Category: Psychology

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Clinical Emotion Empathy General Humanistic Psychology Narrative Palliative Care Poetry Psychiatry Psychology Reflection Spirituality

The Dying Man

The Dying Man
Written by Janie Cao
Edited by Mary Abramczuk
A few years ago, I spent half my day with a dying man. I remember these things about him: his name, his past profession, and that he was dying alone.

I never saw his résumé, the size of his house, or how much money was left in his bank account. I was not curious to know, either. But I bet they seemed significant once upon a time, at a dinner party, maybe. He worked as an engineer.

On that day—the day he died—no one who had cared about those things was there.
I was a stranger, yet I saw his last breaths. It was a curious day.

This world teaches us to do many things. To set goals (S.M.A.R.T ones, in fact) and to meet them. To maximize profit and minimize loss, and to use other people, to our advantage. We learn to build storage houses and efficiently fill them with glorified trash; to talk like we matter, and live like it, too.

Someday, we will all be that dying man. Not fully here, and not quite there; mere wisps of breath. When that day comes, will this world be at your bedside? 
Sometimes, I wonder.




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Dedicated to a friend: May you find what you are searching for.
Photo credit: Jörg Lange
Categories
Emotion Empathy General Humanistic Psychology Literature Opinion Patient-Centered Care Psychiatry Psychology Public Health Reflection

Book Review: Loose Girl by Kerry Cohen

Hi MSPress Blog Readers!
……
We didn’t have a blog post scheduled for this week, so here’s a book review instead 🙂 I read this book last week for my Adolescent Sexual Health MPH course and enjoyed it.There’s a lot of interesting tidbits on sexual health issues. I mention two.
Even if you don’t agree with everything the author says, I think memoirs can be helpful in showing you unique life perspectives based on true experiences that you may never have experienced yourself. Furthermore, reading memoirs can get you acquainted with potential resources to help others. Ever heard of bibliotherapy, anyone? 🙂
……
Your Blog Associate Editor,
Janie Cao

Categories
General Healthcare Cost Humour Lifestyle Opinion Pharmacology Psychiatry Psychology Public Health Reflection

Well, Well, Well: Products and services compete for shelf space in trendy wellness market, but are they worth your money?

When a friend recently asked me to join them for a class at Inscape, a New York-based meditation studio that New York Magazine described as the “SoulCycle of meditation”, I was skeptical. On the one hand, I usually meditate at home for free, so paying almost $30 for a meditation class seemed a bit silly. On the other hand, my meditation practice had dropped off considerably since the beginning of the year. Maybe an expensive luxury meditation class was just what I needed to get me back into my regular practice. Stepping off bustling 21st Street into the clean modern space, I heard the sounds of, well…nothing. It was incredibly quiet. Before getting to the actual meditation studios, I had to pass through Inscape’s retail space. The minimalistic shelves hold a variety of supplements, tinctures, and powders that include unique ingredients like Reishi medicinal mushrooms and cannabidiol extract. Many contain adaptogens, herbal compounds that purport to increase one’s resistance to stress, though their efficacy has never been quantitatively proven.[1] These products’ promises run the gamut from shiny hair and stress relief to aura cleansing. I may be a super-skeptic, but even I am not immune to the lures of top-notch marketing. With great consideration, I purchased one of the many magical powders for sale labeled as ‘edible intelligence.’

Since wellness has become trendy, a considerable space in the retail market has opened for associated products dedicated to helping people live their best lives. As Amy Larocca pointed out in her June 2017 article The Wellness Epidemic, “[In the wellness world] a loaf of bread may be considered toxic, but a willingness to plunge into the largely unregulated world of vitamins and supplements is a given.” Even a recent episode of Modern Family poked fun at the wellness trend when Haley Dunphy applied for an ultra-competitive job with fictional wellness guru Nicole Rosemary Page. During her interview at Page’s Nerp company headquarters, Page laments, “People say that Nerp is nothing more than a con-job, a cash grab vanity project from a kooky actress. I want to turn Nerp into the next Disney-Facebook-Tesla-Botox. It’s a world changer.” Though Page is a fictional character, I can’t help but wonder whether the character was inspired by the very real Amanda Chantal Bacon, the founder of Moon Juice, which bills itself as an adaptogenic beauty and wellness brand. Bacon’s Moon Dusts retail for $38 a jar and come in varieties such as Spirit, Beauty, and Dream.

The bottom line is that a sense of well-being needn’t come at the price of thirty-plus dollars an ounce. In fairness to those who choose to spend lavishly, I believe that plunking down a chunk of cash might create an intention to use and derive value from a product, thus positively influencing one’s perception of how well the product works. Rest assured, however, that living with intention and gratitude can be just as easily accomplished without spending any money at all. Carving out time in the day to create a small ritual for yourself can be as simple as spending a few minutes in the morning listening to jazz as you drink your first cup of coffee or allowing yourself to become immersed in a good book before drifting off to sleep. These simple acts allow us to bestow kindness upon ourselves that is especially important in our stressful and busy lives as medical students. My suspicion is that by performing such rituals with intention, we derive much of the same benefit whether our mug is filled with the trendy mushroom coffee or just plain old Folgers.

