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Friday, 30 September 2011

Traveling to the next chapter

Bamboo railway, Cambodia
“I’d love to get away for a while, but I don’t want to travel on my own.”

I hear this a lot.  As people rethink their lives post-divorce, post-bereavement, post-separation, post-depression, post-the-old-life, they often want to travel.

Sometimes travel is just an extreme form of avoidance.  Hey, rather than just avoiding my family, why not avoid my entire country and everything in it?  This is fairly easy for any therapist to detect.

More often, travel is a punctuation mark between chapters of a person’s life.  “My life as an accountant is now over.  I need to move on to what comes next.  But first, I need to get some perspective.”  Travel can be the equivalent of sorbet: something to cleanse the palate before the next helping of life.

Sometimes travel is the next chapter.  “Now that the kids have moved out, I’m going to see the world.”  Or teach English in Japan.  Or volunteer for an agency in Africa.  Or do a house-swap with an Australian family.

But there are barriers.  “I want to travel, but I don’t want to sit in sterile Holiday Inns all day long.  But I don’t want to get myself in over my head either.  And how am I going to know whether it’s okay to walk around in Phnom Penh after dark?  Plus, I don’t know the language in any of the places I want to go, and I don’t want to spend three quarters of my time figuring out where to stay, where to eat, or how to get to Mamallapuram.”

And if the person is solo, “Will I have much fun anyway?  Will I meet anyone?  Will I just spend the entire trip eating at tables for one and noticing all the happy people around me?”

When issues like this come up, I have a recommendation in my back pocket.  Small group tourism.

This calls up bad associations.  “Great.  ‘If it’s Tuesday this must be Belgium.’  Getting up at 5 in the morning to load my luggage onto the Greyhound to traipse around Europe with a bunch of other people who want to say they’ve traveled but don’t really want to experience anything.”

Not so.  Imagine being met by someone who lives in the country and knows where to stay, where to eat, and how to get to interesting spots you’ve never heard of and that don’t appear in the travel guide.  They do the research.  They travel with you.  And you never have to find a hotel or a restaurant if you don’t want to.  There’s a small group of you, and you form a short-term family of sorts.
Overnight stop accommodations, outback Australia

Imagine someone who knows that if you turn right at the next unmarked crossing, then left, then right again onto the dirt road, then over the old bridge, you can visit the family that lives on the site of an old mine?  Or that of the seven sticky-rice makers along a road, the fifth is the best?  Or that if you arrive at the volcano after dark, you can see the glow from the crater?  Or that the deserted-looking building over there is a pub, and that tonight people will come from the desert for miles around, because tonight is the night the visitors from the small-group company will be there?

Imagine being able to be by yourself for a big part of every single day if you want, but being able to hang out with others if you’re feeling more sociable.  Imagine any meal you like being family-style.

The big-bus tour companies are still out there, but more companies are employing local guides, using local transport, and roughing it a bit to give you a real feel for the country you are traveling in.  And if you like the place, you can stay after the group has disbanded, and travel on your own.  Whether you travel solo or as part of a couple or a family, there is a small-group experience that probably suits your taste.
With Intrepid in NW Cambodia

One of the best of these companies, in my experience, is Intrepid Travel (, which offers trips all over the world.  I’ve traveled in SE Asia with them.  Many friends, colleagues, and clients have used them as well.  The maximum group size is 14-16.  At minimum, Intrepid’s site is a great resource to find out about countries you want to visit.  It’s a helper for people who want to start building their “dream list” of places to see, and for those planning their own solo travel.

There are other organizations that specialize in certain countries.  I’ve used several of these to see the backroads of Australia, and have always liked the trips.  They may not be the thing for those who feel that the main thing they want in travel is a high thread count in the bedsheets.  But for almost everyone else they’re a great option.

Tuesday, 27 September 2011

From S-A-R to S-A-R-A-R

I usually refer to the core cognitive model as S-A-R, for Situation Appraisal Response.  As mentioned in the previous post, it’s the “central leader” to which the various ideas and strategies attach.

But SAR isn’t enough.

