Tag: socioeconomics

Categories
Papers, Docs, and Essays

Assessment-Based Ethical Referral of Traumatized Individuals to Psychosocial Services

clouds
Photo by Brett Sayles on Pexels.com

When conducting assessments for trauma as a psychologist, it is important to have a plan in place on the provision of mental health services and resources for the client or participant. Those participants who screen as having posttraumatic stress disorder (PTSD), complex posttraumatic stress disorder (CPTSD), acute stress disorder (ASD), or who may not qualify for a disorder but still have significant symptoms in amount or severity should be referred for more in-depth assessments or treatment. The International Society for Traumatic Stress Studies (ISTSS) (Forbes et al., 2020) suggests treatments of varying evidence bases for recommendations. This also aligns, and in some cases conflicts, with ethical standards as proposed by the American Psychological Association (APA) (2017) and the International Union of Psychological Science (IUPS) (2008). However, a crucial consideration is the barriers to such treatments, such as cultural factors, socioeconomics, and available resources, which may be difficult to access in some areas of the world.

Trauma assessments could occur in at least two different scenarios, either within the context of a research assessment, or in a clinical environment. In a research context, the APA’s Ethical Principles of Psychologists and Code of Conduct (2017) states in section 8.08 that in order to reduce the risk of harm to participants, debriefing should occur quickly following the conclusion of the research. However, this is conflictual with debriefing as an early intervention in a clinical setting following assessment. The ISTSS (Forbes et al., 2020) reviewed evidence and found that debriefing interventions were largely ineffectual, including psychoeducation, in both individual and group interventions. It must be noted, though, that this was specific to those who had been exposed to trauma within the prior three months, and there appeared to be little research included for its use with survivors and refugees of civil war and genocide. This is relevant because the author of this paper, Emily Lutringer, is working to adapt the International Trauma Questionnaire (ITQ) (Cloitre et al., 2018) into cultural idioms of distress for Syrians, who have significant rates of multiple trauma exposures occurring for potentially over a decade (Hassan et al., 2015). In doing an assessment for research purposes, individuals may have been exposed to trauma longer than three months ago. ISTSS (Forbes et al., 2020) guidelines found strong evidence to recommend the following psychological treatments for adults with PTSD: cognitive processing therapy, cognitive therapy, EMDR, trauma-focused CBT, and prolonged exposure.

In conducting clinical assessments, there may be clients who are recently exposed to trauma, and therefore could partake in prevention and early interventions if they show symptoms of trauma on the assessment. ISTSS (Forbes et al., 2020) found that single sessions of EMDR and Group 512 PM had emerging evidence to prevent or treat symptoms of PTSD. Brief dyadic therapy and self-guided internet-based interventions also showed emerging evidence for multiple-session prevention. Stronger evidence was found in early treatment multi-session interventions of trauma-focused CBT, cognitive therapy, and EMDR. Of pharmacological interventions, only hydrocortisone showed emerging evidence.

In any situation in which an individual screens positively for trauma symptoms or PTSD, there may be barriers to accessing the most effective treatments – or even any interventions at all. Firstly, the interventions proposed by ISTSS (Forbes et al., 2020) are primarily Western models, and may not be culturally appropriate in other contexts (Narvaez, 2019). While ISTSS (Forbes et al., 2020) offers a few treatments which may have limited efficacy which could be culturally accessible, such as acupuncture, it is notably lacking in covering the evidence for interventions from indigenous psychologies which would be highly culturally relevant.

Another serious concern is the lack of access, such as low rates of mental health providers, remote areas, high demand with limited availability, and socioeconomic factors (Patel, 2007). Rojas et al. (2019) found that mental health care could be utilized in such situations through the use of internet-based interventions in a variety of formats, such as virtual counseling, phone apps, and specialized video games. As more people worldwide have access to the use of internet and cellphones, these interventions could reach larger populations and at lower costs. There are two caveats to this, though. Firstly, there are still many areas of the world without such internet or cell phone access. Secondly, internet and phone-based interventions appear to have mixed results in their effectiveness, although ISTSS was able to give a standard recommendation for the use of guided internet-based trauma-focused CBT in adults diagnosed with PTSD (Forbes et al., 2020).

Other barriers include stigma and poor mental health literacy (Wong et al., 2019). For example, Syrians typically hold strong stigmas around mental health and may be afraid to seek help for how others may judge them or their families (Hassan et al., 2015). Wong et al. (2019) had positive results in their pilot study evaluating the reduction of stigma through a mental health course in Hong Kong. Similar strategies for psychoeducation and normalization may be valuable when working with people in high-stigma cultures, as they may otherwise resist any PTSD intervention.