I’m always thinking about ways I can improve my own well-being, but as graduation approaches I also find myself thinking about how these practices might help my patients as well. One of my fundamental goals as a future psychiatrist will be to help my patients see the value in themselves and in their own lives. I predict that for many of my patients, achieving this goal will depend perhaps on medications but also on the deployment of simple wellness tactics such as I described. I’m not going to lie…I’m still intrigued by many of the wellness products that can be found in places like Inscape, Whole Foods, and the Vitamin Shoppe, especially when I think about the potential benefits they might have for my future patients. I figure that if these products do even half of what they promise to, some of them might even be worth the money. So what happened when I added a sachet of intelligence powder to my usual morning smoothies? Pretty much nothing. At one point, I got excited when I began to feel my fingers getting tingly. Then I realized I had been leaning on my ulnar nerve. Not so brainy after all.

[1] Reflection Paper on the Adaptogenic Concept, Committee on Herbal Medicine Products of the European Medicines Agency, May 2008.

 

Photo credit: Open Grid Scheduler / Grid Engine

Categories
disability Emotion Lifestyle Patient-Centered Care Psychology

Nodding Along

My grandmother was a strong and compassionate Egyptian woman, a mother of three, and a pathologist. On a glass slide, exactly like the ones she used daily, cells from her colon biopsy were identified as undifferentiated, and within days she was diagnosed with Stage IV Colon Cancer.

Although I am learning how to care for people in sickness and health, someday, the chest compressions will be applied to my chest. Disease knows no discrimination, and death unites us all. Thousands of cancer diagnoses and precise and growing knowledge of cancer cell types did nothing to protect my grandmother from that which she knew so much about.

In Egypt, cancer is called ’the bad disease’, and bad it is. Over the next couple months, we watched as the bad disease took our beloved grandmother away from us. During that time, my family members, and my grandmother, had to make a series of challenging decisions that they were very obviously not prepared to make.

Medical advancements, although the main reason we are living longer lives, have caused the complexity and variety of end-of-life decisions to be ever increasing. Uneasy about the series of decisions that my family had to make and handicapped by my ignorance, I found myself reading Being Mortal by Atul Gawande. Atul Gawande led me through a vulnerable and imperfect but inspiring conversation about death and dying, exposing our medical system’s inability to understand health beyond the one-dimensional, and presumptuously noble, endeavor to prolong life at any cost.

While reading Being Mortal, I found myself enthusiastically nodding along, agreeing with the theme of the book: we need to change everything about our simple but destructive approach to aging and our increasing elderly population. Our singular approach to prolonging life simplifies complex social and medical decisions. It seems the attitude now is that longer life is all that matters. Ensuring nutrition and shelter is our only standard for a viable living environment for the elderly. We are failing our parents and grandparents.

Atul Gawande’s presentation of ideas changed how I perceive aging and our healthcare decisions at the end of life. I became a strong advocate of having conversations about the inevitability of our death and the choices we want to be made during our end-of-life care. I was convinced that society and healthcare should ensure that the elderly remain the authors of their own stories for as long as they are willing, and actively empower them to do so. Nutrition, shelter, and minimizing fall risk are minimums of care, not acceptable standards.

The Literature in Medicine Student Interest Group at my school decided to read Atul Gawande’s Being Mortal, and I could not be more excited. In the middle of our meeting discussing the book, as I was passionately sharing my ideas, it occurred to me that although I was full of strong opinions, I had done absolutely nothing to be a part of the solution. My grandfather had come to live with us after his wife of 55 years, my grandmother, passed away from colon cancer, and my only roles/concerns in his care have been to ensure food, sleep, and meds. My strong opinions had not inspired my actions.

Nodding along to Atul Gawande’s criticisms of our medical system is easy, but having an honest conversation with my grandfather about his priorities and end-of-life care preferences as he reaches 90 years of age is not so easy. How might I empower my grandfather to continue to be the author of his story? Believing that healthcare is a right and not a privilege is easy, but carrying out the responsibility that this belief invokes is not so easy. How might I work to help provide all my neighbors with equal access to high-quality care? Practicing the invaluable intervention of presence is not easy, and working day after day to hone my abilities at the art of empathy is not easy. How might I overcome my doubts, fears, and insecurities, and avoid being frozen into lack of compassion?

Too often my strong opinions do not inform my actions. Too often my hate for dysfunctional and unjust systems overshadows my love for the people in the systems. I call myself to love my neighbors more than hate the systems, for love is actionable and hate is stifling and tiresome. Let love fuel the tank, for compassion-based activism is the only kind that goes the distance.

Photo Credit: Dan Strange

Categories
Emotion Empathy General Humanistic Psychology Narrative Patient-Centered Care Psychology Reflection

Immigrant’s Suitcase: Ordinary people with the will to do extraordinary things

A mother separated from her missing husband flees a war-torn country, her homeland, to provide a brighter future for her children. She’s a dentist by training and practiced dentistry back home; but here, here she’s cleaning homes for a living. Why? When she left her home with her four children by her side, headed to a safer place, to America, what was in her suitcase? Alongside the picture of her missing husband and the few possessions that remained after the destruction of her home, in her suitcase, she has hopes and dreams, fears and doubts. She looks to her children for strength, but she’s terrified every time she looks them in their eyes. She is not optimistic, but she is hopeful; she looks the odds straight in the face and proceeds anyway. Because hope is not logical, it is powerful.