Critics of cognitive work often roll their eyes at what can seem like an overly simplistic approach.  (I’ve been working with it for decades and parts of it still escape me in session, so apparently it isn’t all that simple, at least for me.)  As typically presented, it can seem like the root of cognitive work is “It ain’t as bad as you think.”

But what if it is?  What if you really do have a terminal illness?  What if your spouse really does move out?  What if your company really lays you off?

Even here, of course, we can work with the traditional model.  The problem may not be the thought “I’m going to be fired” which, it turns out, is correct.  The problem might be a subsequent thought.  “And I’ll never get another job and have to live the rest of my life in poverty.”

But often the subsequent thoughts are no longer about the situation at all.  They are about our initial reaction.  “I’m getting all panicky just because I might lose a job I don’t like all that much anyway.  I’m such a child.  If people knew I was whining like this they’d reject me.”

We can handle this within the traditional model, which usually involves identifying the person’s chain of thoughts to the original trigger situation.  But it’s useful to separate out the reaction to the situation and the reaction to the initial reaction.  For this we can use SARAR:

Situation   ⇨   Appraisal   ⇨   Response   ⇨   Appraisal   ⇨   Response

If we like, we can talk about the primary appraisal and the secondary appraisal.  Often, a person’s problem resides not in the appraisal of the event (“I don’t like being in this overheated mall just before Christmas”) but in the appraisal of their response (“I’m hot, sweaty, and uncomfortable.  Maybe I’ll have a panic attack and humiliate myself…”).

Panic disorder is usually all about the appraisal of initial anxiety symptoms.  But so too are problems in which guilt, shame, and feelings of inadequacy are prominent.  “Look at me getting all nervous about having to speak up at the meeting.  No one else feels like this.  I don’t have what it takes to be in this job.”

In recent years Acceptance and Commitment Therapy (ACT) and Mindfulness Based Cognitive Therapy (MBCT) have become prominent.  Neither emphasize a reappraisal of the trigger situation.  Instead, both emphasize an acceptance of internal experience.  “Yes, my heart rate is higher than usual, and I am pretty anxious.  I have felt like this thousands of times and lived, so I can allow the anxiety to be present.  If it wants to, it can fade.  But it’s not essential.”

Let’s not oversimplify ACT or MBCT.  But much of the work in these approaches emphasizes the appraisal of one’s emotional and behavioural responses, and moving from a combative stance (“Let’s eliminate my fear!”) to a more accepting one (“I’m afraid, but I can still decide whether to stay or leave; the fear isn’t lethal”).  In effect, SARAR can be a bridge from traditional cognitive work to acceptance-based work, without seeming to give up on one model or switch to another without explanation.

Friday, 23 September 2011

OCD: Doing it TOO Right. PsychologySalon at UBC Robson Square, September 27 2011

How do you know you’ve finished something?

Partly, you look at it.  The icing on the cake looks smooth. The window looks closed. There are no visible crumbs on the kitchen counter.

But how many crumbs are acceptable?  Given that you are trying to reduce the number of germs, which cannot be seen, the sight check doesn’t fully satisfy.

Partly you’re waiting for a feeling that psychologists call “just rightness.” It is a sense that the task at hand has been completed, allowing you to let it go and shift your attention to whatever comes next.

In obsessive compulsive disorder, or OCD, the need to attain the feeling of just rightness seems stronger, and the ability to achieve it seems to be impaired. We lock the door, but we still have the nagging feeling that it hasn’t been done properly. We know we turned off the stove, but something tells us that it may still be on. We have great difficulty getting out of the house until “just rightness” has set in.

On September 27 at 7 pm I’ll be at UBC Robson Square (in the courthouse complex, near the ice rink beneath Robson Street) for the first of the fall series of PsychologySalon talks. The talks are $15, and the fee is intended to pay for the space and the cost of advertising.  This one is on OCD.

OCD is a common disorder characterized by, as anyone can guess, obsessions and compulsions.

