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An Anthropological Hybrid: The Pragmatic Arrangement

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An Anthropological Hybrid: The Pragmatic Arrangement of Universalism and

Culturalism in French Mental Health
Didier Fassin and Richard Rechtman
Transcultural Psychiatry 2005 42: 347
DOI: 10.1177/1363461505055620

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transcultural
psychiatry
September
2005

ARTICLE

An Anthropological Hybrid: The Pragmatic

Arrangement of Universalism and Culturalism in
French Mental Health

DIDIER FASSIN
University of Paris North and Ecole des hautes études en sciences sociales

RICHARD RECHTMAN
CESAME (CNRS, Université Paris 5)

Abstract As in most European countries, the mental health of immigrants

in France has recently been the subject of scientific scrutiny. Since the end
of World War II voluntary special mental health services for migrants and
refugees have been created in France and especially in Paris, but none has
been based on epidemiological data. Generally, this lack of objective data
gave rise to the assumption that many immigrants might not be getting the
type of services they required. The birth of a new type of service (e.g. for
migrants, refugees, ethnic groups, trauma and torture victims) was a politi-
cal reaction to what was, at the time, expressed as an essential unmet need
regarding this very specific population. In this article we review, from an
anthropological point of view, the different paradigms that have prevailed
over the last 50 years.
Key words culturalism • ethnopsychiatry • French transcultural psychiatric
services • immigrants • universalism

Vol 42(3): 347–366 DOI: 10.1177/1363461505055620 www.sagepublications.com

Copyright © 2005 McGill University

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Transcultural Psychiatry 42(3)

At the heart of the French politics of otherness lies a remarkable paradox:

the nation that has historically represented the quintessential ideal of
universalism in its official policy appears to also be the one that has surrep-
titiously reintroduced the ideological opposite, culturalism, in its un-
official practices. If we define universalism as the promotion of shared
values and rights in the name of a common humanity, and if we consider
culturalism as the defence of distinct and essentialized communities in the
name of the respect for differences, the contradiction seems unsolvable.
Theoretically, it is. Pragmatically, as politics always is, the two paradigms
become compatible. This is what the recent history of France reveals.
Nowhere is this paradox more obvious than in the field of mental health,
when looked at from the perspective of immigrants and minorities
(Rechtman, 2000). On the one hand, the French health system is based on
a principle of equality: whatever his/her nationality or origin, a sick person
residing on national territory receives the same medical care, which may
even be completely free below a poverty threshold (Palier, 2004). For
psychiatry, this tendency is further reinforced by a public network of
hospitals and clinics (Piel & Roelandt, 2001). On the other hand, the
French health administration has developed a multiplicity of differentiated
niches: in order to correct for its own deficiencies and to adapt to the
supposedly specific needs of certain categories, it has delegated part of its
prerogatives to specialized associations or professionals (Mizrahi &
Mizrahi, 2000). In mental health, ethnopsychiatry and its avatars have thus
become the main actors in the psychological, as well as the political, treat-
ment of otherness (Fassin, 1999). Universal in its legislation, exemplified
with the 2000 Universal Health Coverage act1 (Borgetto, 2000), French
policy simultaneously encourages the most radical approach in terms of
cultural assignation of aliens and their descendants (Nathan, 1994).
Universalist de jure and culturalist de facto: this anthropological hybrid of
the mental health system can only be interpreted in the broader perspec-
tive of French history.

The Republican Model of Integration and

its Ambiguities
The bright side of this history has its roots in the Age of Enlightenment
and its political extension under the French Revolution, with the 1789
Declaration of the Rights of Man and of the Citizen. Universalism was
proclaimed not only for every individual in France, but also for the whole
of humanity. Under the new regime, the nation became indivisible, with
the State ensuring the protection of its citizens. However, a series of
peculiarities reduced the theoretical ambition of the revolutionary model
and unveiled a darker side of the Republic. First, the distinction between

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Fassin & Rechtman: An Anthropological Hybrid

