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Nichter M. From idioms of distress, concern, and care to moral distress leading to moral injury in the time of Covid. Transcult Psychiatry 2022; 59:551-567. [PMID: 35938212 DOI: 10.1177/13634615221115540] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In this invited commentary on the thematic issue of Transcultural Psychiatry on idioms of distress, concern, and care, I provide a brief overview of how my research agenda evolved over the years while conducting community and clinic-based research in South and Southeast Asia as well as North America. I then suggest areas where future research on idioms of distress, concern, care, and resilience will be needed among different demographics given social change and shifts in how we communicate face to face and in virtual reality, the impact of medicalization, pharmaceuticalization and bracket creep, changes in indigenous healing systems, and hybridization. I further call attention to the importance of conducting idioms guided research in occupational settings. Toward this end I highlight the moral distress health care workers in the U.S. have experienced during the Covid-19 pandemic and point out the importance of differentiating individual burnout from moral injury related to structural distress. I conclude by discussing the general utility of an idioms of distress perspective in the practice of cultural psychiatry and suggest that this perspective needs to be included in the training of all practitioners regardless of the system of medicine they practice. Doing so may enable the formation of mental health communities of practice in contexts where there are pluralistic health care arenas.
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Affiliation(s)
- Mark Nichter
- School of Anthropology, University of Arizona, Tucson, AZ, USA
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2
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Sigmund K. COVID-19 and decreased asylum access: mother work, precarity and preocupación among Central American asylum-seekers in Los Angeles. ETHNIC AND RACIAL STUDIES 2022; 46:295-315. [PMID: 36523746 PMCID: PMC9744180 DOI: 10.1080/01419870.2022.2079382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 05/10/2022] [Indexed: 06/17/2023]
Abstract
In 2020, the public health response to the COVID-19 pandemic and the U.S. government's increased legal restrictions on asylum-seekers acted together to increase social, economic and legal precarity in the lives of Central American asylum-seeking mothers in Los Angeles. In this context, these asylum-seeking mothers discussed their intersectional precarities through the idiom of distress "preocupación", which signalled the concerns, worries, and fears they had in relation to the daily mother work of raising their children. Using ethnographic data collected during the COVID-19 pandemic, I examine how the intersectional precarities Central American asylum-seeking mothers faced necessitated protecting their children from their own preocupación. Through this, I argue that by using the analytic of preocupación it is possible to see exactly how racial and legal barriers to care increase precarity in the lives of asylum-seeking mothers in the U.S., and the detrimental impact that intersectional precarities have on asylum-seekers' mother work today.
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Affiliation(s)
- Kim Sigmund
- Department of Anthropology, University of Amsterdam, Amsterdam, Netherlands
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3
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Simpson N. Kamzori: Aging, Care, and Alienation in the Post-pastoral Himalaya. Med Anthropol Q 2022; 36:391-411. [PMID: 35485448 PMCID: PMC9544331 DOI: 10.1111/maq.12707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
As the Gaddi community of Himalayan India transition from agro-pastoralism to waged labor, configurations of kinship and care have shifted. Such shifts have introduced relational tensions, especially between elderly women, who have labored in the house and fields, expecting care in old age, and younger generations, who experience their own pressures of class aspiration. This article examines how the myriad tensions of the post-pastoral economy are experienced in the bodies of elderly women. It presents insights on kamzori, bodily weakness that is experienced by women who feel that their contribution of labor and care is unreciprocated by their kin or wider milieu. It recuperates alienation as a concept that captures distressed social relations. Alienation might be used by anthropologists studying aging, care, and debility to envisage the body in scalar relation to people, things and places, and illness or distress as disruption of such relations. [weakness, aging, care, gender, alienation].
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Affiliation(s)
- Nikita Simpson
- Department of Anthropology, London School of Economics and Political Science
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4
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Backe EL, Bosire EN, Kim AW, Mendenhall E. "Thinking Too Much": A Systematic Review of the Idiom of Distress in Sub-Saharan Africa. Cult Med Psychiatry 2021; 45:655-682. [PMID: 33387159 DOI: 10.1007/s11013-020-09697-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 12/15/2022]
Abstract
Idioms of distress have been employed in psychological anthropology and global mental health to solicit localized understandings of suffering. The idiom "thinking too much" is employed in cultural settings worldwide to express feelings of emotional and cognitive disquiet with psychological, physical, and social consequences on people's well-being and daily functioning. This systematic review investigates how, where, and among whom the idiom "thinking too much" within varied Sub-Saharan African contexts was investigated. We reviewed eight databases and identified 60 articles, chapters, and books discussing "thinking too much" across Sub-Saharan Africa. Across 18 Sub-Saharan African countries, literature on "thinking too much" focused on particular sub-populations, including clinical populations, including people living with HIV or non-communicable diseases, and women experiencing perinatal or postnatal depression; health workers and caregivers; and non-clinical populations, including refugees and conflict-affected communities, as well as community samples with and without depression. "Thinking too much" reflected a broad range of personal, familial, and professional concerns that lead someone to be consumed with "too many thoughts." This research demonstrates that "thinking too much" is a useful idiom for understanding rumination and psychiatric distress while providing unique insights within cultural contexts that should not be overlooked when applied in clinical settings.
