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Anth 207: Helping (revised)

Slides for lecture in Psychological Anthropology by Greg Downey, Macquarie University, 2015.
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Greg Downey

on 2 November 2015

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Transcript of Anth 207: Helping (revised)

Helping
Refugees in the US
Kohrt followed Nepali Bhutanese refugees, including to the United States.
Reading discusses how ethnopsychiatry can be brought together with various psychiatric techniques.
Cross-cultural competence?
Success in intercultural encounters determined by both motivation & knowledge, but what knowledge?
Inuit self-harm
Laurence Kirmayer argued that the only way to understand and treat high rates of self harm in Inuit communities in Canada was to recognise that these were not individual cases or individuals' psychiatric problems.
Hamatsa emerging from the woods--Koskimo:
Photo by Edward Curtis, 1918, Public domain
'Hamatsa shaman, three-quarter length portrait, seated on ground in front of tree, facing front, possessed by supernatural power after having spent several days in the woods as part of an initiation ritual.'
psychological anthropology
Anth 207
greg downey
macquarie university
how do we move beyond critique to offer advice and assist in healing?
prezi slideshow created by Greg Downey
copyright 2015, 2013 (where relevant)
made available for use under CC license (BY NC SA)

For Semester 1, 2016.
ANTH224: Mad, Bad, Sad
Aaron Denham
Behaving Badly: Normality, Danger and Disorder
Seven Deadly Sins: Ethnographic Perspectives on the Moral Life
Madness and Culture
Against the Social Order: Witchcraft and Sorcery
Zones of Social Abandonment: The Homeless, Vulnerable and Unwanted
Bad parenting: Infanticide and Child Abuse
Addictions: Circuits of Dependency
Deviant Sexualities
Dark Technology: Online Addictions, Cybercrime and the Underground Economy
Consuming the Body: Vampires, Cannibalism and Organ Theft
On Happiness: Ethnographic Perspectives on Living Well
Cross-cultural perspectives on madness, difference and deviance and their moral and social implications. This unit examines what happens when people find themselves outside the bounds of normality. Topics include:
Nepal
Bhutan
Brandon Kohrt
India
(also India)
Nepal Civil War (1996-2006)
Monarchists opposed by Maoists
Conflict grew more bitter after Royal Army joined police against rebels in 2002.
A nominal democracy required king's support.
Maoists dominated rural areas; loyalists controlled population centres.
Kathmandu
2001 - Royal Massacre: 11 members of royal family killed, allegedly by Crown Prince who died 3 days later.
Over time, the sides hardened against each other so that worst fighting in 2004-5.
"Democracy and progress contradict one another... In pursuit of liberalism, we should never overlook an important aspect of our conduct, namely discipline."
King Gyanendra
Civil War undermined tourism (dropped from 10th to 27th top global destination).
Many Nepalese fled as refugees.
Child soldiers
Although both sides used children, the Maoists employed child as front-line soldiers.
“I joined the Maoist army for the sake of liberating my country from repression but now I am suddenly not qualified any more to be in the army,”
Karki
“I always wanted to get into politics to liberate our repressed people. I’m not interested in making candles or baskets,”
Sunita
child soldiers discharged in 2010
fear that former child soldiers might be recruited to paramilitary or criminal organisations if not reintegrated.
“Teachers would call them ‘little Maoists,’ force them to sit on the floor and mock them, and sometimes not even let them into the classroom because they [the teachers] were afraid of them [the children],”
Former child soldiers had evidence of anxiety, depression, even post-traumatic stress disorder (PTSD).
“So what we did,” Kohrt continues, “was to train community psychosocial workers to meet with the teachers and ask them to discuss their fears and concerns about these children. The community psychosocial workers then brought the teachers and former child soldiers together. The children said that the most important thing about coming home was to be able to reenter school. Slowly the teachers improved their treatment of the youngsters, and when they did so, the youngsters’ classmates and other members of the community did as well.”
One year after the intervention, former child soldiers had mental health profiles similar to children without the experience.
community-based, etnographically-informed intervention
“Often you are perceived as someone who has a lot of resources at your disposal, which can lead to superficial agreement with whatever ideas you present. So what my colleagues and I do before designing an intervention is attempt to foster dialogue with community leaders, religious leaders, and traditional healers to identify people’s needs, concerns, and expectations. And only after we’ve taken this participatory approach do we design an intervention.”
Brandon Kohrt
ethnopsychiatry as ethnography
principle of genuine consultation
Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it's the only thing that ever has.
attributed to Margaret Mead
Since psychiatric problems are almost inevitably mixes of biological, cognitive & social factors and effects...
...they can often be addressed on multiple fronts.
This is an opportunity, not a limit, for a non-dogmatic approach to helping.
Too often, highly dogmatic approaches take tools off the table before healing even starts.
Since meaning & empowerment almost inevitably part of healing, it is practical & effective to listen.
Est 12,000 under the age of 18 at the end of the war in Maoist forces.
UN verified 9000 in camps.
Unlike the popular impression of child soldiers, many joined voluntarily for standard of living, subsistence, to escape bondage & because of perceived good treatment.
Brandon Kohrt and Maya Shrestha interview a former child soldier.
indigenous model of self
Laurence Kirmayer has argued that anthropology provides a external perspective, especially for practitioners who are in the thick of dealing with individual cases.
Also encourages us to see the therapeutic relationship as space for mutual learning, not just the application of what we already know.
Some research suggests that knowledge of what others know (meta-knowledge) is crucial.
This observation is sort of obvious, but applying it when one is dealing with a 'sick' or 'mentally ill' person is much less likely.
The ill individual is a partner in self-healing.
Announcements
Final exam.
Advice
The sooner you start doing something you care about, the easier it will be for you.
Don't wait to become what you want to be -- do it, and then find someone to hire you to do what you're doing.
Check your motivations; too many bad decisions come from fear.
why was it therapeutic helpful to understand Nepali ethnopsychiatry?
examples
the components of psychotherapy:
hope & expectancy of change
extra-therapeutic & contextual factors
therapeutic alliance
specific psychotherapeutic technique
Kohrt points out that both ethnopsychiatries (other cultures' understandings of the self & psyche) as well as Western psychotherapies are, in fact, heterogeneous.