human rights and citizens’ rights deepened, and citizens were differenti-
ated into ‘active’ or ‘passive,’ the latter including women and the poor
(Hargreaves, 1995). Second, the progressive restriction of the nation to the
autochthonous population excluded aliens from citizenship and even
hospitality (Wahnich, 1997). Third, the emancipation of slaves was a short
historical parenthesis with little effect until the second half of the nine-
teenth century (Botte, 2000). This contradiction between the universality
of rights and the differentiation of their application, between the
proclaimed equality of all human beings and the evidence of inequality
within the real world, between the idealized nation and the concrete
society is thus inscribed in the origins of the French paradigm. And it is
certainly in the relations with foreigners in mainland France (Noiriel,
1988) and with local populations in the colonies (Conklin, 1997) that this
contradiction is most visible. There were always good reasons – some of
them cultural – for the exceptions made to the general rule of the Republic
at the expense of these categories.
Not surprisingly, Africa became the central site of the ideological
tension: because it symbolized the most exotic difference within mankind,
it gave birth to a mixture of racial and cultural prejudices that justified a
specific regime of governance under colonial rule and later in the post-
colonial world (Butchart, 1998). Psychiatry and psychology played a
crucial role in culturalizing racial representations and at the same time
naturalizing cultural specificities (Fassin, 2000). The birth of ethno-
psychiatry in the 1940s allowed this construction of a racial and cultural
stereotype of the African(s) – alternatively mentioned in the singular or
plural grammatical form – and often served to legitimize the imperial
power – as well as to discredit local resistances interpreted as psycho-
pathological (McCulloch, 1995). Certainly, this was not the only possible
political use of mental health, and French psychiatrists and psychologists
distinguished themselves by their personal involvement in the defence of
the colonized. Within the dying empires, Octave Mannoni in Madagascar
and Frantz Fanon in Algeria actively contributed to the radical criticism of
the colony and colonial racism. However, the ‘Malagasy dependency
complex’ of the former (Mannoni, 1964) and the ‘North African
syndrome’ of the latter (Fanon, 1967) were still inscribed in an essential-
ization of difference. In the aftermath of the African Independences, the
Dakar School in the Fann Hospital offered an interesting insight into
traditional conceptions and therapeutics within the framework of a public
healthcare structure (Collomb, 1965). The theorization of this practice was
one of the most ambitious attempts to link psychoanalysis and ethnology,
i.e. the universality of the personality structure and the specificity of local
culture, explicitly rejecting any culturalistic legacy (Ortigues & Ortigues,
1973). Ethnopsychiatry itself was thus submitted to this tension, which

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Georges Devereux expressed with the distinction he proposed between

Culture, approached in a universalistic way as the symbolic and empirical
material produced through socialization, and culture, considered within a
culturalistic reductionism as the specific local configuration of a given
group (Devereux, 1977). It is this heuristic tension that his intellectual
heirs have dissolved, definitively choosing the lower case letter to qualify
their object.
Going back to the historical context of the French mental health policy,
it is worth noticing two facts that appear to have a structural role in its
contemporary definition. First, from the end of World War II and even
more from the time of the Independences, the flow of immigration
progressively shifted from European to African origins (and more generally
from former colonies). Until the early 1970s, this immigration was not
only welcome: it was desired, as a cheap labour force was needed for
economic reconstruction. From 1974, policies changed dramatically:
labour immigration and soon after even family immigration were increas-
ingly restricted (Weil, 1991). A new entity was born: undocumented aliens,
whether clandestine workers, laid-off employees, rejected asylum-seekers,
illegally present spouses or children. The larger consequence of this
situation was the production of an illegitimate population (Ferré, 1997).
During the same period, the health insurance system was actively
developed, leading to extended coverage of people residing in France
whatever their nationality. The notion of social rights, present in the 1946
Constitution, defined a new citizenship through a form of social property
(Castel, 1995). Although foreigners remained excluded from some of the
benefits, most of these rights were shared by all those who were legally
present on French territory, this was especially true in the field of health,
which became a sort of ideological sanctuary. Accessibility to medical care
for all, including undocumented individuals via a special assistance
programme, is now written into law. Health has become the most legitimate
domain in social life, even though it appears that effective access remains
unequal (Lombrail, 2000). It is this coexistence of an illegitimate popu-
lation and a legitimate domain which nowadays provokes a contradiction
in French health policy for immigrants and minorities (Fassin, 2004). This
contradiction creates a unique opportunity for the specific treatment of
some categories under the cover of undifferentiated protection.
However, the French Republican model should not be refuted too
quickly. It has been truly effective, and that cannot be ignored, as it has
permitted a demographic and social melting pot under the auspices of
citizenship favoured by an active promotion of naturalization through the
dominant jus soli (Schnapper, 1998). In recent years, however, the façade
of this model has started to crack and its ambiguities have become
more obvious. The idea of integration, which corresponds to what is called

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Fassin & Rechtman: An Anthropological Hybrid

elsewhere an assimilationist ideology, has been criticized not because it is

wrong, but simply because it works less and less well. For a long time, this
deficiency was considered to be a consequence of the impossibility for
immigrants and minorities to adapt to French society. It now appears that
it is French society that discriminates against immigrants and minorities,
in the labour market, in housing and in everyday life (De Rudder, Poiret,
& Vourc’h, 2000). A new reality has been painfully recognized by the State:
the persistence and, probably, the aggravation of racial discrimination. It
has given birth to a new policy, still timid and not very effective. Neverthe-
less, for the first time, it has become possible to name social facts that are
obvious for their victims but not admitted by the authorities (Fassin, 2001,
2002). Discrimination is a complex phenomenon, however. On the one
hand, it is the privation of a right – a lack of universalism. On the other
hand, it assigns an obligation – an excess of differentialism. In health, both
phenomena are associated when it comes to immigrants: access to care is
sometimes impossible or difficult (when the law is not respected); and
specific paths are designed and standardized (mainly on the argument of
culture). This is what contemporary developments in mental health
demonstrate.

