Discourses of culture and illness in South African mental health care and indigenous healing, Part I: Western psychiatric power

This discourse analytic study explores constructions of culture and illness in the talk of psychiatrists, psychologists and indigenous healers as they discuss possibilities for collaboration in South African mental health care. Versions of 'culture', and disputes over what constitutes 'disorder', are an important site for the negotiation of power relations between mental health practitioners and indigenous healers. The results of this study are presented in two parts. Part I explores discourses about western psychiatric/psychological professionalism, tensions in diagnosis between cultural relativism and psychiatric universalism, and how assertion of 'cultural differences' may be used to resist psychiatric power. Part II explores how discursive constructions of 'African culture' and 'African madness' work to marginalize indigenous healing in South African mental health care, despite repeated calls for collaboration.     

Social relationships and quality of life moderate distress associated with delusional ideation

Purpose

In a previous study, individuals who followed a particular new religious movement (NRM) reported significantly less distress even though they reported similar levels of delusional ideation when compared with individuals diagnosed with psychotic disorders. Protective factors such as social relationship quality and quality of life (QOL) were hypothesized to explain attenuated distress associated with delusional ideation.

Methods

NRM individuals (n = 29), individuals diagnosed with psychotic disorders (n = 25), and control individuals (n = 63) were recruited. Psychotic symptoms, delusion-proneness, and facets of social relationships quality and QOL were examined across group. Potential moderators of the relationship between group membership and distress were further examined in multiple regression models.

Results

NRM participants reported more social relationships that were of higher quality (as demonstrated by more crisis supports, unique and overlap supports, more helpful supports and more reciprocated supports) than individuals with psychotic disorders. NRM participants also reported significantly higher QOL than individuals with psychotic disorders. Furthermore, NRM participants reported more distinct and less reciprocated supports, and significantly higher psychological, environmental, and total QOL, when compared with control participants. The relationship between group membership, delusional ideation, and distress was moderated by relationship reciprocity as well as by total QOL.

Conclusions

Findings highlight the importance of establishing healthy reciprocal social relationships and improving QOL in people diagnosed with psychotic disorders, as these factors may act as a buffer against distress associated with delusional beliefs.     

Social Support and Religion: Mental Health Service Use and Treatment of Schizophrenia

The perceptions and religious beliefs held by family members, mental health and health care professionals, and the community may affect the treatment of individuals with schizophrenia. To better identify and understand the influence of families, professionals and community members on individual’s treatment for schizophrenia, this review paper examines: (1) the religious perceptions of families, professionals, and the public towards schizophrenia; (2) religious perceptions of the etiology of schizophrenia; (3) how others perceive religion as a coping mechanism; and (4) how religion influences treatment engagement and help-seeking behaviors. MEDLINE and PsycInfo databases were systematically searched from 1980 to 2010 using the terms schizophrenia, schizoaffective, schizophreniform, psychotic disorder not otherwise specified and religion, religiosity, spirituality, and faith. Forty-three (n = 43) original research studies met the inclusion criteria. This study found that religious beliefs influence the treatment of schizophrenia in the following ways: Religious themes were positively associated with coping, treatment engagement and help-seeking behavior. Evidence of religious underpinnings was found in perceptions of etiology. The findings also indicate that there is often both a preference among family members and caregivers to utilize religious-based professionals and caution toward mental health professionals. Researchers and professionals may find avenues for improving treatment through examining the interaction of religious and schizophrenia at the social support level.     

