Posts Tagged 'evidence based practice'

Global Mental Health Capacity Building at the 2012 ISTSS Annual Meeting

The annual meeting of the International Society for Traumatic Stress Studies (ISTSS), this year held in Los Angeles, wrapped up this weekend. This year’s theme, Beyond Boundaries: Innovations to Expand Services and Tailor Traumatic Stress Treatments, was in large part a response to a lack of global and cross-cultural perspectives at most ISTSS meetings. This year the planning was directed by two global mental health researchers, Debra Kaysen (University of Washington’s Global Mental Health program)and Wieste Tol (Johns Hopkins). Thanks to Debra and Wietse and their deputies (disclosure: the latter crowd includes yours truly), global perspectives were given the main stage. This was most obvious in two of the keynote addresses, one by global mental health luminary Vikram Patel (Kings College London School of Hygiene and Tropical Medicine and founder of Sangath) and longtime transcultural psychosocialist Joop de Jong (the founder of Transcultural Psychosocial Organization (TPO), professor at VU Amsterdam (which is the link), the University of Amsterdam, Boston University, Rhodes University in South Africa). (A request to academics from the blogosphere: If you’re going to hold appointments at multiple institutions, please host your own website — finding which link to post ain’t easy.)

In addition to the international perspectives, it was good to hear the issue of capacity building addressed head on. This was addressed in the keynotes, but it also had it’s own symposium. Theresa Betancourt (Harvard) chaired “Capacity Building in Low-Resource Settings,” and she laid out the issue as movement from “relief to resource,” which sums it up nicely. Speakers included Vikram Patel, Mary Fabri (formerly of Heartland Alliance in Chicago), and Joop de Jong. One of the key problems in global trauma practice is that mental health professionals from high income countries fly in to low and middle income countries (LMICs), do their thing for a few weeks or a few months, then fly out — leaving nothing in terms of increased ability to deal with the long-term issues related to disasters, let alone in terms of preparation for subsequent ones. Capacity Building in Low-Resource Settings was a discussion of how to guard against this all too frequent phenomenon.

Vikram Patel noted that a key to “scaling up” access to empirically supported treatments was identifying “primary tools of mental health… skilled human beings.” Patel is well-known for advocating “task-shifting” to “nonspecialists” — in the US we would call them paraprofessionals. His preferred term is “counselors,” as it is a now globally familiar term because of the widespread use of counselors for medication adherence issues in HIV/AIDS work and breastfeeding (the two global public health predecessors Patel looks to as models for global mental health). Important “soft skills” (i.e., non-content specific capabilities) that are basic to counseling include: engaging patients, assessing their mental health, suicide assessment, and knowing when to refer to more skilled professionals. The next stage of training involves advanced competencies that are disorder-specific, treatment-specific, and health context specific. Acquiring these competencies involves brief (a few days) classroom training and then moving trainees on to supervised field work (a few months). One of the major stumbling blocks to sustainability of any counseling program is the lack of consistent supervision. Patel has moved to a model that includes peer supervision with web-based (e.g., Skype) supervision done remotely. He noted that as very often counsellors do much more therapy than senior supervisors, peer supervision is often better than supervision by senior intervention researchers.

These themes were taken up by Mary Fabri and Theresa Betancourt in explications of their clinical interventions efforts with women in Rwanda and former child soldiers in Sierra Leone, respectively. A common problem was remote supervision. Certainly Skype and other web-based communication helps connect experienced clinicians, but connection speeds being what they are — or rather, what they are not — in many lower income countries, these are often simply not feasible. Fabri makes frequent trips, and Betancourt gets by with large telephone bills for weekly supervision.

Only just touched upon was how these programs, sustained largely with external funding, can be integrated into a countries’ national health strategies. One particularly sticky issue related to certification. Joop de Jong noted that “professionalizing” lay workers has historically been accompanied by nongovernmental organizations’ (NGOs) ignorance to local politics. The inability to engage established local authorities makes them (understandably) angry, which then leads to barriers to certifying those who have been working with NGOs following post-conflict periods (and may extend to them being unable to access educational resources as well). It is during these “post-post-conflict” periods where the sustainability of programs is proven.

