In diesem Beitrag stellen wir eine Fallstudie von Dr. med. Ali Chahvand vor. Wir haben diesen gemeinsam lektoriert und freuen uns erstmalig auf Englisch zu posten. Auch hier geht es wieder um stigmatisierende Aspekte in der Behandlung kulturfremder Patienten. Wir wünschen viel Spaß beim Lesen!
Dr. med. Ali Chahvand ist Oberarzt in der Kinder- und Jugendpsychiatrie des Universitätsklinikums Eppendorf (UKE). Seit 2016 arbeitet er mit geflüchteten Jugendlichen und mit jugendlichen Straftätern, die häufig einen Migrationshintergrund haben. Er ist ein Kind iranischer Eltern und kann so kultursensitiv mit den Jugendlichen arbeiten. Immer wieder engagiert sich Ali Chahvand für die Versorgung von Kindern und Jugendlichen auch über Hamburgs Grenzen hinaus und gibt sein Wissen regelmäßig als Trainer im “Curriculum Middle East” an, in kurdischen Regionen, in Palästina und im Irak tätige PsychiaterInnen und PsychotherapeutInnen weiter. Vor Ort in Hamburg hat er eine Homepage zur Vernetzung von Erstversorgungseinrichtungen für Flüchtlinge mit niedergelassenen Kinder- und JugendpsychiaterInnen und PsychotherapeutInnen geschaffen, die einen leichteren Zugang und Überblick in die Versorgung ermöglicht.
“Go! Pursue a better life in Europe”
This is about Mehdi (name was changed for reasons of privacy), aged 15, a refugee living in Hamburg, Germany since 2018. This is also about Mehdi, living in Kabul, Afghanistan. Mehdi was the youngest of five children when he left Afghanistan at the tender age of 12. Actually, he left all behind. His family encouraged him though: “Go! Pursue a better life in Europe”, they told him as war had destroyed their country, family and livelihood.
Mehdi started his journey with a backpack filled with food and clothes to set off for the Iranian border. There, a cousin waited for him, who knew people who could pave his way to Europe over a safe route. Mehdi reached the Iranian border without much trouble. The experiences he encountered over the next months before reaching Germany is perhaps a story, he’s told a thousand times. Maybe it is even the story of a standard refugee journey that we certainly regard as “hard”, “inhumane”, “devastating” or “unbelievable”. Stories we usually read in magazines or newspapers. In the following short excerpt of my experience working with Mehdi over an extended period of time.
“Where you from?” he asked somehow cheekily.
The care worker called me and told me that the newly arrived “Mehdi” had entered his new “home”. In these shelters up to 10 under-aged refugees with severe psychological ailments live together. Mehdi, frightened, hid from the staff. As they offered him food, he began throwing clothes, glasses and tables at them. Actually, before coming to this facility, he had been treated by other doctors with many different medications. Even high doses of tranquilizers had little effect. He usually fell into a deep and long sleep waking up as depressed and anxious as before. A vicious circle had set in and was hindering his emotional and psychological development. I was told that it would be very difficult talking to him today. Still I decided to drive to the community-home in order to gain a better understanding from the colleagues on the ground. When I arrived, I decided to wait before introducing myself to Mehdi. Finally, after a couple of hours he left his room and asked for tea. He was used to drinking black tea with plenty of sugar. As he sat at the kitchen table where I was seated, I introduced myself in Farsi. Highly skeptical but intrigued someone had caught his attention. “Where you from?” he asked somehow cheekily. As a therapist I was not used to self-revelation, but I understood that working with Mehdi required to let go of the customary therapeutic abstinence. Obviously as I revealed some private information Mehdi’s questioning became bolder. Rapidly it became a subtle act of balancing professional expertise with cultural awareness and Mehdi’s needs of rapport building. In fact, he had lost everything and possibly the only and main legacy left for him was his cultural heritage, his language, the socio-cultural understanding of his interactions, his eating habits and his middle-eastern appearance. I understood that connecting with Mehdi, meant connecting with his heritage, which we shared after all. In fact, based on cultural identity, we had started our therapeutic process. This first encounter was only three minutes long, yet very promising.
As a therapist I was not used to self-revelation, but I understood that working with Mehdi required to let go of the customary therapeutic abstinence.
In the beginning he did not attend our sessions on a regular basis. Only when he realized that I would reliably wait for him every week in the facility, did he join the sessions. After several weeks Mehdi gradually opened up, recounting his experiences of extreme poverty, violence, emotional deprivation and deep feelings of loneliness and isolation. One day he recollected, the Taliban had entered his home, severely striking his father while the family has witnessing the scene. Also, his brother-in-law, member of ISIS, would regularly humiliate and mistreat his mother and sister. It was difficult and hard for Mehdi to articulate the content of his memories which were for the most repressed. At the age of only 10, Mehdi had already experienced in the most ferocious manner defenselessness, powerlessness and helplessness. He had become a silent observer of violence.