Ethnopsychiatry and Transcultural Psychiatry in

the Context of Psychiatry in France
As in most European countries, no specific epidemiological studies of
immigrant and refugee populations have been carried out in France that
would enable us to accurately assess the health needs of these population
groups (Anonymous, 1990). This absence of epidemiological data mirrors
political unwillingness, at the national level in France, to treat the health
problems of immigrants and refugees outside the general healthcare
system. Thus no national policy for the prevention and treatment of
psychiatric illness aimed at these groups has been pursued by the State,
even though public health has seen unprecedented development in the last
40 years and mental health has been a national priority since 2000
(Kouchner, 2001a, 2001b). Only a few independent initiatives have been
undertaken to create centres offering psychiatric care for immigrants and
refugees. These initiatives have indeed received public funding, but they
remain marginal in the statutory healthcare system, have never been recog-
nized in their own right as part of the public health structure and have
never been supported by any public policy.
This paradox is a fundamental feature of the French system. While the
integration of immigrant population groups, particularly non-western
immigrants, has become a major political issue in France since the early
1980s, to the point of provoking broad national debate and exposing

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Transcultural Psychiatry 42(3)

sometimes extreme tension regarding urban policy, the national school

system, and the participation of ethnic minority groups in local politics
and in the national parliamentary representation, this collective awaken-
ing has not had a significant impact on French public health policy. Even
the most recent reforms, such as the legislation enacted in 2001 (law of 4
March 2001) hailing the creation of a ‘healthcare democracy’ (Jospin,
1999) in which users will at long last see their specific profiles and needs
recognized and addressed, make no mention of immigrants and refugees.
As discussed earlier, immigrants and refugees do not constitute an
autonomous public-health constituency in France.
The field of mental health is probably the most revealing of this contra-
diction. Unlike other fields of medicine, psychiatry took an interest very
early on in the eventual clinical and therapeutic variants linked to culture.
No other branch of medicine has questioned its theoretical and universalist
foundations to the same degree, by confronting cultural difference
(Rechtman & Raveau, 1993) and thereby necessarily framing psychiatry in
an anthropological paradigm (Lantéri-Laura, 1992). From the very begin-
nings of modern classifications of mental illness, in particular, that of
Emile Kraepelin (Bendick, 1990; Kraepelin, 1904), cultural variability
crops up repeatedly, sometimes as negligible data, sometimes as a deter-
mining factor, but always as a stumbling block in psychiatric thinking, in
a way encountered nowhere else in the history of medicine. This is not to
say, far from it, that there is a historical continuity between the cultural
psychiatry outlined in the early twentieth century, and the more sophisti-
cated issues of contemporary ethnopsychiatry or transcultural psychiatry.
The former sought in the study of mentally ill patients in other societies a
hypothetical confirmation of universalist postulates, while the latter were
elaborated in the wake of updating of the DSM (Kirmayer, 1998; Mezzich,
Kleinman, Fabrega, & Parron, 1996) and were quite specifically aimed at
nuancing this universalist claim. Clearly, these different approaches have
little in common, other than, perhaps, their relatively marginal positions
in the psychiatric corpus (Rechtman, 2003). Even so, the study of cultural
variability and the issues raised by multiple waves of immigration have
never been absent from research and teaching in psychiatry, contrary to an
image often propagated in ethnopsychiatric literature that erroneously
fixes the origins of this questioning in the 1980s (Nathan, 1984). Traces are
found in the main psychiatry textbooks that devote at least several sub-
chapters (Ey, Bernard, & Brisset, 1978; Lempérière & Féline, 1983) to this
topic, or several entries as in the alphabetical handbook of psychiatry
(Porot, 1952). Well before the emergence of French ethnopsychiatry in the
1980s, many psychiatrists, some of them renowned and authoritative
voices in their discipline at the time, were also advocates of a ‘cultural’
approach to psychiatry. While their contributions in this domain are often

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Fassin & Rechtman: An Anthropological Hybrid

neglected or forgotten today, it is nonetheless true that these psychiatrists,

each in their own way and with quite different ideological orientations,
aimed to take certain social, cultural or economic aspects of immigrant
populations into account. Contemporary ethnopsychiatrists reject any line
of filiation with these early authors (Mouchenik & Ferradji, 2002), and
most particularly with the Algiers School whose colonialist tenets were a
vehicle of racial ideology for many years.