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Affiliation(s)
- Emma Louise Backe
- Department of Anthropology, The George Washington University, 2110 G St NW, Washington, DC, 20037, USA.
| | - Edna N Bosire
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Wooyoung Kim
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Anthropology, Northwestern University, Evanston, USA
| | - Emily Mendenhall
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Edmund A Walsh School of Foreign Service, Georgetown University, Washington, DC, USA
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Jespersen BV, Korbin JE, Spilsbury JC. Older Neighbors and The Neighborhood Context of Child Well-Being: Pathways to Enhancing Social Capital for Children. AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY 2021; 68:402-413. [PMID: 33890310 PMCID: PMC8693895 DOI: 10.1002/ajcp.12520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Drawing on Coleman's concept of social capital, researchers have investigated how the quality of neighborhood social networks influences child development and well-being. The role of non-kin older neighbors in advancing child well-being through the enhancement of social capital, however, has been under-studied. Our objective was to delineate specific pathways through which non-kin older neighbors contribute to neighborhood quality for children and families and potentially advance child well-being. We examined open-ended interview data from 400 parents who cared for at least one child under 18 years of age and resided in 20 neighborhoods in Cleveland, Ohio. A subsample of 113 parents connected older neighbors to neighborhood quality for families and children in their narratives. Our analysis identified three primary pathways through which parents positively linked older neighbors to neighborhood quality: older neighbors support parents and children, promote neighborhood safety, and contribute to neighborhood residential stability. These contributions are evidence of intergenerational closure, reciprocated exchange, and informal social control working together to create social capital in neighborhoods for children. It is by enhancing social capital that older neighbors potentially improve child well-being. We discuss the implications of our findings for neighborhood research and practice.
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Affiliation(s)
- Brooke V. Jespersen
- Case Western Reserve University, Department of Anthropology, 11220 Bellflower Rd., Cleveland, Ohio 44106, USA
| | - Jill E. Korbin
- Case Western Reserve University, Department of Anthropology, 11220 Bellflower Rd., Cleveland, Ohio 44106, USA
| | - James C. Spilsbury
- Case Western Reserve University School of Medicine, Department of Population and Quantitative Health Sciences, Iris S. & Bert L. Wolstein Research Building, 2103 Cornell Road, Cleveland, Ohio 44106, USA
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6
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Abstract
Drawing on ethnographic research among asylum seekers in the Midwestern United States, this article investigates how a profound sense of limbo informed the use, meaning, and experiences of psychotherapeutic interventions, namely psychiatric medication and psychotherapy. In doing so, the article brings into dialogue a consideration of temporal and spatial uncertainty as a key feature of refugee distress, on the one hand, and attention to the subjective experiences of mental health care, on the other. Asylum seekers used therapeutic interventions and found them meaningful in the multiple ways these modalities help claimants endure the asylum process. Yet, ultimately, because they identified the unjust, protracted asylum system as the primary locus of their distress, asylum seekers perceived therapeutic interventions to be limited in their ability to assuage their suffering. In this context, legal status was often understood as the most effective form of healing. Thus, a sense of limbo was often both the impetus for using mental health care and the reason for its perceived limitations. My analyses have implications beyond the context of political asylum, underscoring how attention to temporality is important to better understanding the use and experience of mental health care more broadly.
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Affiliation(s)
- Bridget M Haas
- School of Medicine and Department of Anthropology, Case Western Reserve University, Mather Memorial Bldg., Rm 238, 12200 Bellflower Rd., Cleveland, OH, 44106, USA.
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7
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Gómez-Carrillo A, Lencucha R, Faregh N, Veissière S, Kirmayer LJ. Engaging culture and context in mhGAP implementation: fostering reflexive deliberation in practice. BMJ Glob Health 2020; 5:e002689. [PMID: 32967978 PMCID: PMC7513569 DOI: 10.1136/bmjgh-2020-002689] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 01/11/2023] Open
Abstract
In 2002, WHO launched the Mental Health Gap Action Programme (mhGAP) as a strategy to help member states scale up services to address the growing burden of mental, neurological and substance use disorders globally, especially in countries with limited resources. Since then, the mhGAP program has been widely implemented but also criticised for insufficient attention to cultural and social context and ethical issues. To address this issue and help overcome related barriers to scale-up, we outline a framework of questions exploring key cultural and ethical dimensions of mhGAP planning, adaptation, training, and implementation. This framework is meant to guide mhGAP activity taking place around the world. Our approach is informed by recent research on cultural formulation and adaptation, and aligned with key components of the WHO implementation research guide (Peters, D. H., Tran, N. T., & Adam, T. (2013). Implementation research in health: a practical guide. Implementation research in health: a practical guide.). The framework covers three broad domains: (1) Concepts of wellness and illness-how to examine cultural norms, knowledge, values and attitudes in relation to the "culture of the mhGAP"; (2) Systems of care-identifying formal and informal systems of care in the cultural context of practice.; and (3) Ethical space: examining issues related to power dynamics, communication, and decision-making. Systematic consideration of these issues can guide integration of cultural knowledge, structural competence, and ethics in implementation efforts.
