Suicide Prevention: Insert Culture Here

Authors

This article, Applying Nepali Ethnopscyhology to Psychotherapy for the Treatment of Mental Illness and Prevention of Suicide Among Bhutanese Refugees, was co-written by two MDs, a photographer, and a medical anthropologist with a PhD and an MD. Brandon Kohrt and James L. Griffith both currently hold positions as medical doctors at the George Washington University School of Medicine and this is likely where their decision to collaborate on this study stemmed from.

Brandon Kohrt has both an MD and a PhD. He earned both of these degrees at Emory University in 2009 and has been working in Nepal since 1996. His work in Nepal has included conducting research and aiding victims of war. He is a medical anthropologist and a psychiatrist. Since 2006, Kohrt has worked with the Transcultural Psychosocial Organization and in 2010 he became a consultant to The Carter Center Mental Health Program Liberia Initiative. He currently holds an adjuct associate professor of psychiatry and behavioral sciences at Duke University and a medical faculty associate position at George Washington University in Washington DC.

James L. Griffith is an MD in psychiatry that he received at the University of Mississippi School of Medicine in 1976. He also received an MS in Neurophysiology from the same university in 1979. He is currently a professor and the chair of the Department of Psychiatry and Behavioral Sciences at George Washington University School of Medicine in Washington DC.

Sujen M. Maharjan is a photographer in Nepal.

Damber Timsina at the time that this study was published held a position at Grady Memorial hospital in Atlanta Georgia.

Background on the Conflict

If you’re like me and only somewhat remember talking about the Bhutanese during high school history but you don’t remember a whole lot about it then this section is for you. Bhutan is a small country in Asia that is settled between India and China and next to Nepal. During the 1990s, there was an effort made by the Bhutanese government to rid the country of Lhotshampas, or ethnic Nepalis. An elitist political group in Bhutan viewed this group of people as a cultural threat. During this time, Lhotshampas were beaten, attacked, and killed until the ethnic group was forced to flee Bhutan to neighboring Nepal. By 1996, over 100,000 Bhutanese refugees were living in camps in Nepal. This ethnic group has not been able to return to Bhutan since.

Overview

This article addresses the importance of personalized mental health treatment and the necessity of understanding a person’s background and culture when discussing delicate topics. The authors address how ethnographic practices can be integrated into neuroscience to make treatments more successful.

Part One: Neuroanthropology and Psychotherapy

Neuroanthropology is emphasized throughout this article as a means to bridge the gap between medical care and individual people. It is defined as “the enculturation of the nervous system”. Psychotherapy is the other important concept put forth in this article as a way to use psychological methods to help a person heal. The main components of psychotherapy are laid out as the hope for change, environmental and contextual factors, the relationship with the therapist, and a specific plan. Neuroanthropology steps in to explain the enculturation of a particular person so that a personalized plan can be draw up and so that the therapist knows how to interact with their patient to build a better relationship.

Part Two: From Ethnography to Ethnopscyhology

Ethnography is the primary fieldwork method utilized by cultural anthropologists. It’s a way for the anthropologist to tell the story of the particular culture that they are studying. This section of this article is explaining the process in which psychology has been able to take notes from cultural anthropology and create mental health treatment plans best suited for individuals from cultures other than that of the therapist. The ethnopschological work done for this study includes defining the divisions of self within the Nepali culture. These divisions include heart-mind, brain-mind, and soul. Without an understanding of these divisions, the Nepali refugees would have been unable to receive the help that they needed from their therapists.

One of the most important divisions in Nepali culture that of the brain-mind and the heart-mind. The heart-mind is related to emotional feelings such as sadness and depression while the brain-mind is focused on behavioral control issues. Ailments of the heart-mind that go untreated can often affect the brain-mind. Brain-mind disorders carry heavy social stigma in Nepali culture and knowledge of how to approach this cultural idea is imperative to properly treating mental health issues with Nepali patients.

Part Three: Psychotherapy for Nepali and Bhutanese Patients

Cognitive behavior therapy, interpersonal therapy, and dialectical behavior therapy are three methods that are commonly used with Ethnopscyhology because of how easily these methods can be adapted to fit the needs of the patients. An advantage of Ethnopscyhology is that the therapist is able to act as an ethnographer, meaning that they can communicate with their patient in a way that puts them as ease when discussing their home culture and allows both the patient and therapist to design a treatment plan that best fits the individual.

Cognitive Behavior Therapy

A technique designed by Aaron Beck to treat depression, the basic idea of this method is to tackle the ‘automatic thoughts’ associated with negative experiences. The example given in the article was that of a man who suffered seizures after his mother had a stroke and after he was relocated away from his parents upon entering the US. Through CBT, the man and his therapist were able to determine that his seizures were caused by his thoughts that if anything were to happen to his parents that it would be his fault. Through treatment, he was able to overcome these thoughts and develop healthier ways to handle his thoughts of guilt.