 Any mental health resources should include facilities or providers who have experience working with the specific population, to meet the ethical standard of competency (APA, 2017; IUPS, 2008). A researcher would ideally, finding an option that participants could engage in immediately after the study if they chose would allow them to process any trauma that came up without a waitlist. As the assessments are specifically measuring for trauma, a participant may suddenly become aware for the first time that they are suffering from a mental illness and may need immediate support. Furthermore, providing exceptional mental health and other resources is critical to preventing the re-enactment of trauma or intergenerational trauma which could lead to a continued cycle of violence (van der Kolk & McFarlane, 1996). It constitutes the ethical responsibilities of beneficence and nonmaleficence, fidelity and responsibility, justice, and respect for people’s rights and dignity (APA, 2017) not only to individual participants, but in taking a responsibility in the reduction of harm in communities as well.

References

American Psychological Association [APA]. (2017). Ethical Principles of Psychologists and Code of Conduct. https://www.apa.org/ethics/code

Cloitre, M., Shevlin M., Brewin, C.R., Bisson, J.I., Roberts, N.P., Maercker, A., Karatzias, T., Hyland, P. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and Complex PTSD. Acta Psychiatrica Scandinavica. DOI: 10.1111/acps.12956

Hassan, G., Kirmayer, L.J., Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel, P. (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Conflict. Geneva: UNHCR.

International Union of Psychological Science [IUPS]. (2008). Universal Declaration of Ethical Principles for Psychologists. https://www.iupsys.net/about/governance/universal-declaration-of-ethical-principles-for-psychologists.html

Narvaez, D.F. (October 20, 2019). Indigenous Psychologies Contrast With Western Psychology. Psychology Today. https://www.psychologytoday.com/us/blog/moral-landscapes/201910/indigenous-psychologies-contrast-western-psychology

Patel, V. (2007). Mental health in low-and middle-income countries. British medical bulletin, 81(1), 81-96.

Rojas, G., Martínez, V., Martínez, P., Franco, P., & Jiménez-Molina, Á. (2019). Improving Mental Health Care in Developing Countries Through Digital Technologies: A Mini Narrative Review of the Chilean Case. Frontiers in public health, 7, 391. https://doi.org/10.3389/fpubh.2019.00391

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

Wong, P. W. C., Arat, G., Ambrose, M. R., Qiuyuan, K. X., & Borschel, M. (2019). Evaluation of a mental health course for stigma reduction: A pilot study. Cogent Psychology, 6(1), Article 1595877. https://doi.org/10.1080/23311908.2019.1595877

Categories
Papers, Docs, and Essays

Social determinants of mental health in a global context

The readiness of a woman for pregnancy can impact the mental health of both the mother and child.  This is not necessarily related to age – in the U.S., teenage pregnancy is seen as a problem, but it is not in many other cultures (Sorel, 2013). However, socioeconomic factors can be a major influencer.  Poor nutrition increases risk of birth defects, as does exposure to toxins – both of which are increased among those living in poverty, in addition to lack of education around pregnancy needs and medical checkups, as well as abstaining from tobacco, alcohol, and drugs. Additionally, to create the best environment for mental health, the CDC suggests that the mother should be in a safe environment, have healthy behaviors, and a strong support system, and recommends counseling to understand genetic risks, mental health issues, and domestic violence.

In early childhood, a strong bond between the mother or parent to the child is critical to healthy social and emotional development (Sorel, 2013).  If the primary caregiver suffers from depression, this can impact the formation of this bond. Breastfeeding reduces risk of later obesity in children, protects infants from illness and infection, and breastfeeding for 6 months or longer reduces risk of mental health issues later in life. Children who are breastfed longer have less behavioral problems.  Socioeconomic factors in here as well – “mothers who breastfed for less than six months were younger, less educated, poorer, and more stressed and were also more likely to be smokers than the mothers who breastfed longer.  They were also more likely to suffer from postpartum depression…” (Sorel, 2013, p. 80).  In the U.S., Mexican-Americans and White mothers, higher incomes, and mothers over 30 increased the likelihood that a baby was breastfed.  African Americans have a much lower rate, likely connected to the stigma of breastfeeding from historically being forced to be wet nurses during slavery. And throughout childhood, the environment plays a large role in development of mental health, and again often is connected to socioeconomic status.

