Archive for the 'traditional medicine' Category

Publication: Review of posttraumatic cultural concepts of distress

Although not every human culture would recognize psychological terms as we use them in North America and Europe, every culture has ways of talking about how individuals feel, and every culture has terms that describe extreme and abnormal versions of these feelings. Cultural concepts of distress are those culturally-specific ways that people from within a given group express their psychological distress. For example, Cambodians talk about a khyal attack” as an experience whereby “wind” that flows naturally through the body (akin to chi in Chinese medicine) is blocked from exiting, causing problems that Western psychologists would call symptoms of panic attack (if you’re at all curious, you really should visit the website dedicated to explaining khyal attack).

A couple of colleagues and I recently published a review in Social Science and Medicine of the symptoms that are included in the various ways that different cultures think about the emotional distress following trauma. Our review included 55 studies and identified 116 different cultural concepts of distress. We categorized these concepts based on their symptoms (using hierarchical cluster analysis), and found that the 116 concepts could be described in four basic categories: (1) somatic dysphoria, which largely concerned bodily complaints; (2) behavioral disturbances, “odd” behavior (relative to cultural norms), (3) anxious dysphoria, which as its name implies included lots of anxiety; and (4) depression, which was surprisingly similar to depression as it appears in North American and European medicine. Notably, none of these groups of concepts looked like the psychological disorder that most mental health professionals in North America and Europe think of when they think about trauma — posttraumatic stress disorder, or PTSD.

Of course there are all sorts of limitations to our review, and some would argue that the way we categorized cultural concepts of distress using symptoms alone misses the point of the diversity of these concepts globally (which is broader concerning explanations for distress than it is concerning symptoms). Others would argue that PTSD is actually somewhere in the mix of concepts we reviewed. I’d like to think our review is a starting point for discussion of these issues, rather than a definitive answer to any of these questions.

You can find a link to the publication in Social Science and Medicine here.

Article supplement: Posttraumatic idioms of distress among Darfur refugees

The September 2011 issue of Transcultural Psychiatry is out, and it includes an article by myself and some colleagues based on some work we did with Darfur refugees a few years ago. Publication lag times as they are (a colleague this morning compared them to the aging of fine wines), by the time an article is finally comes out in print the author’s ideas about what he/she sees as the “take-home” message may have shifted slightly. So here’s my chance to provide the 2011 take-home to a study written in 2009.

The article, Posttraumatic idioms of distress among Darfur refugees: Hozun and Majnun, details the development of a questionnaire (a structured interview, really) for Darfur refugees that we used to help evaluate a psychosocial intervention in camps in Chad. From the article:

We took an emic-etic integrated approach, identifying local constructs and then measuring both Western and local distress constructs within the same population in order to compare associations between two sets of symptoms of theoretically related concepts.

This means we (1) talked to a lot of refugees to hear how they defined their problems (including symptoms of psychological distress) and then followed-up with traditional healers to hear how they categorized these symptoms into larger psychological problems (“idioms of distress” for you budding transcultural psychiatrists out there); and (2) conducted a survey that included these problems and Western concepts (PTSD, depression) to measure how the Darfur problems and Western concepts were differentially associated with trauma experiences, loss, and impairment in daily living. The two Darfur problem sets were labeled hozun — “deep sadness” — and majnun — “madness.”

I’ll let you read the article to get the details, but suffice it to say that these sets of disorders — hozun and majnun on the one hand and PTSD and depression on the other — shared many symptoms in common. Related to this, they were associated with traumatic events and functional impairment at comparable levels — in other words, one could “predict” functional impairment using hozun and PTSD and get similar effect sizes (with slight favor for the locally-defined problems).

One might think that if a measure of PTSD is as good as measure developed for a local distress idiom in predicting a third variable you are interested in, then there is really no reason to develop the local measure. In the article we emphasized that the response to this argument had to do with respecting local populations and avoiding psychiatric colonialism. Now although I agree with those ideals, I would emphasize another point we made (but did not emphasize): Just because many of the symptoms of two different disorders from the Western psychiatric canon (here PTSD and depression) overlap with two different disorders from a different medical tradition (here hozun and majnun), it is how the symptoms are arranged in their respective traditions that define the disorders. From the article:

although they accounted for similar variance in Study 2 as a set of items, these symptoms were categorized by traditional healers into sets that were different that the sets of symptoms in PTSD and depression. This, then, suggests that it would be incorrect to argue that PTSD and depression are culturally valid constructs in settings in which respondents report variance on PTSD and depression simply because of that variance.