Obsessions are thoughts that the thinker realizes (at least some of the time) are irrational, that cause anxiety, and that signal some sort of danger or risk. The person doesn’t want to have these thoughts, but they come anyway.

Compulsions are thoughts or behaviours designed to eliminate or undo the obsessive thought or to reduce the risk that they imply.

For example, the obsessive thought that one’s children have been injured might result in the compulsion to call their school repeatedly to check. An intrusive obsession such as an image of one’s plane crashing might be undone by the compulsive repetition of a specific prayer.

To count as a true compulsion, the action must be either somewhat irrational (such as counting backwards by threes to keep illness away) or obviously excessive (such as checking the door six times before bed).

Although OCD can sound odd, most of us have at least a taste of it. Surveys show that over 90% of people have at least occasional intrusive thoughts that resemble the ones seen in OCD. And almost all of us have felt the impulse to go back and check the iron, or proofread a document one more time, or scrub just a little harder to overcome some unseen contamination.

In this talk I’ll draw the somewhat arbitrary line between everyday obsessiveness and OCD. I’ll review some common types of the problem and discuss the way it manifests for a few celebrities who have “come out” about having it.

Of course, whether we are close to the line or well beyond it, the real question is what to do about it. I’ll discuss some strategies that help “knock back” OCD, including exposure and response prevention (or ERP) and cognitive experiments. I’ll also show why some of the strategies people use most frequently – including thought stopping, reassurance seeking, and stress avoidance – can actually make the problem worse.

We have two additional talks planned for fall.  October 25 will feature Dr Nancy Prober on trauma, and November 22 will have Dr Lindsey Thomas on the ways our minds deceive us.

Information and online registration for all talks can be found here.  Tickets can also be purchased at the door.

Tuesday, 20 September 2011

On Simplifying Cognitive Therapy

When pruning an apple tree, you look for the central leader, a vertical branch from which the others depart horizontally creating a series of platforms for the fruit. Taking note of the central leader simplifies the rest of the process.

When supervising therapists, I often notice that they get overly complicated when orienting clients to cognitive work. They get distracted by the leaves, the twigs, and the platform branches, and the central leader is left undetected in the middle.

But we don’t really care whether clients appreciate all the complexity of cognitive work at the start. All they need is a rough idea of the core concept. Some of the complexity will never be used, so they don’t need to learn it. Some details will be relevant, but these will be more easily absorbed if clients have a sense of the core of the matter.

So it’s best if we stop trying to impress clients with how much we know, and simply tell them about the central leader.

“So last week I mentioned that we would start in on cognitive work today, and I’d like to take a minute to tell you what it is. Basically it’s not very complicated.

“The core idea of cognitive work is that we don’t live in the real world. When something happens, it feels like we react to that thing. We might run away, we might get angry, or we might feel afraid. And if someone said ‘Why are you afraid’ we’d point at what just happened.

“But actually we’re reacting to our interpretation of what just happened. We call this the appraisal.  So if we’re at the bank and someone produces a gun, our fear is based on our guesses about the situation.  ‘This guy probably isn’t the security guard. This is probably a robbery. Maybe terrible things are about to happen.’ It’s not the gun itself that makes us afraid, it’s what we think it means.

“Now: usually our appraisals are pretty accurate. When you came in today you looked at that object and sat down in it, because you interpreted it as a chair. You’re right.

“But all of us routinely get some things wrong. The boss frowns and we think we’re about to be fired.  The customs officer looks at us and we feel guilty even though we’re not smuggling anything. We get a rash and think it might be a serious illness. Or we pay attention to part of what’s happening, like a friend who’s irritated with us, and ignore the rest of the situation – like the friends who quite like us.”

At this point the therapist can share a routine (but mild) distorted thought that he or she gets, and invite the client to do the same.

While giving this explanation, the therapist can draw the core cognitive model on a clipboard or whiteboard:

Situation   ⇨   Appraisal   ⇨   Response (emotions and behaviour)

That’s not the end of it, obviously. We have to go on to find the core issues troubling the client, see whether cognitive distortions are part of the problem, and try out ways of investigating them. Some cognitive strategies (like identifying distortions and cognitive challenging) are obvious from the core model. Others (like decision-making techniques or cost-benefit analyses) seem more tangential.