She’s cleaning the home of a happy family; the father is an engineer and the mother is a doctor and the children play piano. Their life, their hopes, goals and dreams are dependent on the stability of their country, but they cannot see it. The same hands that used to place crowns to relieve the pain of the suffering are now scrubbing the floor of another woman’s bathroom. But hope is powerful, and she lives through the dreams of her children. Two of her daughters want to be doctors. Her third daughter wants to be an artist. Her son is eight and he loves math. In her suitcase, she brought with her the dream of a better education for her children. “In Syria, we ate grass. In Egypt, we didn’t have food. In Indiana, I love school.” These are the words of her eight-year-old son.

A man runs to catch the bus. He can’t miss the interview; he really needs this job. It is his third interview in as many days. His last job got him enough money to get his family off the streets for a couple weeks. But motels are more expensive than he ever imagined. He’s homeless. His family is homeless. This wasn’t a possibility he considered when he graduated with his MBA. He had a great job, but the hurricane took everything away. And he hasn’t been able to get back on his feet. He catches the bus and pays the $1.75 in quarters. He checks the email that he printed; the interview is in room 4015. He runs up the stairs; he really hates being late. As he enters his interviewer’s room, a bead of sweat runs down his forehead. What’s in that bead of sweat? Desperation and nervousness, humiliation and self-pity, purpose and resilience.

His interviewer gives him the job offer. He smiles and shakes his head. A tear runs down his face. He can’t take the job; he can’t manage the branch that makes most of its revenue through alcohol sales. Another day and another interview, but his family remains homeless. He needs the job, but rejecting the offer was an easy decision. He believes that although alcohol may have small benefits to people and society, the harm it causes is much larger than its benefits, and wants to play no part in its distribution; he will not be a co-creator in the intoxication of his neighbor’s mind.

A young woman sinks into herself on the examination table. Her husband is holding, squeezing her hand. The doctor is still talking. He looks very sympathetic. The young woman just learned that she has a cancer growing inside of her lungs, an aggressive cancer. The doctor thinks ‘we can fight it.’ The young woman’s mind is overwhelmed into quietness. All she can think about is her daughter’s play after school that she doesn’t want to miss, even for this. The doctor brings her back, ‘Do you feel comfortable about our next step? I think that’s the best place for us to start.’ The young woman shrugs. What is in that shrug? Fear and uncertainty, peace and tranquility, ambivalence, a need for normalcy, a desire for time to make meaning.

The young woman is herself a physician, trained and licensed as a radiologist. She knows enough about cancer and the late stage non-small cell lung cancer she has been diagnosed with to know that the longevity of her future has been called into question. And yet this is not the topic of discussion with the doctor. Instead, he discusses treatment options, which is fancy talk for a long list of big words in different orders and combinations. When asked about the next step, she shrugged. She shrugged because there didn’t seem to be room for her in that room. (Insert young woman with terminal cancer here). Although it is more comfortable for the doctor to rattle off treatment options, the patient wants to take time to acknowledge the inexorability of our life cycle. To the doctor, it was the end of a beginning, and they were, together, supposed to begin a new chapter of strength and resilience. While he rattled off treatment options, she just wanted to catch her daughter’s play after school, and she was running late.

In the words of HL Menken, ‘For every human problem, there is a solution that is simple, neat, and wrong.’  Without taking a moment to explore what’s inside the immigrant’s suitcase, the homeless man’s bead of sweat, the sick young woman’s shrug, we stand a sorry chance to witness, help, and learn from ordinary people with the will to do extraordinary things. This is the power of narratives; the power of listening. I call myself to look inside the suitcase, to investigate the bead of sweat, and to ask about the shrug; I call myself to listen.

I find myself in an imperfect world, full of injustice and oppression. I find myself an imperfect man perfectly given the ability to alleviate suffering, on a personal level with a smile or a hug, and on a larger scale by fighting injustice and refusing to stand idly in the face of oppression. Poverty belongs in a history museum. And hunger…we have enough food in the world for every member of the human family to eat a balanced 3000 calorie meal. When we eliminate poverty and hunger, there will be many other injustices for us to face. I want to make facing these injustices my mission. My mission is to be ‘human’ as best I can; to work to establish justice in any capacity that I can, from a generously given smile to an honest political campaign.

Photo Credit: Robot Brainz

Categories
Opinion Psychology Public Health

Take a Stand against Domestic Violence

October is Domestic Violence Awareness Month. This is particularly relevant at the moment, because on October 7th the Washington Post published a 2005 recording of President-Elect Trump bragging about kissing and grabbing women without permission. Since the leak, the president-elect has consistently referred to such comments as “locker room talk.” In a recent interview with Anderson Cooper, Melania Trump further dismissed the seriousness of her husband’s comments by stating, “I heard many different stuff—boy’s talk. The boys, the way they talk when they grow up and they want to sometimes show each other, ‘Oh, this and that’ and talking about the girls.”