In other words, just because non-Western participants in a study answer that they have problems (or do not have problems) that fit into Western DSM-IV ideas of psychiatric disorder does not mean that Western DSM-IV ideas of psychiatric disorders are valid definitions of their problems. Figuring out what are valid definitions for their problems is not, at its most basic, a statistical task, but rather a theoretical one. You have to talk to the people who know the theory, not just the people who have the problems.


More from McGill’s Summer Program: The Affliction Film Series

McGill University’s Summer Program in Social and Cultural Psychiatry is not just about the differences between Swedes and Irish. As part of the summer program’s keynote course, Cultural Psychiatry, McGill luminary Laurence Kirmayer includes a number of film clips in the syllabus to give students a chance to observe some of the phenomena that gets diagnosed by psychiatrists using Western psychiatric categories, but may perhaps make more sense by examining the patient’s cultural and historical context.

One of the most striking films shown (so far) comes from Robert Lemelson’s psychiatric anthropology series, Afflictions: Culture and Mental Illness in Indonesia. In “Shadows and Illuminations,” a man presents with visual and auditory hallucinations of Balinese spirits, disorganized behavior and inappropriate dress. His family and neighbors regard him as odd, so it’s not the case that he is just odd to our foreign eyes. Our psychiatric practice tells us to look for schizophrenia. He reports the symptoms began with the death of his daughter, and we think perhaps it is a posttraumatic stress reaction of some sort. He is examined by two traditional healers and a psychiatrist, all of which have their own treatments, but none of which seem to help. Accommodations are made for the man’s behavior in his own home, and he seems to get a little better. Improvement had nothing to do with our diagnosis, or lack thereof.

Each story in the series situates behavior and concepts of illness within the families and societies in which they occur. Not satisfied with biological explanations of these patients’ problems, Lemelson’s films remind us that psychiatric practices have non-psychiatric implications, specifically around family relations, historical meaning-making, and even implications related to the freedom of the individuals with mental health problems.

The Catholic bishops’ exorcism workshop: Distinguishing demonic possession from mental illness

Next week, Catholic bishops from around the US will meet in Baltimore for their general assembly. As happens before many large conferences, this weekend attendees can take a workshop in order to improve their professional skills: the Conference on the Liturgical and Pastoral Practice of Exorcism. Bishop Thomas Paprocki of Springfield, Illinois has organized the workshop in response to a rising number of requests for exorcisms nationally. The Catholic News Service reports that 56 bishops and 66 priests have signed up.

The Catholic News Service report explains that not everyone in the Catholic clergy can do exorcisms:

Under canon law — Canon 1172 specifically — only those priests who get permission from their bishops can perform an exorcism after proper training.

The Catechism of the Catholic Church explains that an exorcism occurs when the church, in the person of an exorcist, asks “publicly and authoritatively” in Christ’s name “that a person or object be protected against the power of the evil one and withdrawn from his dominion.”

Exorcism is rooted in the acts of Jesus Christ:

Scripture contains several examples of Jesus casting out evil spirits from people.

“We don’t think that’s poetic metaphor,” Bishop Paprocki said.

Not surprisingly, there is a fair amount of tongue-in-cheek coverage of the conference in the US press. However, for mental health professionals like myself, the Catholic Church’s response to this increased demand is nothing to laugh at. Reports of spirit possession are commonplace in many parts of the world, and certainly not limited to Catholics — my own experience with people “tormented by demons” comes from work with Muslim refugees from Darfur, Sudan. Although many of us have psychiatric interpretations of these phenomena when we encounter them, we are in minority; there are many more people who are convinced of their supernatural etiology. In other words, for most of humanity, the reasons for odd thoughts and behavior are spiritual, not scientific. The US is one of only a handful of countries in which spiritual explanatory models do not hold sway. In a global perspective, it is the exorcism conference’s media attention and tongue-in-cheek coverage that is notable, and not the topic of exorcism itself.

“Explanatory models” are sets of reasons for why things happen the way they do. Mental health practitioners are often interested in their patients’ explanatory models of their psychological problems in order to treat them more effectively. Reading through media coverage you get the sense that although rooted in a predominantly supernatural explanatory model, the perspective of the US bishops organizing the conference is actually somewhat of a hybrid, combining a concern for spiritual hygiene with a concern for psychological well-being. Although the US may be globally out-of-step in terms the majority’s emphasis on scientific explanations, hybrid spiritual-scientific explanatory models are the norm in our globalized world. In other words, in the US most people tend to emphasize scientific parts of explanations for odd behavior whereas in most other parts of the world most people emphasize spiritual parts, but in reality many people hold both types of explanations for such behavior simultaneously. The New York Times report devotes a fair number of column inches to the difference between “real” possession by the Devil and other possession-like states, and this seems to be the point of the conference:

“Not everyone who thinks they need an exorcism actually does need one,” said Bishop Thomas J. Paprocki of Springfield, Ill., who organized the conference. “It’s only used in those cases where the Devil is involved in an extraordinary sort of way in terms of actually being in possession of the person.

