In Reply: We read with interest the letter about our brief report by Dr. Mathews and colleagues. We agree with several points, especially with the need to assess social connectedness. We did find fewer issues of anxiety and depression among the Iraqi civilians than among the prisoners of war, which may well be attributable to social connectedness. The civilians formed a community while on board the ship that served as our treatment setting, whereas the prisoners were not allowed to for safety reasons.
We also strongly agree that we were not the best suited for the job of assessing and treating Iraqis. However, we were the only trained personnel available to these wounded persons. Our paper was not intended as research but as a report of the difficulties of practicing in a different culture and through interpreters who also may have had problems understanding the culture. As such, we did not reify a nosological category developed for a particular cultural group and then apply it to members of another culture for whom it lacks coherence and for whom its validity has not been established (1).
We did not use DSM-IV diagnoses but looked at the broader concepts of depression and anxiety without trying to "shoehorn" our patients into diagnoses that did not fit culturally. In fact, the language barrier kept us from forming any formal DSM-IV diagnoses; therefore, I do not think that we committed a categorical fallacy. An example of the type of intervention that we made was teaching a friend of one of the blinded prisoners to organize his dinner plate so that he could feed himself.
We also strongly disagree with the statement of Dr. Mathews and colleagues that having medically trained interpreters would not benefit future assessment. As we mentioned, we spent a great deal of time having to explain medical and mental health concepts to our interpreters before we could assess the first patients. Providing this education before the need for it arises would decrease the response time of providers.
Finally, one important difference between the views expressed by Dr. Mathews and colleagues and our experience is the difference between the theoretical best and the real world. We agree that the best of all possibilities for these patients would have been to obtain an Iraq-born and Iraq-practiced psychiatrist; however, this was not a possibility. To some degree we had to "fight with what we brought." This meant having to learn, as Western mental health providers and interpreters, to bridge the gap between ourselves and our patients. This phenomenon is not new, and it has been well documented. The real world does not always provide the best fit for our patients.
Kleinman A: Anthropology and psychiatry: the role of culture in cross cultural research on illness. British Journal of Psychiatry 151:447-454, 1987