Opportunities to build alliances between forms of psychotherapy & profiles of ethnopsychiatry.
thank you for a great semester!
Kamal - young man, refugee, with conversion disorder, suffering from pseudoseizures.
What was the response of the patient to the use of anti-seizure medication?
To cognitive-behavioural therapy?
Why was it helpful to Kamal to identify his seizures as a 'heart-mind' problem?
Phulmaya, older woman, met clinical criteria for major depressive disorder.
What form of therapy worked for her?
Why was it helpful to call her depression a 'Heart-mind-society' problem (manosamajik)?
placebo or 'meaning' effects in Australia
grief
interpersonal disputes
role transitions
interpersonal deficits
interpersonal therapy
distress is an intersection of social & individual problems. Therapy focuses on transforming relationships.
Kohrt's approach
treats individual as partner in healing, with his or her own resilience & recuperative powers, as well as effective modes of self-understanding.
psychoeducation as an exchange between partners, not a one-way transmission of knowledge or techniques.
well known that placebos (inert substances) can help bring about healing.
non-relevant qualities of treatment can have an effect (colour of pill, branded/generic).
effectiveness of placebos highlights the combined power of 'meaning', form of treatment & patients' own resilience.
Daniel E. Moerman
placebo effect v. meaning response
In one study, patients with irritable bowel syndrome were given a 'placebo' and told it was inert, yet they still experienced significant improvements.
"I was really surprised at how well the non-placebo group did,” Moerman says in email. “Note I don’t call them a ‘no treatment group’ because they, and everyone else, received exemplary treatment here: they were listened to, examined, encouraged, supported. They were able to talk with, and be taken seriously by, people who understood their issues, things they probably had serious difficulty discussing with their own families. I think it likely that the effectiveness of the placebos above and beyond all the other treatment would have been diminished without the whole system of compassionate care.”
in other words
even IBS was a 'culture-bound syndrome' in that it had dimensions of meaning that were amenable to modification with effects on the patient's state.
1.a. A substance containing no medication and prescribed or given to reinforce a patient's expectation to get well.
2. Something of no intrinsic remedial value that is used to appease or reassure another.
b. An inactive substance or preparation used as a control in an experiment or test to determine the effectiveness of a medicinal drug.
placebos are effectively harnessing our own expectations about treatment to build hope, compliance, resilience, coping...
in fact, since the 2000s, placebos are getting MORE effective, so much so that rates of drug approvals are dropping because they must best placebos in clinical trials.
why?
because pharmaceutical companies & biomedicine have successfully persuaded us to become even more confident in the whole mechanism & practice of biomedicine?