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Affiliation(s)
- Ana Gómez-Carrillo
- Division of Social and Transcultural Psychiatry, Culture Mind and Brain Program and Global Mental Health Program, McGill University Faculty of Medicine, Montreal, Quebec, Canada
| | - Raphael Lencucha
- School of Physical and Occupational Therapy, McGill University Faculty of Medicine, Montreal, Quebec, Canada
| | - Neda Faregh
- Department of Psychology, Carleton University, Ottawa, Ontario, Canada
| | - Samuel Veissière
- Division of Social and Transcultural Psychiatry, Culture Mind and Brain Program and Global Mental Health Program, McGill University Faculty of Medicine, Montreal, Quebec, Canada
| | - Laurence J Kirmayer
- Division of Social and Transcultural Psychiatry, Culture Mind and Brain Program and Global Mental Health Program, McGill University Faculty of Medicine, Montreal, Quebec, Canada
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8
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Fast D, Bukusi D, Moyer E. The knife's edge: Masculinities and precarity in East Africa. Soc Sci Med 2020; 258:113097. [PMID: 32540514 DOI: 10.1016/j.socscimed.2020.113097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 11/16/2022]
Abstract
In our field sites and clinical practice in East Africa, we regularly encounter men who have become overwhelmed by "thinking too many thoughts" and "gone crazy from confusion," brought about by the problems of life created by deepening social, economic and political precarity. Across diverse settings, many African men continue to be enmeshed in social and material obligations and expectations that position them as economic consumers and providers for those they care for and love. When these gendered obligations, expectations and fantasies are left unfulfilled, this sense of failure can be embodied to produce particular kinds of health effects. Namely, men may become plagued by troublesome and confusing thoughts, leading them in some cases to "give up on" (as our research subjects put it) pursuing work and education, to become immersed in problematic drug and alcohol use, and even to take their own lives. While these afflictions can be glossed using the language of depression, anxiety, addiction and suicide, such medicalizing frames may obscure more nuanced social, structural and affective diagnoses of what is happening to men across Africa and globally. Anthropology provides us with alternative frames through which to understand how psychological wounds are made-and healed.
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Affiliation(s)
- Danya Fast
- Department of Medicine, University of British Columbia, Vancouver, Canada; Department of Anthropology, University of Amsterdam, Amsterdam, the Netherlands.
| | - David Bukusi
- Department of Anthropology, University of Amsterdam, Amsterdam, the Netherlands; Kenyatta National Hospital, Nairobi, Kenya
| | - Eileen Moyer
- Department of Anthropology, University of Amsterdam, Amsterdam, the Netherlands
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9
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Piperata BA, Salazar M, Schmeer KK, Herrera Rodríguez A. Tranquility is a child with a full belly: Pathways linking food insecurity and maternal mental distress in Nicaragua. Ecol Food Nutr 2019; 59:79-103. [PMID: 31573333 DOI: 10.1080/03670244.2019.1671835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A growing body of literature identifies food insecurity (FI) as a critical social determinant of mental health. Across settings, quantitative studies report positive correlations between FI and mental distress, especially among women. Less understood are the pathways by which FI undermines women's mental well-being. To address this gap, we conducted six focus group discussions with 45 Nicaraguan mothers. Thematic analysis identified three themes linking the management of FI and maternal mental well-being in this setting. The theme, la lucha, underscored how the chronicity of FI served as a constant mental strain by demanding mothers strategize on a daily basis to resolve it. The themes "tranquility is a child with a full belly" and "the despairing and frustrated mother" emphasized how FI challenged women's abilities to fulfill the responsibilities of motherhood and served as a reminder of social status. Our findings advance earlier quantitative work by identifying how the management of food insecurity undermines maternal mental well-being in a low-middle income setting and indicate that policies aimed at combating food insecurity can concomitantly improve maternal mental well-being if they bolster women's agency and work to reduce the stigma associated with being food insecure.
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Affiliation(s)
- Barbara A Piperata
- Department of Anthropology, The Ohio State University, Columbus, OH, USA
| | - Mariano Salazar
- Department of Public Health Science, Karolinka Institutet, Stockholm, Sweden
| | - Kammi K Schmeer
- Department of Sociology, The Ohio State University, Columbus, OH, USA
| | - Andrés Herrera Rodríguez
- Center for Demography and Health Research (CIDS), Nicaraguan National AutonomousUniversity, León, Nicaragua
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Mendenhall E, Rinehart R, Musyimi C, Bosire E, Ndetei D, Mutiso V. An ethnopsychology of idioms of distress in urban Kenya. Transcult Psychiatry 2019; 56:620-642. [PMID: 30672722 DOI: 10.1177/1363461518824431] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Idioms of distress have become a central construct of anthropologists who aspire to understand the languages that individuals of certain sociocultural groups use to express suffering, pain, or illness. Yet, such idioms are never removed from global flows of ideas within biomedicine that influence how cultural idioms are conceived, understood, and expressed. This article proposes a preliminary model of ethnopsychology described by urban Kenyans, which incorporates local (traditional) and global (biomedical) idioms of distress that are both distinct and overlapping in symptomology and experience. This ethnopsychology was generated from analyzing 100 life history narrative interviews among patients seeking care in a public hospital in Nairobi, Kenya, which explicitly probed into how people experienced and expressed the Kiswahili idioms huzuni (roughly translated as sadness or grief) and dhiki (stress or agony) and English terms stress and depression. Kufikiria sana, or "thinking too much", emerged organically as a powerful cultural idiom and as a symptom or sign of other forms of psychological distress. We propose a preliminary model of ethnopsychology that: 1) highlights social and political factors in driving people to express and experience idioms of distress; 2) reveals how the English terms "stress" and "depression" have been adopted into Kiswahili discourse and potentially have taken on new meaning; 3) suggests that the role of rumination in how people express distress, with increasing severity, is closely linked to the concept of "thinking too much", and; 4) emphasizes how somatization is central to how people think about psychological suffering.