Left untouched was the issue of building research capacity. But research capacity building was not left undiscussed at the conference. Later in the evening I had the good fortune to be at dinner with Marc Jordans, the Research Director at HealthNet TPO (also at Kings College London School of Hygiene and Tropical Medicine), who has made research capacity a priority. He explained the process as excruciatingly slow, as the challenges are largely educational. Here’s where the distinction between lower income countries and middle income countries is critical. Middle income countries (MICs — e.g., India, Peru) tend to have university systems, and therefore a pool of educated researchers in a field that uses research methods applicable to mental health research (.e.g, sociology, anthropology, public health); lower income countries (LICs — Sierra Leone, Nepal), however, often have one or two universities, and a very small pool of people with the base level research understanding to build upon. In essence, groups like HealthNet TPO are engaged in educational development, which, like all development work, is a multi-decade proposition. Jordans added, however, that the payoff for homegrown LIC researchers with a PhD is great, given that they are one of a few in their countries with the expertise and legitimacy to advise governmental and international organizations working in their regions.

Two press pieces on the science (and anti-science) of PTSD in the military

The past weekend saw two articles in the popular press concerning PTSD among U.S. soldiers that are worth a read. First, the Seattle Times reported that the Army’s new PTSD screening guidelines fault the established screening tests designed to root out PTSD fakers. Why would anyone fake PTSD? The Army pays an average of $1.5 million in disability benefits per soldier (over his/her lifetime) with PTSD. It is estimated that 22 percent of returning soldiers have PTSD. The difference between those who have it and those who may be faking is no small chunk of change.

In part because of pressure by Senator Patty Murray (D-Washington) to investigate screening at the Madigan Army Medical Center (in Tacoma, Washington), the Army Surgeon General has issued new guidelines that criticize the use of the Minnesota Multiphasic Personality Inventory — or, MMPI, as most psychologists know it. The MMPI is one of the most venerated of psychological screening questionnaires, holding up pretty well in over 60+ years of research (it has been revised several times, most recently in 2008). At issue in this case is the MMPI’s “lie scale,” which has been shown to detect malingerers of various stripes in multiple studies.

According the the Seattle Times, the Army’s new policy “specifically discounts tests used to determine whether soldiers are faking symptoms of post-traumatic stress disorder. It says that poor test results do not constitute malingering.” Technically this is true; malingering scale scores on any normed test like the MMPI are associated with higher or lower probabilities of malingering, and not absolute certainty. Still, by throwing out the best tool they have to detect whether soldiers are malingering or not, what the Army really seems to be doing is trying to avoid appearing callous by relying on scientific methods.

Ironically, the same guidelines include empirically-based treatment improvements regarding medication:

The document found “no benefit” from the use of Xanax, Librium, Valium and other drugs known as benzodiazepines in the treatment of PTSD among combat veterans. Moreover, use of those drugs can cause harm, the Surgeon General’s Office said. The drugs may increase fear and anxiety responses in these patients. And, once prescribed, they “can be very difficult, if not impossible, to discontinue,” due to significant withdrawal symptoms compounded by PTSD, the document states.

Score one for research on meds, zero for research on screening questionnaires (or maybe: psychiatrists one, psychologists zero).

The second article of note wasn’t a report, but an editorial. Writing in the New York Times’ Sunday Review, Weill Cornell Psychiatrist Richard Friedman builds the case that one possible reason for the increase in cases of PTSD among returning soldiers from Afghanistan and Iraq is an increase in stimulants prescribed to them on the battlefield. With the help of the Freedom of Information Act, Dr. Friedman found that military spending on stimulants increased 1,000 percent over five years.

Stimulants do much more than keep troops awake. They can also strengthen learning. By causing the direct release of norepinephrine — a close chemical relative of adrenaline — in the brain, stimulants facilitate memory formation. Not surprisingly, emotionally arousing experiences — both positive and negative — also cause a surge of norepinephrine, which helps to create vivid, long-lasting memories. That’s why we tend to remember events that stir our feelings and learn best when we are a little anxious.