Even without a diagnosable mental illness, people can fall anywhere along the spectrum of mental health and mental illness (Sorel, 2013). Some people are able to function while having some mental illness, while others are not.  Some people are subject to environmental and social factors which impair their ability to maintain good mental health, and impede their ability to avoid mental illness.  There is a strong link between mental health and physical health, both impacting the other. Other factors include low quality or unstable housing, violent relationships, poor nutrition and adequate food, job insecurity, high crime rates, and alcohol and drug use (p.85). Factors which contribute to positive mental health include: “intact family, maternal attachment, public safety, social support and inclusion, housing quality, food security, quality education, employment, income security, access to quality health care, religiosity, and moral values” (Sorel, 2013, p.85). The inverse of these increases risks for mental illness.

In addition to the factors above, it must be reiterated that the biggest structural driver of social determinants of mental health is poverty. This also connects to an individual’s location – often those in poverty are forced to live in areas with limited access to resources, from public transportation to health care to recreational opportunities (Sorel, 2013, p.88).  They also are more likely to have poor quality housing, high crime rates, gangs, poor education, and unemployment, among other things. “These inequalities in the allocation, distribution, acquisition, and utilization of resources affect mental well-being and create conditions of unequal hardship and opportunity, racism, discrimination, and stigmatization, all of which result in negative mental health outcomes” (Sorel, 2013, p.88). In order to change these conditions, governments as well as individuals will need to challenge them and actively work to improve the allocation and utilization of resources.

The best promotion of good mental health is prevention.  To do so takes both external and internal support for the community.  Internally, people can be trained in parenting education and then become trainers themselves for others in their community, for example (Sorel, 2013).  Schools can develop policies which build their relationship with parents, increase parental involvement, and provide information on the emotional and cognitive needs of their kids. Sorel (2013) outlines numerous ideas for the government to improve social determinants for mental health.  Some of these include: reducing inequalities in education, economic status, housing, and health care, utilizing welfare systems to help people find and keep jobs, make college education more affordable, including personal economics classes as part of the core curriculum in schools, using tax credits and incentives to promote positive social determinant factors, expanding healthcare policy to include mental health and meet the needs of those who need it most, and focus on prevention, using employee assistance programs to provide needed mental health care to workers, and including mental health promotion programs in emergency and crisis response.

References

Carr, S. C. (2003).  Poverty and psychology: An introduction.  In S. C. Carr, & T. S. Sloan (Eds.), Poverty and psychology: From global perspective to local practice (pp. 1-15).  New York, NY: Kluwer Academic/Plenum Publishers 

Collins, P., Patel, V., & Joestl, S. S. (2011).  Grand challenges in global mental health.  Nature, 475, 27-30. 

Knifton, L. (2012).  Understanding and addressing the stigma of mental illness with ethnic minority communities.  Health Sociology Review, 21(3), 287-298.

Sorel, E. (2013).  21st Century global mental health.  Burlington, MA: Jones & Bartlett Learning. Chapter 4, p. 73-94.

Categories
Papers, Docs, and Essays

Psychological Impacts of Terrorism

Tanielian and Stein (2006) write about the impacts on and needs for addressing the psychological impacts of terrorism. While terrorism is an act which is marked by physical destruction, loss of life, economic collapse, violence, and political aims, it is also intended to provoke fear in the population. It has psychological effects additionally through targeting “the social capital of a nation – cohesion, values, and ability to function. Therefore, successful counterterrorism and national continuity depend on effective interventions to sustain the psychological, behavioral, and social functioning of the nation and its citizens” (Tanielian & Stein, 2006, p.690). However, this aspect is woefully under addressed and not well understood.

Emotional and psychological responses to terrorism, even by those not immediately affected or witness to the event itself, can be present from no reaction at all, to mild symptoms, to development of severe mental illnesses (Ursano, Morganstein, & West, 2020). Distress reactions include changes in sleep, reduced sense of safety, isolation and avoidance, and irritability and distraction. Health risks include increased behaviors of smoking, alcohol, becoming overly involved in work or other tasks, separation anxiety, and fears about traveling nationally, internationally, or even outside one’s neighborhood or home. Psychiatric disorders can include anxiety, PTSD, acute traumatic stress, depression, and complex grief. In others, or in initial stages of a “honeymoon period” following an attack in those who later develop symptoms of mental distress or illness, there may be a sense of resiliency, of bonding, of heroism, and optimism. There can also be a reaction of anger and wanting retaliation. This can lead to pressure to develop harsher policies toward a broad group perceived to be associated with an attack, such as in the case of anti-Muslim policies in the U.S. following 9/11 and leading to the “Muslim ban” implemented by former President Trump (Haner, et al., 2019). This can also lead to a reaction of building of a group identity, framing those with any perceived association with the attack as bad and devaluing their humanity, and leading to the formation of extremist groups, further escalating conflict (Staub, 2012).