So just what are the symptoms of demonic possession?

Some of the classic signs of possession by a demon, Bishop Paprocki said, include speaking in a language the person has never learned; extraordinary shows of strength; a sudden aversion to spiritual things like holy water or the name of God; and severe sleeplessness, lack of appetite and cutting, scratching and biting the skin.

A person who claims to be possessed must be evaluated by doctors to rule out a mental or physical illness, according to Vatican guidelines issued in 1999, which superseded the previous guidelines, issued in 1614.

(That’s 385 years between guidelines, for those of you who were wondering. The next set of guidelines is presumably due in 2384.)

I think it’s safe to say that most Catholics in the US do not believe that training priests in the proper procedure for exorcisms is a priority in 2010. Some posit that other factors are in play behind the pre-meeting exorcism institute. Notre Dame Professor of Catholic history R. Scott Appleby says that the conference is best explained as a way to bring back those among the flock who have strayed because the church is no longer seen as distinct from other, more secular institutions.

“What they’re trying to do in restoring exorcisms,” said Dr. Appleby, a longtime observer of the bishops, “is to strengthen and enhance what seems to be lost in the church, which is the sense that the church is not like any other institution. It is supernatural, and the key players in that are the hierarchy and the priests who can be given the faculties of exorcism.

“It’s a strategy for saying: ‘We are not the Federal Reserve, and we are not the World Council of Churches. We deal with angels and demons.’ ”

Book review of Crazy Like Us on

STATS is an organization that examines the reliability and validity of quantitative findings in social science and medicine for laypeople, specifically journalists. Today they feature a book review of Ethan Watters’ Crazy Like Us: The Globalization of the American Psyche, by none other than yours truly. Here’s a teaser:

those of us who work in the small corner of mental health research that examines the differences in diagnoses and symptoms between cultures are somewhat surprised by Crazy Like Us; our field, generally, remains well hidden in the crease between psychology and anthropology. That our first popular treatment should be a highly critical survey of this field of mental health is doubly shocking.

Keep reading, here .

Flying monks, talking turtles, brain tumors: A cautionary tale in cross-cultural medicine from Laos

A few weeks ago, a young woman named Chloe Thomas contacted me in response to the placebo series. She has a fascinating real-life cautionary tale in global health: what the clash between Lao traditional medicine and globalized Western medicine means for a man with a potentially operable brain tumor. No easy answers, stories like these are important in illustrating the sticky points and pitfalls of cross-cultural health care.

Last year when traveling through Southeast Asia I was deeply inspired by the beauty of the people of Laos yet frustrated by their lack of access to basic health services. Small and landlocked, Laos routinely places among the lowest in many health and development indicators. I returned, college idealism in hand, dedicated to help in anyway I could. I found a volunteer opportunity with a NGO in the capital, Vientiane. The NGO’s work attempted to preserve Lao traditional medicine for both its cultural heritage and importance as the sole access to healthcare of any kind for most rural and impoverished populations.

I know many of you reading this may share my initial skepticism, traditional medicine as hokum, an almost ignorant naiveté. But approximately 60- 80% of the global population is dependent on medicinal plants to fulfill primary healthcare needs, and in Africa and Asia, this figure may be upward of 80%. This widespread use is most often attributed to confidence in efficacy, accessibility, and affordability. (For those needing further persuasion, information and/or definitions see the WHO’s Traditional Medicine Strategy.) Furthermore, the use of medicinal plants employed by these various cultures is often the first step in the discovery of bioactive compounds that lead to novel drugs[1] — think artemisinin.

As a medical school aspirant I was eager to explore the evidence-based efficacy of traditional medicinal plants and their potential health benefits, as well as understand different cultural perspectives in medicine. Armed with only a BA and having no experience in either the aid world or ethnomedicine, I was aware I needed to reach out to those more capable of undertaking research and inducing change. Promoting the safety and standardization of plants currently being used was, and should be, a priority. I hungrily began reading, researching, and contacting those in the field.

