How does cultural beliefs and practices impact the recovery of by gjjur4356


									        Geography of Mental Health

• Where are mental health patients located?

• What are the attitudes of the community towards the
  mentally ill and mental health facilities?

• Policies of deinstitutionalization – what is the
  public‟s reaction?

        Geography of Mental Health

• In 1866, Edward Jarvis noted that mental hospitals
  were “much more local in their usefulness„” than
  they were intended to be

• “Jarvis's Law”, as it came to be known, postulated
  that distance from a mental hospital predicted

• In district after district, the farther the distance
  from the hospital, the lower the utilization.
      Geography of Mental Health …

• For example over a 23 year period in Oneida
  County in the District of New York, the
  geographic area closest to the hospital sent an
  average of 1 patient for every 2,772 residents.

   – second closest district, the ratio was 1 in 5,820
   – third closest it was 1 in 7,351,
   – in the farthest district it was 1 in 11,535.

        Geography of Mental Health …

• Jarvis concluded that distance counts.

• Patients are hospitalized in direct proportion to
  their nearness to the institution.

• Secondly, the closer individuals were to
  transportation corridors, the higher the hospital

        Geography of Mental Health …
• Counties that were situated along the course of
  rivers, canals, or roads leading directly to the
  hospitals, sent proportionately more patients than
  counties of equal distance but not within easy
  access to transportation corridors.

• He understood the problem to be one of under-
  utilization in remote areas and argued that large
  and far-away regional hospitals should be replaced
  by smaller local hospitals located in the very midst
  of the populations they were intended to serve.

        Geography of Mental Health …

• Jarvis's Law has been replicated numerous times
  and been found to apply to both inpatient and
  outpatient care settings

• The generalizability of this finding across different
  treatment locations suggests that distance-decay
  factors should be a key consideration when
  determining the placement of mental health
  services or facilities

      Social ecology of mental disorders

• By charting the place of residence of persons
  admitted to hospital for psychiatric evaluation or
  treatment in large US cities, Farris and Dunham
  (1960) identified what came to be known as a
  “typical ecological distribution” or gradient of
  mental disorders.

• The highest rates were found in the city centers
  and the lowest in the suburban areas.

• This gradient was subsequently replicated in
  Europe and in the United States.
       Social ecology of mental disorders
• These studies generated a broad range of possible
   – Social selection (though migration or infant
   – Geographic variability in the definitions of
     mental illness (bias);
   – Social support or the lack of capacity of some
     households to maintain the mentally ill without
     public assistance; and
   – Social causation, both the direct and indirect
     effects of the living environment on mental

A Global Understanding of Mental Health

• Globalization has meant that concepts of mental
  health are now increasingly applied across borders
  and cultures.

• The World Health Organization (WHO) developed
  the International Classification of Diseases (ICD-10),
  which, also indicated that culture plays a
  significant role in the manifestation, treatment,
  and course of psychiatric disorders.

 A Global Understanding of Mental Health

• Many people have challenged the prevailing diagnostic
  system, claiming it is too based in the culture and
  values of the West.

• Given the extent to which understanding of behavior is
  mediated by cultural norms, it is not surprising that
  psychopathology, which manifests itself
  behaviorally, must be to some extent contingent on
  cultural forces.

       A Global Understanding of Mental

• It is the interaction between universal biological
  aspects of psychiatric disorders and contextual cultural
  forces that creates the challenge in understanding and
  treating them.

  Cultural beliefs and practices impact the
   recovery of people with mental illness

• What society considers a healthy and meaningful life
  is inextricably bound up with cultural values and
  belief systems.

• For people with psychiatric disabilities, while they
  may share diagnoses with people from different
  cultures, how they manifest and respond varies

 A comparison of psychosocial rehabilitation
     of mental illness in India and the US
• Stanhope, 2002

• Whereas the West has generated much of the
  theoretical and clinical knowledge about psychiatric
  disorders, there have not always been corresponding
  good outcomes for people with psychiatric disabilities
  in these countries.