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Affiliation(s)
| | | | | | | | - David Ndetei
- Africa Mental Health Foundation and University of Nairobi
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11
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Kaiser BN, Jo Weaver L. Culture-bound syndromes, idioms of distress, and cultural concepts of distress: New directions for an old concept in psychological anthropology. Transcult Psychiatry 2019; 56:589-598. [PMID: 31347475 PMCID: PMC6724704 DOI: 10.1177/1363461519862708] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This issue of Transcultural Psychiatry showcases some recent work on idioms of distress – the latest in a long line of anthropological research concerned with cross-cultural concepts and experiences of distress.1 Mark Nichter’s (1981) seminal paper introducing idioms of distress has become a cynosure for psychological anthropology and transcultural psychiatry. A growing body of work has since accumulated; however, the last time a collection of such research was brought together was the 2010 publication of a special issue in the journal Culture, Medicine and Psychiatry organized by Devon Hinton and Roberto Lewis-Fernández. In the decade since, new questions have arisen about the boundaries and applications of idioms of distress research. In this introduction, we provide a brief history of work on idioms of distress and related concepts. Then, we introduce several major themes explored by the papers in this special issue.
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Gibson K, Haslam N, Kaplan I. Distressing encounters in the context of climate change: Idioms of distress, determinants, and responses to distress in Tuvalu. Transcult Psychiatry 2019; 56:667-696. [PMID: 31067153 DOI: 10.1177/1363461519847057] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Across the globe there is a critical need for culturally informed and locally valid approaches to mental health assessment and intervention, particularly among disadvantaged and marginalized populations. To be optimally effective, such approaches must be informed by a sound understanding of locally relevant idioms of distress and its determinants, including those caused or exacerbated by global power disparities and structural inequities. Climate change, arising due to anthropogenic sources located predominantly in industrialized nations, is one potential determinant of distress having disproportionate adverse impacts on already marginalized populations. The present study formed part of a broader project examining the intersections of culture, climate change, and distress in the Polynesian nation of Tuvalu - a focal point of global concern over the human costs of climate change. The study explored determinants and idioms of distress and culturally prescribed responses to coping with distress. Results are based on fieldwork conducted in 2015 entailing semi-structured interviews with 16 key informants and 23 lay residents of Funafuti atoll, recruited using maximal variation purposive sampling. Findings are examined in consideration of the unfolding impacts of climate change and the threat it portends for the future, both of which were identified as salient determinants of distress, in keeping with theorized relationships between climate change and mental health. The study underscores the necessity of attending to the relationships between global forces, local cultures, and individual experiences of distress, as efforts to provide access to culturally informed social and mental health services expand globally.
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Yahalom J. Pragmatic truths about illness experience: Idioms of distress around Alzheimer's disease in Oaxaca, Mexico. Transcult Psychiatry 2019; 56:599-619. [PMID: 31092130 DOI: 10.1177/1363461519847304] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article explores the pragmatic sensibilities that are implicit in idioms of distress among family caregivers for Alzheimer's disease in Teotitlán del Valle, a rural Zapotec-speaking community in Oaxaca, Mexico. Through analysis of caregivers' perceptions of progressive memory loss and related etiological understandings, this article emphasizes the pragmatism inherent to local health perspectives. In so doing, the article revisits Nichter's earliest formulation of idioms of distress as providing an alternative epistemological framework to appreciate how illness is varyingly understood. Such a framework is useful for understanding how idioms of distress are not aimed towards attaining accuracy about what illness is in an objective sense, but rather put into focus how such descriptions are both constitutive of-and themselves pragmatic responses to-broader social circumstances. This article concludes with a consideration of how idioms of distress empower individuals as agents of action.
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Affiliation(s)
- Jonathan Yahalom
- US Department of Veterans Affairs; University of California, Los Angeles
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Wooyoung Kim A, Kaiser B, Bosire E, Shahbazian K, Mendenhall E. Idioms of resilience among cancer patients in urban South Africa: An anthropological heuristic for the study of culture and resilience. Transcult Psychiatry 2019; 56:720-747. [PMID: 31299876 PMCID: PMC6738567 DOI: 10.1177/1363461519858798] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite the large body of research on idioms of distress in anthropology and transcultural psychiatry, few scholars have examined the concepts that people use to describe social and psychological resilience. The experience of social and psychological resilience is embedded in and shaped by social, political, and economic contexts-much like the factors that shape idioms of distress. As resilience literature more broadly has adopted a socio-ecological rather than trait-based approach, anthropology has much to contribute. This article investigates what idioms of resilience and cultural scripts emerge among low-income patients with cancer residing in Soweto, a peri-urban neighborhood in Johannesburg, South Africa. We conducted 80 life history interviews to better understand what social and psychological factors led some people to thrive more than others despite extraordinary adversity. We describe one idiom of resilience, acceptance (ukwamukela in isiZulu), and three broader themes of resilience that emerged from life history narrative interviews (social support, religious support, and receiving medical care). We also present two examples from study participants that weave these concepts together. Our findings suggest that rarely is one form of resilience experienced in isolation. A focus on idioms of resilience can help chart the complex dimensions of acceptance and the dynamic social, religious, political, and temporal factors that mediate both suffering and resilience within individuals and communities.
