Psychiatry in the Land of the Sphinx: Is an Overseas Elective Justified?

WHY EGYPT?

My psychiatric training was predominantly undertaken in the United Kingdom and the prospect of practicing psychiatry in a linguistically and culturally different environment interested me. I had lived in the United Arab Emirates, and was therefore familiar with the Arabic language. My Arabic skills, however, were rusty as I was not using them on a regular basis and by no means was I proficient in communicating with Arabic psychiatric patients. It meant adopting a different dialect and interviewing style. Another reason I chose Egypt was that it has a good psychiatric training structure, with 17 teaching psychiatric departments within medical schools.

PSYCHIATRY IN EGYPT

Egypt has a population of over 70 million and has about 1000 psychiatrists (one psychiatrist for approximately 70 000 citizens), more than 1300 psychiatric nurses and about 200 clinical psychologists, with hundreds of general psychologists working in fields unrelated to mental health services.[5] Australia in comparison has 10.6 psychiatrists per 100 000 population. For a review of psychiatry in Egypt, see the article by Okasha in the British Journal of Psychiatry.[5]

PREPARATION

I was in my third year of training in the UK when I decided to embark on this sabbatical. My preparation began a year before my actual departure to allow for application processing times and for my department to arrange locum cover. I surveyed the various hospitals on the web, based on their training structures, and chose a private hospital in Cairo where training is accredited by the Royal College of Psychiatrists (UK). I applied for a 6-month post and was offered a registrar position.

THE PLACEMENT

Behman Hospital, a private psychiatric hospital in a suburb of Cairo, was going to be my home for the next 6 months. It is the largest (250 beds) and oldest private psychiatric hospital in the Middle East. The hospital is perched on top of a hill from which one can see the pyramids in the distance on a clear day. It consists of a number of small bungalows surrounded by gardens. The wards in the hospital include general adult, learning disabled, old age psychiatry, rehabilitation and two addiction wards (one for detoxification and the other for rehabilitation). The teams consisted of psychiatrists, nurses, social workers, psychologists and occupational therapists. Most of the consultants and psychologists had trained and worked in the West and academic training was similar to training in Australia and England, with ward rounds, journal clubs and case presentations held regularly. Discussions between doctors and nurses were mainly in Arabic but English was the predominant language during medical discussions between doctors. The patients were from all over the Arab world, which exposed me to a wide range of mental health issues. One particularly therapeutic aspect was the involvement of the staff and patients in physical activities such as brisk walking and squash. There was also a squash coach appointed as a member of staff.

CULTURAL VARIATIONS IN PSYCHIATRIC ASSESSMENT, PHENOMENOLOGY AND MANAGEMENT

The following are some of the cultural differences I observed during my placement, many of which are generalisable across the Arab world and are useful to consider when treating Arab patients. For further detailed reading, refer to Images in Psychiatry.[6]

Broadly speaking, the main difference between Egyptian and Western culture is the concept of self identity. An individual's self identity in Egypt is intimately related to family, societal and religious values, and therefore the individual strives to achieve conformity, in contrast to self realization, status and distinctiveness, which are valued in Western cultures. Any deviation from the societal norm or non-observance of religious rules may be considered a manifestation of mental illness. This ‘psychologization’ of social deviance preserves a facade of adherence to the Islamic code of conduct and may save the family from shame and the individual from punishment by the legal system.[6]

Psychological distress was much more commonly expressed in physical terms. For example, depression was often expressed as feeling tired (‘ta'aban’). The greater number of somatic symptoms may be a reflection of the stigma in society towards psychiatric issues, and expression of physical distress is more acceptable that psychological distress. Islam as the main religion in Egypt shapes the general psyche to a great extent. “What is your religion?’ was the commonest question during my interactions with locals. Religion also shapes psychopathology in the psychiatric disorders. Religious delusions were the commonest type of delusions in psychosis. Feelings of hopelessness and intention to kill oneself were not as common among Muslims, as this is regarded as blasphemous. In contrast, religion provided patients with powerful forms of connectivity and acceptance within Egyptian society. Patients often had the notion of an eternally observing god that was aware of their existence and fate. It was also an important factor in maintaining abstinence from drugs and alcohol for fear of betraying their religion.

An acceptable cultural belief was the belief in ‘jinns’ (spirits) as part of the living world. Interestingly, the colloquial word to describe a mentally ill person is derived from the word ‘jinn’ (‘majnoon’). These would be divided into bad or good spirits, and illness would often be attributed to a bad jinn. This belief could take the form of psychosis and careful eliciting of the intensity and its bizarreness (deviation from the norm) would be helpful in differentiating it from psychosis. One factor that I felt contributed significantly to patients’ management was hope and, with that, an external locus of control. For example, an explanation of prognosis or responses to “Will I get better?” would end with the word “insha'allah” (“god willing”) from myself and the patient, in order to conform to the patient's belief that his fate ultimately lies with god. This was irrespective of the person's religion. Even in daily life, responses to “What time will the bus arrive?” would be met with ‘the time” followed by “insha'allah”. This is very much in contrast to the average Western practice where religion or spirituality is not always integrated within psychiatric management.