Since PTSD is basically a pathological form of learning known as fear conditioning, stimulants could plausibly increase the risk of getting the disorder.

Dr. Friedman goes on to explain the neurochemistry behind the proposed interaction of stimulants and trauma, review new research showing ameliorative effects of beta-blockers, and (appropriately) call for more transparency and more research on the topic.

A “daily stressors & trauma” debate & the temptation of mental health evaluation for everything

In a special issue on “Conflict, violence and health” earlier this year, Social Science and Medicine published an editorial on trauma-focused versus psychosocial perspectives in humanitarian aid that Ken Miller and I wrote (see my blog post from June 29th, 2010 for related material). This week the second October 2010 issue of the same journal includes a critique of our editorial from the accomplished refugee trauma researcher Frank Neuner and our response to this critique. Lest you think that publishing a second October issue in mid-September is the sign of general silliness, let me inform you that (1) the virtual world resides somewhere in the future, and (2) Social Science and Medicine consistently publishes high-quality health research and — notably — debates (like ours) in subfields that could use a healthy does of academic energy.

Our debate primarily concerns how best to provide “psychosocial” and “trauma-related” mental health services to displaced populations (i.e., refugees). The three articles are a somewhat academic read (all of us are, after all, academics), but I would not say that the topic is purely academic. Psychosocial aid and trauma interventions are hot topics in humanitarian aid, and agencies’ perspectives on these issues has direct relevance for the design of programs in the field.

I won’t repeat the detailed back-and-forth here, as you can read the articles yourselves (if you have trouble accessing the links above please let me know). I do, however, want to highlight one important point of agreement. Even though we reiterate this point in our response, I think Neuner says it better in his critique of the editorial:

Reducing hardship and daily stress is without a doubt a key objective of humanitarian assistance. No one would disagree that increasing security in refugee camps, improving child protection and medical care, reducing violence and poverty, increasing awareness of gender issues, and reducing discrimination should be high priority goals that deserve much attention by humanitarian agencies. The respective programs should clearly state their goals and be evaluated according to their specific aims. However, it is premature to claim that such programs heal psychological disorders or foster mental health. The increasing tendency to justify widespread programs on the basis of mental health is worrisome and seems to reflect the tendency to comply with donors’ fashions. Why must a program that aims at reducing discrimination of former child soldiers also improve mental health? Reducing discrimination, just like improving development and reducing violence is a worthy objective on its own right.

The increasing tendency to judge interventions in refugee camps — even interventions with the label “psychosocial” — solely by examining rates of psychiatric diagnoses pre- and post-intervention is indeed a problem. Having participated in such evaluations, I can attest that apart from the considerable cross-cultural assessment issues and challenging diagnostic environment, these efforts leave me with the sinking feeling that many in humanitarian aid have succumbed to the temptation of scientific — or perhaps better put, “scientistic” — validation. In other words, evaluations that were specific to specific programs (e.g., measuring change in social and economic indicators in order to judge child soldier reintegration programs) became mental health evaluations (measuring reductions in anxiety in order to judge child soldier reintegration programs), thereby getting the stamp of approval of medical science. This curious turn of events has meant that many programs (at least those not directly tied to food, water, and other basic needs) are now “sold” to donors in the language of mental health, even though they may working towards some other — also worthy — objective.

Randomista 2: Medical marijuana for veterans with PTSD?

Only moments after writing this morning’s entry about randomized control trials, a friend sends me a link to the following, from this morning’s Morning Edition on NPR:

The arguments around marijuana and PTSD start running in circles at a certain point. Scientists say more research is needed. Activists counter that the federal government has blocked research because marijuana is illegal. The American Medical Association has called for controlled studies to settle this and other questions about the effectiveness of marijuana.

Meanwhile, policymakers in states with medical marijuana programs have to make decisions now, and they’re reaching different conclusions. While New Mexico found there’s enough evidence to approve marijuana use for PTSD, next door in Colorado lawmakers recently rejected a similar proposal.

