Introduction
“Turn now to the lives of people with mental illness in poor societies. Appalling, dreadful, inhumane—the worst of words pile on each other to name the horrors of being shunned, isolated, and deprived of the most basic of human rights.”(Kleinman 2009). Throughout my life, I have been privileged to be a middle-class, American citizen, with access to health insurance. Both of my parents are first-generation college graduates with advanced degrees. My parents have been the biggest impact on the person I am today, not only based on the development of my character, but additionally my worldly outlook. Despite my privilege, the reality of those less fortunate than me often feels very present. My mother immigrated from Jamaica at the age of seven, and spent all of her adolescence in a position of poverty. My father grew up in a rural-Maryland as an African-American male, and additionally faced poverty. Many of my family members still face issues which harm persons of low-socieo economic status. In this essay, I will explore anthropological literature that surrounds the link between poverty, and treatment of mental health illnesses. “In the USA.. the prisons are the functioning mental-health-care system. Somewhere between a third and half of all the homeless people in American cities suffer from mental illness. Yet balancing this abysmal record, mental health care in the USA is finally receiving renewed attention and resources aimed at closing the gap in parity with the rest of health care.”(Kleinman 2009) Medical costs within the United States are often at the forefront of many conversations regarding government funding. The United States is one of the only “developed” nations that does not have a universal health care system. We have discussed how an inability to access treatment is often a roadblock for receiving care for illnesses. This lack of access can be significant for persons of lower social-economic status for numerous reasons. If an individual works an hourly job, seeking treatment or even solely evaluation for a mental illness can prevent them from receiving pay for essential bills.
Based on the rising costs of mental health treatment practices, brainstorming is done in order to find ways to cut costs. “By the late 1980s, the costs of psychiatric and substance abuse treatment were growing more rapidly than the costs of other medical specialties … causing employers (as purchasers of private insurance plans) and public policymakers to search for ways to contain expenses. The solution that has emerged is what is known as ‘managed care’”(Ware et al. 2000) Many of the solutions, like managed care, that have been proposed through the years to help alleviate the rising costs of mental health care have been controversial. “Advocates as well as critics credit the cost containment of aged care with bringing particular treatment modalities to the … most of these are intended to replace long-term … less expensive forms of treatment.”(Ware et al. 2000) I will additionally delve into the drawbacks and benefits of solutions to disparities in treatments that involve compromising care for more favorable costs.
Medical systems based in biomedical practices are very reliant on patients seeking treatment from professionals. Although these methods have been found to be effective, quantitatively, utilizing these methods for treatment of mental illness are very time consuming. In a system where it is very challenging for impoverished individuals to access treatment, it can lead to a cyclical issue in which poverty is continued generationally. In terms of cross-cultural perspectives on medicine and healing, I will synthesize some differences of mental health care treatment. Differentiating between the lived experience of persons with different cultural backgrounds and practices regarding mental health will help me gain insight on their interpretations of how they believe mental illness should be treated. An anthropology-centered focus on a topic focuses on how culture and qualitative circumstances impact observations that are taken. “Qualitative techniques such as observation, in depth interviews, and focus groups …can be used to provide a description and understanding of a situation or behaviour.” (Pope & Mays 1995) Qualitative research tactics can be used in conjunction quantitative work to further explain findings. Qualitative methods add depth to broad claims that are often taken from analysis of large amounts of people.
