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Tuesday 26 February 2013

Travel: A Psychologist in Cuba

Ride to the beach in 1950s style. Trinidad, Sancti Spiritus province.
I recently travelled across Cuba, staying with Cuban families in casa particulares (homestays) in Havana, Cienfuegos, Camaguey, Trinidad, Santiago de Cuba, and Baracoa.

Along the way I had an opportunity to speak with a psychologist about the practice of psychology in the country. For what it's worth, here's a bit of a summary.


Since shortly after the revolution in 1959, Cuba has been relatively isolated due in part to the Cuban government’s policies and partly to the United States embargo that remains in place, with some minor shifts, to this day. US citizens are still restricted in their ability to travel to Cuba, but the rest of the world (particularly Canada) has made it into a middle-league tourism destination.

In recent years Raul Castro has begun the process of economic and social reform, perhaps in recognition of the fact that the economy has not prospered under the communist system. For decades Cuba was supported by the former Soviet Union until it fell (precipitating what the government called the “special period” starting in 1991 during which the economy virtually collapsed).  More recently it has relied on other allies – notably Venezuela and China – to keep afloat.

In terms of exports and material wealth of its citizens Cuba has not done well, though the US embargo has paradoxically muddied the cause for this, enabling observers (and the government) to attribute economic problems to US policy rather than to the command economy. Some of the Cuban citizens I spoke with suggested that the primary effect of US policy had been to unite the country under the Castro government, supporting the very situation that the policy was supposedly intended to disrupt.

Health and Education
Not the best accommodation, apparently.

On at least some aspects of the social front, Cuba has done markedly better. The arts occupy a prominent position in Cuban society, and appear to be supported more than in either Canada or the USA.

Cuba, like Canada and most “first world” nations other than the US, has a socialized medicine system that covers all citizens. Unlike Canada, dental care is also included free of charge.

Infant mortality rates are correspondingly low: in the most recent 5-year period reported by the UN, Cuba beats Canada by one spot, while the USA sits 8 positions down the list (just behind Lithuania, just ahead of Belarus).

In life expectancy Cuba does not do so well, sitting at 37th (78.5 years) on the UN list for 2005-2010, behind Canada at 11th (80.54 years) but still ahead of the USA at 40th (77.97 years).

Young revolutionaries on school trip, Camaguay.
The education system is reasonably well-regarded internationally. School and University are available at no charge to students. A 1998 UNESCO study of Latin American countries ranked Cuban 3rd and 4th graders first in math and reading, far ahead of runners-up Argentina, Chile, and Brazil. On international rankings of literacy, Cuba (5th) passes both the USA (22nd) and Canada (34th), though varying definitions of literacy and country self-reporting make this a somewhat less reliable data point.

Traveling across Cuba one constantly sees packs of children in school uniforms in the early mornings and late afternoons, and seldom during school hours. A 3 or 4-room school I visited had a “computer lab” but was equipped with only a few fairly antiquated machines.

Psychology in Cuba

Sr B, with almost certainly unnecessary confidentiality.
I met with a psychologist in one of the cities I visited. Although he spoke excellent English, I was not quite able to fully explore the question of how appearing in an internet blog might play out with his employer. There was absolutely no sign from anyone I met in Cuba that talking with foreigners is a problem at all, but I'm naturally cautious.

He repeatedly waved his hand saying “no problem” but I’m still not entirely sure he knew what a blog was. Access to the internet is quite restricted in Cuba, though it has been showing signs of opening up a bit recently. Consequently, let’s just call him Sr B.

Our psychologist works on a medical ward of the local hospital, assisting patients receiving dialysis with the emotional consequences of their conditions. He also provides services to a community high school, diagnosing and treating psychological conditions and dealing with circumstances like parental neglect and coping with the consequences of divorce.

Treatments are largely psychotherapy-based. We did not have time to get into the details of technique, but it seemed that basic counseling practices formed much of what was done. Much of the work is family-based, and Sr B described home visits that would be carried out to see how patients lived and got along with other family members.

Taxi, Baracoa
I discussed cognitive behaviour therapy briefly and it was clear that this was not prominent in psychological training – interestingly, given its predominance in many other countries and its focus on immediate problems and practical strategies. It would be tempting to get all gung-ho about exporting CBT to Cuba, but the sobering experience of reading Ethan Watters’ book Crazy Like Us (about which I wrote a 4-part review here, here, here, and here) makes me hesitant.