Pot for posttraumatic stress disorder? This is a good example of how randomized control trials can help. Everybody knows that pot makes people “feel good” (or so I hear), but to decide that doctors should be prescribing it to patients with PTSD — and whether health insurance should cover costs associated with medical marijuana — we’d have to know that for more people than not it reduces symptoms over a certain period of time more than the counseling and medication the patient is already using.

Incidentally, I’ve always suspected that the medical marijuana movement was a little bit of a backdoor to legalization, for the following reason: most people in the movement seem to think that smoking it is medically necessary. If smoking a drug is the most efficient delivery system, why don’t we smoke Paxil or Zoloft? Cannabinoid pills seem to make more sense. In the NPR story, the young man mixes his cannabis into hot chocolate in order to better control the dosage. I suppose we could randomly assign medical marijuana users to “smoking” and “hot chocolate” conditions to get to the bottom of this.

Read/listen to the entire story on a young New Mexican veteran’s use of marijuana to control his PTSD symptoms by linking to the article here. If what I’ve written isn’t enough to get you there yet, consider the following: his wife says, “Medical cannabis saved our marriage.”

Randomistas, development economics, and the poetry of evaluation

Last week’s New Yorker featured an engaging portrait by Ian Parker of MIT development economist Esther Duflo, perhaps the leading light among that field’s “randomistas.” These (mostly) young economists have made their mark on their profession by applying randomized control trials (borrowed from medicine) to development strategies. This really shouldn’t surprise anyone — randomized control trials have been used for other types social programs (e.g., delinquency prevention) for years now, and given that economics is about human behavior it’s surprising that economists haven’t embraced this earlier.

Also familiar to behavioral scientists are the objections to assigning participants at random to experimental and control groups.

“You shouldn’t be experimenting on people.” O.K., so you have no idea whether [your programs] work–that’s not experimental?

The former is met far to infrequently with the latter. Someone comes up with an idea for some intervention, they announce their intentions and put that idea into practice, and all of a sudden it is accepted as the right thing to do… and to test whether it works better than doing nothing (which really means “better than engaging the variety of things people do that you don’t know about”) thus becomes the wrong thing to do. That’s some sloppy ethics, at best.

The one objection to randomized control trials mentioned in the article that might hold water is that an intervention shown to be empirically supported in one context might not be empirically supported in another due to variation in ecological and temporal phenomena. Of course, the logical solution is more experimentation, not less. In their psychosocial programs in the Democratic Republic of Congo, the Center for Victims of Torture has instituted what Research Director Jon Hubbard calls “rolling control groups” to address the problem of changing context. The situation in conflict zones is often very fluid, and so if a program is shown to be better than doing nothing during one intervention period (6 weeks for CVT’s program) that doesn’t mean that it will be better during the next. So Hubbard came up with the rolling control: at the beginning of each intervention period, the program accepts and screens 125% of their capacity, then randomly assigns 25% to a wait list control; after the intervention period they give post-tests for each group, viola! They have a small-scale randomized control trial that shows their funders that they are monitoring the effectiveness of their programs for each cohort.

The article on Duflo ends with a couple paragraphs on the art of the evaluator’s profession that I found particularly striking — but admittedly, maybe only a data nerd like myself would love:

“It can’t only be the data,” Duflo said, showing a rare willingness to generalize. “Even to understand what data means, and what data I need, I need to form an intuition about things. And that process is as ad hoc and impressionistic as anybody’s

It can’t only be the data, but there must be data. “There is a lot of noise in the world,” Duflo said. “And there is a lot of idiosyncrasy. But there are also regularities and phenomena. And what the data is going to be able to do–if there’s enough of it–is uncover, in the mess and noise of the world, some lines of music that may actually have harmony. It’s there, somewhere.”