But until clients can see the central leader, the leaves and branches have nowhere to attach. Therapy will be more foggy than it needs to be, and clients may bog down more readily and frequently.

Friday, 16 September 2011

Next to Normal (Revisited)

Technically, I’ve managed to disqualify myself from writing a review of the Arts Club Theatre’s production of Next to Normal (which I previously wrote about here).  

Photo by David Cooper
Caitriona Murphy, the actress and music therapist who plays Diana, the show’s lead, is a friend of a friend and consulted me about the presentation and style of people with bipolar disorder. From there I was asked to meet with another cast member to answer a few questions about his role, and to offer the pre-show “coffee chat” for the afternoon performance on Sunday September 18.

If PsychologySalon was a newspaper, this would immediately place me in a conflict of interest and I would not be considered objective enough to write a review.

Thankfully, this isn’t a newspaper.

To be honest, I felt that my involvement, miniscule (and ultimately unnecessary) though it might be, was a welcome dodge. If I was less than impressed with the production, I would be able to keep my mouth shut. “Sorry,” I’d say.  “I was involved. Professional ethics and all. Can’t offer an opinion.”

The New York production I saw in spring 2010, was the culmination of over 10 years of work by the authors, from a 10-minute workshop piece to a full-scale 2009 Broadway debut featuring actors who had been with the piece through several incarnations of the show and with the input of the original writers.

The Arts Club production, by contrast, features people who had never seen that show, had never met the writers, and had only a few weeks to rehearse the piece before appearing onstage at the Stanley Theatre. How could it expect to be anything more than a faint echo of the Broadway version?

Answer: This production does extremely well, and I think it is comparable to the New York production. Caitriona is excellent in the lead role and portrays the confusion, anger, and resolve of a woman with severe mental illness with conviction and a great singing voice. At the end of the show on opening night last night, much of the audience remained in their seats until she appeared onstage – not, it seemed, because the other cast members were not terrific (they were) but in order to give her her due by standing when she appeared.

The show starts a bit light, lulling the audience into a false sense of security, then takes a steep dive into serious depths in the second half of the first act. People in the lobby at the break seemed uncertain where the play was going to go next – back to the lighter tone or deeper into the drama of the situation.

I wondered too. Would the Arts Club, conscious of the Vancouver public’s seemingly endless thirst for light diversions, shy away and underplay the drama of the second act? No, it turns out. One potential fault of the piece is that it offers the potential to play at full intensity from curtain to close, becoming a bit numbing in the process. Director Bill Millerd’s gradually increasing gravity works well at drawing the audience deeper in, rather than defensively pulling back.

My one problem with the New York production was a neon-lit chrome set that looked like they got it second hand from the 1980s’ Solid Gold Dancers (you can see it in a few YouTube clips). Ted Roberts at the Arts Club has come up with a somewhat more naturalistic set that results in rapid scene changes and suggests a real family home. It works better than the New York version.

So any concern I felt about recommending a show I hadn’t seen has now passed. This is a great piece of theatre, a deserving Pulitzer Prize winner, and is given a terrific production by the Arts Club with an extremely talented cast. It’s well worth seeing.

Update:  On Sunday September 18 I did the pre-show "coffee talk" for the Sunday matinee and stayed to see the show.  Everyone has settled into their roles even more, and I now think that the production rivals the New York production and surpasses it in several respects.  Caitriona is remarkable as Diana and Matt Palmer does a great job with the two clinicians.  Everyone else in the cast is very strong as well, and Warren Kimmel does brilliantly as the husband in a role that otherwise would run the risk of being eclipsed by Diana's story.  I don't think you'll see a stronger production of this piece.

For tickets and information, go to

Tuesday, 13 September 2011

Do I Deserve This? Really?

Australia. Can I get some world peace?
It seems that on a weekly basis I am informed of the reason that I should avail myself of one luxury product or another.

“Because you deserve it.”

Really?  How do they know?

