>> So I said, as I said, we are going to be talking about one of your assigned readings, social determinants of health among internally displaced persons in Northern Uganda. And I'm using this as an example of intersections between culture and mental health practice in the global context. So the first think you need to know is a bit of context about international mental health. There have been, unfortunately, many incidents in recent years where there have been populations dealing with natural disasters, man-made disasters, war, conflict, genocide, all kinds of things. And now it's very common for there to be international responses to this. So people will be sent over from Canada, for example, the U.S., the U.K., all kinds of other countries to go in and do relief work, and some of that work is to deal with mental health issues. So one of the things that they found out pretty quickly was they went over there and they thought, well these people have obviously been through a trauma, so what we need to do is get in there and deal with their post traumatic stress disorder. And so they came in armed with cognitive behavioral therapy and discovered that actually the people they were seeing did not look like they had post traumatic stress disorder, and those interventions were not very helpful to them. And what I think people have come to understand and have become better at doing is, is finding ways to, to collaborate with existing services and, and ways of healing within these contexts. And really people are putting a lot of work into trying to understand what are appropriate interventions in these circumstances and how can we collaborate more effectively with local people. And a lot of the international relief work you see now is to try to support local and indigenous strengths and resources as part of building sustainable responses to these kinds of natural disasters and other things. So, in this paper it's a research paper. So I'm just going to take a minute talking about the research because I know not all of you will necessarily be familiar with, with what they're describing. So the team that went in conducted qualitative interviews. And qualitative interviews are interviews where people are not using a questionnaire per se. What they're doing is interviewing people in a more conversational way about things that are going on in their lives. So there are particular areas that they want to cover, and here you see that they had started with hol, this holistic definition of health. What they wanted to do was talk to people about what had happened to them, what they understood to be health, and how, how these things had, had an impact on it, and then also what they were doing. So the, so they did these interviews with I think about 21 people. I wrote that down somewhere. Don't have it here that, where they asked them about these issues. The article reveals the following social determinants of health for internationally, sorry, internally displaced persons in Uganda. I'm hoping you recognize that we've talked about these in our lecture on social determinants. They are largely issues that are located in the social context, with some that you could also identify as being part of the environmental context. These are commonly issues that you see facing populations in the aftermath of war, disaster, civil unrest. And I'm sure you won't be surprised that they are associated with the development of both physical and mental health problems. Certainly from a social determinants perspective, they, they seriously undermine people's physical and mental health. So this article through its use of qualitative interviewing gives us a glimpse into what are the idioms of distress in this context. I've mentioned idioms of distress a few times in this lecture, and I apologize because I don't think I've given them a proper definition before now. Idioms of distress refers to the specific ways that people express the distress, distressing feelings that they're having. And these are always terms and ways of behaving that make sense within their specific context. And that might be a cultural context, but that also can be a family context, a professional context, basically within any kind of, you know, social environment they're in. This is the way that people express this type of distress. For the people interviewed in Uganda, the idioms of distress that were described included overthinking, madness, and physical sickness, and of course we have to bear in mind that in trying to communicate this to us as an English language audience, these may not, these are undoubtedly not the precise terms that people used, but this is how they've been translated. So overthinking seems to refer to sadness, rumination, and obsessive thoughts that we would probably associate with depression. Madness seems to refer to post trauma effects, although in this context, there was the additional and very specific component of being affected by the presence of vengeful ghosts and spirits. And certainly if you consider that part of this conflict involved people being involved in the killing of other people in the community, that makes sense. And then finally, the physical sickness that they described was recognized as being a physical manifestation of the social and emotional pain that many of them were experiencing. There were also some indigenous components of this experience that are not as easily translated into North American idioms. Because these were people who had worked the land for their livelihood and survival, the separation from the land was an important component of their suffering. It had tangible consequences in terms of not having any resources and living in poverty, but it also had emotional consequences, because separation from the land made people feel unwell, inadequate, and negative about themselves. Another indigenous component was the rendering of the social fabric. The loss of people in the community and the aftermath of an experience in which people once known to you became people who could harm or kill you was that the social connections that had once been in place were broken. Without that community in place, without that social fabric intact, people felt lost and unsupported, and this had consequences for mental health as well. I'm hoping that as you think about this, it's reminding you of the indigenous approaches to mental health that were described in an earlier segment. Clearly the loss of connections between individuals, families, communities, and nature were causing high levels of, of distress among the survivors of this conflict. So because we've been talking earlier about what is universal versus indigenous in our understandings in mental health, I've created a table here where we can look at what is described by these displaced perpens, persons in Uganda and how it corresponds to what we in North America would call a post traumatic stress experience. Clearly there are points of overlap, ways in which we can take the idioms of distress in Uganda and translate them into idioms of distress that we see in North America. But there are other places where there is not a correspondence, and it may be that these reflect the influence of culture-specific elements. Although the experiences that trigger these reactions could be similar, they are interpreted through a cultural matrix that makes them manifest differently, in different cultural contexts. Another thing we learned from this paper is that it is possible to merge the indigenous with other modes of helping to promote mental health. The people interviewed talked about their use of doctors, counselors, healers, religion, family and friends, and at times isolation to engage in healing. Here we see a real demonstration of the way in which a biopsychosocial approach to mental health can work. And we see additional dimensions of spiritual and cultural that can be part of the healing process. In our last segment, we are going to try to bring these things together to think about how an understanding of the intersections between culture, mental health, and mental illness might influence the way we think about providing care in multicultural contexts like North America, and the U.K., and the U.S., and so many other places.