Vikram Patel at NYU, and a genuine global mental health agenda

Last Friday, March 6, the good folks at NYU’s program in Global Public Health hosted a lecture and discussion with global mental health luminary Vikram Patel. Dr. Patel is one of the forces (perhaps the driving force) behind the field of global mental health, and one of the architects of the Lancet’s series on the subject in 2007. This relatively new field combines public health, cross-cultural psychology, and human rights, and seeks to expand concern for mental health disability from it’s purview as a Northern luxury into a worldwide movement. For more general information on the topic, visit www.globalmentalhealth.org.

Dr. Patel’s talk at NYU was largely a call to action, as opposed to an empirical evaluation of the field’s successes and failures to this point. This is not to his discredit; Dr. Patel knows of what he speaks. From his groud-breaking work on Shona idioms of distress in his native Zimbabwe to his more recent clinical trials of community health workers’ delivery of mental health services in his family’s homeland India, Dr. Patel is well-steeped in several of the field’s parent disciplines. But Friday’s purpose was to spread the word. Lauding the success of the HIV/AIDS public health movement, Dr. Patel called on public health workers — or at least the public health trainees present — to take up similar strategies to convince public officials and other healthcare workers that mental health must be a priority in the developing South as well as developed North.

As for research, Dr. Patel noted that 90% of mental health research is done in the developed North (and within that, most in the US), and insisted that that must change. Research must guide practice in order to avoid the mistake of simply applying US or European models elsewhere. Along these lines, he pointed to recent funding interest in global mental health, even by the US’s NIMH (specifically, a recent blog post by director Thomas Insel titled “Disorders without Borders” — good grief!), a research body not known to fund many international projects.

This brought a question from the crowd (well, actually a question from me): If 90% of the mental health research is done in the developed North — the place where academics have the technology, funding, and financial interests to do research — and more research needs to be done in the less developed South, how should this be accomplished without running roughshod over local explanatory models of mental distress and local service models that may do some good? Dr. Patel acknowledged that this was a major concern, and provided the following solution: work with and teach local practitioners to do the research.

This simple-sounding solution is actually a tall order. The money and research technology (and here I’m talking about specialized research training as well as computer software) is in the North. The academic motivation for high-quality research is also largely Northern — “publish or perish.” It’s hard to see how NIMH-funded research would not evince a preference for US-led projects. So at the moment, beyond projects that hire locals to collect data, it’s hard to find projects that really substantively involve local ideas and researchers and people schooled and based in the research-resourced North (like the students at NYU last Friday). But there are a few — although very few — projects that fit the bill.

The first is Patel’s own work. Although he holds several professorships throughout the Europe and North America, he is based in Goa, India, and his research is there, and includes local staff. However, until more Vikram Patels arise (which won’t be too long, I think), his remains a special case of a culture-spanning researcher, trained in Northern/Western models and adapting, applying and distributing them throughout the developing world.

The best example of a US-led project is a USAID-funded program out of the Center for Victims of Torture (CVT) in Minneapolis, the International Program Evaluation Collaborative, or IRPEC. The brainchild of Jon Hubbard, the Research director at CVT, IRPEC aims to transfer the technology of empirical research to NGO’s working in mental health and human rights around the world in order better collect and analyze data to improve their services (and, of course, to get grants from Northern foundations which require such information). At this point I should probably disclose that I was an evaluator for IRPEC this past summer (see entries on Cambodia and Peru for related material), and that I was pretty impressed.

During this evaluation Jon told me a story of meeting a researcher who evaluates such programs who asked him, “Okay, but where’s your data?” Jon replied, “It’s not my data. It’s their data.” Until we can take up Hubbard’s example, those of us in the North who work in global mental health will always be in danger of “getting it wrong” — both ethically as well as empirically — in our quest to answer Vikram Patel’s call.

NPR puts mental health after buildings in Haiti; now we’re getting it

This morning, bleary eyed and half asleep, I turned on National Public Radio’s Morning Edition, as I do pretty much every morning of the week. Following a feature on structural instability of buildings in Port Au Prince, Haiti, Alix Spiegel reported on the field of disaster mental health. Usually popular depictions of my field make me cringe — stories of mass trauma, generations of psychological damage, and heroic psychologists healing the unthinkable are everywhere these days — but today I was delightfully surprised.

