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Geography of Mental Health
• Where are mental health patients located?
• What are the attitudes of the community towards the
mentally ill and mental health facilities?
• Policies of deinstitutionalization – what is the public’s
reaction?
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Geography of Mental Health
• In 1866, Edward Jarvis noted that mental hospitals
were “much more local in their usefulness‘” than
they were intended to be
• “Jarvis's Law”, as it came to be known, postulated
that distance from a mental hospital predicted
utilization.
• In district after district, the farther the distance
from the hospital, the lower the utilization.
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Geography of Mental Health …
• For example over a 23 year period in Oneida
County in the District of New York, the
geographic area closest to the hospital sent an
average of 1 patient for every 2,772 residents.
– second closest district, the ratio was 1 in 5,820
– third closest it was 1 in 7,351,
– in the farthest district it was 1 in 11,535.
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Geography of Mental Health …
• Jarvis concluded that distance counts.
• Patients are hospitalized in direct proportion to
their nearness to the institution.
• Secondly, the closer individuals were to
transportation corridors, the higher the hospital
utilization.
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Geography of Mental Health …
• Counties that were situated along the course of
rivers, canals, or roads leading directly to the
hospitals, sent proportionately more patients than
counties of equal distance but not within easy
access to transportation corridors.
• He understood the problem to be one of underutilization in remote areas and argued that large
and far-away regional hospitals should be replaced
by smaller local hospitals located in the very midst
of the populations they were intended to serve.
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Geography of Mental Health …
• Jarvis's Law has been replicated numerous times
and been found to apply to both inpatient and
outpatient care settings
• The generalizability of this finding across different
treatment locations suggests that distance-decay
factors should be a key consideration when
determining the placement of mental health
services or facilities
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Social ecology of mental disorders
• By charting the place of residence of persons
admitted to hospital for psychiatric evaluation or
treatment in large US cities, Farris and Dunham
(1960) identified what came to be known as a
“typical ecological distribution” or gradient of
mental disorders.
• The highest rates were found in the city centers
and the lowest in the suburban areas.
• This gradient was subsequently replicated in
Europe and in the United States.
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Social ecology of mental disorders
• These studies generated a broad range of possible
explanations
– Social selection (though migration or infant
mortality);
– Geographic variability in the definitions of
mental illness (bias);
– Social support or the lack of capacity of some
households to maintain the mentally ill without
public assistance; and
– Social causation, both the direct and indirect
effects of the living environment on mental
health.
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A Global Understanding of Mental Health
• Globalization has meant that concepts of mental
health are now increasingly applied across borders
and cultures.
• The World Health Organization (WHO) developed
the International Classification of Diseases (ICD-10),
which, also indicated that culture plays a
significant role in the manifestation, treatment,
and course of psychiatric disorders.
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A Global Understanding of Mental Health
• Many people have challenged the prevailing diagnostic
system, claiming it is too based in the culture and
values of the West.
• Given the extent to which understanding of behavior is
mediated by cultural norms, it is not surprising that
psychopathology, which manifests itself
behaviorally, must be to some extent contingent on
cultural forces.
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A Global Understanding of Mental
Health…
• It is the interaction between universal biological
aspects of psychiatric disorders and contextual cultural
forces that creates the challenge in understanding and
treating them.
11
Cultural beliefs and practices impact the
recovery of people with mental illness
• What society considers a healthy and meaningful life
is inextricably bound up with cultural values and
belief systems.
• For people with psychiatric disabilities, while they
may share diagnoses with people from different
cultures, how they manifest and respond varies
considerably.
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A comparison of psychosocial rehabilitation
of mental illness in India and the US
• Stanhope, 2002
• Whereas the West has generated much of the
theoretical and clinical knowledge about psychiatric
disorders, there have not always been corresponding
good outcomes for people with psychiatric disabilities
in these countries.
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A comparison of India and the US…
• In fact, the developing countries with far less
resources and services, have often produced better
prognoses for those with disorders such as
schizophrenia.
• So what role has culture played in the treatment
and rehabilitation of people with psychiatric
disabilities?
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India vs. US
• Significant factors in caring for people
with psychiatric disabilities in India
– an emphasis on interdependence,
– externalized locus of control
– family involvement
• Significant factors in caring for people
with psychiatric disabilities in US
– focus upon independence
– individual productivity.
