Archive for August, 2014

15
Aug
14

despedida a puebla

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. 

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04
Aug
14

Culture, Gender, and Mental Health

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…