Psychologists, like other professionals in Cuba, appear to be dedicated to their work. They labor at challenging jobs despite extremely limited remuneration. Psychologists and physicians make an average of 20CUC (about $20 CDN or US) per month (yes, per month) – plus some perks involving housing and childcare – along with the universal ration card that allows citizens to purchase some basic foods for sharply reduced rates.
Old Havana

This rate of pay is double what some workers make, but still only allows a very basic life, even with the low prices in the Cuban economy. The real money comes from any job outside government employment, or a job with a government agency that allows for tips (the very best job, multiple people told me, was taxi driver). Consequently, many professionals moonlight at jobs that provide private income. The desserts at one restaurant were baked by a local physician, and the casa I stayed at in Baracoa was run by a dentist, who made breakfast for guests before heading off to the clinic for the day.

I’d been briefed by other travelers that books, clothes, and other supplies were extremely welcome throughout Cuba, so I gave up my Canadian Psychological Association t-shirt and with some embarrassment handed over a copy of my assertiveness book, which I had narcissistically packed and which he enthusiastically (and perhaps somewhat politely) received.

Recently restored square, Havana.
I also made a point of stressing the Canadian custom of paying for the time of busy professionals and enclosed a “bookmark” (with some anxiety: too small? too large? offensive?). The following day I ran into Sr B on the street in town, where he thanked me effusively and said that now he could afford to buy a pair of shoes for work that he had seen in one of the stores for local citizens.

If I go back, which I may – Cuba is a beautiful country and the casa particular system allows for a kind of mixing with local people that you seldom get anywhere in the world – I will look up Sr B again, perhaps with some advance warning so that I can get more of a sense of practices in his country.

In Sum
You can watch the change coming.

Cuba is changing fast. Under Fidel's brother Raul, the economy is opening up in a hurry and the next ten years look like they will be startling for Cuba's citizens. It was only a little over a year ago that hundreds of thousands of private businesses were permitted to start up. Just three weeks before my visit the international travel restrictions were significantly relaxed. Havana's streets are torn up and being repaved as we speak.

Talking with people I heard the same refrain over and over: "Cuba needs to change. But right now it's changing too fast."  There is a real fear of a Russian-style collapse and a race to kleptocracy-style capitalism that will provide much-needed cash but sacrifice the real gains Cuba has made over the past 50 years. They want to keep their successes: their education and healthcare systems, the sense of equality, the care for the poorest in the society. Can they do it?

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Tuesday 19 February 2013

Mental Health Planning: A Script for Failure

Planning documents in my collection.
Lots of writing, little change.

Let me declare my bias right at the outset:  I don’t believe in mental health planning.

To be more precise, I don’t believe that mental health planning usually has any significant impact on mental health services. In fact, I think that real change happens seldom enough that it wouldn’t be too far out of line to call most mental health planning fraudulent.

I’ve been in practice for many years, and I have seen many mental health planning reports released in that time. I watched enough of these processes at a distance in my early career that I swore never to become involved in them.

And then at one point the subject was so close to my clinical interests, and the prospects for systemic change seemed so bright, that I convinced myself that “this time for sure” things would go well. Of course, this is precisely how everyone gets involved in these things, and of course the project went exactly the same way all the others do.

There’s a reticence among professionals to talk about this issue. Part of the problem is the faint hope that someday a planning project will come along with ironclad guarantees and a genuine chance of having an impact on services – and if you have blabbed about how little you think of the planning biz you probably won’t be asked to take part.

Another sticking point is the fear that anything you might say will be ignored anyway because people will think you are just burned out or disgruntled that people didn’t pay attention to your own grandiose ideas.

I have no plans to take part in future planning efforts, and most of my disappointment has to do with the fate of planning efforts in which I was not involved, so I don’t really have any reason to hold back. My rant on the subject has gotten loose on various occasions, so let’s keep a leash on it and discuss just three points: the sequence of planning, the types of benefits, and the motive for planning.

The sequence of planning

The first time I watched as a colleague became involved in a mental health plan, the sequence of events seemed so nonsensical that I assumed it would never be replicated. Since then I’ve noticed that it is almost invariant.