It is time to be clear. Trump’s comments may echo in locker rooms or be the status quo among young men, but that does not make it forgivable to joke about sexual violence. And to imply that joking about sexual violence against women is somehow more tolerable when it is said by an immature male or in a sporting environment only further encourages the perception that men have an implicit ownership of a woman’s sexual rights.

In a 2010 report entitled “Preventing Intimate Partner and Sexual Violence Against Women,” the WHO emphasizes the need to understand and target the factors that commonly lead to intimate partner violence and sexual violence against women. Unfortunately, an overwhelming burden of intimate partner violence and sexual violence against women occurs at the hands of men. This becomes unsurprising when one identifies the factors that promote violence against women. The WHO lists “patriarchy, power relations, and hierarchical constructions of masculinity and femininity as a predominant and pervasive driver of the problem.” The paper further argues that “dismantling hierarchical constructions of masculinity and femininity predicated on the control of women, and eliminating the structural factors that support inequalities are likely to make significant contribution to preventing intimate partner and sexual violence.”

Several examples of such social and cultural norms are cited in the report, but one appears to be particularly relevant in the setting of Trump’s recent comments: the idea that a man has a right to assert power over a woman and is considered socially superior to her. In the leaked video, Trump supports his right to kiss and grab women with the argument that “when you’re a star, they let you do it. You can do anything.”

No, Mr. Trump, you cannot.

The WHO highlights methods to prevent intimate partner violence and sexual violence against women, stating that there are three main approaches for changing social and cultural norms: correcting misperceptions that the use of sexual violence is normal and common among peers, media awareness campaigns, and directly working with men and boys to educate them on the topic. I hope that the media storm surrounding the video’s release, as well as the responses to it by prominent figures will serve to raise awareness, because women, men, and children alike should be able to live a life free of violence.

Readers, take a stand against domestic violence of all forms. Challenge jokes that diminish the seriousness of such acts. To fail to question only perpetuates the pervasive social and cultural acceptance of violence against women. Do not tolerate the perception that men are socially superior to women. Educate others that domestic violence, including intimate partner violence and sexual violence against women, is a global epidemic that affects us all.

I encourage current and future medical providers to seek the education they need to be a first resource for survivors of domestic violence. Make preventing and responding to intimate partner violence and sexual violence a priority in your clinical practice.

The National Intimate Partner and Sexual Violence Survey (NISVS) 2010 Summary Report defines five types of sexual violence:

  • Rape – “any completed or attempted unwanted…vaginal, oral, or anal penetration through the use of physical force, threats to be physically harmed, or when the victim was drunk, high, drugged, or passed out and unable to consent.”
  • Being made to penetrate someone else
  • Sexual coercion – “unwanted sexual penetration that occurs…after being pressured in ways that included being worn down by someone who repeatedly asked for sex or showed they were unhappy; feeling pressured by being lied to, being told promises that were untrue, having someone threaten to end a relationship or spread rumors; and sexual pressure due to someone using their influence or authority.”
  • Unwanted sexual contact
  • Non-contact unwanted sexual experiences – “unwanted experiences that do not involve any touching or penetration, including someone exposing their sexual body parts, flashing, or masturbating in front of the victim, someone making a victim show his or her body parts, someone making a victim look at or participate in sexual photos or movies, or someone harassing the victim in a public place in a way that made the victim feel unsafe.”

According to the NISVS, nearly 1 in 5 women (18.3%) and 1 in 71 men (1.8%) in the United States (U.S.) have been raped at some point in their lives. And nearly 1 in 2 women (44.6%) and 1 in 5 men (22.2%) in the U.S. experienced sexual violence other than rape. Worldwide, this rate is higher, with 1 in 3 women (35.6%) experiencing either physical and/or sexual intimate partner violence or non-partner sexual violence.

Domestic violence can refer to intimate partner violence, but also encompasses child abuse, elder abuse, or abuse by any member of a household. The World Health Organization (WHO) identifies four forms of intimate partner violence: acts of physical violence, sexual violence; emotional (psychological) abuse; and controlling behaviors.

Intimate partner and sexual violence disproportionately affects women worldwide, and can significantly impact a woman’s reproductive health and the health of her baby if she is pregnant. Women who have been physically or sexually abused by their partners have a 16% higher risk of having a low birth weight baby (16%). They are twice as likely to have an induced abortion, and almost twice as likely to experience depression.  In some regions, women who experienced partner violence were 1.5 times more likely to acquire HIV and 1.6 times more likely to have syphilis. Of women who experienced non-partner sexual violence, they were 2.5 times more likely to have alcohol use disorders and 2.6 times more likely to have depression or anxiety.

In 2013, the WHO produced a clinical and policy guideline entitled “Responding to intimate partner violence and sexual violence against women,” noting that health care providers are identified by survivors of intimate partner violence as the first and most trusted professional contact they would seek. These WHO guidelines emphasize the need for undergraduate medical curricula to include education on how to recognize, manage, and treat issues of IPV and sexual violence. Providers need to be prepared to give survivors immediate access to post-rape care, ideally within 72 hours, which includes psychological support, emergency contraception, and HIV and other STD prophylaxis.