Why do I deserve first class?  A cheeseburger? A day at the spa?  Or a hundred other products and services?

Is it because I had the good fortune to be born in a wealthy culture?  Because I have experienced remarkably good luck throughout my life?  Because I have worked so much harder than people who labour 16 hours a day in rice fields?

How is it that consuming vastly more than my fair share of the world’s resources, living in a wasteful culture, and having available to me luxuries that the wealthiest of people in the past could never have dreamed of somehow imbues me with the right to consume even more?

The idea that I deserve these things is a statement about justice.  But of course it’s really a means of getting past any sense of complacent sufficiency I may feel, so that I will open my wallet.

After all, if I am deserving of the treat being advertised and do not get it, now that would be a true injustice.  Wouldn’t it?

So... Is this just another tiresome rant about advertising?

Well, yes.  Partly.  But the terminology of advertising has seeped into the culture.  I hear people say “Hey, I deserve that” all the time.

What’s the impact of this idea?

If I deserve a nice home, an extra serving of ice cream, a day in the country, then there is nothing for me to feel grateful about.  Receiving these … these … well, we used to call them blessings, is nothing more than my right.

When we build such “rights” into our expectations for the future, they cease to be treats.  They are elements of the baseline of our experience, and their presence can pass without notice.  If every time we look in the cutlery drawer we find a needed spoon, we do not feel we have received anything significant.  If unreliable room-mates make such a discovery chancy, we are more likely to murmer, “Oh, thank you, a spoon” and feel that our day has been made a little bit brighter.

Our sense of gratitude, in other words, depends not on what we receive, but on what we expect.  If we grow up expecting to live in a mansion with servants, then a privileged servant-free life in a pleasantly-located condo will feel like penury rather than what it is: a better standard of living than that experienced by the vast majority of people who have ever lived.

If I justify every indulgence by telling myself that I deserve it, which is surely a lie, then I inoculate myself against much of the psychological lift that the indulgence is likely to provide.

I’m not generally a fan of the alternative approach either, which says that we are worthless chaff undeserving of anything but the fires of eternal damnation for our own fairly venal sins and those of alleged leaf-clad ancestors.

By mentioning the ideas of gratitude or blessings, I run the risk of necessitating an entity to whom one is grateful.  A bless-or.  Such an entity is possible, I suppose, but not essential to feel grateful or blessed.

The key point is where we place our minds.  If we expect that the flat-screen television, supportive partner, or peaceful nation that we had yesterday will still be there when we awaken, and believe that they are nothing more than we deserve, then we will not feel the impact of their presence.

We will only notice them when they are gone.

Not everyone is the same.  But although there have been some trials in my life, I have already been the beneficiary of more events, people, and resources than I can in any way claim to deserve.  If I deserved any storehouse of treasures, I have surely exhausted it by now.

So in order to experience the full flavour of the chocolate, the luxury of driving through the Rockies, the satisfaction of receiving a cheque in the mail, or the warmth of my friends, I need to acknowledge the truth.

I am receiving this.  It is a benefit.  An extra.  It is worth thanking life for.  It is not a payoff in kind for something I have done.

Friday, 9 September 2011

Readings. Crazy Like Us. Part Four: Marketing Depression to Japan

This is the last of four posts about issues raised in Ethan Watters' new book Crazy Like Us: The Globalization of the American Psyche (2010, Free Press). (Previously we looked at Anorexia in Hong KongPTSD in Sri Lanka, and Schizophrenia in Zanzibar.)

The final focus of Watters’ book is depression – specifically the efforts undertaken to export western-developed conceptions of the disorder and its treatment to Japan.

One might think that this would be an easy sell to a country with a legendary suicide rate. Not so.

Clinical depression in Japan, into the 1990s, was conceived as an extremely severe psychotic-spectrum disorder afflicting relatively few people in the population. Garden variety sadness and anxiety were regarded as normal phenomena, and to a degree were even valued as signs of a sensitive, thoughtful nature.

And suicide? Suicide was not regarded as predominantly linked to a disorder called depression.

