Archive for the 'academia' Category

WEIRD paper redux

Ethan Watters is at it again. Watters is the author of Crazy Like Us the book and blog of the same name, and a few weeks ago he published “We Aren’t the World” in Pacific Standard, a very readable piece about the WEIRD paper — Heine, Norenzayan, and Henrich’s “The Weirdest People in the World.” The paper is not new — it was published in 2010 — but it does continue to raise intriguing questions about the cultural specificity of most findings in psychology.

What’s WEIRD? Western, Educated, Industrialized, Rich and Democratic. What’s weird about them? It turns out they… er, we… are probably the worst population to do psychological research with if you want to get a picture of the average human psychology. Read the paper here.

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.

Partners in Health fellowship in Global Mental Health

The good people up at Partners in Health in Boston have an opening for a postdoctoral position in global mental health. Here’s the spiel:

Please see the following link for post-graduate fellowship experiences in global mental health delivery in Haiti and Rwanda through Harvard Medical School and the non-governmental organization, Partners In Health. This opportunity is now in its third year.

Information about the Fellowships and application links can be found here.

Although in the previous two years the fellowship has been filled by doctors, the director assures me that other Ph.D.’s would be more than welcome as well.

Looking for graduate school applicants for research in forced migration, trauma and stress at Fordham University

Fall is graduate school application time, as many programs have application deadlines in October, November and December. I have recently moved to Fordham University’s Department of Psychology, and will be looking for graduate student applicants to the Clinical Psychology Division for the 2013 cohort. If you read this blog you know my experience and general research interests, so you know what kind of student researchers I am looking for. Current research projects include comparing the social networks of forced and voluntary immigrants and the health and mental health implications of network differences, measuring trauma and stress in different culturally-defined subgroups, and community-based participatory research with immigrant populations in general. If those are topics that interest you (and you want to get a PhD in Clinical Psychology), follow the links on the Clinical Psychology website and apply.

Deadline for 2013 applicants is Wednesday, December 5, 2012.

If you are not sure you want to commit to a PhD, but know that you are generally interested in psychology, program evaluation and related skills, please visit Fordham University’s MS in Applied Psychological Methods page. Fordham’s APM program is a relatively new course of study that draws heavily on it’s well-respected Psychometrics and Applied Developmental Psychology divisions within the Department of Psychology. Admissions are “rolling,” meaning that you can apply at any time and start the following semester. Students can be full- or part-time.

Proposed DSM-5 Cultural Formulation guidelines: A report from the SSPC

Last week saw the annual meeting of the Society for the Study of Psychiatry and Culture (SSPC) in New York City. SSPC’s mission includes “furthering research, clinical care and education in cultural aspects of mental health and illness,” and although somewhat small includes some of the most prominent thinkers in the world of psychiatry and culture. These are the people who go beyond simplistic cultural diatheses (e.g., individualism versus collectivism), incorporating multidimensional frameworks that include political factors as well as ethnicity and race.

Among the livelier presentations was a report by Roberto Lewis-Fernandez, Neil Aggarwal (both at Columbia), Laurence Kirmayer (McGill), and Renato Alarcón (Mayo Clinic and Universidad Peruana Cayetano Heredia) on much needed updates to the Cultural Formulation guidelines in the upcoming DSM-5. The DSM — Diagnostic and Statistical Manual — is the American Psychiatric Association’s official guidebook to human psychopathology, and the current version, DSM-IV-TR, is largely accepted as the last word on mental health problems in psychiatry, psychology, social work, and related disciplines. Cultural Formulation guidelines are suggestions for how clinicians should conceptualize the role of culture in patients’ mental health problems. The guidelines appeared first in the pages of the DSM-IV (1994), but, along with a short and messy list of “Culture-Bound Syndromes,” were placed in the back of the book where few practitioners would ever find them.

This time around there is a widespread effort to place the Cultural Formulation front and center in the DSM-5. Drs. Lewis-Fernandez and Aggarwal reported on a tool designed to make cultural formulation quicker and easier, the Cultural Formulation Interview, or CFI. The CFI is meant to be administered during patients’ initial assessment, and consists of 14 questions. Many of these questions are just good clinical practice. For instance, the first question is, “What problems or concerns bring you to the clinic?” Although there are hints at what might be considered culture by question three (“People often understand their problems in their own way, which may be similar or different from how doctors explain the problem. How would you describe your problem to someone else?”), it’s not until the seventh question that culture is explicitly mentioned: “Is there anything about your background, for example your culture, race, ethnicity, religion or geographical origin that is causing problems for you in your current life situation?”

The point of framing the questions this way  is to not make a big deal of culture while at the same time getting a good person-centered assessment that considers culture as important to how patients view their problems. This is meant to avoid the stereotyping that considering culture often leads to in situations in which clinician and patient differ on some cultural dimension. The CFI seems to provide space for individuals to define their problems as they see fit — i.e., to make explicit their own explanatory models — and then relate this to how others within their social networks (including family members and those that don’t share their culture) may see their problems.

My favorite exchange came after one audience member looked over the CFI and asked, “For whom would these questions not be relevant?”

Dr. Lewis-Fernandez replied: “Yes, exactly.”

The CFI is currently undergoing field trials. Read more about the proposed DSM-5 Cultural Formulation and the CFI, and express your opinion as to whether it should be emphasized (or not, I suppose), by following this link to the DSM-5 commentary website. Common sense needs advocates.

On a related note: If you haven’t read it yet, Allen Frances’ Op-Ed in Saturday’s New York Times, provocatively titled Diagnosing the DSM, is worth it. In it Dr. Frances, one of the architects of the DSM-IV, argues strongly that the DSM-5 development process should be untethered from professional psychiatry in order to build a better product. A teaser:

Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.

