A critical engagement with the DSM-5 and psychiatric diagnosis

Classifications in psychiatry can result in the reification of hypothetical approaches, arbitrary categorisation and social injustice. This article applies a social constructivist approach to critique the DSM-5 as a neurobiological model of psychiatric diagnosis which ignores psychosocial factors such as poverty, unemployment and trauma as causes of mental distress. It challenges the universality of psychiatric diagnosis and proposes that cultural psychiatry's framing of ‘culture-bound syndromes,’ or ‘cultural case formulation’ guidelines, is oversimplified. Use of the DSM in the South African context risks perpetuating injustice by labelling and stigmatising people who have in the past been racially stigmatised by apartheid. In culturally diverse South Africa, psychiatric diagnosis should take into account alternative explanatory models that provide a more balanced view of the complex and dynamic relationship between biological and sociocultural forces in the manifestation of psychopathology.     

Effect of Poverty on Mental Health of Children in Rural China: The Mediating Role of Social Capital

Underprivileged children are a relatively special vulnerable group in rural China, but the relationship between poverty and children’s mental health has been rarely examined. This study aimed to investigate the effect of poverty on children’s mental health and the mediating role of social capital in their family, peer, school, and community level. Data used in this study were collected in 2015 from a school-based survey of 1314 children in grades 4–9 through a multi-stage cluster random sampling method in Xiushui, a poverty-stricken city in Mainland China. The result of structural equation modeling indicated that poverty elicited a significant predictive effect on children’s negative and positive mental health. Family social capital and peer social capital played intermediary effects between poverty and children’s mental health. However, the mediating effects of school and community social capital are not significant. The implications of these findings on theory, social policy, and social work services were also discussed.

     

Reply by Edward S. Casey

Stigma and discrimination against mental illness represent chronic social stressors that can inflame psychiatric symptoms and limit functional adjustment. The implication is that the prevalence and severity of mental illness is determined, at least to a certain extent, by aversive socio-cultural factors. In a hostile social environment, these factors may seriously limit the effectiveness of professional interventions; whereas, removing social barriers to functioning often results in a favorable clinical outcome. For example, studies show that inclusive settings with supportive employment decrease psychiatric symptoms and the use of mental health services. By extrapolation, these results point to the possibility that a society-wide reduction in the prevalence and severity of mental illness may come from benevolent changes in the social climate, not just from innovative treatments. Public health policies rarely take this possibility into consideration in resource allocation decisions.     

The stigma of mental illness: Explanatory models and methods for change

For people with mental illness, diminished quality of life and loss of personal goals does not result solely from the symptoms, distress, and disabilities caused by their psychiatric disorder. Quality of life and personal goals are also hindered by people who embrace the stigma that accompanies mental illness and mental health care. This paper reviews evidence of the impact of mental illness stigma and strategies for seeking to ease its impact. To achieve these goals, we (a) describe the ways in which stigma harm people with mental illness, (b) summarize models that explain the development and maintenance of these stigmatizing effects, and (c) review strategies that have been shown to decrease the impact of stigma. Concerns about stigma are on the political agendas of many mental health advocacy groups. It has recently also become the focus of extensive research. Our goal in this paper is to balance the practical concerns raised by mental health advocates against data that support or contradicts specific assertions.     

Poverty and Serious Mental Illness: Toward Action on a Seemingly Intractable Problem

This paper examines the issue of poverty among people with serious mental illness (SMI), positioning it as a key issue to be confronted by community mental health systems and practitioners. The paper reviews three perspectives on poverty, considering how each sheds light on poverty among people with SMI, and their implications for action: (a) monetary resources, (b) basic needs, and (c) capabilities. The paper argues that community mental health programs and systems are currently unable to address poverty as they are overly focused on individual‐level interventions that, on their own, cannot raise people out of poverty. The paper calls for a social justice value, informed by the concept of citizenship, as a necessary complement to the recovery concept that has informed community mental health practice for almost 25 years. Finally, the paper argues that community psychologists, with their concepts, methods, and values, are well positioned to contribute to this important issue. However, it also contends that addressing poverty requires collaboration from community psychologists with researchers and practitioners from other fields and domains of expertise to begin to make progress.     