For more information about domestic violence or how you can help please see the resources below:

If you are in immediate danger, please call 911.

If you or a loved one think that you are a victim of abuse in any form, please call the National Domestic Violence Hotline at 1-800-799-7233 (SAFE) or 1-800-787-3224 (TTY) now for anonymous, confidential help available 24/7.

REFERENCES

  1. Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G., Walters, M.L., Merrick, M.T., Chen, J., & Stevens, M.R. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
  2. WHO/LSHTM. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva/London, World Health Organization/London School of Hygiene and Tropical Medicine, 2010.
  3. WHO/LSHTM. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva/London, World Health Organization/London School of Hygiene and Tropical Medicine, 2013.
  4. Violence against women: Intimate partner and sexual violence against women. Fact sheet. Reviewed September 2016. Accessed on 10/14/2016 at http://www.who.int/mediacentre/factsheets/fs239/en/

Featured image:
utopia banished by kr428

Categories
Psychology Reflection

Reassessing Resilience

Recently, I had the opportunity to work with a young female patient whose healthcare history could rival that of an octogenarian in complexity. At the end of our 70-minute intake interview, the physician with whom I was working asked our patient a question that made my head snap up from my notes: “What are your hopes and dreams?”

What a simple question to ask, and yet, with my medical student mindset, medication interactions and pending test results were more prominent on my radar than ever considering this patient’s future goals. According to the CDC, half of all American adults live with a chronic health condition, and 25% of American adults live with two or more of these conditions[1]. We are living in an age of chronic disease, and this state of unwellness is never more apparent than when we see patients with healthcare records and medication lists thicker than a Tolstoy novel. With so many health issues to track in just a single patient, it can be a challenge to see the patient through the problem list.

After the physician asked his question, I thought about how easily a member of the healthcare team could fail to foster patient resilience. Resilience is defined as “the ability of systems to mount a robust response to unforeseen, unpredicted, and unexpected demands and to resume or even continue normal operations.” [2] Even for patients with multiple healthcare concerns, including those with multiple adverse childhood experiences (ACEs), it is not unreasonable to believe that resilience can act as a protective factor against those concerns. Asking this patient about her ambitions allowed us to learn about the person that existed outside of the hospital. Understanding that this patient had a plan for her life, and had some notions about how to manifest those plans into reality proved that despite her numerous medical concerns and previous history, the capacity for resiliency was still there. For the first time in that hour-plus interview, I thought about her health conditions as interruptions of her regular life, rather than letting her life be defined by her illnesses.

Most of the research about resilience can be found in psychology literature. The American Psychological Association created a guide called the Road to Resilience, which lists ten recommendations for developing and maintaining characteristics of resilience. These include maintaining relationships with friends and family members, as well as desire and ability for one to improve their life circumstances. [3] It would be appropriate to inquire about these characteristics while taking a patient history. Another tool that we can use to assess patient resilience is the Resilience Questionnaire created by psychologists Mark Rains and Kate McClinn of the Southern Kennebec, Maine Healthy Start program. [4]

There is still plenty of room for research on resilience in the medical literature, but we need not wait for this research to develop our own understanding of the importance of resilience in our care delivery. In the case of our patient with the convoluted medical history, we were not seeing a difficult, diseased, bedridden patient with several chronic illnesses. We were seeing an artist and future psychologist whose life had been set off course by a series of medical misfortunes. It is certainly easier to think of resilience in terms of our younger patients, and while resilience may seemingly be less applicable to certain groups of patients who cannot necessarily overcome their medical concerns, it is still appropriate to help patients set reasonable goals and maintain their support systems. Furthermore, it is always appropriate to understand our patients’ identities outside of their hospitalizations or medical concerns, and it may be helpful to use this personal information to inform our medical therapies.

As medical students, we are rarely able to follow patients over time, so it can be difficult to think of them beyond the confines of their hospital rooms. It is easy to relegate patient “bonding” to the nurses who spend countless hours with these patients. I think one of the most meaningful things we can do as students is to periodically pause to remind ourselves, and our patients, that their hospitalization is only a freckle on their identity as a whole person. At one point, all of our patients had hopes and dreams that likely never involved illness. Part of our delivery of patient care ought to be reflective of helping patients work toward these hopes and dreams, and to identify, and foster, resilience traits whenever possible.

References:

  1. http://www.cdc.gov/chronicdisease/overview/
  2. http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-Nemeth_116.pdf
  3. https://philosophy-of-cbt.com/tag/resilience/
  4. https://acestoohigh.com/got-your-ace-score/

Featured image:
Slope Point by Ben

Categories
General Psychiatry Psychology

The Case Against Global Mental Health

‘We have become not a melting pot but a beautiful mosaic. Different people, different beliefs, different yearnings, different hopes, different dreams.’
– Jimmy Carter

Western culture is taking over the world; from supermodels on television screens, to fashion accessories in shopping outlets around the world, to the movies made in Hollywood and disseminated worldwide online. Globalization has opened new doors. It has allowed us to build new relationships and learn about new cultures. It has opened our eyes to the worlds beyond our borders – to different languages, religions and beliefs. It has had an impact on every aspect of our lives, including medicine and healthcare.