Underlying Issues with Poverty
One of the key issues with poverty is how detrimental it can be during one’s early stages of development. “Research linking poverty and the brain starts by establishing that there is a problem first—that lower socioeconomic status (SES) during childhood does indeed lead to negative outcomes in adults. That established, the research presents a developmental framework to understand that linkage.”(Lende 2012) This issue is further exemplified when examining the root of the damage poverty does to one’s psyche through anthropogenic factors. The central argument of Daniel Lende’s piece is regarding a slogan, “Poverty Poisins the Brain”. Lende examines how this slogan can demonstrate the implications of a neuroanthropolical approach to disparities caused by poverty. “the heart of the poverty poisons the brain story—the combination of proximate environmental factors that shape childhood development and internal neurological mechanisms that translate proximate factors into structural and functional brain changes and associated capabilities and deficits.”(Lende 2012) Lende is suggesting that many of the factors that anthropologists observe in ethnographic works is direct causation for the neurochemical effects that mental health practioners observe. “Thus, a neuroanthropology of poverty shows that poverty is not bad simply because of lower social status, increased environmental stressors, and a lack of resources. Poverty is bad because it unites individual and societal lack of control, creates unpredictable adversity, sets conditions that leave people unable to respond, and creates a sense of helplessness and despair.” (Lende 2012) This speaks on how living in poverty can be detrimental to the hope of an individual. A feeling of hopelessness in a America, which prides itself as a land of opportunity, can place further pressure on individuals to succeed despite being at many disadvantages.
The ability to assume the status of sickness is a luxury in many circumstances globally. Identifying oneself as a person who is sick often has far reaching impacts beyond a biological, or potentially spiritual phenomenon occurring in one’s body. Talcott Parsons defines the “sick role” in a fashion which is based on certain rights and responsibilities. Under Parsons’ model for the sick role, an individual becomes exempt from their typical social responsibilities until well. Additionally, Parsons views the sick role as a role where a person generally has someone who can care for them while their illness takes its course. While under this conceptualization, the individual should have the desire to at some point leave the role. Lastly, they individual should seek out a practioner that is trained to alleviate their ailment(Parsons 1951) Parsons’ model is an effective one for understanding how debilitating short term illnesses often affect individuals. Unfortunately, one of the main limitations of this model is the ability to apply it to chronic illnesses. Mental health ailments are often chronic in nature, and positioning oneself in a role similar to the one that Parsons described is unsustainable for impoverished people. Parsons’ perspective also resembles the biomedical perspective that patients are “passive” and “helpless”, and that physicians are the individuals best equip to cure disease. Combining the model of Parsons with lens that Lende proposes can possibly help overcome some of the limitations present in each model.
Poverty Under Cross-Cultural Perspectives
I come from a background where allopathic medicine is considered the most effective form of treatment. Growing up in the United States, I am privileged to have access to many forms of allopathic treatment in highly populated areas. Arthur Kleinman constructed a model for the comparison and contrasting of medical systems cross-culturally. Kleinman created the model in order for medical systems and medical practices to be considered as a part of culture. Additionally, Kleinman believes that healthcare systems each are comprised of three different social settings where individuals feel sickness and others react to it. These are the “popular”, “professional”, and “folk” arenas. Within the popular arena, there are individual, family, social, and community based health care actions. Kleinman noted that, in western and non-western settings alike, between seven-tenths and nine-tenths of the populations undergo the majority of their care in the popular arena (Kleinman 1978) This has extreme relevance for the context of poverty and mental health treatment. Presumably, the majority of health care occurs in the popular setting because this will take the least external time and resources short term. Kleinmann acknowledges not only biomedical scientists as professionals but also professional indigenous healers. Kleinman overall does not believe his method of evaluation of health systems as cultural systems should lead to distinct solutions, rather it could be used as one of the many tools to evaluate certain limitations across various health systems(Kleinman 1978).