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Affiliation(s)
| | - Bonnie Kaiser
- University of California San Diego and Duke University
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Otake Y. Suffering of silenced people in northern Rwanda. Soc Sci Med 2019; 222:171-179. [PMID: 30658290 DOI: 10.1016/j.socscimed.2019.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 11/19/2022]
Abstract
To contribute to understanding the association between silence and suffering in the context of war and political repression, this study sheds light on the meaning-making process and explores the underlying mechanisms by which silence leads to suffering and how this suffering could be alleviated. The ethnographic research was conducted in 2015-2016, with 43 participants from northern Rwanda, who survived massacres after the 1994 genocide but were prevented from speaking about the experience by political constraints. The findings first describe their suffering, through grief, social isolation and loss of meaning in life and death (expressed as existential questions). Their suffering was worsened by 'unspeakability'; that is, the political context that prevents victims from speaking freely about their war experience, including discussion of those who killed and those who were killed. Unspeakability exacerbated suffering since participants were obstructed from applying ready narratives (e.g. funerary rituals, traditional reconciliation systems) or constructing their own narratives which could ordinarily help them to process mourning and reconciliation and to make sense of the loss. They selectively employed silence for coping and protection, avoiding speaking about the past to maintain everyday life. However, at the same time, unprocessed mourning remained a serious problem, resulting in mental health problems such as hallucinations of the spirits of the dead; participants expressed a strong need for mourning rituals. Overall, this paper highlights the ways in which the suffering of the silenced population worsens when meaning-making processes are obstructed. To alleviate the suffering, it is essential to secure mourning rituals for all survivors, particularly those who, as part of the defeated group of war, are silenced and marginalized in history.
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Affiliation(s)
- Yuko Otake
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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16
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Abstract
Kinship processes contribute to the experience and interpretation of depression-generating empathy as well as silencing. We explore intersubjective experiences of depression among kin with the aim of understanding how depression can reveal kinship expectations and evolving concepts of distress. In interviews with 28 low-income rural Appalachian women about their depression, participants articulated depression as a social process that neither starts nor ends in themselves. Yet kinship obligations to recognize family members' depression limited women's ability to admit distress, let alone request care. The intersubjective experience of depression among kin can challenge the individual expression of distress.
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Affiliation(s)
- Claire Snell-Rood
- Division of Community Health Sciences School of Public Health University of California, Berkeley 207H University Hall Berkeley, CA 94720-7360 859-559-7640
| | - Merkel Richard
- Department of Psychiatry and Neurobehavioral Sciences, School of Medicine, University of Virginia, P.O. Box 800623, Charlottesville, VA 22908-0623, 434-243-4646, rlm3
| | - Nancy Schoenberg
- Department of Behavioral Science, University of Kentucky College of Medicine, 125 Medical Behavioral Science Building, Lexington, KY 40536-0086, 859-323-8175, n
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Hinton DE, Pollack AA, Weiss B, Trung LT. Culturally Sensitive Assessment of Anxious-Depressive Distress in Vietnam: Avoiding Category Truncation. Transcult Psychiatry 2018; 55:384-404. [PMID: 29623775 DOI: 10.1177/1363461518764500] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The present study investigated what complaints are prominent in psychologically distressed Vietnamese in Vietnam beyond standard symptoms assessed by Western diagnostic instruments for anxiety and depression. To form the initial Vietnamese Symptom and Cultural Syndrome Addendum (VN SSA), we reviewed the literature, consulted experts, and conducted focus groups. The preliminary VN SSA was then used in a general survey (N = 1004) of five provinces in Vietnam. We found that the VN SSA items were highly and significantly correlated with a measure of anxious-depressive psychopathology (a composite measure of the General Anxiety Disorder-7; Posttraumatic Diagnostic Scale; and Patient Health Questionnaire-9). The VN SSA item most highly correlated to anxious-depressive psychopathology was "thinking a lot" ( r = .54), reported by 15.8% of the sample. Many other symptoms in the addendum also were prominent, such as orthostatic dizziness (i.e., dizziness upon standing up; r = .41), reported by 22.9% of the sample. By way of comparison, somatic complaints more typically assessed to profile Western anxious-depressive distress, such as palpitations, were less prominent, as evidenced by being less strongly correlated to Western psychiatric symptoms and being less frequent (e.g., palpitations: r = .31, 7.1% of the sample). Study results suggest that to avoid category truncation when profiling anxious-depressive distress among Vietnamese that items other than those in standard psychopathology measures should also be assessed.
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Jenkins JH, Stone A. Global Mental Health and Adolescent Anxiety: Kin, Care and Struggle in New Mexico. Cult Med Psychiatry 2017; 41:609-629. [PMID: 28717863 DOI: 10.1007/s11013-017-9542-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
While recent developments within the field of global mental health have illuminated the reality of serious mental health difficulties worldwide, particularly in low-income settings, research that focuses on children and adolescents remains underdeveloped. This is especially the case with respect to ethnographic studies of lived experience of adolescents diagnosed with serious mental health conditions. Drawing from an interdisciplinary study of adolescents in New Mexico who were afflicted with a broad range of disorders according to contemporary research diagnostic criteria, this article focuses on anxiety-related conditions with respect to subjective experience and social-ecological contexts of living with such conditions. We offer preliminary observations regarding the value of linking ethnographic and research diagnostic data to address questions of resilience, endurance, capacity and struggle. These observations are intended as the basis for the formulation of more precise hypotheses about adolescent anxiety, kin, and care under conditions of structural violence marked by psychological, residential, and intergenerational adversity.