He had become a silent observer of violence.
In our psychiatric assessment Mehdi demonstrated classical symptoms of posttraumatic stress disorder. In severe cases, emotions, thoughts and behaviors are disrupted and the individual dissociated from regular processes of communication and disengage in the fulfilment of basic needs. For short periods of time it was not clear whether he could perceive the real reality or an imaginary one. This was especially challenging as his rages became uncontrollable. When he drifted into delusional thinking, resulting in situational misjudgments, he felt threatened by the staff and attacked them in an attempt of self-defense. These punctual delusional episodes where accompanied by severe depressive symptoms: sadness, insomnia, nightmares and loss of appetite. Parallel to all the inner struggles and the exhausting oscillations between depression and hypomania, the outer world also caused an extreme ambivalence. The environment and cultural behaviors contradicted all of his socio-cultural understandings. On the one hand it was exciting to witness girls and boys wandering around the city holding hands. At the same time, he was irritated that the majority of girls were not wearing head-scarfs; how the youth drank alcohol, consumed marihuana and slept with each other openly, without apparent boundaries. Intrigued by these new liberties, Mehdi plunged into the abyss of substance abuse and risky sexual behavior. He stopped going to his language courses and in order to finance his new lifestyle he started working illegally on a building site. Unchecked by educators, social workers and doctors he lived his life the way he wanted.
Intrigued by these new liberties, Mehdi plunged into the abyss of substance abuse and risky sexual behavior.
Taking socio-cultural aspects into consideration, I understood the potential causes of his helplessness and lack of self-control. Being raised in a family where men provided for the family, he now felt impotent, incompetent and his self-esteem had disappeared. Migration by itself, even without the violence and crime Mehdi had experienced, is traumatic. Thus, each of his symptoms had a unique meaning. At times, changes in his environment, the smell of sweat, rapid movements of people in a room and also new sounds flooded his mind and he immediately became anxious and hid in a quiet room. They reminded him of the torture he had suffered from at the hands of his perpetrators (mostly adult men) and he literally fled into isolation to escape the humiliation he had experienced. Yet again, all he was trying was to ephemerally banish the feelings of numbness and sorrow. In fact, when Mehdi was reminded of this pain, numbness overcame him. Most probably for reasons of self-preservation, his mind would shut down. To regulate his impulsiveness and emotional numbness he started cutting himself. Pain was inevitable proof of existence, that he was real. However, his ever-growing emotional anesthesia resulted in deeper cutaneous cuts, ephemerally hoping to quiet the feelings of numbness and sorrow. Other dysfunctional coping mechanisms included the use of drugs causing a vicious circle: This young man was precipitated into psychological distress due to craving, economic pressure due to a lack of financial means, petty theft and juvenile delinquency to overcome the financial struggle and finally causing more mental distress.
Over the next 7 months he broke three windows, got regularly into fights with cohabitants, inflicted major cuts to himself and damaged the interior of the refugee facility almost weekly. Initially we thought we needed to transfer him to a psychiatric ward as his self-harm and the danger of harming others was having a considerable impact on all stakeholders. Yet our regular weekly meetings and built of trust and rapport showed crucial in keeping Mehdi from further traumatic experiences and while accompanying him through his crises I was able to grow as a therapist.
Actually, I learned tremendously from working with Mehdi. He showed me the complex psychological and physical strains a young individual might experience when fleeing his home country.
Actually, I learned tremendously from working with Mehdi. He showed me the complex psychological and physical strains a young individual might experience when fleeing his home country. Also, upon arrival, I was astounded by the challenges he faced when engaging within a completely new cultural, as well as economic and social environment. I further understood that the therapeutic process would stagnate if theoretical assumptions were carelessly imposed on Mehdi without taking the cultural background into account. In our sessions for instance, he was extremely attentive and sensitive to changes in emotions, gestures or prosody. Crucial topics such as his origin, family structure and cultural aspects were at first impossible to question or challenge. In fact, he would control the pace of the process, holding on were necessary, pacing through when required. Indeed, as an emotional intelligent adolescent he was able to take into consideration different perspectives. During our sessions, he thus quickly and accurately analyzed the structure of social norms, cultural specificities and rules of communication and adapted his actions and thought accordingly. Finally, I learned that rust was at the very base of our relationship. Mehdi felt that caregivers and doctors supported him to reach his goals and he himself worked hard to heal physically and mentally in order to “pursue a better life in Europe”.
Sex, drugs and rock ‘n’ roll lies in the past - prosperity, autonomy and maturity in the future.