that Ali used to describe Moroccans:
‘’Dutch people, when you work with them, they don’t give you attention, you know? They don’t talk with you (…) Dutch people are closed, they don’t like to express themselves (…) Sometimes it’s like they don’t have feelings, you know? Hard people, cold people (…) What I don’t like about them is they are negative about Moroccans, you know? I don’t like that about them’’ (Hassan)
As well as this, for Hassan, the fact of being immigrant seems to be important in the description of Moroccans’ perceptions about him:
‘’In Morocco you get discriminated too. Because if you’re European Moroccan, when you go to Morocco you get discriminated too because they see you are different, outsider, you know? (…) They see you different, different, they don’t see you like Moroccan’’
It could be argued that Moroccan immigrant patients’ narratively expressed identity is being constructed in distinction to both Moroccans and Dutch. These groups are both perceived as ‘’others’’ and considered different from each other. Recognition of cultural differences between Moroccans and Dutch are explicit in all of the patients’ speeches, as well as appreciation of different social conditions or circumstances between the two groups with reference to schizophrenia. This is last idea is especially noticeable in Mohamed’s explanations:
‘’Dutch people are different to Moroccan people. I think there’s a difference, because if you are a Dutch person and you have so much love from your family and friends, it makes life easier. If you need money, they can get it for you; if you need something, they can get it for you; if you have a problem with some kind of psychiatrist, they help you, no problem. But if you come from a family with no money (…) and you have a problem with the psychiatrist, nobody can help you, (…) the psychiatrist has the power over you. So you get more depressed and you get more fear, and you get more suicidal, you know? That’s the difference. You can see it around you also. People who are laughing and everything good, and other are afraid and are depressed and they don’t like the world, and the world is nothing. That’s the difference (…) A family with a lot of love, a lot of friends, a lot of money, they have it easier in psychiatry. They have it all easier. The first one is mostly Dutch people, but the second one, people who don’t have money and don’t have lawyers in the family and they have nothing, they must survive in the psychiatry, because if the psychiatrists says ‘’This’’, it goes like this, but if you tell to the Dutch people ‘’This’’, they say ‘’No, I’m going to Mama, I’m going to tell what you’re doing’’ so they get a lawyer, everything, and then everything is OK. So that’s the difference, that’s the difference, yeah’’ (Mohamed)