In contrast to Western cultures, alcohol dependence was not common. Cannabis and heroin were the most misused substances. This probably is a reflection of societal norms, as alcohol is not readily available and only found in exclusive bars or hotels in the city and tourist resorts.

Traditional healers were often the first point of contact for many patients. They have acquired special importance because of their affiliation with the community and their claim to deal with the ‘unknown’, the mystical and the superstitious.[7] In Egypt, they deal with minor neurotic, psychosomatic and transitory psychotic states, using religious and group psychotherapies, suggestion and devices such as amulets and incantations. It has been estimated that 60% of patients at the university clinic in Cairo serving the lower socio-economic classes have consulted traditional healers before consulting the psychiatrist.[7] These healers constitute an important informal component of the healthcare system and it is recognized that working with traditional healers is a more acceptable model for detecting and treating psychiatric illnesses in Egyptian society.

The family plays important roles in the social rehabilitation of the patient as outreach teams are not readily available. From a Western point of view, families can often appear over-involved and confidentiality is not a major issue. In the case of married women, the opinion of the spouse needs to be taken into consideration and often the woman's worries are voiced through the man's words.

As I was residing in the hospital, I would often meet patients during my walks or would enjoy a game of squash with some of them. This was not considered a boundary violation. The consultants were aware of this and I did not feel that this interfered significantly in the management of my patients. I personally found that it improved my therapeutic relationship with patients and contributed positively to overall management.

SOCIAL LIFE

I worked 7 days a week and took a week off every month to travel the country. Egypt is a fascinating country with a rich history and culture. It gave me a good opportunity to interact with the locals. Many found it strange that I had taken a break to come and work in Egypt. They also showed a genuine interest in mental illness and were especially curious about the effect of ‘bango’ (marijuana). A common perception among the people I met is that mental illness is a result of being tempted by the devil or jinn due to being irreligious.

BENEFITS

The placement provided me with a greater awareness of cultural aspects of psychiatry. I believe I am able to form a good therapeutic relationship with Arabic patients. Currently, in my practice in Australia I am much more aware of the complex needs of different ethnic minorities. I view individuals as products of their culture, society, religion and family, and as a result I am able to be flexible in my approach to managing mentally ill patients. Besides the benefits that I derived, I received positive feedback from my Egyptian colleagues. They found the elective mutually beneficial, both academically and culturally.

ARE THERE ANY SHORTCOMINGS?

Anyone considering a sabbatical in a foreign country should give due consideration to language, especially in psychiatry. Not being able to understand the language could leave one isolated both socially and vocationally. Arrangements for a translator should be discussed. There is always the possibility of a strained relationship with the employer or college tutor who might consider the placement as ‘going on a long holiday’. Looking back, I would have liked to have had the opportunity to plan the project with input from my seniors prior to leaving for Egypt. Instead, I had to plan the placement and its aims on my own. One should also consider finances. I financed the entire trip and was paid by the hospital according to Egyptian rates. This is considerably less than the Australian rates of pay. I also lost the pay protection from my employer on my return, which was significant. One should also consider political stability, medical registration and the immigration requirements in the country of choice.

DISCUSSION

With increasing migration worldwide, it is becoming increasingly common for psychiatrists to treat patients with cultural backgrounds different from their own. It is important that treating psychiatrists are aware of the person's cultural circumstances to avoid misdiagnosis and inappropriate treatment. Thus the need to incorporate culture into psychiatry is becoming increasingly important. An overseas elective offers an exciting practical opportunity to broaden one's personal and professional experience of transcultural psychiatry and obtain a different perspective on mental illness and its cultural variations. It also promotes an understanding of health service management in low- and middle-income countries and offers the opportunity to contribute to their healthcare at a minimal cost. Potentially, such electives could result in nurturing psychiatrists with expertise in treating a particular cultural group. The returning psychiatrist can impart the experience to other trainees and psychiatrists through journal clubs and tutorials, enhancing the overall cultural capability of the service. In addition, the existing resources of overseas psychiatrists can be tapped into to further the understanding of different cultural groups. Although I found the elective a valuable experience during my training, it may not be practical for a service as it results in the loss of a trainee for 4–6 months, with expensive locum cover often required. This raises the question of the optimal timing for undertaking such electives. These may thus be more appropriate for advanced trainees or consultant psychiatrists who could offer their skill and expertise, resulting in a ‘true’ exchange between international psychiatric services.

CONCLUSION

An overseas placement can be a valuable experience for a psychiatrist. However, it needs to be implemented at an optimal period in the psychiatrist's career and with minimal disruption to local services. Training schemes and employers could provide more opportunities for interested trainees with specific projects and aims in mind to undertake training placements in other countries in order to broaden the understanding of transcultural psychiatry and develop particular expertise with certain cultural groups. This, in turn, would help to produce ‘culturally capable’ psychiatrists for the wide range of ethnic minorities in Australia.