This cartoon speaks to the sentiment I and many of my colleagues are feeling about the historical moment of racism and xenophobia that has given rise to Trump. It’s scary and often we feel paralyzed in the face of the hate and ire that Trump spouts, which gives voice to the anti-Obama racist backlash and the backlash to the multiculturalism of the 1990s and 00s more generally. What to do in the face of this? Short of emigrating to Canada or Mexico following a possible Trump Presidency, this phenomenon seems to give those of us working in higher education even more import and motivation for our work – building acceptance, understanding, and value for cultural differences through our teaching and research.
This is a great blog on the intersection between migration and health. I’d encourage all my colleagues and students to consider posting and responding in order to reinvigorate this site.
Link to piece I wrote with Heide Castañeda at:
another summer in Puebla draws to its end, students are back at the School of Medicine, in their white coats and shoes, buying textbooks and registering for coveted classes. I return to Eugene to the task of developing my book manuscript during a much-needed no-teaching term this fall. As always, the work I do with MHIRT in Mexico continues to inform my conception of mental health, illness, culture, psychiatry, and contemporary globalization. In a compelling 1997 article in Transcultural Psychiatry, Gilles Bibeau argued that, to remain relevant to contemporary globalization, anthropologists working on issues of mental health need to hone their conceptualizations of both culture and of mental illness. He proposed that notions of borders, margins, and paradoxes are most useful in our conceptual toolkit, for they help us make sense of “the transitional stage in which most individuals and societies find themselves…living at the interface of local and global worlds, torn between multiple attachments and … the necessity to assume a more flexible pluralist frame of reference in the shaping of a larger world” (Bibeau 1997:10). In thinking about several interviews with psychiatric patients this summer and last, this quote is incredibly apropos to their situation. For instance, in one case – that of a 40-something year old man, he attributed his psychosis to a period of unemployment that followed nearly a decade of work as an upper-level manager for a major multinational firm in Puebla, which shut its doors in the late 90s partially as a result of NAFTA’s effects on the Mexican economy; in another – that I describe below – a 20-something woman attributes her major depression and anxiety to the rifts that have formed between herself and her parents around her gender identity, desire for independence, and rejection of “traditional” female gender roles. There are many other cases to mention, including that of a 20-something year old university student who told us that his first major depressive episode was a result of the “shock” of moving to Puebla (city) from a small pueblo, which he describes as like a “boom” (his word) of cultural change, which drastically reshaped his sense of self and social relationships. I can also apply Bibeau’s insights to my own lived experience of Puebla, a city that is as “traditional” (in its centro histórico, with its zócalo, iglesia, cafés, artesian shops, narrow streets, and 18th-century tiled buildings) as it is “modern” (in its zona Angelópolis, filled with multi-lane freeways, track housing developments, huge shopping centers, and chain stores like Costco, Mega grocery store, and import car dealerships). Moving around the city everyday, it’s hard not to feel the city as caught between the historical tensions of Mexican development and national identity; further, I often think in a city such as this, where the “traditional” and “modern” coexist and clash, how much sense disorders such as major anxiety and schizophrenia actually make – they seem apt embodied expressions of the state of this particularly unruly social and cultural world.
Culture, Gender, and Mental Health
In my research in Mexico with two fantastic MHIRT trainees, we are exploring the utility of the Cultural Formulation Interview (CFI) of the DSM-V. To our knowledge, ours is one of the first research studies to examine the CFI in clinical practice outside the United States. The DSM-V was only released in 2013, and the inclusion of the CFI in this manual (albeit as an Appendix) has been viewed by medical and psychological anthropologists as a step forward in the effort to incorporate what we refer to as patients’ illness experience (basically, how sufferers’ perceive and respond to their mental health problem, how it impacts their social roles and relationships, etc.) and explanatory models of illness (the different ways that clinicians and patients make sense of mental illness, how they view causality, symptomatology, and course of treatment). The CFI, and this lived-experience-of-illness approach, owes a great debt to the decades of work of anthropologist-psychiatrist Arthur Kleinman (for those who don’t know his work, a good primer for a popular audience is the 2006 What Really Matters: Living a Moral Life Amidst Uncertainty and Danger). Our CFI study, which we are conducting in a major public psychiatric hospital in Puebla, includes enrolling providers (psychiatrists and psychiatric residents) and their patients, and observing providers implement the CFI with patients. CFI questions include questions about social support and alternative treatments tried by patients. We are particularly interested in how well this interview picks up on aspects of patients’ cultural backgrounds that are relevant to their diagnosis, illness and treatment. Interestingly, the CFI doesn’t ask directly about gender or family relationships, two dimensions of cultural experience that seem to be salient and significantly associated with mental distress among the patients we are observing. For instance, in two interviews with young women diagnosed with depression-anxiety disorders, it was clear that tensions around independence/education/career choices/women’s responsibilities as caregivers and expectations for women’s marital roles were central to each woman’s experience of depression and (their word) “angustia”. One patient, “Lorena”, attributed her depression and anxiety to the tensions between “como pensaba que iba a ver mi vida y como actualmente la estoy viviendo” (“how I thought my life would be and how I’m actually living it”) – echoing the arguments made by Kleinman about how illness experience always indicates this existential