Academic Performance in Children of Divorce: Psychological Resilience and Vulnerability

This article expands psychosocial and cultural perspectives on the experience and expression of psychotic symptoms and the treatment of schizophrenia by exploring how Spiritism, a popular religion in Latin America, provides healing to persons with severe mental illness. Beliefs and treatment by Spiritist healers of persons with psychotic symptoms, some diagnosed with schizophrenia, are described. Reactions by mental health professionals (psychologists, mental health technicians and psychiatrists) to this alternative treatment are described. Qualitative data have been collected through in-depth interviews with 49 Spiritist mediums in Puerto Rico, and case histories of 22 patients and their family members, all of whom gave informed consent. In Brazil, interviews were conducted with a sample of 115 Spiritist mediums, with their informed consent. These mediums responded to semi-structured interviews and standard measures of social adjustment and mental health. As expected, beliefs and practices of Spiritist healers regarding psychotic symptoms, whether manifested by themselves or by clients diagnosed with schizophrenia or other disorders, differ substantively from conventional psychiatric constructs and treatment approaches. According to patients' self reports and researchers' observations, spirit healers often achieve positive results with persons manifesting psychotic symptoms or diagnosed with schizophrenia in that symptoms become less frequent and/or social adjustment improves. We suggest psychosocial mechanisms to explain these findings and raise questions for future research.     

Pathway to psychiatric care in Bali

The aim of the present study was to trace the help-seeking pathway of mental patients and to elucidate the role of traditional healing in Bali. The source of care before attending Bangli Mental Hospital (Bali) of 54 consecutive patients with no prior psychiatric treatment was investigated. Subjects who had sought help from traditional healers were asked to evaluate treatment effect retrospectively according to a 5-point scale. The pathway to psychiatric care was dominated by traditional healers. Of the patients, 47 (87.0%) consulted a healer (mean number 2.9) before visiting the mental hospital. Consultation with the healers was associated with treatment delay. However, of the 137 traditional healers on the pathway, 11 (8.0%) recommended that the subjects to go to a mental hospital, and all 11 subjects immediately followed the advice. Of the 47 subjects, 14 (29.8%) evaluated the treatment effect as much improved by at least one traditional healer on the pathway, although they ultimately attended the mental hospital. Subjects without psychotic symptoms tended to evaluate the treatment effect as much improved more often than psychotic subjects. Traditional healers function not only as a barrier to reaching psychiatric care, but as either an effective provider of care or a decision-making support for seeking help from psychiatric care for some mental patients in Bali. The knowledge and recognition of psychological disorders by the traditional healers are crucial for early treatment intervention for psychiatric patients.     

Genital self-amputation and the Klingsor syndrome

Two psychotic individuals, who performed acts of genital self-amputation, are presented. One of the patients had self-mutilated with the intention of suicide and had also in the past amputated his hand. Psychotic patients with delusions (often religious), sexual conflict associated with guilt, past suicide attempts or other self-destructive behaviour and depression, severe childhood deprivation, and major premorbid personality disorder, are the group at risk for genital self-amputation. It has been proposed that the eponym, the "Klingsor" syndrome, be applied only to acts of genital self-mutation, involving religious delusions. The author suggests that this syndrome should be expanded to include all cases of genital self-mutation resulting from a psychotic illness.     

Clinical and socio-cultural parameters in Nigerian psychiatric patients. A prospective study

Three hundred and eighteen consecutive new patients presenting at a psychiatric unit in Yorubaland were prospectively studied. The majority were young, and the sexes were equally represented. Most patients came from within 50 km of the unit. Most were brought by their blood-relatives. Significant delay before presentation was observed in most cases. Previous treatment by religious and/or traditional healers was common. According to the DSM-III classification, the majority suffered from functional psychoses, most commonly schizophrenia. Three quarters received neuroleptic medication. The immediate clinical outcome was good in the majority of cases; however, within 6 months of presentation almost half defaulted from treatment. Variables which appeared to be related to delay in presentation, prior treatment by religious or traditional healers and defaulting are presented.     

