Last year, a social worker of Caritas Lebanon, a non-governmental organization, brought a 22-year-old Ethiopian woman to the emergency room of a Lebanese psychiatric hospital. The woman, whom I shall refer to by the pseudonym of Deborah, had just spent two nights in a police station. Deborah’s employer had brought her to the police station because she “was going crazy and couldn’t stop screaming”.

Upon arrival at the emergency room, Deborah’s body was covered with bruises, and the social worker explained that “the policemen had to constrain her because of her extreme agitation”. Other bruises that didn’t appear to be recent were also seen on her back.

During psychiatric examination, Deborah was mute with a rigid psychomotor posture and a haggard look. She let the doctor on duty examine her with total passivity. She was admitted to the hospital the same day of examination. Her employer, who had to cover the costs of hospitalization, insisted for a short stay in order to send her back to Ethiopia as soon as possible.

The attending psychiatrist diagnosed Deborah with a “catatonic syndrome” in the context of a “brief psychotic episode”, and prescribed her high doses of psychotropic medications. The next day, Deborah had her first electroconvulsive therapy (ECT) session, and six days later, she was sent directly back to Ethiopia along with the report issued by the psychiatrist.

Deborah is only one example among many foreign domestic workers (FDM) in Lebanon that are admitted to the psychiatric hospital as a transitional step, before being sent back to their native country due to “behavioral disorders”. The high frequency of these admissions and their particular context raises two main issues among others:

The causal relationship between maltreatment at work and the emergence of severe psychiatric conditions, emotional distress and suicidal behavior. Establishing such a relationship would incriminate employers and the whole system that regulates domestic work in Lebanon as an essential triggering factor of psychiatric decompensation.

The transposition of social discrimination against FDWs to places of mental health care and the issue of the validity of diagnosis under such conditions.

Effect of Maltreatment and Exploitation on Mental Health

According to Human Rights Watch, an average of one FDW dies per week in Lebanon from unnatural causes such as suicide and/or falling from upper floors of buildings (Zahreddine et al., 2013).

Conditions of trafficking exploitation and abuse of FDWs, especially those of African origin, are now well known in Lebanon. These include violations of essential rights such as retaining the worker’s passport, physically and sexually abusing them on a frequent basis, as well as locking them up at home. All such violations take place in the absence of any legal control or regulation specifically addressing working conditions.

All these forms of structural and social exploitation have devastating effects on the psyche of FDWs (such effects of systematic racism have been amply elaborated by Fanon, 1961). Internalized stigma develops progressively in the foreign employee. The stigma generates a feeling of helplessness and hopelessness. It triggers an identity crisis leading to a feeling of dehumanization with subsequent passive resignation and total submission to the employer. In the absence of a possibility of escaping or rebelling against the aggressor, this effect of “internalized aggression” by victims of maltreatment and abuse (or returning the aggression against the self), has been largely studied in social psychology (Myers, 2012). This psychological process leading to emotional distress constitutes a major risk factor for suicidal behavior and the emergence of psychiatric conditions.

Thus, environmental conditions of maltreatment and abuse are well-established risk factors for suicide, as well as depressive and anxiety disorders. They have more recently been correlated with the emergence of psychotic symptoms (Beards et al., 2013). This link has some neurobiological basis, as shown by studies on “neuronal plasticity” or the concept of “dynamic brain”: life events and environmental changes constantly modulate throughout life neuronal circuits that are responsible for perceptive, cognitive, affective and behavioral manifestations (Kays et al., 2012).

Genetics studies (more specifically, epigenetics) also demonstrate that the genetic potential of the individual is far from being static and immutable, but rather is constantly under the influence of the environment (Sweatt, 2009).

It is also possible that a person suffered already from a psychiatric condition in their native country and relapsed after their immigration. This would render them even more fragile to the effect of maltreatment and exploitation, which are well-known factors of relapse in case of prior psychiatric history. Heredity and certain genetic predispositions play a role in many psychiatric conditions, but recent scientific studies show that any predisposition is linked to the environment and seldom determines by itself the expression and severity of symptoms.

Immigration in itself has been correlated to the emergence of psychiatric symptoms, due to the stress of adaptation to a new environment and acculturation. However, studies exploring this link reveal a significant association between these symptoms and the perception among immigrant people of being the target of discrimination and racism (Martens, 2006).

FDWs in Lebanon are at high risk of developing this perception, even when they are not maltreated or abused in the home where they work. Indeed, the nature of their work, as well as the restrictions imposed on their freedom, such as restricting their access to certain public areas, are violent and demeaning forms of social discrimination and racism, regardless of the “kindness” of their employer.

In short, the frequent belief that certain psychiatric conditions are genetically and biologically determined since birth, independently of the environment where the individual grows and evolves, is not supported by recent scientific studies. The justification given by certain employers and agencies in Lebanon that the employee “was already crazy, that’s why she committed suicide”, for example, does not alleviate their responsibility towards the employee, nor does it annul the direct incrimination of maltreatment and exploitation in the emergence of psychiatric conditions and suicidal attempts.

Controversy of Diagnosis and Management in Places of Psychiatric Care

The high frequency of psychiatric hospitalizations of FDWs has recently led a team of Lebanese psychiatrists to conduct a retrospective study over a period of five years (from 2007 to 2012). The authors compared the psychiatric diagnosis and management between a sample of FDW patients (n=235, mostly from Ethiopian origin), and a sample of Lebanese patients (n=224) admitted to the same psychiatric hospital. A recently publicized study (Zahreddine et al., 2013) yielded interesting results: FDWs are far more frequently diagnosed by psychiatrists as having a “brief psychotic episode” compared to Lebanese patients, who are more frequently diagnosed as having a “mood disorder” (namely, depression or mania).