Tanielian & Stein (2006) discuss the need for further support and research of psychological reactions and distress from terrorist attacks. They note that “little national or local policy has focused on the importance of addressing psychology or mental health” as a part of the counterterrorism funding, policies, and response in the U.S.  Many research articles have studied the frequency, type, and intensity of psychological and mental health consequences of terrorism and natural disasters such as earthquakes. Both indirect and direct victims of a terrorist attack can experience psychological symptoms, but the most heavily affected are those who were directly affected, in the immediate area, or first responders. Vulnerable populations are also heavily impacted, “such as children, racial and ethnic minorities, and those with an existing psychiatric illness” (Tanielian & Stein, 2006, p.693). The article specifically details impacts on children, and how the interactions between parents and children can either increase symptoms in children, or possibly increase parents’ reporting of distress in their children. The article does make a cross-cultural reference to studies in Israel and compares it to studies in the U.S.

The article does also mention that there may be differences in reactions between ethnic and cultural groups, identifying disparities in increases of PTSD and lower utilization of medications and mental health services among Black and Latino people compared to White people (Tanielian & Stein, 2006). This is attributed to “various cultural factors, including valuing self-reliance, expressing emotions in certain ways, and having reservations about sharing emotions with others” (Tanielian & Stein, 2006, p.694). Considering this article was written in 2006, there was a lot less awareness of structural and systemic racism than there is today in 2021 in the U.S. I would argue that what is missing from this analysis of disparities in seeking services is the general distrust of the medical – inclusive of mental health – systems among Black communities due to a history of being abused by such services. This includes experiments done on slaves, and the infamous Tuskegee Syphilis study (Wells & Gowda, 2020). Other factors to consider in this population is the severe lack of Black physicians which are much preferred by the Black community, White physicians lacking cultural competency, history of segregated cities, and socioeconomic barriers.

Additionally, Latinos are the least likely ethnic group in the U.S. to utilize mental health services (Barrera & Longoria, 2018). Reasons for this also include socioeconomics, acculturation issues for immigrants (such as language barriers or not understanding the health care system), cultural stigma towards mental illness, and distrust of the medical and mental health systems due to “past experiences of discriminatory treatment or ineffective care” (Barrera & Longoria, 2018, p.3). The article by Tanielian & Stein (2006), while it touches lightly on the disparities and the need for increased cultural competence in delivering mental health services following a terrorist attack, does not fully account for such deep-rooted issues, which could limit much needed mental health care. Understanding the depth of these systemic factors are incredibly important for not just improving mental and physical health for minority populations in general, but even more so after an acute event such as a terrorist attack.

Tanielian & Stein (2006) note that one of the most important and beneficial strategies for reducing psychological distress after a terrorist attack is to build and strengthen community relationships. They also suggest that response strategies target the needs of specific groups such as victims, vulnerable groups, and first responders. They discuss the use of psychological first aid, and how the Red Cross has recently (as of the time of the article in 2006) begun a Disaster Mental Health program to specialize in and provide these services following disaster incidents, including terrorist events. The authors do note that there may be still problems with this, however, with a lack of cultural-specific training and training specific to terrorist attacks. I am a Disaster Mental Health volunteer with the Red Cross, and I find this absolutely to be the case – I did not receive any training for how to change services or tactics dependent on the type of disaster, nor any training on how to work with people of different cultural groups.

Tanielian & Stein (2006) focus their article on working on the psychological distress with victims following a terrorist attack. However, they fail to include broader implications in preventing the victimized groups developing their own group identity and resorting to retaliatory violence and extremist ideologies, dehumanizing anyone who might be perceived, often incorrectly, of having some association to the terrorists. This potentiality can build into exacerbated group conflict and encourage a cycle of dehumanization and violence towards the ‘other’ (Staub, 2012). While addressing mental health issues both short and long term for victims of a terrorist attack is incredibly important, I think it is also important to incorporate prevention plans to mitigate the growth of retaliatory group identities and future conflict. Finally, any mental health interventions must include comprehensive cultural training for professionals providing aid, including understandings of implicit bias and systemic factors.

References

Barrera, I., & Longoria, D. (2018). Examining cultural mental health care barriers among    Latinos. CLEARvoz Journal, 4(1).

