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.
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.
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.
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.
- How do you think the social stigma of certain mental illnesses impacts treatment here in the United States?
- Explain how you would create a treatment plan for a refugee using Dialectical Behavior Therapy.
- 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?
- Are there other places in our medical system that could benefit from ethnographic practices and an understanding of different cultures?