15
India vs. US…
• Prevalence Rates of Psychiatric Disorders in
India and United States
• It is estimated that 10 to 30% of the population in
India have a psychiatric disorder at some point in
their life
• Hence, India experiences psychiatric disorders
among its population at similar rates to Western
countries including US
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India vs. US…
• However, beyond incidence, differences in
manifestation and prognosis rates indicate that
culture is a significant determining factor.
• Indigenous understanding of psychiatric disorders,
help-seeking behaviors, available services, social
structures, and rehabilitation strategies all combine
to shape the course of psychiatric disorders.
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Help-Seeking Behaviors: India vs. US
• Help-seeking behaviors in India are dictated as
much by community perception and beliefs about
the nature of a psychiatric disorder as by resources
and availability of services.
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Help-Seeking Behaviors: India vs. US …
• In a study of 300 patients with psychiatric disorders,
55% attributed their psychiatric disorders to
supernatural forces including ghosts, evil spirits,
and witchcraft, and chose to consult traditional
healers before seeking mental health services
• In rural areas with populations of lower socioeconomic status, studies have found that up to 80%
of people who have psychiatric disorders seek help
from healers rather than physicians
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Help-Seeking Behaviors: India vs. US…
• However, there is also a pragmatic side to many of
the help-seeking behaviors among Indian
communities.
• Although traditional healers are the first care choice,
if symptoms are acute and persistent, alternative
services including modern medicine will be pursued.
• And there is often a close relationship between
modern medicine and traditional healing systems in
India.
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Prognosis for People with Psychiatric
Disabilities in Developing Countries
• The shortage of psychosocial rehabilitation
facilities in India leaves many people with
psychiatric disabilities, especially in rural areas,
without access to services.
• And those with access to services often do not
choose to utilize them due to discrimination and
alternative beliefs about the nature of psychiatric
disorders.
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Prognosis for People with Psychiatric
Disabilities in Developing Countries …
• However, despite large numbers of people with
psychiatric disabilities being untreated, studies have
found better prognoses for people with psychiatric
disabilities in India and other developing countries.
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Prognosis for People with Psychiatric
Disabilities in Developing Countries …
• Example:
• The International Pilot Study of Schizophrenia was a
WHO sponsored study to investigate if similar
symptom clusters for schizophrenia occurred in
differing areas of the world.
• While incidence rates were found to be comparable
throughout the world, follow-up studies revealed
that outcomes for schizophrenia were significantly
better in the developing countries
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Prognosis for People with Psychiatric
Disabilities in Developing Countries …
• With 51% showing good outcomes in India as
compared with 7% in Russia and 6% in Denmark
(WHO, 1979).
• Subsequent studies, such as the Determinants of
Outcome of Severe Mental Disorders have confirmed
the findings that outcomes for people with psychiatric
disabilities are more favorable in developing countries.
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Prognosis for People with Psychiatric
Disabilities in Developing Countries …
• Patients in developing countries experience a more
benign course or remission from psychiatric
disorders at almost twice the rate as those in the
industrialized countries (Warner, 1994).
• These unexpected findings strongly indicate that
cultural context is a major factor in the course of
psychiatric disorders.
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Prognosis for People with Psychiatric
Disabilities in Developing Countries …
• They also raise questions about the appropriateness of
developing countries basing their models of mental
health care on theory and practices generated by
the West.
• Instead, exploring the role of culture as a mediating
factor in the course of psychiatric disorders has the
potential to improve our understanding and practice in
the field of psychosocial rehabilitation.
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Role of Cultural Beliefs and Values
• Belief systems play a large role in the formulation and
outcome of the rehabilitation process
• Some have argued that just the adoption of western
diagnostic interpretations of psychiatric disorders in
India has negatively impacted prognosis for
psychiatric disorders.
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Role of Cultural Beliefs and Values …
• Indian healing systems have always recognized and
treated acute short psychotic episodes, but now the
trend is to diagnose these conditions as schizophrenia
• The labeling process has brought with it all the
discrimination and implied severity that surrounds
schizophrenia in the West.
• Therefore, better prognosis rates in India may be due
in part to bypassing the labeling process and, instead,
subsuming a psychiatric disorder and its symptoms
into ongoing social rituals, including indigenous
healing systems.