Marginality Versus Liberty: The Price of Independence

Beyond the deep disagreements that separate these authors and currents of
thought, which we discuss later, a first observation merits formulation.
Issues related to immigration have never been absent from psychiatric
thinking in France. They testify to a reinforcement of the opposition
between universalism and relativism even within the discipline of
psychiatry, mirroring the fault line that has run through all of French
society since the Revolution of 1789, opposing the individual and the collec-
tive, the individualization of needs and statutory law that applies to all. We
find similar debates at each stage of the construction of the public health
system, and ultimately the specific clinical features associated with one
group or another are not taken into account in the organization of this
system. This aspect is essential for understanding the French system,
because it highlights the existence of a significant gap between the discipline
of psychiatry, with its debates, controversies and theoretical advances, and
the organization of psychiatric care. This organization follows above all a
political model, and even an ideological model, that is broader than and
independent of psychiatry; at times it coincides with advances in the disci-
pline, but almost by accident. In this setting, the absence of epidemiological
data on the psychiatric needs of immigrant groups, like the absence of
specific healthcare policies for these same groups, is not due to any dis-
interest for these issues within the discipline of psychiatry. This disparity is
much more the product of the history of public health in France, and in
particular that of mental health. This situation has two major consequences
for care targeting immigrants and refugees.
First, psychiatric care for immigrants and refugees has regularly
oscillated between indistinct inclusion of these groups under the statutory
system, sometimes disdainfully ignoring their needs, and the creation in
the early 1950s of independent structures outside the statutory system that
focus on a specific feature of the immigration phenomenon.
Second, in the absence of objective data, these independent structures
were founded on objections to the inadequacy of the statutory system, in
order to promote responses that were thought to be non-existent else-
where.

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Transcultural Psychiatry 42(3)

Consequently, in a statutory system where initiatives by healthcare

professionals are tightly circumscribed by public health regulations,
advocates of specific arrangements are granted an astonishingly broad
freedom to innovate and propose their ideas, because no regulations exist
to define their area of competence. At the national State level in France,
health care for immigrants is a political issue rather than a strictly medical
one, and a subject where the principles of the French strain of univer-
salism are regularly reiterated. Even so, to address the aspirations and
eventually the specific needs of certain population groups, the State has
conceded significant room for action to ‘civil society,’ i.e. non-profit
groups, whose activity can range from definition of needs to implementa-
tion of responses. By providing financial support for theses initiatives,
without imposing the regulatory framework of public services, the State is
no more renouncing its prerogatives than it is retreating from its univer-
salist ideology. On the contrary, it is reaffirming by its very action that the
derogations and exemptions it concedes can in no way undermine the
statutory system as a whole. The price of liberty for these initiatives is their
marginality. The proposals for specific psychiatric care for immigrants and
refugees that have emerged in the recent history of the French psychiatric
care system are, above all, a symptom of these tensions, and reflect how
French society and psychiatry represent the needs of these groups at a
given moment in time.
Several radically different models have succeeded each other over time,
and some of them continue to coexist today. These models can be roughly
divided into five major paradigms, corresponding to the positions of the
advocates of these proposals in relation to the ideology and organization
of the statutory system: (i) pragmatic universalism, (ii) neo-colonialist
relativism, (iii) the political sociogenesis of migration pathology, (iv)
‘apolitical’ cultural essentialism, and (v) integrative pragmatism.

Alternative Models in Mental Health Services for

Non-Western Patients
The evolution of psychiatric care for immigrants and refugees is marked
by four fundamental stages: World War II, the fight for liberation in the
French colonies, decolonization, and the end of officially sponsored
immigration. These four periods outline the profound changes that have
shaken French society and its representation of foreign population groups
present on its soil. To each of these periods corresponds a dominant model
under which one aspect of otherness is construed as the difference that is
problematic between immigrants (or other groups) and native-born
French people, socially as well as in terms of health care, and thereby
justifying specific measures. The proposed typology that we present here

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Fassin & Rechtman: An Anthropological Hybrid

is based on the status of this difference as the main reference for justifying
and organizing the specific care measures that have successively emerged
and often overlapped over the last 50 years. This is not an exhaustive
examination of the origins and organization of these different measures,
but rather an attempt to establish an anthropological perspective on the
social and historical conditions that fostered the development and success
of these models.

The Utopian Vision of Psychiatry For All: Community

Psychiatry and Principles of the ‘Psychiatry Sector’
Since the 1960s, France has progressively acquired a vast public system of
psychiatric care based on a geographical system of psychiatry ‘sectors’
covering the whole country (Carrière, 2001). In theory, each sector
possesses a full range of structures for care (hospital, dispensary, day
hospital) and social/medical assistance housing to meet all psychiatric
needs and ensure ongoing care for the people in the sector (Petitjean &
Leguay, 2002). Designed to break with internment in asylums, the sector
concept is based on a policy of proximity, care provided free of charge, and
psychiatry in the community, and is inspired by an ideal of psychiatry for
all, available to the least privileged members of society. The concept was
extended during the 1960s and applied in all of France in the 1970s.
Initially it was the work of a handful of politically active pioneers –
F. Tosquelles, L. Bonnafé, G. Daumezon – who after World War II
promoted this new utopian vision throughout the profession (Chaigneau,
1997).
Over 40,000 mentally ill patients died in asylums during World War II
as a result of a famine orchestrated by the prefectoral administration
(Laffont, 1987), but in some places the staff took steps to protect patients,
welcome patriots and actively participate in the Resistance movement. The
most famous of these is undoubtedly the hospital Saint Alban in the Lozère
department, where Tosquelles, a psychiatrist of Spanish origin who had
fought alongside Republican troops in the Spanish Civil War, and his
friends decided to share the conditions of daily life with their patients,
while at the same time sharing daily Resistance action with them. Mental
patients who had, until then, spent most of their lives behind asylum walls
were reinserted into the community, learned sharing and freedom, as well
as danger and risk-taking, alongside their guardians and care-givers who
for a time were their comrades in misfortune.
It was only several years after the Liberation that this wartime experi-
ment evolved into the founding myth of the new policies of French
psychiatry. Posing as a basic principle that the recognition of patients as
human beings and the articulation of care with life in society should be