dilemma – opening up the differences between life as we imagine or envision it to be and the uncertainty and challenges involved with life as actually lived. Lorena referred specifically to having studied for a post-secondary degree in tourism and administration, having travelled for her work to different parts of the country, and having a professional career as experiences that have shaped her expectations for independence as a woman – she seeks parity in gender roles and greater control over her life choices and wants these same things for her daughter (now 6 years old). These desires are raising conflicts for Lorena, however — both with the father of her child and with her own parents, who don’t necessarily share the same expectations for their daughter. Such dynamics around gender, family, and generation are very much “cultural” – reflecting shifts between “tradition” and “modernity” in contemporary Mexican society (and have been described by Anthropologist Jennifer Hirsch in her work on changing expectations for conjugal relationships in Mexican and Mexican-American communities). Nonetheless, and despite their apparent importance to patients such as Lorena, the CFI doesn’t ask about gender roles nor do providers view gender as part of “cultural” experience. The role of gender in culture and mental health/illness is definitely something I will continue to contemplate in this research…
In her wonderful book, Life Writing and Schizophrenia: Encounters at the Edge of Meaning, my colleague Mary Wood analyzes first-person accounts of schizophrenia, including that of her own mother, and shows how those suffering from major mental illness are in fact able to make sense out of their experiences. The interpretive process in Wood’s book is multi-layered: family members try to make sense of signs of distress, psychiatrists interpret clinical symptoms, and sufferers reflect on past psychotic episodes in ways that inscribe them with significance within particular social, historical, and cultural worlds. Wood writes, “Rather than being merely swept up in confused, fragmented, chaotic narratives, my mother was caught within too many narratives whose endings were already known. This is an important lesson I learned from my mother about schizophrenia and one that clinicians do well to keep in mind. It’s a distortion to say simply that someone living with schizophrenia has a false sense of reality. It is rather the case that the person’s sense are perceiving something with acute intensity” (pg. 288). I’ve been reading Wood’s chapter on her mother’s illness this first week of fieldwork in the major public psychiatric hospital here in Puebla. The interviews we are conducting ask patients to describe their explanatory model of illness- drawing directly on the work of Arthur Kleinman and other psychological anthropologists, the interviews aim to elicit first-person accounts of: what caused the “problem”, what the “problem” is, what possible remedies for the “problem” are, and how the psychiatric care the patient is receiving at the hospital can be improved to better address the “problem” — all from the patient’s perspective. I will describe the source of this interview guide in another post, but for now I want to share a bit of the story of a patient I will call Marcelo, who I interviewed yesterday. Marcelo is in his early 50s but has been living with schizophrenia for over 30 years, his first major psychotic episode occurred when he was 21, and he attributes the break to several factors: the death of a brother, the death of his father, and early childhood trauma, including hunger, poverty, and violence. Keeping Wood’s claims about sufferers’ ability to narrate their own experiences in mind, I was struck by how much Marcelo’s account of his illness support Wood’s argument. Marcelo remembered with lucidity dates of important life events and of major hospitalizations, he recalled names of many of his past clinical providers, and told a detailed story about being a goat-herder as a child but facing his father’s beatings when he lost a goat. Interestingly, and in what is not unusual in my experience working with those diagnosed with schizophrenia in Mexico, Marcelo also attributes one crisis episode (“crisis of nerves” in his words) to his experience as an undocumented migrant living in the U.S. for four years several decades ago. Throughout an over 40-minute interview, Marcelo was attentive to the interviewer, illustrative in his responses, and seemed comfortable with the setting. I was particularly surprised by his ability to narrate his experience because, after reviewing his chart notes, the attending psychiatry resident had warned me that Marcelo had recently suffered an episode of psychosis and she wasn’t sure he would be able to participate in our interview. This clinical perception – of schizophrenics as unable to narrate their experience – pervades not just the clinical encounter, but prevention programs and popular perceptions as well. Even well-established prevention programs are based on recognizing signs and symptoms of schizophrenia, such as false beliefs or hallucinations, that reinforce the idea that a schizophrenic mind doesn’t “make sense” but rather “makes nonsense”. While, like Wood, I in no way want to minimize the suffering that comes with major psychotic episodes, Marcelo’s case reminds me of the importance of recognition – here, I mean, recognizing the other’s ability to make sense and make significance out of suffering.
In my third summer of work with the Minority Mental Health Research & Training program (http://dornsife.usc.edu/latino-mental-health), I am helping mentor students conducting research related to prevention, diagnosis, and treatment of major mental illness. My days are spent at the BUAP (Benemérita Universidad Autónoma de Puebla)’s department of psychiatry, and at the psychiatric hospital where we are conducting research. The research project I’m supervising aims to assess the applicability, acceptability, and utility of the Cultural Formulation Interview, a tool that is part of the new DSM-V and is intended to evaluate the relation of culture to patients’ experiences of mental distress. So far, the major obstacle to our research is the reluctance of clinicians (psychiatrists and residents) to participate in the study. I think they believe we are evaluating them, rather than the instrument itself; also a barrier is their lack of time with back-to-back patient appointments, doing our 45 minute interview is a burden that our offer of a 200 peso gift card just can’t compensate for! More posts soon, from Puebla…