They came after the Oklahoma City bombing, and flooded Sri Lanka in the wake of the South Asian tsunami. They came in droves to New York after 9/11. And according to Richard Mollica, a professor at Harvard who’s spent his life researching mental health responses to natural and man-made disasters, mental health professionals will soon come to Haiti as well.

“There’s going to be many, many, many, many hundreds of organization—– big, little and small—– doing mental health work in Haiti, “ Mollica says. “ And they will all have their own agenda, and their own donors, and their own goals.”

All will come with the best of intentions, says Mollica, but the work of a mental health professional in the aftermath of a major disaster like Haiti’s isn’t always clear. The science of how to treat psychological trauma is still very much evolving.

“Mental health has had a hard time figuring out how to fit in with the medical response,” says Mollica. Apparently while mending a broken leg is a straight forward process, mending a broken heart is much more fraught.

Okay, so “broken heart” is not what psychologists treat (usually), but other than that, the story’s pretty good. Why? First, as you can read above, the primary issue is coordination of services, as outlined by Richard Mollica (Harvard luminary in disaster mental health). Second, the piece provides a healthy dose of criticism of how our field’s embrace of PTSD as the main trauma-related problem led us to limit our thinking for what we should do (from Sandro Galea, PTSD research wunderkind). Third (and related to the second), there’s a good discussion of critical incident stress debriefing (mistakenly referred to as simply “debriefing”), which may have resulted in more people developing PTSD than would have if they had simply been left alone. Finally, as Dr. Mollica points out, psychological first aid is really more like social work 101:

The funny thing about “psychological first aid” though, is that there’s very little that’s particularly “psychological” about it. Mollica says it’s mostly very practical, basic social work.

“You can’t find your son? Well, this is who you need to talk to at the Red Cross to find your son. You don’t have enough water for tonight? This is who you need to talk to to get water for yourself.”

A couple weeks ago, I wrote in these blog pages that we really haven’t gotten much further than this. This is still true, but there is, according to Charles Marmar in an NYU Psychiatry Grand Rounds a few weeks ago, work afoot to test a behavioral treatment for the acute phase of trauma reactions (disclosure: Dr. Marmar is one of my bosses, and I like the guy). Based on  cognitive behavioral treatment for panic attacks, this treatment would involve anxiety reduction through brief education about reactions to trauma, breathing control, muscle relaxation, and thought stopping (a basic CBT technique). It would not involve reviewing or processing the trauma expereince, contraindicated in the acute posttrauma phase (the problem with critical incident stress debriefing).

In his talk, Marmar emphasized what Mollica alluded to this morning: “Mental health intervention the absence of basic needs is generally not effective.” So let’s make extra sure that mental health relief provided to Haiti follows material relief (as it did on NPR this morning).

The globalization of American psychology

I know it’s bad form, but I’m going to quote myself, from yesterday’s entry:

For those of us who are trained in the US system and interested in global mental health, I can’t think of anything more important than developing a critique of our own failures. Let’s not globalize American medication or our rejection of empirically supported treatments.

And today, I open up my New York Times magazine, and voila: The Americanization of Mental Illness. (Am I controlling the New York Times through my blog?)

Ethan Watters presents a summary of his soon to be released book “Crazy Like Us: The Globalization of the American Psyche” and it’s worth a read. I won’t rewrite the whole piece here, but his essential argument is the good faith efforts of Euro-American mental health care practitioners is serving to change how people in other cultures view non-normative behaviors, and that’s not all good. He makes it clear that he is not belittling mental illness or the suffering that accompanies it, and that he respects Western medical science’s contribution to examining the mechanisms of mental illness. Here’s his follow-up:

Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening. Thoe stories, whether they rely on spirit possession, semen loss or serotonin depletion, predict and shape the course of the illness in dramatic and often counterintuitive ways… mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits, and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

This is good cultural psychology, and it’s great to see it’s getting fair play. Watters goes on to present research showing that the mental health literacy movement’s push to destigmatize schizophrenia by presenting it as a “brain disease” actually has the opposite effect, and how the medicalization of mental illness (as opposed to viewing it as a psychosocial problem) can result in the formation of a sufferer identity rather than as someone suffering from an affliction.