Interpersonal Therapy

Harry Stack Sullivan was the man who created the method of interpersonal therapy because he understood the importance of culture and saw the need to address relationships in psychiatric treatment. Based on the ethnographic data collected, the therapists working with the Nepali refugees are aware that issues regarding mental health often affect social status and family relationships. This method of therapy works to reduce relationship disputes and interpersonal sources of distress rather than focusing solely on the individual.

Dialectical Behavior Therapy

This method was developed by Marsha Linehan to help people who engaged in self-harm and suicidal behavior. The rate of suicide among the Nepali refugees is 35 of 100,000, which is higher than the national average of 21 of 100,000. At the point that this paper was written this method had not been directly applied to a Nepali refugee. The basic idea of this method is to alter the perceptions the patient has of their emotions and sensations of their stress. The main goal of this treatment method is to lower the rate of self-harm and suicidal behavior.

Part Four: Can Ethnopsychology Usefully Inform Mental Health Interventions in Other Populations?

 

Due to the understanding of Nepali culture, more personalized psychiatric treatment plans can be implemented. During treatment, the therapist was able to work with a fuller knowledge of the patient’s culture and was able to develop a plan that would treat the mental health issue at hand while lowering the social stigma of the disorder for the patient. Ethnopsychology can be used to create personalized treatment plans for patients of all cultures. Generalizations can be made from culture to culture while still altering certain aspects as needed to properly treat a patient.

Summary

It’s very important that the therapist is able to communicate with the patient to work through the issues that the patient is experiencing. In the case of the Nepali refugees, cognitive behavior therapy and interpersonal therapy have proven to be effective in improving the lives of the refugees following their move to the US. Using the same ethnographic processes of learning about new cultures and determining what is socially unacceptable and how the body is divided within these cultures is extremely important in developing the best treatment plan for a patient.

Discuss

  1. How do you think the social stigma of certain mental illnesses impacts treatment here in the United States?
  2. Explain how you would create a treatment plan for a refugee using Dialectical Behavior Therapy.
  3. Where do you think the most stigma lies in our culture and which psychotherapy methods presented here in this article would be most useful in treating mental health illnesses here in our country?
  4. Are there other places in our medical system that could benefit from ethnographic practices and an understanding of different cultures?

13 thoughts on “Suicide Prevention: Insert Culture Here”

  1. I think that there are plenty of other places in our medical system that could benefit from ethnographic practices and an understanding of different cultures. For one, the doctor-patient relationship is crucial to the outcome of treatment. Like that articles on dance movement therapy and art therapy have stated, the therapist’s personal, empathetic relationship matters on the outcome of therapy. Similarly, different culture’s practitioners behave in different ways. For example, some cultures see a good doctor as one who negotiates with the patient and asks questions while other culture’s see that type of behavior as incompetence and are less likely to follow doctor’s orders. It’s important to know peoples’ values, beliefs, etc., in order for the outcome of therapy to be the most effective.

  2. I think what Monkia said is important. The doctor-patient relationship really is crucial when it comes to developing a unique and personalized treatment plan. The idea of ethnographic practice, playing off cultural beliefs, and incorporating them into treatment is something that is beneficial even just inside the U.S. We spoke earlier in the class about how medical practice and even degree preference differs within the U.S. For instance, in more liberal, densely populated areas a D.O and wholistic medical stances may be of more value than in suburban or conservative areas. Especially in large cities with greater diversity, I think ethnographic practices would be particularly of value.

    1. After discussing in class how we could get these therapies out to refugees, I came up with many other ideas where our medical system could benefit from an understanding of different cultures. Just by using a pragmatic approach, one of the barriers to getting refugees CBT or DBT therapy is possibly the language barrier. How can you teach CBT and DBT to someone who speaks a different language than you? Are CBT and DBT treatments translated into other languages? And if so, have we tested their efficacy with people from different cultures who speak different languages? Furthermore, if a doctor’s orders is for an individual to do at-home practices and take a prescription in addition to in-office therapy, what if the individual cannot read their homework or read the instructions on their prescription because they are in English?

    2. I did some research on D.O. and M.D. concentration in the U.S. and it turns out as of 2016, there are more than 129,000 osteopathic medical physicians (DOs) and osteopathic medical students in the United States. Which is a huge jump compared to the 13,000 in 1960. The majority of this increase has also been from 1980 to 2005, so I would definitely say this degree is gaining traction. Also, osteopathic doctors are able to practice all medicine and even perform surgeries in all 50 states and are recognized in 65 other countries. I know that is something we talked about in class and being a difference between M.D. and D.O.