The pathophysiology of most disease is similar throughout the globe. The diagnosis of a myocardial infarction will have similarities across different continents; an ECG that is normal in the UK will likely be deemed normal in the USA. But when it comes to our inner thoughts and our minds, a similar comparison cannot be made. The Western model of mental illness, of the divisions of neurosis, psychosis and personality disorders yields more than just mere categories. It also produces a set of values and beliefs – namely, that these thoughts and behaviours are outside the remit of social norms. Does a person with a diagnosis of Major Depressive Disorder in the USA show the same symptoms as someone in South Africa? Does this diagnosis hold the same meaning on the other side of the continent? My answer: no, it does not.

Mental health problems go beyond human anatomy and pathophysiology, and treating them like they do not leads to inappropriate therapies. Culture and mental health have close ties that are not addressed when treatment involves only the prescription of a drug. Our mental health colors how we view the world around us; how we view ourselves, our failures and our successes. It defines our identity. In the West our society is based upon science and rational thought. Such a focus has placed a large emphasis on the ‘biomedical model,’ i.e. that symptoms can be clustered together into categories, leading to a diagnosis and a form of treatment. Yet in other countries the idea of being labeled with a ‘disease’ seems bizarre. In many cultures, mental distress is explained through a spiritual lens, based upon the power of one’s ancestors or a curse placed upon one’s family. Who are we to step into this other world and banish such beliefs in the name of the ‘superior’ Western thought?

It can be argued that by placing people within a scientific category, one is filtering out a person’s lived experiences. Sure, a diagnosis may be appropriate in certain circumstances, allowing appropriate support and treatment to be offered to those who are in distress, but we must remember that the diagnoses written in the textbooks do not always correlate with the chaos that is human life.

What is it that makes someone ‘mentally unwell?’ More than anything else, it is a social judgment; it is based upon the idea that everyone over this line is unwell, while those of us who are able to follow the norms of our society are deemed ‘sane.’ Every society is different, and every society has its own ideas of what an illness is and is not. We can often be so determined to get out there and ‘save lives’, that it can be easy for us to forget that when it comes to mental health, it is they (the patients) who have the far superior knowledge of what they are going through. They are the ones who know what emotions they are feeling, what thoughts skip through their mind, what fears drench their hearts. They are the masters of their lives. What is needed is not a rush to produce pills, to prescribe, to diagnose and to medicalize – no, what is needed is humility. The appreciation of our own ignorance in a culture that is different from our own – an understanding that human beings are different. Only then can we begin to take that step to alleviate the distress of mental health problems worldwide.

If we were to take out our Diagnostic Statistical Manuals and set about drawing boxes in other countries, we would find that such a rigid classification system does not translate well to other cultures; a person who fits the criteria for Major Depressive Disorder in London, UK does not necessarily experience the same illness as someone in New Delhi, India. We need to go beyond the symptoms and think about the person’s suffering and pain; what is it that has led them to feel such despair? For some it may be the loss of a job, or status, or wealth. For others, it may be a fall within their social circle, the death of a spouse, or the belief that they are being cursed or punished. We need to be able to understand another person’s suffering if we want to help them. A setback within someone’s life needs to be seen within its context. This involves sitting with people, attempting to understand their lives, eating their food, conversing in their language and understanding what it means to be a citizen in their country. It is not a process that can be ticked through in a few minutes based on a checklist of symptoms. Such arbitrary methods do not capture the emotional and spiritual parts of mental distress, nor do they take into account the vastly different cultural contexts in which patients may live.

Remember that the labels we put on our patients are often value-laden. These criteria we use from our diagnostic manuals are often drawn from the concept of right and wrong – what each society chooses to accept and reject as the norm. When it comes to mental health, what is most important is not the structure of the neurons, nor the actions of their neurotransmitters; it is the effect on the individual, the person within, the person who breathes and feels and cries and laughs.

All of these issues can be illustrated with the worldwide response to the Tsunami in 2005. Following the disaster, many NGOs provided ‘mental health assistance’ by using the Western psychological models of distress, particularly to describe the response to trauma. Most of the workers were ignorant of the local cultural beliefs and traditions, which resulted in a set goals that were more in line with the charities than the victims.

“We are fishermen and we need space in our houses – not only to live but also to store our fishing equipment. After the tsunami we have been living in this camp, which is 12 kilometers away from the coast and in this place for reconstruction. When the international agency came and started building a housing scheme, we realized that they are building flats, which is not suitable to us. But when we try to explain this to the foreigners who are building this scheme, they looked at us as if we were aliens from another planet. What are we supposed to do?”
[..] We have lost our families, now we are having our homes stolen too.”
– Action Aid International 2006 (8)

Such interventions have raised questions as to whether this ‘external mental health aid’ is actually harmful, leading to a division between the ‘superior’ external workers with their Western knowledge, and the locals who have been left helpless and vulnerable.

I am not suggesting that we place a hold on Global Mental Health. I am not suggesting that we stop giving aid. What I am suggesting is that when it comes to mental health, we acknowledge the diversity of the human race. We accept that to be mentally unwell means more than to have an imbalance of chemicals. And by accepting that mental illness affects not just a brain but a person, an identity, a family and a society, we are able to put on our boots and trudge deep into the mud alongside those who we are hoping to help, and perhaps we may even help ourselves along the way.