I encourage you to read the article, but I can’t resist a few quotes here. A Chinese psychiatrist is interviewed about an epidemic of Western-style anorexia in Hong Kong, and sums up the larger problem thusly:

As Western categories for diseases have gained dominance, micro-cultures that shape the illness experiences of individual patients are being discarded… The current is too strong.

Describing the anemic section of the DSM-IV given to non-Western mental illness categories:

Illnesses found only in other cultures are often treated like carnival sideshows. Koro, amok and the like can be found far back in the American diagnostic manual (DSM-IV, Pages 845-849) under the heading “culture-bound syndromes.” Given the attention they get, they might as well be labeled “Psychiatric Exotica: Two Bits a Gander.”

And here’s the kicker, on our exporting the culture that Judith Warner discussed yesterday:

The ideas we export often have at their heart a particularly American brand of hyperintrospection — a penchant for “psychologizing” daily existence. These ideas remain deeply influenced by the Cartesian split between the mind and the body, the Freudian duality between the conscious and unconscious, as well as the many self-help philosophies and schools of therapy that have encouraged Americans to separate the health of the individual from the health of the group. These Western ideas of the mind are proving as seductive to the rest of the world as fast food and rap music, and we are spreading them with speed and vigor.

Placebo effects, traditional healers, and cross-cultural psychology

Placebo effects and non-evidence based practice (December 6 post) have direct relevance for cross-cultural psychology, including post-disaster mental health in non-Western contexts. There’s a healthy debate occurring in trauma psychology concerning the most appropriate modes of service delivery following mass violence. Specifically, the debate revolves around whether disaster mental health professionals s should upport traditional (or at least local) healing or import Western psychological practices into the local context.

First, a few basics. When psychologists talk about traditional healing, they usually mean the treatments applied by traditional healers, locally-identified experts specific to the cultural context in which they are working. So, for example, in eastern Chad where there are lots of refugees from Darfur, traditional healers are marabouts, or fakir, people who have studied healing practices, including the use of local medicinal plants and spiritual practices (e.g., incantation of verses from the Koran, for instance). You can include Inuit shamans, Tibetan emchis, etc. in this category. In general, traditional healers are usually thought of as separate from medical and psychological professionals trained in Western medicine. In other words, they are “culturally bounded.” (Of course, the reality is that traditional healers may integrate many aspects of Western medicine, and may even be Western-trained professionals who use culturally-bounded practices as well as those they learned in their Western professional training.)

Usually we think of traditional healing as easy to “respectfully dismiss,” as clearly it’s not evidence based… right? Well, actually, there is some evidence supporting traditional healing. Joop de Jong, one of the founders of the global Transcultural Psychiatry Organization, presented some evidence just over a year ago that in a randomized clinical trial of counseling versus traditional healing in Burundi, the traditional healers had a much greater healing effect. In other words, traditional healing is evidence based practice for mental health problems (at least in Burundi). Of course you’ll want to know more about this study… but for that you’ll have to ask Joop.

So what does traditional healing have to do with the placebo effect? In the US, dismantling studies have shown that some 30-40% of the efficacy of therapy is just showing up for that first appointment. Patients have a belief – a culturally-grounded belief – that going to therapy is the right thing to do, so it works. This is essentially a placebo effect (of course, if you read the December 6 entry, you knew that). Cross-culturally, the placebo changes. Placebo effects are culturally-bounded.

An example: In eastern Chad traditional healers from Darfur told me that they cured “madness” (majnun) by writing Koranic verses on a tablet of wood with charcoal, then washing the tablet and making the patient drink the water that they washed the tablet with (which presumably holds the power of the verses as well as charcoal dust and whatever else was on the wooden tablet). Do patients get better? Some seem to, at least a little bit, in the short term. Would anyone reading this blog get better in a similar situation? Probably not. Why? Because the placebo effect depends on whether or not you accept the practice/practitioner as medically legitimate.