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Affiliation(s)
| | - Annika Stone
- University of California San Diego, La Jolla, CA, USA
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19
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Hinton DE, Barlow DH, Reis R, de Jong J. A Transcultural Model of the Centrality of "Thinking a Lot" in Psychopathologies Across the Globe and the Process of Localization: A Cambodian Refugee Example. Cult Med Psychiatry 2016; 40:570-619. [PMID: 27085706 DOI: 10.1007/s11013-016-9489-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We present a general model of why "thinking a lot" is a key presentation of distress in many cultures and examine how "thinking a lot" plays out in the Cambodian cultural context. We argue that the complaint of "thinking a lot" indicates the presence of a certain causal network of psychopathology that is found across cultures, but that this causal network is localized in profound ways. We show, using a Cambodian example, that examining "thinking a lot" in a cultural context is a key way of investigating the local bio-cultural ontology of psychopathology. Among Cambodian refugees, a typical episode of "thinking a lot" begins with ruminative-type negative cognitions, in particular worry and depressive thoughts. Next these negative cognitions may induce mental symptoms (e.g., poor concentration, forgetfulness, and "zoning out") and somatic symptoms (e.g., migraine headache, migraine-like blurry vision such as scintillating scotomas, dizziness, palpitations). Subsequently the very fact of "thinking a lot" and the induced symptoms may give rise to multiple catastrophic cognitions. Soon, as distress escalates, in a kind of looping, other negative cognitions such as trauma memories may be triggered. All these processes are highly shaped by the Cambodian socio-cultural context. The article shows that Cambodian trauma survivors have a locally specific illness reality that centers on dynamic episodes of "thinking a lot," or on what might be called the "thinking a lot" causal network.
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Affiliation(s)
- Devon E Hinton
- Center for Anxiety and Traumatic, Massachusetts General Hospital, Harvard Medical School, Stress Disorders, One Bowdoin Square, 6th Floor, Boston, MA, 02114, USA.
| | - David H Barlow
- Center for Anxiety and Related Disorders, Boston University, Boston, MA, USA
| | - Ria Reis
- Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
- The Children's Institute, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Joop de Jong
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
- Boston University School of Medicine, Boston, MA, USA
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20
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Mendenhall E, Yarris K, Kohrt BA. Utilization of Standardized Mental Health Assessments in Anthropological Research: Possibilities and Pitfalls. Cult Med Psychiatry 2016; 40:726-745. [PMID: 27553610 PMCID: PMC5476841 DOI: 10.1007/s11013-016-9502-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In the past decade anthropologists working the boundary of culture, medicine, and psychiatry have drawn from ethnographic and epidemiological methods to interdigitate data and provide more depth in understanding critical health problems. But rarely do these studies incorporate psychiatric inventories with ethnographic analysis. This article shows how triangulation of research methods strengthens scholars' ability (1) to draw conclusions from smaller data sets and facilitate comparisons of what suffering means across contexts; (2) to unpack the complexities of ethnographic and narrative data by way of interdigitating narratives with standardized evaluations of psychological distress; and (3) to enhance the translatability of narrative data to interventionists and to make anthropological research more accessible to policymakers. The crux of this argument is based on two discrete case studies, one community sample of Nicaraguan grandmothers in urban Nicaragua, and another clinic-based study of Mexican immigrant women in urban United States, which represent different populations, methodologies, and instruments. Yet, both authors critically examine narrative data and then use the Center for Epidemiologic Studies Depression Scale to further unpack meaning of psychological suffering by analyzing symptomatology. Such integrative methodologies illustrate how incorporating results from standardized mental health assessments can corroborate meaning-making in anthropology while advancing anthropological contributions to mental health treatment and policy.
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Affiliation(s)
- Emily Mendenhall
- Science, Technology, & International Affairs, Walsh School of Foreign Service, Georgetown University, Intercultural Center, 37th & O Streets, NW, Washington, DC, 20057, USA.
| | - Kristin Yarris
- Department of International Studies, University of Oregon, Eugene, OR, USA
| | - Brandon A Kohrt
- Duke Global Health Institute, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
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Jerves E, De Haene L, Enzlin P, Rober P. Adolescents’ Lived Experiences of Close Relationships in the Context of Transnational Families: A Qualitative Study From Ecuador. JOURNAL OF ADOLESCENT RESEARCH 2016. [DOI: 10.1177/0743558416664027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although transnational migration and its impact on families and society has received considerable attention from scholars, still little is known about its effects on the family members who stay in their home country. The aim of this qualitative study was to explore adolescents’ experiences of close relationships in the context of transnational migration. The study was based on in-depth interviews with male and female adolescents whose parents had migrated. For administration of these interviews, a tool consisting of 15 pieces of wood was developed in order to invite participants to represent family members in an expressive modality that could facilitate discussion and decrease tension provoked by parental migration. Thematic analysis showed that adolescents experienced growing up within tri-generational families whose structure and dynamics allow for a sense of stability. In these families, adolescents experience meaningful relationships that are important sources of support to cope with the delicate emotional situation inherent in transnational families. However, the present study also revealed that adolescents experience the relationship with their migrant parents as a recurrent source of distress and emotional ambivalence, leading to a potential perspective on the parent-child separation in the context of transnational migration as an experience of an ambiguous loss.