References

  1. Gilbert, J. 1999. Responding to mental distress: Cultural imperialism or the struggle for synthesis? Development in practice. 9:287-295
  2. Aggarwal, N.K. 2013. From DSM-IV to DSM-5 an interim report from a cultural psychiatry perspective. British Journal of Psychiatry. 37:171-174
  3. Alarcon, R.D. 2009. Culture, cultural factors and psychiatric diagnosis: review and projections. World Psychiatry. 8:131-139
  4. Canino, G., Alegria, M. 2008. Psychiatric diagnosis – is it universal or relative to culture? The Journal of Child Psychology and Psychiatry. 49: 237-250
  5. Harpham, T. 1994. Urbanization and mental health in developing countries: A research role for social scientists, public health professionals and social psychiatrists. Social Science & Medicine. 39:233-245
  6. Kirmayer, L.J. 1989. Cultural variations in the response to psychiatric disorders and emotional distress. Social Science & Medicine. 29: 327-339
  7. Thakker, J., Ward, T., Strongman, K.T. 1999. Mental disorder and cross-cultural psychology: A constructivist perspective. Clinical Psychology Review. 19: 843-874
  8. Gilbert, J. 2007. Mental Health: Culture, Language and Power. Global Health Watch 2.
  9. Gilbert, J. 2007. What is it to be human? Finding meaning in a cultural context.
  10. Gilbert, J. Cultural imperialism revisisted. Counselling and globalization. Critical Psychology.
  11. Gilbert, J. 2006. Cultural imperialism revisited: Counselling and Globalisation. International Journal of Critical Psychology, Special Issue: Critical Psychology in Africa. 17:10-28
  12. Gilbert, J. 2000. Crossing the Cultural Divide? The Health Exchange. April 15-16

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Mental Health Conditions by amenclinicsphotos ac

Categories
Empathy Humanistic Psychology Patient-Centered Care Psychology Reflection

Applying Humanistic Psychology to Medical Practice

“People are just as wonderful as sunsets if you let them be. When I look at a sunset, I don’t find myself saying, ‘Soften the orange a bit on the right hand corner.’ I don’t try to control a sunset. I watch with awe as it unfolds.” –Carl Rogers1

We as human beings love categories. We enjoy dividing the body into its constituents, from the bones to the muscles to the skin, from the heart to the vessels to the blood cells. The more we can break something down, the more we can dissect it, understand it and build from it. It can be argued that this method of reductionism is what has led to many of the insights of the present day. It is by becoming so specialized within one area that one is able to build upon one’s expertise and develop novel ideas.

This method of classification, however, cannot be used to explain everything around us. While insightful in some areas, it can be destructive in others; namely, the human mind.

Look back at the history of Psychology and we see ourselves jumping through the same hoops of categorization, attempting to reduce our inner worlds into hierarchies and models. From the psychodynamic theories of Freud to the behavioristic perspectives popularized by Pavlov and Skinner, we are led to believe that if we can merely slice apart the human mind into chunk-sized pieces, perhaps we can gain insights into humanity itself.

But unlike the heart or the lungs, the way we choose to see a particular human mind can have profound effects upon that person. Tell someone that they are a mess of electrical impulses and chemicals, and they may see themselves and the world around them far differently than a person who believes that it is they themselves who have control over their lives.

There is a reason Psychology and Psychiatry garner so much criticism from the general public in a way that no other specialty does.  There is a reason that an anti-psychiatry movement exists, but there are no anti-surgery or anti-cardiology movements. It is because these theories, these categories, have an impact on how we see ourselves. They touch upon what it means to be human.

The argument I wish to propound is to urge us all to go beyond these categorizations, be they biomedical, psychological or social, and to take a more holistic approach, which I believe can best be viewed through the lens of Humanistic Psychology.

What is Humanistic Psychology?

Humanistic Psychology arose in response to the more mechanistic views of human behaviour that were gaining popularity in the 1950s2. Rather than focusing on one aspect of a person, be it our childhoods or our innate animalistic needs, Humanistic Psychology proposes that what is important is how the person themselves experiences the world around them. The human being is central. It is not the objective measurement of chemicals, electrophysiology or set questionnaires that lies at the heart of humanity, but how we think and feel.3

There are many contributors to the Humanistic canon, but I wish to focus on just one aspect of it: Carl Rodgers’ person-centered therapy. Although the word “therapy” implies a form of treatment for those with mental health problems, I wish to apply these principles to the arena of healthcare as a whole. I believe the therapeutic relationship between therapist and client can teach us much about our own relationships with patients within hospitals, emergency rooms and clinics.

Person-centered therapy is built upon three principles4:

  1. Congruency
  2. Unconditional Positive Regard
  3. Empathy

I will go through each of these in turn and focus on how they can transform our relationships with our patients.

Congruency

Congruency refers to genuineness, that is, displaying ‘your actual self’4 when dealing with a patient. This involves letting go of one’s mask and revealing one’s true feelings as they come and go. It requires a level of self-awareness, which allows us to fully experience the moment instead of remaining walled-off from our true inner state.