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Transcultural Psychiatry 42(3)

the very foundation of the ethics of care, the ideal of health for all was
proclaimed each day in a militant battle against all the forms of exclusion
from which mental health patients suffered. It was therefore of prime
importance not to reproduce any discrimination within these structures.
The status of patient took precedence over all others, and was sufficient to
justify the best of health care.
Distinguishing between groups, notably immigrants or refugees, was
tantamount to calling them ‘foreigners’ or ‘strangers,’ and was unaccept-
able in the eyes of the militant advocates of this new psychiatry. But the
limitations of this approach are found in its proclaimed generosity. By
refusing any distinction, by proclaiming that the ideal of psychiatry for all
should be achieved by disseminating the same objectives, the same means
and the same responses everywhere, the architects of the psychiatry sector
failed to see that they were running the risk of closing the door to
categories of patients whose needs might vary, for different reasons. And
yet these principles were applied to the letter, despite the unequal distri-
bution of means across the country. Even though the usual terms of French
republican universalism are found in this ideal vision, defence of the
psychiatry sector cannot be reduced to this ideological perspective alone.
This position is much more informed by humanist concerns; a rejection
of segregation and discrimination were the arguments of sector psychia-
trists who refused to undertake a specific approach to psychiatric problems
related to immigration. As a result, the structure of public psychiatric care
opened a breach through which independent initiatives could enter to
offer responses that the public system refused to provide.

Language and Access to Care, the Paradigm of

Pragmatic Universalism
It was also in the aftermath of World War II that the first psychiatric
dispensary for immigrants and refugees was opened in Paris. Created in
1951 by Eugène and Françoise Minkowski in a clinic called the Dispensaire
Populaire de Paris, this bore the unmistakable mark of its founder. Born in
St. Petersburg, and raised in Warsaw, a graduate of medical school in
Berlin, Minkowski emigrated to Paris in 1915 where he served as a military
doctor in World War I. Between the wars he became famous for his
innovative work on the phenomenological approach to schizophrenia
(Minkowski, 1927) and in 1927 he founded the society known as
l’Evolution Psychiatrique. From his multiple experiences of exile in Europe,
Minkowski retained an acute sensitivity to problems affecting immigrants,
but his psychiatric and philosophical training endowed him with a
resolutely universalist tradition, within which the emergence of a human-
istic psychiatry was founded above all in a universal vision of psychology.

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Fassin & Rechtman: An Anthropological Hybrid

World War II reawakened his sensitivity as an exile, but also bolstered

his humanist convictions, leading him to make a personal commitment
to the immigrants from eastern Europe who flocked to France after the
Liberation. When, with his spouse Françoise and a colleague of Polish
extraction, he founded the centre that still bears his name, it was first and
foremost to meet what he thought to be the needs of the thousands of
European exiles who sought refuge in France. The suffering of war and
exile coupled with the language barrier were the two motives behind the
creation of a specific structure for psychiatric care.2 The aim was to
facilitate the insertion of these immigrants in French society, to enable
them to overcome the trauma of exile, and give them initial care in their
native tongue before sending them into the statutory system. The
emphasis was on access to care, education and socialization within the
host society, and the psychological or psychiatric aspect was, in the end,
secondary, and mostly intended to make this insertion easier. The struc-
ture’s organization is a result of these general principles. The medical
innovation resided in the use of patients’ native language during consul-
tations with psychiatrists who were also immigrants from the same
countries. With each new wave of immigration, the centre expanded its
range of competencies and opened new consultations, always in the
native language and following the same principles. This care structure, a
model of pragmatic universalism, is emblematic of the way in which the
question of difference was framed in the years following World War II.
From a medical point of view, neither psychiatric knowledge nor the
public care structure was questioned. On the contrary, the ideal under-
lying the creation of these new structures clearly proclaimed adherence
to the values of the French Republic and to the universalism of
psychiatry. The necessarily temporary existence of a specific approach to
the needs of migrants was justified for the most part by the social
problems and language barriers faced by these population groups. More
precisely, immigrants’ mental health needs were considered to be more or
less the same as those of the native-born population, and required simply
a modest adjustment of existing care to allow them to receive the same
services. Even specific pathologies linked to war or exile were not seen as
major distinctive elements, insofar as psychiatric knowledge at the time,
and particularly E. Minkowski’s phenomenology, appeared to be
equipped to address and treat them.
In this respect, this model remains very close to the preceding one. It
does not promote a new conception of psychiatry, no more than does its
predecessor, nor does it denounce the existing statutory healthcare system.
It is unambiguously framed in the spirit of French institutions and
proclaims its affiliation with the psychiatry of its time.