  3. Another component to consider when attempting to communicate between different ethnopsychiatric domains is measurement and assessment. This is a large problem in general, and especially in areas with hundreds of languages and potentially hundreds of different ethnopsychiatric domains, and is critical considering treatment ostensibly comes after assessment. It’s imperative, then, that the scales being utilized are understood by those in the different ethnopsychiatric groups, but can also be comparable in some meaningful way. Dr. Snodgrass and I just presented a paper at the AAA where we discuss this topic exactly, directly comparing our approach of an emically freelisted scale with the translated scale that Kohrt uses in Nepal. I can talk more about that if people are interested.

    1. Kohrt tends to be more on the applied side of global mental health research, in terms of applying interventions and getting out there and helping people. I find this admirable in a way, as many other researchers are focused on determining local understandings in order to later apply interventions more effectively, which is the side I tend to lean toward. I think there needs to be some kind of middle ground, as with assessment, in terms of local understandings and interventions. He discusses, for example, the vast difference in the concept of self that the Nepalese have, but is still applying Western interventions that have a completely different basis. I’m not sure how to reconcile these different approaches, but I think both sides–actually applying interventions and thorough emic understandings– are necessary as global mental health moves forward.

  4. I have always held CBT in a really high regard for the fact that it can be just as beneficial as medication, and is an “actionable” form of therapy where you actively change thinking patterns. I really like how that’s put into context by using the example of pseudoseizures. But I definitely now understand how in some cases, that model can’t be as meaningfully adapted to other cultures. Of course we can all recognize the importance of tailoring the treatment plan to the patient who needs help, but the fact that it needs to get so specific I think is the novel concept here. Therapies have come a long way from Freud suggesting a universal version of therapy, interpreting dreams the same way, and placing everyone into schemas. The fact that we are beginning to break down these treatments into really meaningful subcategories that can effectively help more people within their own culture, and that we can see real, measurable results, is really really cool.

    1. I think our discussion on DBT was really on the right track, but it’s really hard to nail down. Like we mentioned in class, really the only time it’s used is for Borderline Personality Disorder. It’s also hard to specialize in, because as we decided in class, it’s really hard to operationalize the goals. Also as you brought up, BPD has an extremely low recovery rate. Something we didn’t get to mention though is that Personality Disorders, in general, are realyy hard to treat because it’s literally part of that person’s personality- essentially, it’s what makes that person who they are. That’s part of why DBT is effective in preventing self-harm and suicide, because these people have valuable lives they just think in such absolutes that they can’t see an end.

  5. Culturally relative therapy is a very interesting concept. It seems like something that is often overlooked. We can often see mental healthcare such as this as something very Western and try to implement across the globe without much tailoring. That is part of the reason why this article is so important. It acknowledges that there are not necessarily universals when it comes to mental healthcare and that in order to be effective, culture needs to be taken into account.

    1. I honestly had not heard about cognitive behavior therapy really before this class. I had heard the phrase but never really looked into it. It is interesting and its disappointing that different kinds of therapists that use CBT or dialectal behavior therapy are not common everywhere. Borderline Personality Disorder is incredibly hard on individuals’ and their families. It is upsetting to me that it is hard for them to access the care they need that could truly help them and make life so much easier.

  6. I think a lot of the social stigma about mental health in the United States lies in which mental illness you’re talking about. I think a lot of people are quick to believe certain ailments like Schizophrenia, PTSD, Alzheimer’s, Dementia, etc. But some, like ADHD, or Depression are seen as not real, or just being lazy. Similarly, OCD is often seen as just being really controlling. I don’t really know where the disconnect is, maybe because the previous are more easily visible in many cases. Sadly, this also effects the treatment. Those who feel less supported, who are surrounded by people telling them that their mental illness isn’t really, are much less likely to go get treated, afraid of the associated shame and embarrassment. I feel like this fear is exacerbated in populations such as the Nepali refugees because it is hard enough to be living in a foreign population, let alone trying to get treated for stigmatized mental illnesses.

    1. After hearing more about DBT in class, I think it is a really good idea, but I question its effectiveness solely because I feel as if it is not very accessible and is extremely difficult. Finding a therapist who practices DBT is very uncommon, I would imagine. And it requires a lot of work on the patient’s part to completely retrain these thought. Therefore, it requires the patient to be very open and accepting, not to mention willing, to try this form of therapy.

  7. Ashley in the HBERG lab actually had me thinking about this last Friday, by talking about Natchez social castes. Her basic overview was that the highest class, the Sun, had to intermarry with the lowest class, the Stinkard, and for every generation, a person moved up a social class. When the person reached the top, the Sun, the next generation once again became the bottom class. In relation to the Bhutanese groups, I wonder if ethnic groups can integrate without losing their entire social identities.

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