Do not think of yourself just as a doctor, a medical student or a healthcare professional. Undoubtedly there are professional boundaries that must always be maintained, and a profession that you represent every day. But be careful that you do not let this professional façade get in the way of your relationship with your patients. Remember that you are only human and the last thing a sick patient needs is a robot. By displaying an open and trusting character, you give your patient the opportunity to relax, to feel at ease and to be open about what is truly troubling them.

Congruency takes us back to our humanity, reminding us that there is little difference between ourselves and the patient sitting opposite. If we can come to terms with our own thoughts and emotions as we deal with the chaos that occurs in the world of healthcare, then we will be able to display a level of respect and understanding that will allow our patients to appreciate that they are speaking to a human being and not just a title.

Unconditional Positive Regard

Unconditional Positive Regard refers to the belief that people should be accepted as they are. For the professional, it involves displaying a non-judgmental attitude that is provided unconditionally, i.e. without limitations or expectations.

Although this is a concept well known to most of us, it can be difficult to put into practice. We all have our prejudices and our own rigid lines that we draw across our horizons. The expectation is not to get rid of all prejudice, but to be aware of how they impact our behaviour towards others.

Do we at times place blame on our patients?
Does our heart sink when we go to speak to certain people?
Do we have certain beliefs about people based on their clothing, their lifestyle, or their occupation?

Of course we do. Think back to a time when any of these thoughts have come to your mind and think about their effects. It may not necessarily mean that you throw everything in the air and scream your prejudices out loud. But it does mean that the way you regard your patient may be subtly altered; you may show less enthusiasm towards certain patients or display less sympathy than you would for someone else. It is by being aware of these little discrepancies that will make us all better clinicians.

Undoubtedly, healthcare places us all into positions where we come face-to-face with lifestyles that we disagree with and behaviours that we feel uncomfortable around. The idea is to go beyond these actions and see the human being lying beneath the layers. We must accept them as they are, and may be surprised to find that the patient responds with gratefulness at being treated as an equal.

Empathy

Perhaps the term most popular out of the three, empathy refers to the ability to understand what the other person is feeling. It involves having an understanding of the other person’s beliefs and values, and being cognizant of why they care about the issues that are important to them – in other words, it involves fully stepping inside another person’s private world.

Within healthcare, it is important that we do not go through a list of tick boxes and forget that our versions of events are not the same as theirs. All too often we may accept simple words such as ‘I’m frightened’ with a mere nod of the head and a simple smile on our faces without digging deeper and asking, ‘What is it you are frightened of?’ Our job does not merely consist of diagnosis and treatment, but of going further into our patients’ lives and understanding what their illnesses mean to them. What it means for them to be in hospital, to be a patient, to lose their role as a parent or a provider. Without this aspect, we may well cure a disease with our drugs and our technology, but we will never get to the heart of the matter.

What does it all mean?

These are all terms that most of us are familiar with. They are words we may write time and again upon reflection, sayings that we repeat year after year during our interviews. But the idea is to put this into practice, which can only happen if we first take a step back and think about the times when perhaps these three concepts were not fulfilled. Those times when the relationship broke down, when the patient closed up, when we walked out of the consulting room thinking that could have gone better.

Remember that patients do not always come to us with a collapsed lung or a broken rib. They come to us as a whole. The idea behind Humanistic Psychology is to go beyond the reductionist theories that focused on one aspect of a person’s being, and to appreciate the totality of human experience.

Why do I think these three concepts are important? Because I believe these are concepts that make all of us much better clinicians, and ultimately much better people. I believe that almost all of the problems we face within healthcare, and indeed outside of it, revolve around our ability to relate to others. How differently would we act if we could truly see through the eyes of the person sitting next to us, feel their pain and suffering, think their thoughts as they swirl between their children, their loved ones, their aims and their worries? These concepts, although integral to person-centered therapy, transcend the therapist’s room and can be practiced in every dialogue across every hospital and by every person, including you and I.

“In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?” –Carl Rogers6

References

  1. Culture of Empathy. Carl Rogers Empathy Quotes. [Accessed: 28th May 2016]. Available from: http://cultureofempathy.com/references/Experts/Carl-Rogers-Quotes.htm [Accessed: 27th May 2016]
  2. com. Humanistic Approach in Psychology: Definition & History. [Accessed: 29th May 2016]. Available from: http://study.com/academy/lesson/humanistic-approach-in-psychology-definition-lesson-quiz.html
  3. McLeod, S. Humanism; 2007. [Accessed: 27th May 2016]. Available from: http://www.simplypsychology.org/humanistic.html
  4. McLeod, S. Person Centered Therapy [Online]; 2008. [Accessed: 27th May 2016]. Available from: http://www.simplypsychology.org/client-centred-therapy.html
  5. Gillon, E. A Person-Centred Theory of Psychological Therapy. In: Person-Centred Counselling Psychology: An Introduction. SAGE Publications Ltd; 2007. p.43-67.
  6. BrainyQuote. Carl Rogers Quotes. [Accessed: 28th May 2016]. Available from:                          http://www.brainyquote.com/quotes/quotes/c/carlrogers202206.html

Featured image:
Genetic inheritance by Patrik Nygren