Convincing people to seek treatment for depression would mean getting them to equate their own unhappiness to a severe and frightening condition.

So why bother? If the people did not see everyday sadness or anxiety as a major problem, why tell them that it is?

Partly the answer is western benevolence. Some seem to have felt that the Japanese had accepted a problem as normal because there was no recourse, just us families in some countries appear to expect – and accept – high rates of malaria or credit card debt. But if the problem can be resolved, then there is no need for such forbearance.

Another motive is profit. If people can be induced to see depression as a problem, we create a need. Needs drive purchases. And if we have a proprietary product that we can sell to meet that need, we stand to make a great deal of money. Who had such a product? The pharmaceutical companies.

I’ll leave it to you to guess which motive Watters seems to feel was more significant in this instance.

Although SSRI antidepressants began to be introduced in the west in the early 1980s, there was a delay in introducing them to Japan. Part of the reason was a set of Japanese regulations requiring drug testing to be carried out on Japanese subjects (whereas many countries simply accept the outcomes from studies carried out in the US and elsewhere). But part of the reason was the Japanese “failure” to appreciate mild to moderate depression as a significant mental health problem.

Watters recounts the story of how the pharmaceutical companies went about changing Japanese attitudes toward depression in order to create a market for their products. This involved public education campaigns, seeded media coverage, direct-to-consumer advertising, and funded professional continuing education for mental health professionals.

Each of the four case examples in Watters’ book can be summarized with the same formula: Poor product, great success. To a great extent, Japan adopted westernized views of depression, and antidepressant sales went up.

As Watters points out, this would be a happy story if the rationale was true: Mild to moderate depression is a distinct and disabling problem independent of culture, and antidepressant medications are remarkably effective antidotes that can eradicate the problem and get a depressed society on its feet again.

It's a shame that reality is often more complex.

Watters reviews data on the antidepressants that is now widely known, and that I may touch on in posts later this fall, so I'll summarize it quite briefly here:

  • Most studies of antidepressants are funded and carried out by the very companies standing to gain or lose millions by the outcome.
  • Despite this fact, many such studies indicate that SSRIs are not markedly more effective than placebos.
  • There's a difference between statistical significance and actually meaningful response to medications, so even when differences between SSRI and placebo are found they are often not particularly powerful.
  • Studies that support SSRI effectiveness appear to be much more likely to find their way into print than studies which do not, resulting in a perception that the pharmacological effect may be more powerful than it is.
  • Side effects of these medications are often under-reported or minimized more than may be wise.
  • Studies of these and other medications are often not, in fact, written by the people conducting the study nor by the authors whose names are on the papers, but by ghostwriters provided by the companies holding the patent for the drug.
Each of these suggestions deserves more consideration than can be given in this post, so let's save that for another day. Suffice to say that many people really do seem to benefit from these medications (for whatever reason), there may be some subtypes of depression that respond better than others, and the way they are used in everyday practice may produce different (possibly better, possibly not so good) effects than are observed in clinical trials.  

The conclusion Watters reaches is difficult to escape: Given that we have such unreliable treatments for depression developed in the west and tested on western subjects, exporting them to other cultures and attempting to convince those cultures to adopt our own ideas about depression (and other illnesses) may not be the altruistic enterprise it is alleged to be.  

*    *    *

To sum up, Watters has produced an interesting and wide-ranging book that challenges many of our culture's pet ideas about mental illness and its treatment. He documents a potent mix of naive altruism, cultural narcissism, and profit motive that combine to make the West's contribution to global mental health questionable at best. It is difficult to come away from the book convinced that the overall impact is a positive one.

I'm tempted to say that the book should be required reading for any mental health professional - certainly any holding a passport. 255 pages.

A BONUS: Want to know more about clinical depression? Maybe my online course "What is Depression?" can help. Click here to access this $20 course for 75% off, or just $5.

(Previous posts looked at Anorexia in Hong KongPTSD in Sri Lanka, and Schizophrenia in Zanzibar.) 

Tuesday, 6 September 2011

Readings. Crazy Like Us. Part Three: Schizophrenia in Zanzibar.