  1. The government of the day, often in response to tragedy or harsh criticism, announces an overhaul of some aspect of the system. Rather than an overhaul, what they actually mean is a mental health planning effort. Often a delivery date for the new plan is mentioned.
  2. The excitement (and news coverage) of the announcement having past, the urgency to get started fades. A long search for the individuals to carry out the planning project ensues. Once they are found, the government delays while it works out the “terms of reference” for the effort.
  3. The supposed start date for the project passes without anything happening.
  4. Once one-third to two-thirds of the planning period have passed, tension rises between contractees and the ministry and the funds are finally released so that the team can get started. The end date is not shifted, however, so that the plan will inevitably be a rush job.
  5. The plan invariably calls for “all stakeholders” to be consulted, meaning that any consensus on specific actions – or any ranking of their importance – is impossible to achieve. Whether this is an intentional or unintentional effect is open to question.
  6. The planning team asks for an extension so that the planning term is as long as originally projected before the government delayed the process. This request is denied.
  7. A report is hastily rushed into print. It is a work of graphic art, with ample real-world quotes and case examples. But the actual recommendations are phrased in such vague terms as to be meaningless (and certainly toothless).
  8. The government greets the completion of the report with enthusiasm and a congratulatory media event, often timed to coincide with a major conference to ensure a large audience for the television cameras.
  9. Time passes. The planners and stakeholders hear nothing about the report. Little evidence can be found that anyone has read it. The funding covered only the planning effort, not systemic change, so there are no resources to put the recommendations into place.
  10. Several years later, another crisis or bout of criticism arises. Rather than dusting off the now-hard-to-find report, the government announces a new planning initiative. If anyone recalls or asks about the recently-completed plan, it is pointed out that the earlier plan was based on old data and the state of affairs that existed perhaps five years ago. What is really needed is a new report based on current conditions.
  11. Repeat steps 2 through 10. 

Two types of benefit

The cynical perspective I’ve outlined above implies that little gets done as a result of these reports. But whenever these efforts are discussed, funders and planners alike go to great pains to describe the tremendous progress that has been made. Unless you listen closely, it can sound as though the original problem has now been solved.

But the progress is always described in the same terms. A jurisdiction-wide consultation has been achieved. All stakeholders have been consulted. Quality assurance subcommittees have been struck. Knowledge exchange has been promoted. A comprehensive listing of services has been developed. It all sounds great, except none of it seems to relate to the actual services being provided to people with mental health issues.

I remember sitting in one of these meetings listening to a self-congratulatory provincial health minister rhyming off the sparkling achievements of one of these projects. Perhaps I’d had too much coffee (or not enough), but I found myself getting more and more angry. I had a suggestion to make, but inhibition (and a secret fear that I must, must, must, be missing something of significance – the emperor cannot possibly be this naked) prevented me.

The thought that occurred to me at the time, and that still strikes me as a good idea, was to divide all outcomes into two categories.

  • Category A would consist of committees struck, shiny publications printed, discussions held, recommendations made, hotel banquet lunches eaten, and so on.
  • Category B would consist of concrete changes that actually alter a real service being provided to any user of the mental health system that increases the quality of their experience in any way whatsoever.

When I read mental health documents, I’m always on the lookout for Category B items. Unfortunately, I seldom find any. Of course, there’s an easy defense for this point: “This is only a plan. Of course it hasn’t been put into action yet, but it WILL.  REALLY.”

So my second thought is that the media opportunity should be saved. Don’t hold the announcement and get your picture in the newspaper when the report is written and handed over. Keep quiet about it. And invite the photographers only when you can announce that a concrete change has actually benefitted a real human being.

An impractical idea, that one. It would mean:

  1. Ministers would seldom get their pictures in the paper, and
  2. Funding for mental health planning would evaporate, because the main benefit of these projects appears to be to get the minister’s picture in the paper.

What’s the motive?

Why do mental health plans exist? And why aren’t they more effective or useful?

Actually, I’ve come to believe that the second question above contains a false premise. In fact, mental health plans are extremely effective and useful. But the effect sought is not the one announced.

Mental health planning is, most often, a money saving exercise. True, it seldom leads to improvements in service. But perhaps that is precisely the point.

Planning is cheaper than service improvement.

Mental health plans cost anywhere from $100,000 to $2 million. Although that can sound like a lot of money, in fact it is unbelievably cheap relative to the cost of upgrading mental health services.

When someone calls the quality of your mental health service into question, one option is to upgrade the service. Another is to set aside an impressive-sounding quantity of money and hire national experts in the subject to design your upgrade.

The planning effort will take a minimum of three years from start to finish. During that time, if anyone asks about your service you can say, “I’m glad you asked. In fact, we have an extensive planning program taking place as we speak.” When the report actually comes out, you can get lots of press and you can word your announcement in such a way that it sounds like you have actually done something.

For the next year, you can respond to inquiries by saying “We have a newly minted plan in hand, and we are examining the way forward based firmly upon the recommendations therein.” In the second year after delivery it’s best to lay low and keep your mouth shut as much as possible. But in the third year following the report, you can start talking about the necessity of a new look at the problem.

And you never have to upgrade a mental health service. Ever.

Tuesday 12 February 2013

Volunteering as Therapy for Depression

Getting in the door can be a challenge.

Some clients who see a therapist are unemployed, or never employed, or are presently on long term disability insurance. Many such clients are depressed.