We are 'true believers' in medicine, and thus make it more effective.
efficacy in psychiatric care
Panic disorder — 50% improvement in symptoms with placebo.
Post-traumatic stress disorder & depression — response > 30%,
Generalized anxiety disorder — c. 30%.
expectations appear to be crucial: animals can be trained to respond to placebos.
opposing 'nocebo' or negative effects can also be produced.
Treating the children effectively meant listening to them, recognising how they were (radically) different to other child soldiers elsewhere, and then comprehensively confronting the specific way that they were distressed.
clear and compelling evidence that the long history of cultural oppression and marginalization has contributed to the high levels of mental health problems found in many [aboriginal] communities
Laurence Kirmayer
Is diagnosis helpful in absence of treatment options?
Practitioners have found humility essential (e.g., not distinguishing what we 'know' from what others 'believe').
Listening carefully to symptoms & to local knowledge (e.g. local foods effective against depression).
Detailed knowledge of culture less vital than openness to consider.
in the case of Inuit youth, success both with cultural heritage approaches & eco-centric therapy.
some success treating the community as the 'primary locus of injury,' not the individual.
China
Laos
Myanmar
(Burma)
Cambodia
Thailand
Vietnam
PTSD in Cambodia & Sri Lanka
Sri Lanka
PTSD (post-traumatic stress disorder) is a condition of hyper-arousal.
Therapists working with Cambodian refugees in the 1980s found patients saying that they 'thought too much' — so characteristic it was called the 'Cambodian sickness.'
Sufferers progressed through stages, from 'small heart' to 'broken down heart-mind'.
Mental deterioration seemed to lead to dissociation.
In Sri Lanka following the Christmas Day tsunami, local individuals were not talking about what had happened to them.
Foreign therapists who arrived wanted individuals to focus on recalling trauma, whereas most victims were more concerned about poverty, housing, food & continued survival.
Therapists found that effective treatment for refugees often included helping victims to develop balanced recall of their former homes.
Suffering exacerbated by overly positive recollection which made current condition more painful.
Patients often responded to very simple emotional coping techniques, such as locating familiar foods, finding fellow refugees, re-establishing community.
Western understanding of PTSD (unfinished emotional processing of trauma) could lead to counter-productive therapeutic techniques.
Recognise that even in the West, there are competing interpretations of trauma.
Mental health as global health problem
6 of the top 20 causes of disability globally.
depression is leading cause of disability.
higher total disease burden than HIV.
although typically represents 12%+ of burden, psychiatric illness worldwide receives approximately 2% of health budgets.
PLEASE take time to do the course evaluation! It will be distributed in tutorials.
Kevin to come by before the end.
Anthropology as tool for change & health
improve communication of distress.
locate indigenous resources.
expand understanding of illness (and health).
partner with local efforts to improve conditions.
Make inquiry & learning part of advocacy.
cultural humility?
therapeutic humility
'Madness Hotel'
Hotel da Loucura, Nise da Silveira Hostpital
Rio de Janeiro, Brazil
Theatre of the Oppressed
(Augusto Boal)
enacting different ways of being in the world.
opposite to 'social death' as treatment for mental illness.
at least temporarily, world conforms to those who see it differently.
challenge to authority of psychiatry & psychology.
‘Creative work can act as a way of structuring chaotic emotions and thoughts, and creating a distance from the source of despair’
Kay Redfield Jamison,
Touched with Fire
(1991)
theatre as rehearsal of alternative lives.
Kevin Groark
ANTH225: Field School in Anthropology: Fiji
For Winter Break, 2016.
Collaborative, community-based research.
Partnered with USP and the Fiji Museum.
Arts-ethnographic approach.
Ethnographic video making.
Museum studies project.
Full 3-credit unit (PACE credit).
New Colombo Plan scholarships available.
drugs as a 'culture bound therapy'?
Full transcript