Back again to a look at Ethan Watters' book Crazy Like Us: The Globalization of the American Psyche (2010, Free Press). Previously we looked at Anorexia in Hong Kong and PTSD in Sri Lanka.

Watters’ third example of the export of western ideas about mental illness focuses on schizophrenia in Zanzibar. He contrasts families treating afflicted members using traditional concepts, including spirit possession, with those that have adopted more western notions.

As with his other examples, western exports do not come off well. Whatever their level of accuracy, traditional views enabled families to accept and incorporate members prone to psychotic episodes. Adopting a western notion of mental illness as a biological affliction effectively invalidated families’ roles and created more stigma.

Yes, we might think, but if schizophrenia really is a biological illness, then it would be important to acknowledge this fact anyway so that effective care could be provided, no?

Well, perhaps not. Watters points to a widely-known phenomenon in the epidemiology of schizophrenia. Those with the disorder in western countries with fully-equipped healthcare systems have poorer outcomes than those in many developing nations.

It’s possible that western models of treatment actually do more harm than good, though even in developing countries patients are typically provided with antipsychotic medication of some sort.

A more likely explanation is that the social structure of developing nations naturally provides a more inclusive environment for people with certain difficulties in functioning than does the individualistic and isolating style of western culture. To the extent that their cultural styles for dealing with psychosis are impaired by the imposition of western ideas, exporting our knowledge and practices may be damaging rather than helpful.

In considering these issues, Watters points to a distortion in western ideas that transcends the issue of exporting North American mental health practices.  

For decades practitioners have attempted to reduce the stigma associated with mental illness. To this end, there have been widespread attempts to train the public to think of mental illness as “just like physical illness.” The idea has been that if we see depression, schizophrenia, or OCD as illnesses not dissimilar from mumps, breast cancer, or HIV infection, then stigma will evaporate.

This reasoning seems to have missed the fact that those with physical illnesses, too, experience stigma, but never mind.

Luckily, the question is testable. We can survey populations to see how they feel about people with various psychological ailments, and we can assess the degree to which they equate physical and mental problems. Presumably, the more the mumps metaphor sinks in, the less the stigma.

Nice idea. But the results turn out the wrong way. In fact, the more people see psychological difficulties as being like physical issues, the less they want to be around the sufferers. Stigma increases rather than decreases.

Once again, we westerners may have put our foot in it. It’s possible that the destigmatization campaigns of the last few decades have actually worked against the goal of increasing societal acceptance of mental illness. If acceptance of some issues seems to have gone up, it may be in spite of our efforts, not because of them.

Intuitively-appealing ideas about how to reduce stigma are sometimes stronger than the data backing them up. They have momentum.

A new Canadian federal body, the Mental Health Commission of Canada, has been established with the mandate to improve mental health care throughout the country. The Commission has adopted a broad – one is tempted to say unrealistically broad – mandate, of which a major plank is the reduction of stigma. Although little appears to have been accomplished as yet, it will be interesting to watch the strategies taken. Hopefully these will be based on the data, not on ideas that seem obvious but may work in the wrong direction.

Next, Watters’ final focus: the marketing of the concept of depression in Japan. (Previously we looked at Anorexia in Hong Kong and PTSD in Sri Lanka.)

Friday, 2 September 2011

Readings. Crazy Like Us. Part Two: PTSD in Sri Lanka.

We’ve been considering Ethan Watters’ idea (2010, Free Press) that the spread of Western notions of mental illness can actually shift the way problems manifest in other cultures.

In the second of four case examples in his book, Watters examines the impact of a tsunami of mental health workers that descended upon Sri Lanka after the earthquake-generated tsunami of Boxing Day 2004.

Accounts of this type of international disaster response, at least as they appear in Western media, have a heroic quality. The wealthy West pitches in with its superior knowledge and mental health resources to lift disaster survivors out of their misery – often while holding the society's "untrained providers" at bay.

The reality may be somewhat different.