Virtually every psychological state brings with it a set of action tendencies, and those in depression are particularly problematic. Little seems appealing or enjoyable, so there is a tendency to withdraw, isolate, and do very little. Similar temptations appear with the flu, but in the case of flu they are helpful in aiding recovery. By contrast, inactivity and isolation only tend to make depression worse. Further, there can be a profound feeling of meaninglessness in life, and a belief that one is useless or has nothing to contribute.

So therapists routinely try to get people more involved and active, and often one of the person’s goals is to seek employment or return to work. But steering directly toward that daunting goal is often counterproductive: it’s too frightening, the employer may not be accommodating, there is a worry about attempting work and discovering it is too difficult, and so on.

Volunteer work is often a better option – for those seeking or hoping to return to work, or for people who are continuing to work but feeling unfulfilled or isolated in their off hours. There are many advantages:

  • Failure is not a problem. If you don’t enjoy it or succeed at it, it need not appear on your resume.
  • Financial considerations are irrelevant. You don’t have to base your choice on how much the position pays.
  • Volunteer work provides structure. Volunteers oblige themselves to get out of bed, get organized, and show up at specific times for specific tasks. This type of structure is usually very helpful in the recovery from depression.
  • You can pursue your passions. Maybe environmentalism, or Buddhism, or community theatre are difficult career choices due to few paid positions being available, but you can become involved based on your interests. 
  • Positions are available. Almost no matter what field you are interested in, it is possible to find some type of volunteer work that is related.
  • You can use existing skills. You’re interested in multiple sclerosis but your training is in databases? No problem – the local association can almost certainly use someone with these skills. And if not, there are hundreds of other tasks you can do.
  • You can explore possible careers. Think that social work might be an interesting pursuit? Volunteering can put you close enough to people in that field that you will get an inside look at what it’s really like.
  • It can go on your resume. Having volunteer work on a resume can be a big help, particularly if the work is related to the field in which you hope to obtain paid employment.
  • You get a social life. Many discover that a huge proportion of their social contact comes from the people they meet at their volunteer work. Because agencies are not paying their volunteers, they often take greater pains to make sure there are social events for them.
  • It can lead to employment. Depending on the type of work, some organizations hire their own volunteers for jobs. Volunteer research assistants at universities, for example, are the obvious first choice when paid research assistantships become available.

Doubtless there are more advantages than these, and doubtless there are a few disadvantages as well. (Readers:  Perhaps you’d like to add some observations?) And no one is claiming that volunteer work is the thing for everyone, or that it’s a moral responsibility for people to do volunteer work, or that it’s a stand-alone treatment for depression.

But for many people who have attended our clinic, it has been an enormous help in their recovery, and we try to keep up on the diverse array of opportunities out there so that we can raise possibilities when appropriate.

The Well-Defended Castle

There is one problem that we’ve noticed, though. Most volunteer organizations run on a wing and a prayer. They’re not very organized. People need to know this and anticipate it.

People call up organizations to investigate volunteer opportunities. They leave a message, and no one gets back to them. Or their email gets lost. Or the next meeting  for prospective volunteers is 4 months away.

The hopeful volunteer can feel like they are imposing on the organization, or bothering people with their repeated calls trying to get information. It’s like they are assaulting a well-defended castle, which is doing everything possible to repel their advances.

For a person with depression, it is easy to overinterpret this experience. “You see? I was right: I can’t even give my time away.” “Nobody wants me.” “Why would I help an organization that treats me this way?” “It’s true, I really am useless after all.”

It’s useful to know in advance that gaining entry to a volunteer organization is often like this. It doesn’t mean much about the prospective volunteer or whether volunteers are valued. It’s more about the underfunding or lack of organization in the volunteer service, or the workload of the volunteer coordinator. People need to accept it, avoid self-attributing the problem, and keep asking.

Yes, of course the organization should roll out the red carpet for people generous enough to offer their time for free. But they can’t and they don’t. They value people once they get in the door and start contributing. Getting through the door can be a challenge.

Online Course

Want more behavioral strategies for depression? Our clinic has developed a cognitive behavioral guide to self-care for depression. Though not a substitute for professional face-to-face care, UnDoing Depression may be a useful adjunct to your efforts.  The preview is below. For 50% off the regular fee of $140 USD, use coupon code “changeways70” when you visit our host site, here.

We also have courses for professionals and for the public entitled What Is Depression, What Causes Depression, Diagnosing Depression, Cognitive Behavioral Group Treatment of Depression, How to Buy Happiness, and Breathing Made Easy. For the full list with previews and substantial discounts, visit us at the Courses page of the Changeways Clinic website.