In developing countries, poverty can take more dramatic forms than the general conception of poverty in the United States. Although there are many people in the United States who are impoverished and lack basic infrastructure like clean water, the upper end of the poverty spectrum in the United States pails in comparison to a majority of the lowest class citizens in developing nations. A study was conducted of countries within the Amazon region on how different ecological and economic factors affect mental health. In this study it was found that,“…higher water insecurity scores were associated with higher levels of depressive symptoms, somatic symptoms, and perceived stress in the total sample.”(Tallman 2019) Within their data analysis, it was also found that there is a correlation between social and cultural factors as well. In this article, a “critical biocultural approach” is used to examine some of the underlying economic factors which lead to water insecurity and its affect on mental health of individuals within the community. “A critical biocultural approach is a perspective that combines theory and methods from the anthropological subdisciplines of human biology and critical medical anthropology to study the interface between biological and cultural factors affecting human health and well-being…”(Tallman 2019) The goal of this approach is to incorporate input from many different persons of expertise in order to create a holistic view on the information collected. Tallman believes a critical biocultural approach commands input from more than solely anthropologists in order to further validate a study(Tallman 2019)
Mental Health Treatment Variation
A study was conducted on residents of Sweden to evaluate socio-economic inequalities in the treatment of persons who are diagnosed with common mental disorders(CMDS). Based on the results of their data analysis it was found that, “Individuals with sickness absence due to CMDs and a high educational level had lower proportions of specialised health care and combined psychiatric medication than their counterparts with low education. (Dorner & Mittendorfer-Rutz 2017) This is a significant finding regarding the variation of mental health treatment from an economic perspective. Persons who are impoverished typically have lower levels of education than those of higher social-economic standing. If individuals with lower education levels are receiving less specialized care for their sicknesses, then they are potentially receiving less scientific expertise on their conditions. This lack of expertise is even more problematic when considering that, “if high educated CMD patients received combined medication, risk estimates for subsequent inpatient care due to mental disorders or suicide attempts were higher compared to estimates for patients with lower education.” (Dorner & Mittendorfer-Rutz 2017) Even though persons with higher education levels are receiving more specialized care, outcomes which lead to adverse outcomes such as suicide attempts have happened. In a system which considers outcomes that lead to a higher rate suicide negative, it is interesting that the persons who are supposedly getting inferior care are having better mental health outcomes. “Findings suggest that socioeconomic inequalities shape differences in treatment measures and mental health development in individuals with sickness absence due to CMDs. These differences might signal discrepancies in treatment per se or reflect morbidity differences requiring different treatment regimens.” (Dorner & Mittendorfer-Rutz 2017) Overall this study brings some clarity on what trends are occurring from a purely quantitative standpoint, but requires further analysis on cultural and person centered causes for the trends. “Anthropologists, armed with a neuroanthropological approach, can help design interventions that can make a difference..These types of interventions can be just as easily subjected to an evidence‐based approach as brain‐based training. Thus, “poverty poisons the brain” can help frame an overall approach to developing effective applied anthropology that can show demonstrable effects”(Lende 2012) Lende’s neuroanthropological approach can be utilized when evaluating the study of CMDs in Sweden.
Madeleine Leininger wrote a piece in which she evaluated community mental health care centers in the United States. She noted, “Ideally, the goal is to provide comprehensive psychiatric services to … a particular community. One of the basic assumptions of the program is that if people in a given community have comprehensive mental health services that are easily available to them, they will use the services and will readily come for help at an early point in their illness.”(Leininger 1971) This piece is slightly dated, published in 1971, but illuminates the state of anthropology during a different time period. Additionally it allows us to evaluate former practices and ideologies that worked well, and others which need to be reevaluated. “A typical comprehensive community mental health center has as its focus a demographic unit or a ‘catchment area’ varying in geographic location and in population. From an anthropological view, one of the most obvious problems and a crucial issue is related to the criteria used to de- fine ‘catchment area’ .” (Leininger 1971) Catchment areas are hard to design because they attempt to define a community based on many factors that do not align with cultural criteria that the community itself has defined. “One of the principal criterions used is that a catchment area must be of a certain population size in order that the agency requesting funds for a mental health center will be approved for federal funding. … Often these geographic boundaries split local communities … in an artificial and fragmented manner. In general, these ‘catchment areas’ do not always give full consideration to the wholeness of a community.” (Leininger 1971) Leninger suggests that these prescribed areas of community can cause even more mental stress than were previously in a community by attempting to redefine the culture of a specific area. In order to attempt to stop this problem from arising, Leninger suggests that individuals who examine culture are called upon to examine plans to create community health centers. “In examining other trends related to community mental health programs, one finds there is still a tendency to stress more the psychopathological aspects of a patient’s behavior than the health aspects or ego strengths.” Additionally, Leninger believes that an examination and emphasis of preventative care needs to happen in order to have a fully supportive community health care center (Leininger 1971).