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Hatala AR, Waldram JB. The role of sensorial processes in Q'eqchi' Maya healing: A case study of depression and bereavement. Transcult Psychiatry 2016; 53:60-80. [PMID: 26337478 DOI: 10.1177/1363461515599328] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Theory and research on the healing practices of Indigenous communities around the globe have often been influenced by models of "symbolic healing" that privilege the way patients consciously interpret or derive meaning from a healing encounter. In our work with a group of Q'eqchi' Maya healers in southern Belize, these aspects of "symbolic healing" are not always present. Such empirical observations force us to reach beyond models of symbolic healing to understand how healing might prove effective. Through the extended analysis of a single case study of rahil ch'ool or "depression," we propose to advance understanding of forms of healing which are not dependent on a shared "mythic" or "assumptive world" between patient and healer or where therapeutic efficacy does not rely on the patient's ability to "believe" in or consciously "know" what is occurring during treatment. In this we demonstrate how the body, as a site of experience, transformation, and communication, becomes the therapeutic locus in healing encounters of this kind and argue that embodied mediums of sensorial experience be considered central in attempts to understand healing efficacy.
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den Hertog TN, de Jong M, van der Ham AJ, Hinton D, Reis R. "Thinking a Lot" Among the Khwe of South Africa: A Key Idiom of Personal and Interpersonal Distress. Cult Med Psychiatry 2016; 40:383-403. [PMID: 26487660 PMCID: PMC4945674 DOI: 10.1007/s11013-015-9475-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
"Thinking too much", and variations such as "thinking a lot", are common idioms of distress across the world. The contextual meaning of this idiom of distress in particular localities remains largely unknown. This paper reports on a systematic study of the content and cause, consequences, and social response and coping related to the local terms |x'an n|a te and |eu-ca n|a te, both translated as "thinking a lot", and was part of a larger ethnographic study among the Khwe of South Africa. Semi-structured exploratory interviews with community members revealed that "thinking a lot" refers to a common experience of reflecting on personal and interpersonal problems. Consequences were described in emotional, psychological, social, behavioral, and physical effects. Coping strategies included social support, distraction, and religious practices. Our contextualized approach revealed meanings and experiences of "thinking a lot" that go beyond a psychological state or psychopathology. The common experience of "thinking a lot" is situated in socio-political, economic, and social context that reflect the marginalized and displaced position of the Khwe. We argue that "thinking a lot" and associated local meanings may vary across settings, may not necessarily indicate psychopathology, and should be understood in individual, interpersonal, community, and socio-political dimensions.
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Affiliation(s)
- T. N. den Hertog
- Amsterdam Institute for Social Science Research, University of Amsterdam, Postbus 15718, 1001 NE Amsterdam, The Netherlands ,African Studies Centre, Leiden, The Netherlands
| | - M. de Jong
- Reha-Prime, Rehabilitation and Physiotherapy, Zurich, Switzerland
| | - A. J. van der Ham
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, VU University, Amsterdam, The Netherlands
| | - D. Hinton
- Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - R. Reis
- Amsterdam Institute for Social Science Research, University of Amsterdam, Postbus 15718, 1001 NE Amsterdam, The Netherlands ,Department of Public Health & Primary Care, Leiden University Medical Center, Leiden, The Netherlands ,School of Child and Adolescent Health, the Children’s Institute, University of Cape Town, Cape Town, South Africa
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Kaiser BN, Haroz EE, Kohrt BA, Bolton PA, Bass JK, Hinton DE. "Thinking too much": A systematic review of a common idiom of distress. Soc Sci Med 2015; 147:170-83. [PMID: 26584235 PMCID: PMC4689615 DOI: 10.1016/j.socscimed.2015.10.044] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 10/14/2015] [Accepted: 10/19/2015] [Indexed: 12/16/2022]
Abstract
Idioms of distress communicate suffering via reference to shared ethnopsychologies, and better understanding of idioms of distress can contribute to effective clinical and public health communication. This systematic review is a qualitative synthesis of "thinking too much" idioms globally, to determine their applicability and variability across cultures. We searched eight databases and retained publications if they included empirical quantitative, qualitative, or mixed-methods research regarding a "thinking too much" idiom and were in English. In total, 138 publications from 1979 to 2014 met inclusion criteria. We examined the descriptive epidemiology, phenomenology, etiology, and course of "thinking too much" idioms and compared them to psychiatric constructs. "Thinking too much" idioms typically reference ruminative, intrusive, and anxious thoughts and result in a range of perceived complications, physical and mental illnesses, or even death. These idioms appear to have variable overlap with common psychiatric constructs, including depression, anxiety, and PTSD. However, "thinking too much" idioms reflect aspects of experience, distress, and social positioning not captured by psychiatric diagnoses and often show wide within-cultural variation, in addition to between-cultural differences. Taken together, these findings suggest that "thinking too much" should not be interpreted as a gloss for psychiatric disorder nor assumed to be a unitary symptom or syndrome within a culture. We suggest five key ways in which engagement with "thinking too much" idioms can improve global mental health research and interventions: it (1) incorporates a key idiom of distress into measurement and screening to improve validity of efforts at identifying those in need of services and tracking treatment outcomes; (2) facilitates exploration of ethnopsychology in order to bolster cultural appropriateness of interventions; (3) strengthens public health communication to encourage engagement in treatment; (4) reduces stigma by enhancing understanding, promoting treatment-seeking, and avoiding unintentionally contributing to stigmatization; and (5) identifies a key locally salient treatment target.