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Transcultural Psychiatry 42(3)

Neo-Colonialist Relativism
Unaware of or indifferent to the debates that moved the profession in
mainland France, psychiatry in the French colonies continued along the
lines of thinking on ‘primitive psychology’ and the ‘primitivism of Blacks
and North Africans’ dating back to the 1920s.3 It is evident that the attitude
of colonial psychiatrists is to be analysed in light of the colonizers’ general
attitude to the colonized peoples. The terms used to think about ‘madness’
in the colonies are nothing more than an accentuation of the discrimi-
nation inflicted on those colonized. As underscored by R. Collignon,
‘whereas in Europe, the madman embodies a radical figure of otherness,
he is the Other of reason, in Africa the colonial subject already occupies
another place in the colonists’ imaginaire, that of the Savage’ (Collignon,
2002, p. 469). Among all the French colonies it was primarily in Algeria
that a genuine theoretical current of colonial psychiatry developed around
Antoine Porot, undoubtedly because Algeria was also the largest colonial
settlement. But the racist tenets of the Algiers School had little impact on
French psychiatry before decolonization (Berthelier, 1994). Prior to de-
colonization the ‘scientific’ contacts between the colonies and the
mainland were restricted to thorny questions of transferring mental
patients to the mainland or creating health care structures in the colonies
(Collignon, 2002). The Algiers School theories were violently contested in
Algeria itself during the war of independence, with Franz Fanon at the
head of this political and scientific struggle. But this debate was hardly
taken up at all within psychiatry on the mainland.
With the independence of Algeria this situation abruptly changed. As
soon as they returned to France, Antoine Porot and his students, all from
French Algeria, took over several chairs of psychiatry in France in the
1960s, and widely disseminated the ‘culturalist’ and ‘racial’ tenets of the
Algiers School. Tempering the most controversial aspects of the theories
of their mentor, Jean Sutter, Jean-Claude Scotto and Yves Pélicier
paradoxically came to associate the generous humanism of phenomen-
ology and the neo-colonialist view in a social psychiatry open to the
pathologies of immigrants. Supporters of the notion of pathologie
d’apport, or imported pathology, which is a sort of residue of their
mentor’s ‘primitivism’, they made a personal rather than a theoretical
contribution to the construction of an immigration psychiatry that does
not call for the creation of specific structures. Once again, this psychiatry
of migration does not contest the psychiatric establishment any more than
it does psychiatric knowledge. It propounds in essence a psychiatric
reading of immigration, along the lines of the psychiatric reading of the
colonized individual elaborated by Antoine Porot. The influence of this
reading was to be decisive, however, in that it aroused an active and

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Fassin & Rechtman: An Anthropological Hybrid

militant counter-reaction among those in France who were to take up

Franz Fanon’s torch and plead the cause of immigrants and work for the
development and implementation of a politically active psychiatry of
immigration (Berthelier, 1994).

The Political Sociogenesis of Migration Pathology

In the early 1970s activist psychiatrists took up this debate again, denounc-
ing their predecessors’ collusion with the colonial order. Their criticism
came on two fronts, clinical and political, and was largely inspired by the
liberation struggles in the former colonies, that they reinterpreted in the
national context with respect to immigrants.
At the clinical level, they rejected outright the culturalist principles that
they held to be responsible for a racist essentialization of the psychological
problems of immigrants, and they clearly called for an approach to
psychiatry for the citizens of the former colonies based almost exclusively
on the social and economic consequences of the phenomenon of
immigration. They also opposed the advocates of pathologie d’apport and
radically contested the idea that those who ‘choose’ immigration are
already subject to psychological problems that encourage them to leave. In
this regard, without attacking the psychiatric corpus itself to which they
continue to refer, they try to include a social genesis of the psychiatric
problems of immigrants (De Almeida, 1975) that would account for and
address the clinical features of immigrants, their specific needs and the
practical responses that the activists proposed to implement in dedicated
structures.
Language was no longer the barrier that impeded access to care. Nor
were cultural particularities, too heavily connoted by neo-colonialists
views, to be addressed in the dedicated structures. The structures that
progressively emerged harked back to Minkowski’s practical universalism.
But by stressing the limitations of the statutory system and in denouncing
its incapacity to take socio-economic aspects of immigration into account,
this model inaugurated a questioning of the psychiatric establishment that
was completely absent from the preceding models.
On the political level, their criticism went much farther, and was, for the
first time, aimed at the French healthcare system itself. Unable to take
charge of immigrants’ specific needs, this system, according to the critics,
reinforces inequality and progressively excludes immigrants and refugees
by denying the economic and social conditions that oppress immigrants.
This is indeed a political criticism in which we can detect the influence of
Frantz Fanon and criticism of the psychiatric institution from the point of
view of a relationship of domination. But the ideal vision of psychiatry for