Belief models in first episode schizophrenia in South India

Background Existing evidence indicates that dissonance between patients’ and professionals’ explanatory models affects engagement of patients with psychiatric services in Western and non-Western countries. Aims To assess qualitatively the explanatory models (EMs) of psychosis and their association with clinical variables in a representative sample of first episode patients with schizophrenia in South India. Method One hundred and thirty one patients with schizophrenia presenting consecutively were assessed. Measures included the patient’s explanatory models, and clinician ratings of insight, symptoms of psychosis, and functioning on standard scales. Results The majority of patients (70%) considered spiritual and mystical factors as the cause of their predicament; 22% held multiple models of illness. Patients who held a biomedical concept of disease had significantly higher scores on the insight scale compared to those who held non-medical beliefs. Multivariate analyses identified three factors associated with holding of spiritual/mystical models (female sex, low education and visits to traditional healers); and a single factor (high level of insight) for the endorsement of biological model. Conclusions Patients with schizophrenia in this region of India hold a variety of non-medical belief models, which influence patterns of health seeking. Those holding non-medical explanatory models are likey to be rated as having less insight.     

Attitudes towards mental health in an urban Pakistani community in the United Kingdom

The aim of this study was to investigate the attitudes of Pakistani families living in an urban area of the United Kingdom, towards mental health issues, to identify the emic models used and compare them with the etic model, predominant in Western medicine. This would allow the exploration of some of the inconsistencies in the research literature relating to the incidence of mental illness in this cultural group. The second aim was to explore the needs of this community, particularly women, in relation to mental health services. Due to problems gaining access to females on their own, interviews were held with family groups. Findings suggested that there were differences in the models of mental illness being employed with greater somatisation of symptoms in the Pakistani group and an emphasis on aggressive behaviour as a significant symptom. Treatment expectations also varied with some emphasis on traditional Pakistani treatments such as Faith healers and Hakims as well as General Practitioners and hospital treatments. Language difficulties, religious and cultural practices were also identified as barriers to female treatment in particular. Recommendations were made for improved training for interpreters and more emphasis on cultural factors and emic models of mental illness as part of medical training.     

Fixity of belief, perceptual aberration, and magical ideation in obsessive–compulsive disorder

Clinicians and researchers have pondered the intersection of obsessive-compulsive disorder (OCD) and psychosis. We examined the records of 395 individuals seeking treatment for OCD and classified participants according to their most frequent or distressing obsession and compulsion. All participants completed measures of fixity of belief, perceptual distortions, magical ideation, and psychotic symptoms. Results indicated that individuals who reported fear of harming self or others via overwhelming impulse or by mistake, and those with religious obsessions, had poorer insight and more perceptual distortions and magical ideation than did individuals with other types of obsessions. These results did not appear to reflect mere differences in OCD severity. Results are discussed in light of previous findings showing that psychotic-like symptoms are associated with attenuated treatment outcome in OCD. More research is needed to assess the absolute magnitude of psychotic-like features in OCD patients with impulse/mistake and religious obsessions and to examine whether these features interfere with standard cognitive-behavioral therapy.     

Hospital Presentation for Self-Harm in Youth as a Risk Marker for Later Psychotic and Bipolar Disorders: A Cohort Study of 59 476 Finns

Expanding clinical strategies to identify high risk groups for psychotic and bipolar disorders is a research priority. Considering that individuals diagnosed with psychotic and bipolar disorder are at high risk of self-harm, we hypothesised the reverse order relationship would also be true (ie, self-harm would predict psychotic/bipolar disorder). Specifically, we hypothesised that hospital presentation for self-harm would be a marker of high risk for subsequent development of psychotic/bipolar disorder and sought to test this hypothesis in a large population sample. This prospective register-based study included everyone born in Finland in 1987, followed until age 28 years (N = 59 476). We identified all hospital records of self-harm presentations, as well as all ICD-10 healthcare registrations of first diagnoses of psychotic and bipolar disorders. Cox proportional hazards models were used to assess the relationship between self-harm and psychotic/bipolar disorders. Of all individuals who presented to hospital with self-harm (n = 481), 12.8% went on to receive a diagnosis of psychosis (hazard ratio [HR] = 6.03, 95% confidence interval [CI] 4.56–7.98) and 9.4% a diagnosis of bipolar disorder (HR = 7.85, 95% CI 5.73–10.76) by age 28 years. Younger age of first self-harm presentation was associated with higher risk—for individuals who presented before age 18 years, 29.1% developed a psychotic or bipolar disorder by age 28 years. Young people who present to hospital with self-harm are at high risk of future psychotic and bipolar disorders. They represent an important cohort for the prevention of serious mental illness.     