Several years ago I attended a talk by several psychologists who volunteered to be sent to a refugee zone in Africa. They spoke in glowing terms of their experience and were eager to return.

But as they described their experiences, it seemed clear that little of their western-based knowledge applied in the refugee camp. Western one-to-one psychotherapy was out, and no one was going to fill in any personality questionnaires. People were ill and dying. They had lost contact with family members. There wasn’t enough food. Sanitation was poor.

These psychologists wound up running errands, tracking down family, digging latrines, holding the hands of the dying, and helping organize bandages. Sometimes they would listen to people’s stories of their experiences. And that seemed to be about as close as they got to performing like psychologists.

Despite this, and perhaps because of it, they felt their contribution was valuable, and this really seemed to be true. But I couldn’t help thinking “Why do we need to talk about this as a psychological aid initiative?” The needs of the people in the camps had little do with the services that a Canadian psychologist is trained to provide. A latrine is a vastly more significant contribution than a vocational test battery. If we want to go, great. But practicing as though a refugee – or a Sri Lankan tsunami survivor – is interchangeable with an urban Canadian is likely to do as much or more harm than good.

A relative of mine was an executive with EMI, a Brtitish entertainment and technology firm that was involved in the development of the early CAT scanners. He told me about visiting an African country lacking all but the most basic medical facilities. He was given the grand tour of a dusty hospital, the crowning glory of which was a brand-new million-dollar EMI scanner purchased with aid dollars. This was obviously intended to impress him. Instead, he was furious. The country needed a vaccination program and mosquito nets, not a diagnostic tool designed to find problems the medical staff would never be able to treat. Some forms of Western counselling aid strike me as similar.

Watters recounts the stories of westerners who flew to Sri Lanka, and the local practitioners who watched the invasion. Try as he might, he is unable to extract from the clinicians any descriptions of specific psychological interventions that helped specific individuals. At best it appears that the play therapy, puppet shows, and group sessions were a distraction from the tedium of the evacuation centres. The children enjoyed playing with the toys. Some of the clinicians reported jettisoning any attempts at western-style treatment and focusing on more practical issues of survival and family reconnection.

But there are troubling examples as well. One clinician, when pressed to say how her services helped, said it came down to simply being there, showing the Sri Lankans that blonde people from the other side of the world cared about them. A British expert declared that PTSD symptomatology was universal and seemed to feel that the country had no expertise in trauma (apparently ignoring Sri Lankan history).

Watters contrasts western and Sri Lankan ideas about trauma. In the western view, trauma manifests as an injury to the individual. The person may need to withdraw from their social roles to engage in self-care. For the Sri Lankans, he reports that the worst aspects of the trauma for survivors was the disruption of social roles, and the most valuable approach was to help people reconnect and contribute, not isolate and withdraw. He implies that western-based trauma “assistance” was not just ineffective, but potentially harmful.

Could this be true? Well, consider that the assistance in question involves the application of services designed for one population and culture, transplanted wholesale into another. This kind of cultural insensitivity is often likely to cause problems.

In addition, considerable evidence suggests that western-developed trauma assistance programs are harmful even when applied to western populations.

The 1990s practice of critical incident stress debriefing is a case in point. The idea was to intervene with affected groups as soon as possible following a tragedy, with the aim of heading off lasting psychological trauma. The idea made so much intuitive sense to policy-makers that it was implemented prior to adequate testing. Subsequent evaluations have indicated that trauma debriefing actually results in more problems, not fewer. The challenge now is to extract (or correct) traumatic stress intervention programs that have become entrenched within social systems such as schools and emergency response professions.

The application of western trauma interventions, insufficiently validated in their home cultures, exported to other cultures without adaptation, testing, cultural sensitivity, or an awareness that most cultures have already developed procedures for dealing with upheaval, seems like yet another manifestation of western cultural narcissism.

Can we help other countries through trauma? Yes, probably. But food is probably more valuable than encounter groups, and helicopters may be more useful than counsellors.

Next:  Schizophrenia in Zanzibar, followed by Depression in Japan. Previously: Part 1: Anorexia in Hong Kong.