     A comparison of India and the US…

• In fact, the developing countries with far less
  resources and services, have often produced better
  prognoses for those with disorders such as

• So what role has culture played in the treatment
  and rehabilitation of people with psychiatric

                India vs. US
• Significant factors in caring for people
  with psychiatric disabilities in India
  – an emphasis on interdependence,
  – externalized locus of control
  – family involvement

• Significant factors in caring for people
  with psychiatric disabilities in US
  – focus upon independence
  – individual productivity.
                 India vs. US…
• Prevalence Rates of Psychiatric Disorders in
  India and United States

• It is estimated that 10 to 30% of the population in
  India have a psychiatric disorder at some point in
  their life

• Hence, India experiences psychiatric disorders
  among its population at similar rates to Western
  countries including US

                 India vs. US…

• However, beyond incidence, differences in
  manifestation and prognosis rates indicate that
  culture is a significant determining factor.

• Indigenous understanding of psychiatric disorders,
  help-seeking behaviors, available services, social
  structures, and rehabilitation strategies all combine
  to shape the course of psychiatric disorders.

 Help-Seeking Behaviors: India vs. US

• Help-seeking behaviors in India are dictated as
  much by community perception and beliefs about
  the nature of a psychiatric disorder as by resources
  and availability of services.

Help-Seeking Behaviors: India vs. US …
• In a study of 300 patients with psychiatric disorders,
  55% attributed their psychiatric disorders to
  supernatural forces including ghosts, evil spirits,
  and witchcraft, and chose to consult traditional
  healers before seeking mental health services

• In rural areas with populations of lower socio-
  economic status, studies have found that up to 80%
  of people who have psychiatric disorders seek help
  from healers rather than physicians

Help-Seeking Behaviors: India vs. US…
• However, there is also a pragmatic side to many of
  the help-seeking behaviors among Indian

• Although traditional healers are the first care choice,
  if symptoms are acute and persistent, alternative
  services including modern medicine will be pursued.

• And there is often a close relationship between
  modern medicine and traditional healing systems in

    Prognosis for People with Psychiatric
     Disabilities in Developing Countries

• The shortage of psychosocial rehabilitation
  facilities in India leaves many people with
  psychiatric disabilities, especially in rural areas,
  without access to services.

• And those with access to services often do not
  choose to utilize them due to discrimination and
  alternative beliefs about the nature of psychiatric
   Prognosis for People with Psychiatric
   Disabilities in Developing Countries …

• However, despite large numbers of people with
  psychiatric disabilities being untreated, studies have
  found better prognoses for people with psychiatric
  disabilities in India and other developing countries.

    Prognosis for People with Psychiatric
    Disabilities in Developing Countries …
• Example:

• The International Pilot Study of Schizophrenia was a
  WHO sponsored study to investigate if similar
  symptom clusters for schizophrenia occurred in
  differing areas of the world.

• While incidence rates were found to be comparable
  throughout the world, follow-up studies revealed
  that outcomes for schizophrenia were significantly
  better in the developing countries
    Prognosis for People with Psychiatric
    Disabilities in Developing Countries …

• With 51% showing good outcomes in India as
  compared with 7% in Russia and 6% in Denmark
  (WHO, 1979).

• Subsequent studies, such as the Determinants of
  Outcome of Severe Mental Disorders have confirmed
  the findings that outcomes for people with psychiatric
  disabilities are more favorable in developing countries.

    Prognosis for People with Psychiatric
    Disabilities in Developing Countries …

• Patients in developing countries experience a more
  benign course or remission from psychiatric
  disorders at almost twice the rate as those in the
  industrialized countries (Warner, 1994).

• These unexpected findings strongly indicate that
  cultural context is a major factor in the course of
  psychiatric disorders.

     Prognosis for People with Psychiatric
     Disabilities in Developing Countries …

• They also raise questions about the appropriateness of
  developing countries basing their models of mental
  health care on theory and practices generated by
  the West.

• Instead, exploring the role of culture as a mediating
  factor in the course of psychiatric disorders has the
  potential to improve our understanding and practice in
  the field of psychosocial rehabilitation.

       Role of Cultural Beliefs and Values

• Belief systems play a large role in the formulation and
  outcome of the rehabilitation process

• Some have argued that just the adoption of western
  diagnostic interpretations of psychiatric disorders in
  India has negatively impacted prognosis for
  psychiatric disorders.

     Role of Cultural Beliefs and Values …
• Indian healing systems have always recognized and
  treated acute short psychotic episodes, but now the
  trend is to diagnose these conditions as schizophrenia

• The labeling process has brought with it all the
  discrimination and implied severity that surrounds
  schizophrenia in the West.

• Therefore, better prognosis rates in India may be due
  in part to bypassing the labeling process and, instead,
  subsuming a psychiatric disorder and its symptoms
  into ongoing social rituals, including indigenous
  healing systems.                                      28
     Role of Cultural Beliefs and Values …
• The World Health Organization has now recognized
  the strengths of integrating traditional healing into
  systems of care for psychiatric disorders.