Furthermore, a consistent and statistically significant difference is found between FDW patients and Lebanese patients in terms of all the parameters of treatment of the psychiatric condition diagnosed by the medical team. These parameters include:

A more rapid increase in doses of medications and a general use of higher doses.

A more frequent use of ECT, often only by one or two days after admission to a hospital.

A more frequent use of physical restraint and injection of tranquilizers.

The authors suggest that the more frequent and overuse of ECT and antipsychotics among FDW patients may be due to the employer’s pressure on the medical team to obtain a rapid “stabilization” of the patient, so that they may be promptly sent back to her native country. This would also explain the much shorter duration of hospitalization among FDW patients (Zahreddine et al., 2013), which is not always sufficient for their full recovery.

The authors also suggest that the more frequent use of physical constraint may be due to cultural barriers, mainly language, which would prevent the medical team from communicating efficiently with the patient or from calming them in case of agitation.

However, it is this author’s opinion that the more frequent use of coercive methods may reflect the transposition of social discrimination to psychiatric institutions. Moreover, the foreign patient is alone and does not usually have a family member or a friend who can give consent to treatment, monitor the evolution of the patient, or denounce an eventual abuse.

This absence of control and supervision would lead to a higher risk of power abuse, as shown by many studies in social psychology (Myers, 2012). It is noteworthy that mandatory hospitalizations in Lebanon are not regulated by any legislation. In the absence of a mental health act, there is a risk of abuse of power for all patients from all nationalities.

FDWs are far more diagnosed by psychiatrists as having a “brief psychotic episode”, placing the patient in the psychotic rather than the affective spectrum of disorders. Even in the case where this diagnosis is accurate, it does not explain the frequent use of ECT, which is not the recommended treatment for brief psychotic episodes (Semple, 2009).

It is thus legitimate to question the validity and the frequency of this diagnosis in these conditions, even in the presence of competent psychiatrists. The medical history linked to the illness is often provided by the social worker of Caritas who brings the patient from the police office, and who has known the domestic worker for only a few hours or a couple of days. The rapidity in which therapeutic measures are decided may not always allow a complete and holistic diagnostic evaluation and assessment.

One explanation for this diagnosis may be the widespread belief among mental health professionals -a belief originating in research studies in psychiatry, and mostly financed by Western Europe and North American institutions- that “African populations usually present psychotic symptoms after immigration”.

However, there is no consistent scientific evidence supporting this claim. Indeed, “post immigration psychotic symptoms” in persons of African origin, when present, are mediated by the experience of social discrimination (Martens, 2006). These symptoms are not an inherent feature of African populations. Moreover, there has already been a description of the tendency among Western psychiatrists to over-diagnose psychotic disorders and to under-diagnose mood disorders in patients of black skin color (Jackson, 2006). Do non-familiar and possibly culturally bounded symptoms seem “psychotic” to us, whereas they may be simply culturally misinterpreted?

In conclusion, FDWs in Lebanon are at high risk of mental health conditions (i.e., emotional distress, depression, anxiety, psychosis, and suicidal behaviors) and this is mainly triggered by exploitation and maltreatment. This link between environmental adversity and the emergence of psychiatric conditions is well established by various studies in social psychology, neurosciences, and genetics.

Moreover, when FDWs are admitted for psychiatric examination, they are more often diagnosed as having a “psychotic episode”. There is also a much more frequent use of coercive measures to calm agitation, as well as ECT, among FDW patients compared to Lebanese patients.

All these issues should raise awareness among mental health professionals about the steps they can take to address these problems. These steps include:

Asking during the initial interview of the FDW upon admission about a history of abuse /maltreatment and reporting it to the relevant NGOs working in the field of legal protection. Indeed, the medical team often omits this aspect, as if it were not relevant enough for diagnosis and management.

This omission may be due to the traditional “neutrality” advocated by medical doctors, or the controversial slogan “heal but don’t say anything”. It may also be due to the polemics around the duty of doctors to report violations of human rights when they witness it.

Developing cultural competence which would allow psychiatric practitioners to better communicate with foreign patients, and to make a diagnostic assessment that takes into account cultural variations in symptomatic expressions.

Questioning the profession’s own discriminative assumptions and beliefs concerning foreign patients, which can insidiously and negatively interfere with one’s medical decisions.

This article is an edited translation from French.

 

References:

Beards, S. et al. (2013). Life events and psychosis: a review and meta-analysis. Schizophrenia Bulletin, 39(4): 740-7.

 

Fannon, F. (1961). Les Damnés de la Terre. (The wretched of the earth). Paris: Editions Maspero.

 

Jackson, A. (2006). The use of psychiatric medications to treat depressive disorders in African American women. Journal of Clinical Psychology, 62(7) : 793-800.

Kays, J.L. et al. (2012). The Dynamic Brain: Neuroplasticity and Mental Health. The Journal of Neuropsychiatry and Clinical Neurosciences, 24(2), retrieved from: http://neuro.psychiatryonline.org

Martens, W.H. (2006). Determinants of increased risk of schizophrenia in immigrants. What could be done by our western governments? Medicine and Law, 25(4):699-713.

 

Myers, D.G. (2012). Social psychology (11th ed.). New York: Mc Graw-Hill.

 

Semple, D. et al. (2009). Acute and transient psychotic disorders, in: Oxford Handbook of Psychiatry (2nd  ed.). UK: Oxford University Press.

 

Sweatt, J.D. (2009). Experience-dependent epigenetic modifications in the central nervous system. Biological Psychiatry, 65: 191-197.

Zahreddine, N. et al. (July, 2013). Psychiatric morbidity, phenomenology and management in hospitalized female foreign domestic workers in Lebanon. Poster session presented at the 21st World Congress of Social Psychiatry, Lisbon, Portugal.