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all was not yet contested. More accurately, it was in confronting this goal
with reality in the field that the advocates of these new structures sought
to show that the ideal was far from being achieved.
Founded by Zulméro de Almeida, the Comité Médico-Social pour la
Santé des Migrants, that later became the Association Migrations Santé, was
the most fully realized structure of this period. It organized consultations
in different cities, and linked awareness and training centres for field
workers (healthcare professionals, social workers) with social services for
immigrants and refugees aimed at helping them get back their rights and
pursue their fight against a system (health care and social services) that
oppressed them. It was from his position as a psychiatrist trained at the
Ecole française de psychiatrie, following its humanist and universalist
convictions, that Z. de Almeida could, for example, denounce the system
of domination that the psychiatric institution wielded over immigrants,
that is to say the organization of care and power structures that it
contained.
The specific structures for immigrants that flourished across the
country during this period were clearly framed as ‘psychiatry of migration’
as opposed to the cross-cultural approach that would later give birth to the
ethnopsychiatry of the 1980s (Douville & Galap, 1999; Rechtman, 2000).
They were also loci of criticism contesting the psychiatric institution, in
keeping with the vast movement sweeping through French psychiatry at
the time.

‘Apolitical’ Cultural Essentialism

A new direction was taken in the 1990s. The halting of official immigration
at the end of the 1970s, followed by the ban forbidding legal immigrants
bringing family members into the country as of the mid-1980s, took place
as the colonial past gradually faded from memory in France. The arrival
of illegal immigrants from various countries also changed the face of
immigration in France. The battles fought earlier against the segregation
and discrimination suffered by immigrants were now hampered by the
illegal status of new immigrants in France. Elements that had constituted
difference, such as language, access to care, pathologies of immigration or
socio-economic disadvantages were no longer sufficient or even relevant
for defending these new arrivals and obtaining recognition of their health
care needs.
The ethnopsychiatric current that was still in its early, faltering stages,
despite this the teachings of Georges Devereux found a favourable context
for its development and extension in this new social situation. It was all
the more favourable in that the movement benefited from the contribution
of clinical practitioners who came from among the immigrants and who

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were having a hard time gaining recognition for their degrees by the
psychiatric institution (Nathan, 1986, 1993).
The reification of cultural otherness spurred on by this movement
suddenly offered a compromise solution that, paradoxically, exonerated
the French State from its responsibility, in particular for its repressive
policies aimed at illegal immigrants. The healthcare shortfall and the
inadequacy of public services to meet the needs of this population group
are explained in this paradigm, which is also attractive to actors in society
such as judges and administrative authorities who have, until recently,
shown little inclination to address the fate of illegal workers.
Proposing a model focusing on cultural otherness and on the import-
ance of traditional aetiologies (Nathan, 1994), ethnopsychiatric structures
by the same token neglect the socio-economic consequences of
immigration (Corin, 1997). This model revives and radicalizes the
criticism of the public system under the preceding model, and shifts the
offensive to attack psychiatric knowledge, by forcefully denouncing its
intrinsic inability to understand and take into account cultural otherness.
This is no longer a political angle of attack, even if the development of
ethnopsychiatry in France indubitably has political ramifications (Fassin,
2000). It is no longer a matter of exposing the failures of the psychiatry-
for-all vision, for example, by accusing the care system of instituting a new
form of exclusion of immigrants, but rather a movement contesting the
very idea of psychiatry for all. Difference has now taken on a new form via
the naturalization of cultural otherness that accounts for the failures of the
public system (political and health care) in relation to the needs of these
groups.

Conclusion and Perspectives: Towards

Integrative Pragmatism
These different models have overlapped in time. The radical features of
each have been progressively tempered by the inclusion of elements from
the other models. Thus the Minkowska centre has abandoned an exclus-
ively social and linguistic approach, in favour of a more cultural and
anthropological outlook, in close collaboration with public services. While
consultations are still conducted in the patients’ languages, the mandatory
recourse to practitioners of the same native tongue has given way to more
frequent use of interpreters. The multiplicity of languages among new
immigrants of course made this requirement impossible to fulfil, but the
change is also due to the fact that the centre has shifted its focus to treat-
ment addressing the cultural issues of immigration (Bennegadi &
Bourdillon, 1986). Likewise, after a period of rapid expansion (Fassin,
1999), Toby Nathan’s radical ethnopsychiatry has become marginal and is

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limited to a handful of faithful followers at the Centre Georges Devereux.