The first few months proved a crash course in aid politics, grant writing and how to tactfully navigate through the Lao bureaucracy. It was also during this time my Director (whom I will henceforth call Mr. Smith) slowly revealed himself as a self-proclaimed master in Lao traditional medicine (though seemingly without formal, or even informal training). I was not too concerned with this, as over 70% of Laotians routinely use traditional medicine. However, when he continued to talk about his ability in the same sentence with flying monks and talking turtles, and then spoke of his life goal of being able cure the sick by simply walking past them, it became clear that this religious conviction and personal ambition would pose a great challenge to any objective approach I made.

Several weeks later, I checked my email to find an attachment from my Director of the medical record of a mid-twenty year-old, complete with a CT scan noting a mass in the right posterior fossa. The clinical impression relayed to me by Mr. Smith (obtained from the patient) was that this was a brain tumor, which without surgery would give the patient only months to live. Although Mr. Smith admitted that he was told the patient would have a good prognosis with an operation, he insisted that he another local traditional medicine practitioner, they could cure him using solely traditional medicine, and that he wanted me to document the progress.

Most likely the patient sought my boss’s care because they could not afford the operation. If this was the case, I was uncomfortable sitting by idly and watching this vulnerable person be used as a human subject to substantiate an experimental treatment. Human lives should be more precious than tools to validate one person’s conviction or to further their ambitions.

What’s worse still is that if the patient had opted for surgery (assuming he could find the means) and it was unsuccessful, Mr. Smith would no longer accept the patient, citing that the traditional medicine treatment would no longer be effective, almost as if it was out of personal vengeance. Choosing to respect one form of treatment should not mean having to reject the other.

Echoing the South African controversy surrounding traditional treatment for AIDS (involving the now deceased Health Minister Manto Tshabalala-Msimang), a myriad of emotions ran through me, bafflement, hostility, frustration. After a heavily emotional argument in which I pressed that we should at least advocate for funds for the operation if money was the sole determinant in the patient’s choice, my Director accused me of not believing in traditional medicine or his ability to cure.

I am not a doctor and still remain unsure about the accuracy of the diagnosis or the validity of the medical team’s consultation. But, I do realize what I was presented with was irresponsible and potentially fatal. While some plants have shown promise in cancer treatments, too many unknowns still remain for me to allow myself to participate in such a high stakes gamble.

No doubt there has been and will continue to be cases such as this. The ethical implications remain thorny, and literature scant (see here for one of the few articles I have found). With the growing use and recognition of the benefits of traditional medicine systems, there is also a growing need for safety, efficacy, quality and rational use. In fact, nationalization of Lao Traditional Medicine is a goal of the Government, and this would undoubtedly necessitate regulation, standardize treatments and hopefully create a governing body to whom malfeasance can be reported. Professionalization among traditional medicine practitioners would also enable a body of educated primary health care providers in the most rural and remote regions. Unfortunately, discerning the tangible from the intangible in these often religiously contextualized treatments will prove harder still.

It’s a sad reality not every person can afford the care they may desperately need. While I will respect this particular patient’s decision, I will only do so if presented with clear and accurate information on his choice, I will not be involved in a situation in which a patient is mislead by the desire of one person’s goal of attaining supernatural ability. My dilemma left me wondering–when do we admit the most realistic options for medical treatment? What’s the middle ground between Western medicine and traditional systems? Can the two ever co-exist in harmony while still respecting the benefits and fundamental beliefs in both systems? Or are there too many differences, areas of profound misunderstanding that make them perpetually destined for conflict. Perhaps my dilemma was just an example of this.

Apart from this instance, most of my experiences working with traditional medicine were positive, forcing me to revaluate my own perception and views of healthcare and medicine. It was challenging finding the delicate balance between science and religion, and acknowledging that my Western train of thought is just one among many world-views. Though I remain without clear resolve on many of the ethical issues that have arisen with the growing use of traditional medicine and alternative treatments, I hope that with more education will come more clarity. However, what I will take into my medical education is the importance of mutual understanding and respect when treating patients humanely and effectively across cultural chasms, for no matter where I work, there is no doubt that I will continue to work with patients whose healing beliefs greatly differ from my own.

Ms Thomas is originally from California, and a graduate from UC Berkeley (2008) in Molecular and Cell Biology. She is currently in the process of applying for medical school in the United States.


[1] R. Alves et al., “Biodiversity, traditional medicine and public health: where do they meet?” Journal of Ethnobiology and Ethnomedicine (2007), 3:14

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.

April 2017
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