FPR-UCLA 4th Interdisciplinary Conference - Summaries

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Trauma psychiatrist J. David Kinzie of Oregon Health and Science University presented the perspective of a cultural psychiatrist who primarily treats refugees living in the U.S. who suffer from PTSD (and very often co-morbid medical conditions such as hypertension). Dr. Kinzie presented a case study of an unemployed Somali man, who had severe PTSD and depression based on his experiences in 1991–1992 during the Somalia civil war and then living for ten years in a Kenyan refugee camp. After an initial 1.5 hr interview, Dr. Kinzie prescribed therapy and medication (fluoxetine and clonidine). Follow-up was erratic, but over time Dr. Kinzie learned that his client was not taking the medication as prescribed, that his 3rd (employed) wife had experienced multiple traumas of her own in Somalia and Kenya and was constantly angry, and that their two children (aged 9 and 12) both suffered from severe ADHD (the wife and children were also being treated at Dr. Kinzie’s clinic). The case, Dr. Kinzie said, exemplifies the changing nature of treatment (as information about context changes or accumulates) and the difficulty in predicting trajectory as persons continuously interact with their environment as well as experience new traumas that re-activate symptoms.

Dr. Kinzie offered four rules of thumb for clinicians to consider: (1) both simple and complex formulations of complex psycho-social-cultural clinical problems are usually wrong; (2) there is no single context or threshold; clinical situations are dynamic and changing and the treatment needs to change in response; and (3) in such a dynamic clinical setting, it is not possible to accurately predict trajectory. He concluded by saying that the optimal clinical approach to psycho-social-cultural disorders is to treat on the basis of known information and patients’ needs, but to modify the formulation and treatment plans a more information is available.

Stanford psychiatric anthropologist Tanya Luhrmann began her commentary by focusing on two “big ideas that speak to the issue of culture and diagnosis” raised in the Ethan Watters NYT Magazine article: (1) the biomedical model is not always helpful for people who struggle with mental illness. Although many hoped that the biologization of psychiatry would reduce stigma, it is clear that the “broken brain” metaphor for schizophrenia is often stigma-generating rather than reducing; and (2) “the way we conceptualize an illness affects the way its symptoms are expressed and experienced.” She said that it is “now clear that (schizophrenia) has a different course and outcome in different countries,” and it is “probably clear that there is a different symptom expression among different groups of people.” Increasing, she said, good psychiatric anthropology research will involve multiple methods, including rich phenomenological analysis accompanied by epidemiological and psychological research, which includes posing structured questions “in ways that can be comparative across multiple contexts.”

The broad inference from the morning talks, Dr. Luhrmann said, “is that it might be more accurate to think of psychiatric syndromes (with multiple moving parts) than of discrete psychiatric illnesses.” However, the fact that the DSM is categorical has limited the kind of research done on illness experience. The roundtable continued this discussion, with Dr. Szyf confessing he does not like the term “mental disease.” Instead, he prefers more neutral language that reflects the notions that mental behaviors are manifested as varied responses in different contexts, including that of culture. The challenge is to determine when the responses are maladaptive. Dr. Good acknowledged the complexity of early life environments and the need for researchers and clinicians to evolve in terms of their own understandings and responses to others’ predicaments, preferably through long-term longitudinal work. Dr. Luhrmann agreed on the value of such research, but said it was very hard to do. She said David Kinzie’s presentation “illustrated beautifully the way in which individuals sneak out of systematic categories.” On the other hand, she said, systematic comparison “really teaches us something that we don’t learn in any other way” and that while such research is difficult, it is crucial.” Dr. Kinzie reiterated that the DSM, while categorical, serves as “a shorthand for communication.” The job of the anthropologist, he added, is to help the clinicians; but to be effective, a coherent management of data is necessary (as well as a structural framework that helps organizes the affect that floods the clinician treating victims of multiple trauma). For Dr. Kinzie, the DSM serves this purpose. One major implication of this session, however, was that a system of social services must be part of the larger academic-clinical structure, particularly in view of the persistent biological effects of early life environment. As an audience member pointed out, achieving this integration requires a long-term focus on parenting, education, and cultural values. Such a change involves vast ethical, legal, and economic issues necessitating discussion and debate not only within the clinical and academic communities, but in the larger society.

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