Dispositional and situational coping and mental health among Palestinian political ex-prisoners

We examined, first, differences in dispositional and situational coping, and psychological distress between political ex-prisoners and their matched controls, and second, coping effectiveness in protecting mental health from impacts of imprisonment and military trauma. Thirdly, we tested the hypothesis that compatibility ("goodness of fit") between dispositional and situational coping would predict low psychological distress. Participants were 184 men recruited from a Palestinian community sample, 92 were former political prisoners and 92 non-prisoners. The dispositional coping was assessed as a general response style to hypothetical stressors and situational coping as responses to their own traumatic experiences. Psychological distress was measured by SCL-90-R, and posttraumatic stress disorder, depression and somatoform symptoms by scales based on CIDI 2.1 diagnostic interview. The results showed that, compared to non-prisoners, the political ex-prisoners employed less avoidant, denying, and emotion-focused coping strategies. Military trauma was associated with avoidant and denying coping only among non-prisoners. The ex-prisoners showed more mental health and medical problems, especially when exposed to military trauma. None of the coping styles or strategies were effective in protecting the mental health in general or in either groups. However, main effect results revealed that the high level of active and constructive and low level of emotion-focused coping were associated with low levels of psychiatric symptoms and psychological distress.     

Understanding the Relationship between Poverty and Children’s Mental Health in Poverty-Stricken Area of China: Social Causation or Social Selection?

This study aimed to explore the relationship between poverty and children’s mental health in the social context of China. Data were consisted of 1314 children, which were collected with a multi-stage cluster random sampling method in Xiushui, a typical poverty city in China. Structural equation modeling was adopted to test the hypothesized model. Results showed that both social causation model and social selection model could explain the relationship between poverty and children’s mental health in Mainland China. The implications of these findings on theory and social work services were also discussed.     

Poverty, Inequality, And Discrimination As Sources Of Depression Among U.S. Women

Poverty, inequality, and discrimination endanger women's well-being. Poverty is one of the most consistent predictors of depression in women, probably because it imposes considerable stress while attacking many potential sources of social support. Economic inequalities within societies are associated with reduced life expectancy and a variety of negative physical health outcomes. Parallel research on economic inequalities and depression has just begun. Discrimination maintains inequalities, condemns women to lives of lessened economic security, and exposes them to unmerited contempt. Although the mental health impact of poverty is documented and largely understood, the implications of inequality and discrimination are less well known. Much important work remains to be done, particularly research that connects individuals' mental health to ecological characteristics of the communities and societies in which they live.     

Mental health needs of the chronically mentally ill elderly

The treatment histories and current social, financial, and clinical status of 111 chronically mentally ill (CMI) persons over the age of 60 were examined. Information was obtained from Ss, family, mental health records, and mental health professionals familiar with Ss. Psychiatric symptoms were observed in 74% of Ss. Many Ss experienced long periods without acute episodes of illness. Recurring episodes eventually appeared in most Ss, however, and ongoing deficits in daily functioning and social contacts were prototypical. Two thirds of the Ss were living in the community, relying heavily on family contacts; the rest lived primarily in nursing homes (23.4%) or psychiatric hospitals (7.2%). Social support was the best predictor of level of functioning. Findings suggest that failure of CMI elderly to use mental health services is not due to lack of need. Mental health services currently do not appear to be meeting the needs of this population.     

Addressing the Challenge of Community Reentry Among Released Inmates with Serious Mental Illness

The purpose of the paper is to discuss the formidable challenges to community reentry and reintegration faced by U.S. prison inmates with serious mental illness and to describe various strategies for improving transitional services for these individuals. We review epidemiologic data supporting the high prevalence of severe mental illness in U.S. prisons as well as the historical factors underlying the criminalization of the mentally ill. The importance and challenges of providing adequate psychiatric care for mentally ill prisoners during their incarceration are discussed. We also review the numerous psychosocial and economic challenges confronting these individuals upon their release from prison, such as unemployment and vulnerability to homelessness, as well as specific barriers they may encounter in attempting to access community-based mental health services. We follow with a discussion of some of the more promising strategies for improving the transition of the mentally ill from prison to the community. In the final sections, we review the evidence for a relationship between serious mental illness and recidivism and briefly discuss emerging alternatives to incarceration of the mentally ill.     