Recent developments in the care, treatment, and rehabilitation of the chronic mentally ill in Nigeria

Nigeria, with a population estimated at 80 million, has fewer than 100 psychiatrists and psychologists and only 20 psychiatric facilities. Most chronic mental patients are cared for by their relatives, by traditional healers, or by religious healers affiliated with the new Christian churches, which have proliferated in recent years. Lack of organized social welfare services makes the family the only consistent source of social support for the mentally ill; patients who lose contact with their families often become homeless wanderers. Although the majority of the mentally ill in Nigeria are cared for outside the mental health system, recent developments, such as the establishment of mobile clinics and village-based psychiatric units, show great potential for advancing the treatment of chronic mental illness in Nigeria.     

The traditional healer and psychiatry

Successful psychiatric treatment for rural Africans should incorporate their traditional belief that illness should be viewed in terms of magical, social, physical and religious parameters. Traditional healers divide illness into those of natural causation and those of traditional cultural aetiology which are peculiar to African people. Natural illness includes epilepsy, familial/genetic disorders, mental retardation and schizophrenia. Traditional, cultural disorders often cause difficulties for Western-trained psychiatrists because sorcery, spirit possession and ancestral worship are central to their aetiology and treatment as practised by traditional healers. They, in a state of altered consciousness, use a process of divination to determine why and from whom the misfortune originated. With this in mind, reputable traditional healers were consulted in therapy-resistant cases of culture-bound syndromes in Africans. Their high rate of success in treating these cases was notable. More recognition should be given to the reputable traditional healers.     

Shared psychotic disorder and criminal responsibility: a review and case report of folie à trois

We present a case of shared psychotic disorder involving three sisters who were successful in establishing an insanity defense on numerous felony charges in the South Carolina criminal court system. Two of the authors of this article were court-appointed examiners in this case. We then present a history of shared psychotic disorder, an overview of the use of this diagnosis in the defense of insanity, and a discussion of the disposition of individuals with "temporary insanity." Finally, we compare shared psychotic disorder, culturally based belief systems, and religious cults, with a focus on their common and contrasting characteristics.     

Religion,Spirituality, and Psychosis

This review discusses the relationships between religion, spirituality, and psychosis. Based on the DSM-IV, we comment on the concept of spiritual and religious problems, which, although they may seem to be psychotic episodes, are actually manifestations of nonpathological spiritual and religious experiences. Studies reporting that hallucinations also occur in the nonclinical population and thus are not exclusive to the diagnosed population are presented. Then, other studies pointing to the strong presence of religious content in psychotic patients are also presented. Finally, the criteria that could be used to make a differential diagnosis between healthy spiritual experiences and mental disorders of religious content are discussed. We conclude that the importance of this theme and the lack of quality investigations point to the necessity of further investigation.     

Stress, the hippocampus and the hypothalamic-pituitary-adrenal axis: implications for the development of psychotic disorders