Haner, M., Sloan, M. M., Cullen, F. T., Kulig, T. C., & Lero Jonson, C. (2019). Public concern       about terrorism: Fear, worry, and support for anti-Muslim policies. Socius, 5,   2378023119856825. https://doi.org/10.1177%2F2378023119856825

Staub, E. (2012). The roots and prevention of genocide and related mass violence. Chapter 2 in    Anstey, M., Meerts, P. & Zartman, I. W. (eds). The slippery slope to genocide: Reducing identity conflicts and preventing mass murder. New York: Oxford University Press.

Tanielian, T. & Stein, B.D. (2006). Understanding and preparing for the psychological        consequences of terrorism. McGraw-Hill Companies, Inc., 2006.             https://www.rand.org/pubs/reprints/RP1217.html.

Ursano, R.J., Morganstein, J.C., & West, J.C. (2020). Essential issues on terrorism: Planning for      acute response and intervention. In Vermetten, E., Frankova, I. Carmi, L., Chaban, O.,   Zohar, J. (eds). (2020). Risk management of terrorism induced stress. IOS Press.

Wells, L., & Gowda, A. (2020). A Legacy of Mistrust: African Americans and the US Healthcare      System. Proceedings of UCLA Health, 24.

Categories
Papers, Docs, and Essays

Based on the Filipino context, what are the strengths and challenges for collaborating with local businesses to support corporate social responsibility for trauma-based initiatives?

A strength of collaborating with local businesses in the Philippines to support corporate social responsibility for trauma-based initiatives is the growth of interest and towards supporting populations in developing countries which provide incomes in addition to overall development (Nielson & Samia, 2008). These types of developments can also be a support to mental health, such as in the case of SAFFY (SAFFY, 2019).  However, challenges which are mentioned in Nielson & Samia (2008), and also in my talks with SAFFY, is the difficulty in selling products at local markets where they earn little for their products and be unable to reach a larger scale of consumers.

Other significant challenges are the lack of a country-wide system and structure to focus efforts on small local businesses rather than large corporations (Nielson & Samia, 2008). Furthermore, initial training in leadership and management, marketing, and having upfront capital are needed, in a somewhat ironic cycle, for a business to prove its viability and usefulness, upon which they may be able to gain additional funding such as from government programs or NGOs, but often the initial stages must come from the grit and pockets of the founders themselves. This can be challenging in areas where people are severely impoverished, and because of social-economical factors which perpetuate themselves and prevent the poor from moving up, many may struggle with appropriate education, or even basic literacy.

Another issue to consider is both the large amount of overseas workers who have been “exported” from the Philippines, due to lack of economic viability within their own country, causing the loss of these intelligent and hardworking individuals who could instead be participating directly in the Philippine workforce (Watt, 2015). In the Philippines, however, these workers are seen as heroes who sacrifice their desire to remain with their family in order to instead send back money which can support family members and also build the economy within the Philippines.

Furthermore, there is a large section of workers in the Philippines who constitute the informal sector (Ofreneo, 2013). These workers are not formally employed by a company, but often hustle in various capacities to earn a daily living, and do not pay taxes to the government. While these workers must certainly have strength of determination, creativity, and adaptability, many times they lack an organized network, additional funding, or the training to implement a movement from these informal skills to creating a viable business. Ofreneo (2013) argues that a “rights based’ approach to social protection, via the passage of protective labor laws for the vulnerable, is insufficient to secure such protection, given the weakness of the economy” (p.421). Therefore, policies and laws for these protections are not completely invaluable, but rather do not target the whole picture of needs to move the economy forward for these workers, in addition to addressing the social transformation and mental health needs of both individuals and communities who have undergone collective trauma.

A strength in the above regard is that there are already organizations which aspire to empower and build people up who might not otherwise have opportunities to do such, such as the work of SAFFY, Pakisama, and Solidarity with Orphans and Widows.  There is a definite need for these types of organizations, and it is inspiring to see their work carving out grassroots efforts to address the above problems, while simultaneously addressing implications and effects of longstanding, as well as immediate, trauma.

References

Nielsen, C., & Samia, P. M. (2008). Understanding key factors in social enterprise development of the BOP: A systems approach applied to case studies in the Philippines. Journal of Consumer Marketing, 25(7), 446-454. doi:10.1108/07363760810915662

Ofreneo, R. E. (2013). Precarious Philippines: Expanding informal sector, “flexibilizing” labor market. American Behavioral Scientist, 57(4), 420-443. doi:10.1177/0002764212466237

SAFFY. (2019). About Us. http://www.saffyinc.com/about-us/

Watt, G. (2015, September 13). BBC HardTalk on the Road in the Philippines . YouTube. https://www.youtube.com/watch?v=A0XUQa55OhI&t=504s