Response style, and the differences between Swedish and Irish Americans

Whenever I teach response style — the tendency people have to express themselves using a consistent and limited range of expressive behavior — I talk about my grandmother. Lavern Rasmussen was a small-town Minnesotan with deep roots in Swedish and Danish communities. When my family would call her to check in, she would let us know that things were great by saying things were “not bad” and that things were not going so well by saying, “Oh, well, you know…” In teaching my students in New York, I ask them to translate Grandma’s responses into those of a randomly selected individual from the 8 million in our fair city, and when they do this (usually both positive and negative responses involve language unsuitable for printing in these pages), it becomes obvious that there are cultural differences within the U.S. as to how people respond to questions.

Why do psychologists care about this? Many of us use responses to questionnaires as our representation of people’s emotions, and if a certain group of people are responding on the low end of the scale and another group on the high end and we want to compare them, we need to know the characteristics of each group’s response style in order to tell if they are in fact having different reactions or not. And now I have a study to help me explain Grandma’s response style.

First, credit where credit is due: it was Andrew Ryder of Concordia University that passed this study along, in a class on statistical models in emotion research. The class is part of McGill University’s Summer Program in Social and Cultural Psychiatry, which I am attending through the month of May. (In my humble opinion McGill has the best collection of thinkers on how culture shapes emotions, cognitions, and perhaps most importantly the practice of mental health.) Professor Ryder was discussing his own work on differences in behavior between depressed European-origin Canadians and depressed Chinese, and noted that each group had particular norms for emotional expression of happiness — for example, when to smile, what to smile at, even how to smile. Note here that emotion researchers make a distinction between emotions — the actual feelings — and emotion behaviors — the things you do to show the feelings.

When emotion researchers talk about happiness behavior, they almost always mention that U.S. Americans are really into expressing their happiness, as did Prof. Ryder. But, he added, there is significant variability in the expression of happiness in U.S. that is connected to cultural identity, even cultural identity four- or five-generations removed. And this brings us to Scandanavian Americans — those U.S. residents with ancestors from Sweden, Denmark, Norway and Finland. It turns out that they are different.

In Variation among European Americans in emotional facial expression, Jeanne Tsai and Yulia Chenstova-Dutton compared facial expressions among “Scandinavian Americans” and “Irish Americans” after inducing six emotions (happiness, pride, love, anger, disgust, and sadness) through a somewhat convoluted (if ethical) “relived emotion task.” And what did they find? What any Swedish grandmother will tell you: the Irish are more emotional. Or, to look at the other side, as Prof. Ryder did, “You have to control for Scandinavian Americans’ ‘Scandinavianness’ to get them to look like the rest of Americans.”

I don’t want to get too emotional here, but I kind of think my Scandinavianness is not too bad — although I don’t want to make a big deal about it.

Windshield ethnographers, Human Terrain Teams, and counterinsurgency: Improving the military’s cultural competence

I just finished reading Nathan Hodge’s Armed Humanitarians: Rise of the Nation Builders, about the evolution of the United States’ military’s mission in Iraq and Afghanistan in the last decade. There’s plenty to learn from Hodge, a staff writer at the Wall Street Journal, and the value of the book will be judged, I expect, for its documentation of (1) the massive philosophical changes that occurred within the military in response to instability in the wake of “regime change” in Baghdad and Kabul and (2) the massive outsourcing of military-relevant tasks to security firms, services corporations, and… anthropologists? Anthropologists and related social scientists were all involved in a new tactic, the use of Human Terrain Systems.

In a chapter titled “Windshield Ethnographers,” Hodge introduces us to the Human Terrain System which was based on the idea that “brigade commanders needed social scientists to provide advice” so that they didn’t have to rely on a “library loaded with ethnographic data” when making their rounds establishing alliances with local sheiks and mullahs. Five-person Human Terrain Teams would be embedded with brigades or regiments in order to provide intelligence — or, as social scientists call it, information (there’s some discussion of this in the awkward situations this distinction produced) — on local customs, relations between local leadership, and the little things that can really mess up inter-cultural communication (like an American soldier talking directly to an Afghan woman of the house).

What convinced the military that they should forge alliances with pointy-headed academics? Well, Hodge describes the source as an article by a policy fellow at the Office of Naval Research, Montgomery McFate, published in Military Affairs in 2005. Anthropology and Counterinsurgency: The Strange Story of their Curious Relationship argued that the military should bring in anthropologists and other social scientists in order to serve their new nation building objectives.

Once called “the handmaiden of colonialism,” anthropology has had a long, fruitful relationship with various elements of national power, which ended suddenly following the Vietnam War. The strange story of anthropology’s birth as a warfighting discipline, and its sudden plunge into the abyss of postmodernism, is intertwined with the U.S. failure in Vietnam. The curious and conspicuous lack of anthropology in the national-security arena since the Vietnam War has had grave consequences for countering the insurgency in Iraq, particularly because political policy and military operations based on partial and incomplete cultural knowledge are often worse than none at all.

Essentially, McFate was arguing that in order to succeed militarily against a counterinsurgency, the military had to improve its cultural competence. (There really are too many cynical comments to make at this point — I will refrain… but feel free to contribute in the comments section below.)

Hodge writes well, and he refrains from the holier-than-thou commentary that has become typical in critiques of the US’s blunders in Iraq and Afghanistan. His history is well-sourced, and much of the book is built on his own, first-hand, reporting. Put this on the required reading list for humanitarian aid workers, and maybe for soldiers too.


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