OBJECTIVE: The experience of stress is commonly implicated in models of the onset of psychotic disorders. However, prospective studies investigating associations between biological markers of stress and the emergence of psychotic disorders are limited and inconclusive. One biological system proposed as the link between the psychological experience of stress and the development of psychosis is the Hypothalamic-Pituitary-Adrenal (HPA) axis. This paper summarizes and discusses evidence supporting a role for HPA-axis dysfunction in the early phase of schizophrenia and related disorders. METHOD: A selective review of psychiatric and psychological research on stress, coping, HPA-axis, the hippocampus and psychotic disorders was performed, with a particular focus on the relationship between HPA-axis dysfunction and the onset of psychotic disorders. RESULTS: Individual strands of past research have suggested that the HPA-axis is dysfunctional in at least some individuals with established psychotic disorders; that the hippocampus is an area of the brain that appears to be implicated in the onset and maintenance of psychotic disorders; and that an increase in the experience of stress precedes the onset of a psychotic episode in some individuals. Models of the onset and maintenance of psychotic disorders that link these individual strands of research and strategies for examining these models are proposed in this paper. CONCLUSIONS: The current literature provides some evidence that the onset of psychotic disorders may be associated with a higher rate of stress and changes to the hippocampus. It is suggested that future research should investigate whether a relationship exists between psychological stress, HPA-axis functioning and the hippocampus in the onset of these disorders. Longitudinal assessment of these factors in young people at 'ultra' high risk of psychosis and first-episode psychosis cohorts may enhance understanding of the possible interaction between them in the early phases of illness.     

Cannabis consumption and its psychosocial effects in a comparison of different cultures

Cannabis consumption is a social and cultural phenomenon. It has a specific place in each society, therefore psychotropic effects are judged differently. In medieval Islam cannabis consumption showed connections with religious and mystic events and was basically formed through consuming sufis. The main risk of cannabis use was especially the induction of "madness" or psychotic states in case of high dosage and high frequency of consumption. Nevertheless there were no social sanctions. Today in western civilized countries cannabis consumption is connected with relaxed activity and is mainly consumed by adolescents. The main risk is seen in the ongoing consumption of illicit drugs, since cannabis consumption is widely held as the first step for such a career. On the other hand the induction of psychotic states or a schizophrenia-like psychosis is rarely named in public discussions. At all times self-reports of cannabis-users named creative aspects of cannabis-consumption, normally seen in the conscious translation into normal reality of astonishing and formerly unknown experiences made in an intoxicated state. This aspect of cannabis use is widely disregarded in scientific research. Various reasons therefore are discussed.     

Religious coping among psychotic patients: Relevance to suicidality and treatment outcomes

Religious coping is very common among individuals with psychosis, however its relevance to symptoms and treatment outcomes remains unclear. We conducted a prospective study in a clinical sample of n=47 psychiatric patients with current/past psychosis receiving partial (day) treatment at McLean Hospital. Subjects completed measures of religious involvement, religious coping and suicidality prior to treatment, and we assessed for psychosis, depression, anxiety and psychological well-being over the course of treatment. Negative religious coping (spiritual struggle) was associated with substantially greater frequency and intensity of suicidal ideation, as well as greater depression, anxiety, and less well-being prior to treatment (accounting for 9.0–46.2% of the variance in these variables). Positive religious coping was associated with significantly greater reductions in depression and anxiety, and increases in well-being over the course of treatment (accounting for 13.7–36.0% of the variance in change scores). Effects remained significant after controlling for significant covariates. Negative religious coping appears to be a risk factor for suicidality and affective symptoms among psychotic patients. Positive religious coping is an important resource to this population, and its utilization appears to be associated with better treatment outcomes.     

Religious involvement and healthy lifestyles: Evidence from the survey of Texas adults

Background: Although research shows that religious involvement is associated with a wide range of individual health behaviors, it has yet to be determined whether the effect of religious involvement extends to an overall pattern of regular health practices that may constitute a lifestyle.Purpose: Building on prior research, we test whether religious individuals tend to engage in healthier lifestyles than individuals who are less religious.Methods: Using data collected from a statewide probability sample of 1,369 Texas adults, we estimate a series of ordinary least squares regression models to assess the net effect of religious involvement on overall healthy lifestyle scores.Results: The results of our study indicate that religious individuals do tend to engage in healthier lifestyles, and this pattern is similar for men and women and across race/ethnic groups. We also find some evidence to suggest that the association between religious involvement and healthy lifestyles may be less pronounced in old age.Conclusions: Assuming that religious involvement is associated with healthier lifestyles, additional research is needed to account for these patterns. Future studies should also consider whether healthy lifestyles may serve as a mechanism through which religious involvement might favor health and longevity.