When tasked with transitioning to the implementation of “managed care” tacitcs to help alleviate costs and provide access to mental health services for a broader group of people, not all physicians welcomed the new system. “Clinicians found themselves constrained to learn the language of managed care as a condition of continuing to practice their profession … Speaking this language was the only reliable method of demonstrating productivity to the payers. Representing patients’ problems in medical and behavioral terms also proved to be a powerful means of winning authorization for treatments … Learning the language of managed care may mean being made over as a professional.”(Ware et al. 2000) In order to gain funding from the payers of managed care systems, the clinicians had to use very specific terms, this can also affect the patient by creating language regarding their conditions in terms that are not easily accessible.
Future Hope: Understanding Poverty
The concept of compliance in rural mental health clinics and its link to the use of psychotropic drugs were evaluated in a study. The main purpose of the study was to closely examine how individuals in a rural area of the Mid-Atlantic region of the United States, understood and used prescription psychotropic drugs. After a combination of data analysis, and person-centered interviewing ultimately concluded, “an illness is defined by the patient, as well as by the health-care community, and the patient’s definition may well extend beyond a collection of symptoms to include social and economic factors. …we must understand the experience of the disease and the meaning of the treatment from the patient’s perspective, as well as from the biomedical perspective… Labeling individuals as compliant or noncompliant reduces the complexity of patient-physician negotiations and leaves unquestioned the continued authority and control of the biomedical system.”(Kaljee & Beardsley 1992) The issues surrounding individuals becoming compliant to the recommendations of practitioners requires individuals in the biomedical system to humble themselves slightly and understand the autonomy of an individual. In a system based in biomedicine like the one in the United States, the physician could deem an individual uncompliant and possibly “unwilling” to receive treatment if they do not follow the professionals orders exactly. This is similar to the limitations of Arthur Klienman’s definition of the “sick role”. In Kleinman’s model, an individual who is deemed “sick” must be willing to get better by following the suggestions of a trained professional. Persons impoverished, especially in circumstances where they lack access to professional resources, cannot always adjust their schedules around doctor recommendations. There are often different cultural limitations that might not be expressed to a doctor, that limits a patient. Simply deeming someone “non compliant” based on their refusal of medication is a privileged and short sided assumption. “The widespread stigma of mental illness … marks individuals with severe psychiatric disorders as virtually non-human. None of the world’s major religions…has been able to break this cycle of misery. Nor have modern anti-stigma campaigns and mental health laws.”(Kleinman 2009). Overall throughout my exploration of the literature on how poverty affects mental health treatment, being understanding while not being condescending is extremely valuable.
References
Dorner, T. E., & Mittendorfer-Rutz, E. (2017). Socioeconomic inequalities in treatment of individuals with common mental disorders regarding subsequent development of mental illness. Social psychiatry and psychiatric epidemiology, 52(8), 1015-1022.
Kaljee, Linda & Beardsley, Robert. (1992). Psychotropic Drugs and concept of compliance in rural mental health clinic. Medical Anthropology Quarterly, 6(3), 271-287.
Kleinman, Arthur. (1978). Concepts and a model for the comparison of medical systems as cultural systems. Social Science and Medicine, 12, 85-93.
Kleinman, Arthur. (2009). Global mental health: a failure of humanity. The Lancet. 374, 603 604.
Leininger, Madeleine. (1971). Some Antropological Issues Related to Community Mental HealthPrograms in the United States. Community Mental Health Journal
Lende, Daniel. (2012). Poverty Poisons the Brain. Annals of Anthropological Practice, 36(1), 183-201. doi:10.1111/j.2153-9588.2012.01099.x
Parsons, T. (1951). The social system. Glencoe, Ill: Free Press.
Pope, Catherine, & Mays, Nick. (1995). Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ, 331, 42 45.
Tallman, P. S. (2019), Water insecurity and mental health in the Amazon: Economic and ecological drivers of distress. Economic Anthropology. doi:10.1002/sea2.12144
Ware, Norma, et. al. (2000). Clinician Experiences of Managed Mental Health Care: A Rereading of the Threat. Medical Anthropology Quarterly, 14(1), 3-27. doi:10.1525/maq.2000.14.1.3