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Role of Cultural Beliefs and Values …
• The World Health Organization has now recognized
the strengths of integrating traditional healing into
systems of care for psychiatric disorders.
• Traditional healing methods provide a cultural
compatible, holistic approach, strong therapeutic
alliance, and close connections with family and
community (WHO, 1994).
• Another important element is the approachability of
indigenous healers.
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Role of Cultural Beliefs and Values …
• People seeking help are able to avoid the stigma of
seeking out a mental health professional by going to
their local healer.
• Stigma plays a significant role in the response of
Indian society to those with psychiatric disorders.
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The Role of Family
• A key part in the process of subsuming psychiatric
disorders within sociocultural settings is the role of the
family.
• The extent of family support for people with
psychiatric disabilities has often been cited as a major
factor in the rehabilitation process:
• Family support, which is so easily available in the
developing countries, is the anchor for treatment and
rehabilitation of the mentally ill in the outpatient
management
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The Role of Family …
• A family's tolerance for a psychiatric disorder, even
when symptoms are at their most acute, helps them
take on caregiving responsibilities.
• In developing countries, up to 90% of people with
psychiatric disabilities live with their families, whereas
in the industrialized countries it is only half this
number.
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The Role of Family …
• The existence of extended families and kinship
networks particularly helps the caregiving process.
• In a study of a tribal community, researchers described
how the strain of caring for a person with a psychiatric
disorder is absorbed by all clan members, who take
turns in providing social interaction and thereby
reducing the burden on individual family members.
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The Role of Family …
• The existence of extended family and kinship
networks can serve as an important buffering
mechanism both for the person with a mental illness
and their caregivers.
• When a family does seek care for a relative with a
psychiatric disorder, be it through a healer or mental
health professional, members are usually highly
involved in this treatment.
34
The Role of Family …
• The healer will be familiar with the family and a part
of the community, and the whole family will be
expected to be involved in care.
• This expectation is in contrast to Western models of
care, which, in the treatment of schizophrenia in
particular, are still tainted by theories purporting that
psychogenic families cause psychiatric disorders.
35
The Role of Family …
• Often, therapists perceive their role as empowering
people so they can separate from a dysfunctional
family, rather than facilitating transition back to the
family.
• Even if the family is seen as functional, promotion of
independent living is a common treatment goal.
• Mental health services in India, both inpatient and
outpatient, not only encourage family involvement, but
also often make it a prerequisite of care.
36
Independence vs. Interdependence
• Despite better access to services and a high level of
professionalization in community mental health
systems in the industrialized countries, the
rehabilitation of those with psychiatric disabilities is
often undermined by cultural expectations of
independence and productivity.
• In contrast, the central goal for psychosocial
rehabilitation in India is interacting within a society
that stresses interdependence.
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Independence vs. Interdependence …
• Individual needs and goals are secondary to living
successfully within the family and community setting.
• This emphasis upon interdependence means that there
is more tolerance for a family member who needs
more supports.
• The family member requiring extra support does not
find this dependent role alien and threatening.
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Independence vs. Interdependence …
• In the industrialized countries, the profound selfdisorganization and ensuing loss of independence that
is associated with onset of a psychiatric disorder is
especially devastating for adults (Lefley, 1999).
• Western notions of identity are very much based on the
ability to be independent, to pursue individual goals,
and to have a sense of control over one's environment.
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Independence vs. Interdependence …
• The transition from this to a more paternal form of
care is extremely stressful for those seeking services in
the West, as it indicates to the person a significant
decrease in status.
• Personhood, a concept which includes self-mastery,
dignity, self-respect, and self-esteem, has becomes an
increasingly important goal in psychosocial
rehabilitation services in the United States.
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Changing Cultural Contexts
• Cultural arrangements and values are not constant.
• Such is the case in India and other developing
countries.
• It is not clear that Indian society can continue to
sustain this model of familial care or that it can be
replicated in the West.
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Changing Cultural Contexts …
• But more significant is the fact that joint families are
becoming less and less frequent in India, especially in
urban areas.
• Some view this shift to more "modern" family
arrangements as indicative of increased focus on
individual rather than communal needs.
• Nuclear families living in urban areas with both
partners employed full-time face the same challenges
and dilemmas as many families in the West when it
comes to caring for people with psychiatric
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disabilities.