Marie Rose Moro, who was one of his students, now occupies a chair of
psychiatry for children and adolescents, and is the leading figure of a more
moderate ethnopsychiatry (Moro & Giraud, 2000). Her approach has
retained the major advances of ethnopsychiatry – work in groups with co-
therapists of different ethnic origins, the ethnomedical view of represen-
tations of illness – but has discarded denunciation of psychiatric
knowledge or the institution, and even encourages collaboration with
public services. Traditional aetiologies are still the central element of
clinical treatment, but are used as therapeutic levers to gain access to more
‘universal’ psychic content (Moro, 1998). Other experiments have prolif-
erated in the public sector, with the intention of providing immigrants and
refugees with psychiatric services that are at least as complete as those
offered to native-born patients, by adapting the constraints of public
service to the specific needs of these patients (Rechtman, 1997, 2002;
Rechtman & Welsh, 1993). The renewal of clinical thinking with respect to
these population groups is now manifest, and regularly achieves original
forms of organization that go farther than earlier approaches, such as Fethi
Benslama’s exile clinic (Benslama, 2002, 2004), or the anthropological
mediation with children’s court judges proposed by Charles-Henri
Pradelles de Latour (2004), to cite only the most fully accomplished work.
The field of psychiatry for immigrants and the specific structures
designed for them has become more tranquil in recent years. But if it is no
longer the theatre of political struggles, if public services have accepted to
adapt to the needs of the different population groups, whatever their
ethnic origins, that it is their mission to serve, and if contestation of the
psychiatric institution is no longer on the agenda, it is not simply because
French ethnopsychiatry and transcultural psychiatry have at last attained
some age of reason. In fact, this integrative pragmatism is, above all, the
product of a far-reaching realignment of the missions and objects assigned
to psychiatry, in which the question of cultural difference is no longer a
crucial issue. In the vision of public health policy and mental health policy
in particular, the dividing line between identity and otherness is no longer
the ethnic boundary. For the first time, consideration and treatment of the
health needs of immigrants and refugees are not in contradiction with the
republican principles of the healthcare system. The presence of these
‘foreigners’ and their specific needs no longer threaten the general
principles of psychiatry for all. Although this evolution is, of course, to be
welcomed, it should also be noted that this sudden acceptance of their
difference has come about at a price; the price of integration of these popu-
lation groups into a larger category that is less problematic as far as
principles go, i.e. the group of the socially excluded.
It is precisely because immigrants, refugees and illegal workers are,

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above all, now classed as ‘excluded’ that they can by virtue of this status be
granted care specifically intended for victims of all forms of ‘exclusion’.4
The inclusion of immigrants and refugees under statutory mechanisms is
part of the opening up of the healthcare system to handle poverty and
precarious social situations, in the absence, often, of any other political
action. The contradiction between universalist and relativist views is
fading, as under policies to integrate different forms of ‘exclusion’ the
healthcare system is gradually becoming the great ‘peacemaker’ with the
role of pacifying social tension. The particular situations of immigrants
and refugees are today less likely to be seen as a problem of language or
culture, precisely because they are taken to be simply part of, or an aggra-
vation of, a precarious social status that does not justify treatment any
different from that reserved for other population groups in social diffi-
culty.

Notes
1. Couverture maladie universelle.
2. See the history of the Françoise Minkowska Center at the portal Santé
Mentale et Cultures, Association Françoise et Eugène Minkowski, http:
//www.minkowska.com/article.php3?id_article=4.
3. See, for example, Antoine Porot (1918) Notes de psychiatrie musulmane –
Annales medico-psychologiques, 74, 377–384, quoted in Berthelier, 1994.
4. The Public Health Act of 4 March 2001, like the mental health action plan,
includes substantial measures to address all forms of exclusion.

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Didier Fassin, MD, MPH, PhD, is an anthropologist, sociologist and physician.

He is Professor at the University Paris 13 and at the Ecole des hautes études en
sciences sociales. He is the director of the CRESP (Research Centre on Public
Health, Inserm – University of Paris North). He is conducting research in the field
of political and moral anthropology. He recently published: Des maux indicibles.
Sociologie des lieux d’écoute (La Découverte, 2004) and Afflictions. L’Afrique du sud,
de l’apartheid au sida (Karthala, 2004). He co-edited Le gouvernement des corps
(Editions de l’EHESS, 2004) and Les constructions de l’intolérable (La Découverte,
2005). Address: CRESP, 74, rue Marcel Cachin, 93 017 Bobigny Cedex, France.
[E-mail: dfassin@ehess.fr]

Richard Rechtman, MD, is a psychiatrist and anthropologist, Médecin-chef

d’Etablissement de l’Institut Marcel Rivière, Editor-in-Chief of l’Evolution
psychiatrique and researcher at the CESAME (Inserm, CNRS, University Paris 5).
He is conducting research on the anthropology of mental health and transcultural
psychiatry with Cambodian refugees. Address: Institut Marcel Rivière, CHS La
Verrière, 78321 Le Mesnil Saint Denis Cedex, France. [E-mail: r.rechtman@
wanadoo.fr]

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