Tag: psychology

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

Featured image:
Mental Health Conditions by amenclinicsphotos ac

Categories
General

Neurology and Us: What Are Our Minds?

Conceptual side profile of a human face, with see through illustration of the brain.

As medical students, we have to take many classes. Some of them are relatively easy, and some of them are hard. One class notorious for being very difficult is neurology. Despite this, though, I find neurology to be one of the most fascinating subjects we study. Think about it: everything we call “us” arises somehow out of vast networks of interconnected neurons. It is mind-blowing to even begin to contemplate the complexity of the neuronal machinery responsible for such tasks as creating our thoughts, emotions, personalities, etc. etc.

For millennia, philosophers have been attempting to accurately describe what it is to be human without the aid of neuroscience. Only recently has neuroscience been added into the mix of this speculation; the first notable contribution of neuroscience to theories of mind appeared in 1949 as Donald Hebb’s book The Organization of Behavior. For the first time in a major publication, a neuroscientist postulated that it was possible for the purely physical processes of neuronal circuitry to explain psychological phenomena like states of mind and learning. Before the advent of neuroscience, learning was considered a psychological phenomenon, and any attempt to explain it in detail had no recourse to neurophysiology. Now, learning is taught in medical school curricula as at least partially due to changes in both presynaptic and postsynaptic neuron adaptations (changes in neurotransmitter release rate in the presynaptic neuron and long term potentiation in the postsynaptic neuron). This represents a paradigm shift in the way we think about ourselves. Is learning the only psychological phenomenon explainable by changes in neurotransmitter release and altered receptor densities? Are all aspects of our minds the result of nothing but extremely complex neuronal circuitry?

Proponents of a theory termed eliminative materialism believe all of the commonly held beliefs about our minds will soon be replaced by neurophysiological explanations at the level of neuron circuitry. As the Stanford Encyclopedia of Philosophy puts it in the entry on the philosophy of neuroscience:

“Eliminative materialism (EM) is the conjunction of two claims. First, our common sense ‘belief-desire’ conception of mental events and processes, our ‘folk psychology,’ is a false and misleading account of the causes of human behavior. Second, like other false conceptual frameworks from both folk theory and the history of science, it will be replaced by, rather than smoothly reduced or incorporated into, a future neuroscience. . . according to EM, continuing development in neuroscience will reveal that there are no such things as beliefs and desires as characterized by common sense.”

Will eliminative materialism turn out to be the correct account of our behavior? Who knows? The debate rages on. Neuroscience continues to uncover more physical processes underlying the way we experience the world, but competing theories claim the irreducibility of our experiences to mere materialistic phenomena. Even if I could, for example, fully explain the state of your nervous system down to the smallest detail after you learned of the passing of your loved one, does that mean I really know what you’re feeling? Does a specific brain state actually equate to an emotion as we experience it as conscious beings? I don’t know, that’s above my pay grade, but it’s fun to think about, isn’t it?

Source: Stanford Encyclopedia of Philosophy

Featured image:
object. by Evan