• Traditional healing methods provide a cultural
  compatible, holistic approach, strong therapeutic
  alliance, and close connections with family and
  community (WHO, 1994).

• Another important element is the approachability of
  indigenous healers.
     Role of Cultural Beliefs and Values …

• People seeking help are able to avoid the stigma of
  seeking out a mental health professional by going to
  their local healer.

• Stigma plays a significant role in the response of
  Indian society to those with psychiatric disorders.

                 The Role of Family
• A key part in the process of subsuming psychiatric
  disorders within sociocultural settings is the role of the

• The extent of family support for people with
  psychiatric disabilities has often been cited as a major
  factor in the rehabilitation process:

• Family support, which is so easily available in the
  developing countries, is the anchor for treatment and
  rehabilitation of the mentally ill in the outpatient
                The Role of Family …

• A family's tolerance for a psychiatric disorder, even
  when symptoms are at their most acute, helps them
  take on caregiving responsibilities.

• In developing countries, up to 90% of people with
  psychiatric disabilities live with their families, whereas
  in the industrialized countries it is only half this

               The Role of Family …

• The existence of extended families and kinship
  networks particularly helps the caregiving process.

• In a study of a tribal community, researchers described
  how the strain of caring for a person with a psychiatric
  disorder is absorbed by all clan members, who take
  turns in providing social interaction and thereby
  reducing the burden on individual family members.

               The Role of Family …

• The existence of extended family and kinship
  networks can serve as an important buffering
  mechanism both for the person with a mental illness
  and their caregivers.

• When a family does seek care for a relative with a
  psychiatric disorder, be it through a healer or mental
  health professional, members are usually highly
  involved in this treatment.

                The Role of Family …

• The healer will be familiar with the family and a part
  of the community, and the whole family will be
  expected to be involved in care.

• This expectation is in contrast to Western models of
  care, which, in the treatment of schizophrenia in
  particular, are still tainted by theories purporting that
  psychogenic families cause psychiatric disorders.

                The Role of Family …
• Often, therapists perceive their role as empowering
  people so they can separate from a dysfunctional
  family, rather than facilitating transition back to the

• Even if the family is seen as functional, promotion of
  independent living is a common treatment goal.

• Mental health services in India, both inpatient and
  outpatient, not only encourage family involvement, but
  also often make it a prerequisite of care.
        Independence vs. Interdependence

• Despite better access to services and a high level of
  professionalization in community mental health
  systems in the industrialized countries, the
  rehabilitation of those with psychiatric disabilities is
  often undermined by cultural expectations of
  independence and productivity.

• In contrast, the central goal for psychosocial
  rehabilitation in India is interacting within a society
  that stresses interdependence.
     Independence vs. Interdependence …

• Individual needs and goals are secondary to living
  successfully within the family and community setting.

• This emphasis upon interdependence means that there
  is more tolerance for a family member who needs
  more supports.

• The family member requiring extra support does not
  find this dependent role alien and threatening.

     Independence vs. Interdependence …

• In the industrialized countries, the profound self-
  disorganization and ensuing loss of independence that
  is associated with onset of a psychiatric disorder is
  especially devastating for adults (Lefley, 1999).

• Western notions of identity are very much based on
  the ability to be independent, to pursue individual
  goals, and to have a sense of control over one's

      Independence vs. Interdependence …

• The transition from this to a more paternal form of
  care is extremely stressful for those seeking services in
  the West, as it indicates to the person a significant
  decrease in status.

• Personhood, a concept which includes self-mastery,
  dignity, self-respect, and self-esteem, has becomes an
  increasingly important goal in psychosocial
  rehabilitation services in the United States.

            Changing Cultural Contexts

• Cultural arrangements and values are not constant.

• Such is the case in India and other developing

• It is not clear that Indian society can continue to
  sustain this model of familial care or that it can be
  replicated in the West.

          Changing Cultural Contexts …

• But more significant is the fact that joint families are
  becoming less and less frequent in India, especially in
  urban areas.

• Some view this shift to more "modern" family
  arrangements as indicative of increased focus on
  individual rather than communal needs.

• Nuclear families living in urban areas with both
  partners employed full-time face the same challenges
  and dilemmas as many families in the West when it
  comes to caring for people with psychiatric

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