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Community and Social Psychiatry. Biopsychosocial Model S tudies the forces which act at the interface between the individual and those around him. Pertains to the individual and his social environment. Concerned with the relationship between disorders of the mind and the social environment.
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Community and Social Psychiatry • BiopsychosocialModel • Studies the forces which act at the interface between the individual and those around him. • Pertains to the individual and his social environment. • Concerned with the relationship between disorders of the mind and the social environment.
The term “social” has two levels: • MACRO, which refers to the attributes of society at large which affects the person (e.g., social cohesion, social support). • MICRO, which refers to the person and his immediate social environment of relationships (e.g., family, friends).
Social Psychiatry looks at the interaction of clinical and social events. • Utilizes the application of relevant data from social sciences to psychiatry.
Life Events • Ascertaining life events is important to the field of Social Psychiatry.
Life Events: Childhood Separation • Separation or threatened separation from the mother leads to distress in child at the time and causes intrapsychicchages which may predispose to depression or abnormal personality in adulthood. • “Actual death of a parent does not cause lasting harm – it is the inadequate mothering subsequent to the loss” (Birchnell). • Relation to the Patient: Guevara was largely separated from her parents, who were very busy during her critical years (0-7 years), developed insecure attachment, characterized by anxiety, abivalence, and possessiveness.
Life Events: Parental Style • The method of caring that a parent uses. • Parenting styles that can lead to psychopathology include persistent unresponsiveness to and rejection of the child, discontinuities of parenting, persistent threats to abandon a child, threats to desert or kill the other parent or to commit suicide, and inducing a child to feel guilty as a means of controlling behavior. • Authoritarian: children are expected to follow the strict rules established by the parents = Obedient and proficient children. • Authoritative : establish rules and guidelines that their children are expected to follow. But parents are responsive to their children and willing to listen to questions = Happy, capable, successful. • Permissive: rarely discipline their children because they have relatively low expectations of maturity and self-control = Problems in self-regulation and happiness. • Uninvolved: characterized by few demands, low responsiveness and little communication= Lack self control, self discipline.
Life Events: Adverse Life Events • Consists of emotionally distressing life experiences, such as separation of parents, persecution, or abuse. • “Clusters of illness most often appear when a person is having difficulty adapting to his environment as perceived by him” (Hinkle and Wolff) • Explains why some people are able to stand up after a major defeat, while others fall into deep depression. • “There is a link between losses and onset of depression and between threatening states and anxiety” (Friday-Jones and Brown, 1981).
Life Events: Adverse Life Events • Disasters, such as combats, rapes, assaults, ad severe vehicular accidents can contribute to the development of Post-Traumatic Stress Disorder. • How does one stay well under adversity? • Some people have an initial underlying strength. • Resilient people. • Some people have a helpful environment after the experience. • People who have helpful family members and friends. • Many people who undergo a great crisis tend to have a higher level of equilibrium. As such, disasters usually “make or break” a person.
Life Events: Bereavement • Death of spouse, child, or parent are among the most stressful life events. • The “widower death phenomenon” – increase in mortality in men after the death of spouse. • “The results are consistent with the hypothesis that excess mortality after the death of a spouse is partly caused by stress. The loss of social support or the inability to cope with stress may explain why men suffer from bereavement more than do women.” (Martikainen and Valkonen, 1996) • Can be lessened by having a partner with whom one can share his or her feelings and stress. • “Then the servant told Isaac all he had done. Isaac brought her into the tent of his mother Sarah, and he married Rebekah. So she became his wife, and he loved her; and Isaac was comforted after his mother’s death.” (Genesis 24:66) • As much as 51% of couples separate after the death of a child. (Schiff, 1960). • In the patient, one event which helped precipitated changes in her persona would be bereavement from death of her grandfather, with whom she was very close.
Life Events: Unemployment • Defined as loss of salary, although it also inadvertently includes loss of belonging, self-esteem, and support systems. • But it also goes both ways. • Changing of jobs more often than usual is a premorbid sign of schizophrenia. • “Very low employment rates are not intrinsic to schizophrenia, but appear to reflect an interplay between the social and economic pressures that patients face, the labour market and psychological and social barriers to working. Barriers to getting employment include stigma,discrimination, fear of loss of benefits and a lack of appropriate professional help”. (Marwaha and Johnson, 2004).
Life Events: Migration • A series of moving, adapting, and eventually acculturating to a new society. • People who abandon their native culture but fail to be assimilated or acculturated in the host culture lose their sense of identity and purpose in life, and are at high risk for suicide, substance abuse, and alcoholism. • Patient experienced migration stress when she lived for some time in the USA, and somehow also when she had to live their palatial home and move to a simpler house.
Life Events: Migration • “The overall findings suggest that immigrants who experience elevated levels of acculturative stress may be "at risk" for experiencing high levels of anxiety and depression. The findings highlight the importance of establishing prevention and treatment services for migrants that aim to increase levels of emotional support, self-esteem, and coping skills.” (Hovey, Magana, 2000). • “Elevated acculturative stress, low self-esteem, ineffective social support, lack of control and choice in living a migrant farmworker lifestyle, low religiosity, and high education were significantly related to high anxiety.” (Hovey, Magana, 2002).
Life Events: Social Support • Beneficial elements, such as human relationships, from the environment, which typically have a protective effect against adversity. • Social Support by itself represents attachment, opportunity for nurturing others, reassurance of personal worth, sense of reliable alliance, obtaining help and guidance from others I facing difficulties, and social integration.
Life Events: Social Support • “Functional social support can be described as emotional (i.e., caring, esteem, etc.) or instrumental (i.e., informational, tangible) support. As expected, many situations that were instrumental in descriptive terms were emotional in terms of meaning; the reverse occurred very seldom. This effect was confined to "private" interactions (i.e. interactions involving family and friends), whereas instrumental behaviors of medical professionals were largely instrumental in meaning as well. Results underscore the importance of giving instrumental support in a way that communicates care and esteem.” (Semmer, Effering, et.al., 2008).
Life Events: Social Support • “Results indicated that general social support was most predictive of depression and life satisfaction, whereas sexuality-specific support was most predictive of internalized binegativity. Both family support and friend support contributed to the prediction of each of the outcome variables. Although it was expected that the link between friend support and positive adjustment would be strongest at low levels of family support, none of the interactions between friend and family support was statistically significant.” (Sheets, Mohr, 2009).