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Affiliation(s)
- Bonnie N Kaiser
- Department of Anthropology and Department of Epidemiology, Emory University, 1557 Dickey Drive, Atlanta, GA 30322, USA; Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC 27701, USA.
| | - Emily E Haroz
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Brandon A Kohrt
- Department of Psychiatry & Behavioral Sciences, Duke Global Health Institute, and Department of Cultural Anthropology, Duke University, 310 Trent Drive, Durham, NC 27710, USA
| | - Paul A Bolton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Broadway, Baltimore, MD 21205, USA
| | - Judith K Bass
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Devon E Hinton
- Department of Psychiatry, Massachusetts General Hospital, 15 Parkman Street, WACC 812, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
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25
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Abstract
In concert with lengthening life spans, emerging forms of care in later life reflect complex and diverse social changes. Embracing a polysemic understanding of care as simultaneously resource and relational practice, this review works across scales of social life and theoretical approaches to care to highlight connections and fissures between global political-economic transformations and the most intimate aspects of daily life. Arguing for analyses of care that account for the kinds of projects, stakes, and obstacles that emerge as people engage in social reproduction in later life, this review traces the circulation of care across aging bodies, everyday practices, families, and nations. Care in later life never exclusively impacts the lives of the old; it is thus a critical site for understanding the diverse ways that increased longevity is shaping the meanings, experiences, and consequences of life itself.
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Affiliation(s)
- Elana D. Buch
- Department of Anthropology, University of Iowa, Iowa City, Iowa 52242-1332
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26
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Abstract
Several Indigenous communities around the globe maintain unique conceptions of mental illness and disorder. The Q'eqchi' Maya of southern Belize represent one Indigenous community that has maintained, due to highly "traditional" ways of life and the strong presence of many active localized healers or bush doctors, distinct conceptions of mental disorders as compared to Western psychiatric nosology. The purpose of this ethnographic study was to understand and interpret Q'eqchi' nosological systems of mental disorders involving the factors--spiritual, cultural, social, historical, cosmological, or otherwise--implicated in their articulation and construction. Over a period of 9 months, and with the help of cultural advisors from several Q'eqchi' communities, 94 interviews with five different traditional Q'eqchi' healers were conducted. This paper demonstrates that the mental illnesses recognized by the Q'eqchi' healers involved narrative structures with recognizable variations unfolding over time. What we present in this paper are 17 recognizable illnesses of the mind grouped within one of four broad "narrative genres." Each genre involves a discernible plot structure, casts of characters, themes, motifs, and a recognizable teleology or "directedness." In narrative terms, the healer's diagnostic and therapeutic work can be understood as an ability to discern plot, to understand and interpret a specific case within the board, empirically based structure of Q'eqchi' medical epistemology.
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Kidia K, Machando D, Bere T, Macpherson K, Nyamayaro P, Potter L, Makadzange T, Munjoma R, Marufu M, Araya R, Safren S, O'Cleirigh C, Chibanda D, Abas M. 'I was thinking too much': experiences of HIV-positive adults with common mental disorders and poor adherence to antiretroviral therapy in Zimbabwe. Trop Med Int Health 2015; 20:903-13. [PMID: 25754063 DOI: 10.1111/tmi.12502] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To document the lived experiences of people with both poor mental health and suboptimal adherence to antiretroviral therapy in high HIV prevalence settings. METHODS In-depth qualitative interviews were conducted with 47 (female = 31) HIV-positive adults who scored above the cut-point on a locally validated scale for common mental disorders (CMDs). Purposive sampling was used to recruit participants with evidence of poor adherence. Six additional key informant interviews (female = 6) were conducted with healthcare workers. Data were collected and analysed inductively by an interdisciplinary coding team. RESULTS The major challenges faced by participants were stressors (poverty, stigma, marital problems) and symptoms of CMDs ('thinking too much', changes to appetite and sleep, 'burdened heart' and low energy levels). Thinking too much, which appears closely related to rumination, was the symptom with the greatest negative impact on adherence to antiretroviral therapy among HIV-positive adults with CMDs. In turn, thinking too much was commonly triggered by the stressors faced by people living with HIV/AIDS, especially poverty. Finally, participants desired private counselling, access to income-generating activities and family engagement in mental health care. CONCLUSIONS Better understanding of the local expression of mental disorders and of underlying stressors can inform the development of culturally sensitive interventions to reduce CMDs and poor adherence to antiretroviral therapy.
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Affiliation(s)
- Khameer Kidia
- Arnhold Global Health Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Debra Machando
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.,Women's University in Africa, Harare, Zimbabwe
| | - Tarisai Bere
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | | | - Lucy Potter
- Institute of Psychiatry, King's College London, London, UK
| | - Tariro Makadzange
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.,Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
| | - Ronald Munjoma
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Marshall Marufu
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Ricardo Araya
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Steven Safren
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Conall O'Cleirigh
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dixon Chibanda
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Melanie Abas
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.,Institute of Psychiatry, King's College London, London, UK
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