贫困对儿童心理健康的影响及其内在机制

儿童贫困问题是世界范围内的一个重大公共卫生问题。近几十年来,国内外的研究发现贫困对儿童的消极心理健康状态和积极心理健康状态均会产生影响。研究者试图从家庭和社会两个层面来解释贫困对儿童心理健康的影响,以揭示其内在影响机制。未来的研究应加强贫困儿童心理健康发展过程中的保护因素研究,探索儿童期贫困对个体心理健康的长期影响及其成因,进一步在我国社会文化背景下开展本土化研究,为实践上的预防和干预提供帮助。     

Koran reading and negotiation with jinn: strategies to deal with mental ill health among Swedish Somalis

In this paper, we discuss traditional Somali concepts of mental ill health. Qualitative interviews were conducted with some 20 Swedish Somali interviewees about factors causing mental ill health, traditional classification, strategies to deal with mental ill health, and attitudes to the mental health care services in Sweden. Social mobilisation and religious healing are cornerstones of traditional Somali measures to deal with mental suffering. Traditional Somali views of mental ill health stand in stark contrast to classification of mental ill health in the western biomedical model. These views deserve attention since they may have an impact on health-seeking behaviour among Somali immigrants in western countries. Yet a too strong focus on cultural aspects may over-shadow the fact that much mental suffering among Somali migrants must be understood within social, economic, and political contexts.     

Indigenous Healing Practices in Australia

ABSTRACT

Indigenous Australian women are among the most disadvantaged women in the world. Over two centuries of colonization have had a damaging impact on perceptions of their gender roles and status as well as many other consequential oppressions. These experiences have affected the social and emotional wellbeing of Indigenous women of all ages, resulting in socio-economic ghettoization, higher suicide rates, psychological distress, illness, and poverty. Generations of women have experienced the forced removal of their children, resulting in complex forms of historical trauma. Despite this, Indigenous women have also maintained strong leadership roles and have kept families and communities intact. In the last few decades, the Australian Indigenous mental health movement has emerged within the context of a broader self-determination movement, restoring and strengthening women’s traditional therapeutic practices. This article offers an overview of the social and emotional wellbeing of Indigenous women within neocolonial Australia and explores women’s relationship to traditional therapeutic practices. Future directions and key issues for the capacity building of Indigenous women’s healing are explored.     

From the Editors

This article examines the relationship between global poverty and terrorism. The approach is built around a concept of ‘social bandit’ developed by Eric Hobsbawm. By social bandits, Hobsbawm refers to those outlaws in pre-capitalist societies who robbed the rich, and gave (at least some of their loot) to the poor. What was common to social bandits is a myth that surrounded their activity, and a strong popular sympathy and support. This article uses Hobsbawm's notion of social bandit to deal with the fact that in today's international setting, particularly in the context of huge international inequality and widespread poverty in the non-western world, violence against western states, particularly the United States, enjoys significant sympathy elsewhere. This is not only an outcome of inequality and has to do with other factors, particularly certain political or military actions of the USA and other western states, but what is important to note here is that violence perpetrated by terrorists is directed at those who are seen as beneficiaries of the existing order, of international inequalities and injustices. In short, the operation of the international order, its asymmetries and inequalities, riches and wealth in developed countries and poverty and misery elsewhere, seems to play a role in the creation of such social bandits, and in providing them with support and legitimacy which they otherwise would not have had.     

Beliefs About Poverty and Inequality: Du Bois and Ethnic Differences Among Catholics

Poverty is among the most challenging social problems in the United States today, and beliefs about the government's role in reducing inequality and raising living standards for the poor are critical to alleviating poverty and its consequences. Du Bois recognized the complex challenges associated with poverty and was ahead of his time in pointing to ethnicity and religion as fundamental to creating change and alleviating poverty. Du Bois’ ideas continue to be relevant today, including for understanding ethnic differences among Catholics in attitudes toward poverty, which are likely changing given the growth of the Latino population. In the spirit of Du Bois’ seminal research, I compare Latino and non-Latino Catholic attitudes toward poverty and inequality using the 2021 General Social Survey. Findings document critical differences among Catholics in beliefs about poverty and inequality and highlight the interdependent role of religion, ethnicity, and demographics (e.g., age, gender, socioeconomic status [SES]) in shaping attitudes.     

Risk and resilience: The moderating role of social coping for maternal mental health in a setting of political conflict

Violence can threaten individual wellbeing and tear at the social fabric of communities. At the same time, suffering can mobilize social coping and mutual support. Thus, the backdrop of political violence increases risk factors and stimulates resilience. The current study examined the moderating role of social coping as reflective of risk and resiliency in Northern Ireland, a setting of protracted conflict. Specifically, structural equation modeling was used to investigate whether social coping protects from or exacerbates the negative impact of sectarian crime and nonsectarian crime on maternal mental health (N = 631). Nonsectarian crime predicted greater psychological distress for mothers in Belfast. Mixed support was found for the buffering and depletion moderation hypotheses; social coping functioned differently for nonsectarian crime and sectarian crime. Greater social coping buffered mothers’ psychological distress from the negative effects of nonsectarian crime, but exacerbated maternal mental health problems when facing sectarian crime. Results suggest that social coping is a complex phenomenon, particularly in settings of protracted political violence. Implications for interventions aimed at alleviating psychological distress by enhancing mothers’ social coping in contexts of intergroup conflict are discussed.     