Of course, with globalization, healing practices are not necessarily unique to specific medical cultures. An example from a little closer to home: In the clinic where I work in New York, which serves patients from all over the world, we find that patients from countries where psychology is not known as a mode to treat common mental disorders often need a lot of convincing that counseling will help them in order for it to stick. Counseling is still a pretty culturally-bounded practice — culturally-bounded within Western medical culture. However, prescribing pills that make them feel better (and then maybe using some evidenced based CBT or relaxation techniques) is a lot more acceptable. Taking pills to relieve symptoms is a practice that seems to have gone cross-cultural.

The challenge for those setting up health systems in cross-cultural or multicultural settings, then, is to figure out how to utilize existing service delivery modes and networks to deliver evidenced based treatments without disrupting culturally-bounded placebo effects.


US health care debate and prayer: Should we reimburse non-evidence based practices?

The New York Times has been running regular articles about the health care debate in the US Congress, and as the debate drags on, the Times gets further and further into the minutia of the proposed legislation. Their “Prescriptions” blog provides running commentary, and today’s includes what seems to me a well-balanced (fair and balanced?) portrayal of a small corner of the larger debate, namely whether the Senate’s health care legislation will cover non-evidence based practices… like prayer.

Turns out that Christian Scientists, some of whom rely on prayer alone in healing illness, have some friends in the Senate. Lest you think this is purely a conservative cause, the late Ted Kennedy was an advocate for government coverage of their services. I’m not exactly sure what the cost structure of prayer is (the Times blog has a figure of $20 a day for Christian Scientist practitioners — uh, separation of Church and State?), but this fascinating debate goes far beyond Christian Science — American Indian medicine includes spiritual practices, and would also likely be covered by the proposed legislation — and may even have relevance for psychology.

How does evidence based medicine apply to psychology? Well, some psychologists test their therapies, and in general they find that… most of them work pretty well in alleviating many problems for many people. Moreover, it turns out that the professional identity of the treater makes little difference — for instance, pastors, on average, get results that are, on average, as good as Clinical Psychologists (for those of you who want evidence of this, do a Google Scholar search for “Dodo bird effect” or “Luborsky et al 1999″). Why might this be? My take on it is that it’s likely related to a psychological “placebo effect.”

Often we hear about the placebo effect in the context of testing new medication. Placebos are pills with no inherent medical properties that doctors conducting experiments give to patients in their “control group” in order to rule out the salutatory psychological effects of getting any treatment (i.e., the expectation that patients will get better contributes to them getting better). If experimental pill X has a greater effect that placebo pill Y, we can say that pill X is evidence based. We know that placebos usually have real effects — in those studies that have a “no treatment” group (i.e., no placebo, no experimental poll), the placebo group almost always does much better than the no treatment group. Thus placebos are actually evidence based, in as much as scientific evidence shows that they work better than nothing. I personally always ask my doctor for the placebo. It usually costs less and has fewer known side effects… er, okay, that’s a joke. Placebos wouldn’t work if you knew they were placebos. You see, you have to believe.

Which brings us to psychology. (And to the very real power of religious faith, but I’m going to focus on psychology.) It is my reading of the literature on evidence based practice in psychology that most of the effect of psychological interventions is due to a placebo effect. Not there aren’t any practices that improve upon the placebo, there are. But those practices (commonly referred to as “evidence based practices” or “empirically supported treatment”) usually have only shown that they do a little bit better than the practices they are compared to. Most of the effect is due to the patient (or “client,” if you prefer) deciding they are going to get treatment and showing up to talk to a welcoming person. So, should we reimburse those practices that we think are akin to placebos simply because they work?

There are lots of things that contribute to well-being, and not all should be considered treatment of the reimbursable kind. Let’s make sure to cover those psychological practices for which we have good evidence are better than simply showing up for treatment and believing you’re going to get better. For those problems for which we don’t have good evidence based practices, let’s (1) encourage health care research and (2) acknowledge the healing power of non-professional support. But let’s not pay for something that can be acquired from somewhere else.


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