China's importation of Western psychiatry: Cultural relativity and mental disorders

As one aspect of China's modernization, the importation of Western psychiatric ideas poses a mystery. How are such ideas integrated with traditional assumptions? The apparently wholesale adoption of Western psychiatric categories runs counter to the fact that the Chinese have been generally reluctant to define problems in highly individualized psychiatric terms. Our lack of knowledge as to how the Chinese and Western medical models interface raises questions about the cross-cultural applicability of psychiatric theory. Ironically, the very conceptual categories intended to facilitate professional discourse obscure cultural, political, and epistemological differences between Chinese and Western thought. This paper focuses on certain incongruities in psychiatric theory and practice in order to underscore many unresolved issues that still exist with respect to our cross-cultural understandings of ‘mental illness’. Insofar as the trend has been towards standardizing methodology, taxonomies have been generated without a corresponding development in textured comparison. Originating from Western theoretical frameworks, comparative analyses have been otherwise devoid of culture-specific knowledge. The goal of this paper is to show that these categorical assumptions are still premature, and that examining the meaning of current ‘rates of mental illness’ in China specifically raises more questions than it answers. Hopefully, this discussion will stimulate a renewed interest in ethnographic methods that would uncover locally-based understandings and thereby create the basis for a more sophisticated epidemiological comparison.     

Le burn-out est-il une entité nosographique distincte ?

Although it has largely been studied since the 1970s, it remains controversial to accurately define what the concept of burnout encompasses. Indeed, burnout is not consensually defined and, although some consider that it is a work-related illness, there is no clear diagnostic criteria. This problem is intensified by the fact that some studies present methodological limitations, thus impeding an appropriate characterization of burnout. As a consequence of this lack of agreement, burnout is not acknowledged as a work-related illness, which minimizes the pain of those individuals who are suffering from it. The present paper will review findings that can help to disentangle whether burnout should be considered as a medical diagnosis. Cultural differences concerning the consideration of burnout as a medical condition will be pointed out and the distinctiveness of burnout compared to depression, adjustment disorder or other stress related symptoms will be highlighted. Moreover, we will explain why considering that burnout belongs to broader diagnostic categories implies that the weight of employees’ discomfort mainly relies on personal causes and therefore weakens the role of existing working conditions. This paper will also summarize clinical, psychological and biological evidences for and against the inclusion of burnout as a medical condition, before embedding them in a wider social, political and economic context. More specifically, we will explain why burnout is intimately related to the political and economic situation of a country: when society promotes cost-effectiveness, it increases stress and psychological pressure, which makes a burnout more likely to appear. Furthermore, if burnout is recognized as a work-related disease, the consequences for organizations will be that they will have to pay for additional health care charges. Finally, more effective prevention techniques could be developed, and more appropriate care could be provided to patients, but only if an agreement on diagnostic criteria was obtained and if reliable assessment tools were developed. As long as these issues are not addressed, treatments specifically targeting burnout symptoms will be further delayed although it is a serious clinical condition associated with physical and psychological symptoms impairing patients’ quality of life. In conclusion, we suggest that burnout should be considered as a medical condition despite the economic and political impediments. Nevertheless, up to now, several methodological limitations preclude to reliably establish a pathological cut-off and to delineate burnout from other mental illnesses.     

Negative social interactions,distress, and depression among those caring for a seriously and persistently mentally III relative

Investigated both positive and negative social interactions and their effect on mental health for 106 individuals caring for a seriously mentally ill family member. Results from mixed-model (hierarchial and stepwise) multiple regression analyses in which caregiver age, socioeconomic status, caregiving demand, and severity of patient symptoms was controlled showed that negative social interaction accounted for a significant portion of variance in the caregivers' feelings of distress and depression. Moderated multiple regression analyses showed that under conditions of high negative interaction, the relationship between demand and distress was intensified. Implications of these findings for the conceptualization and measurement of negative social interaction as well as its clinical implications were discussed. The research for this paper was supported by funds from the Provost's office, University of Pittsburgh, School of Social Work. The authors thank the Pennsylvania Alliance for the Mentally Ill for their support of, and participation in, the study.