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© 2012 Elsevier Masson SAS. All rights reserved. European Psychiatry 27 (2012) / supplement n°2 / S44-S49 Explanatory models and concepts of West African Malian patients with psychotic symptoms F. Napo a,b *, A. Heinz a , A. Auckenthaler b a Department of Psychiatry and Psychotherapy, Charité – Berlin, Germany b Department of Clinical Psychology and Psychotherapy, Freie Universität Berlin, Germany Keywords: Transcultural psychology Illness concepts West African patients Schizophrenia Migration Psychotic symptoms Explanatory models Community psychology 1. Introduction ABSTRACT Subjective illness concepts can be defi ned as opinions, interpretations, explications and predictions regarding factors that impair a person’s health [26,21]. They refl ect the patients beliefs about the constitution, aetiology, the expected duration and treatment of their individual health problem, and their disease- related emotions [4,25]. In the European context, Leventhal and colleagues developed a “processual Common- Sense- Model”, * Corresponding Author. E-mail address: fnapo@zedat.fu- berlin.de (F. Napo) Proofs 68767 EUROPEAN PSYCHIATRY THE JOURNAL OF THE EUROPEAN PSYCHIATRIC ASSOCIATION ISSN 0924-9338 June 2012 Vol. 27 - Supplement n°2 pp. S1-S81 Migration and Mental Health S1 Editorial A. Heinz, U. Kluge S4 The willingness to participate in health research studies of individuals with Turkish migration backgrounds: barriers and resources. A qualitative analysis of focus groups D. Dingoyan, H. Schulz, M. Mösko S10 Socio-economic status and emotional distress of female Turkish immigrants and native German women living in Berlin MC. Aichberger, Z. Bromand, A. Heredia Montesinos, S. Temur-Erman, A. Mundt, A. Heinz, MA. Rapp, M. Schouler-Ocak S17 Mental health of Turkish woman in Germany: resilience and risk factors Z. Bromand, S. Temur-Erman, R. Yesil, A. Heredia Montesinos, MC. Aichberger, D. Kleiber, M. Schouler-Ocak, A. Heinz, MC. Kastrup, MA. Rapp S22 The infl uence of stigma on depression, overall psychological distress, and somatization among female Turkish migrants A. Heredia Montesinos, MA. Rapp, S. Temur- Erman, A. Heinz, U. Hegerl, M. Schouler-Ocak S27 Translation and adaptation of the Zung Self-Rating Depression Scale for application in the bilingual Azerbaijani population F. Mammadova, M. Sultanov, A. Hajiyeva, M. Aichberger, A. Heinz S32 Construction and interpretation of self-related function and dysfunction in Intercultural Psychiatry A. Heinz, F. Bermpohl, M. Frank S44 Explanatory models and concepts of West African Malian patients with psychotic Symptoms F. Napo, A. Heinz, A. Auckenthaler S50 How to express mental health problems: turkish immigrants in Berlin compared to native Germans in Berlin and Turks in Istanbul A. Vardar, U. Kluge, S. Penka S56 Health services and the treatment of immigrants: data on service use, interpreting services and immigrant staff members in services across Europe U. Kluge, M. Bogic, W. Devillé, T. Greacen, M. Dauvrin, S. Dias, A. Gaddini, NK. Jensen, E. Ioannidi-Kapolou, R. Mertaniemi, R. Puipcinós i Riera, S. Sandhu, A. Sarvary, JFF. Soares, M. Stankunas, C. Straßmayr, M. Welbel, A. Heinz, S. Priebe S63 The German concept of “intercultural opening” as an answer to challenges of migration - the development of an assessment tool for the appraisal of its current implementation in the mental health care system S. Penka, U. Kluge, A. Vardar, T. Borde, D. Ingleby S 70 Cross-cultural training in mental health care – challenges and experiences from Sweden and Germany S. Bäärnhielm, M. Mösko S75 Teaching psychiatry and establishing psychosocial services – lessons from Afghanistan I. Missmahl, U. Kluge, Z. Bromand, A. Heinz S80 Afterword A. Kleinman Background.- Subjective explanations of illness concepts and disease can differ from culture to culture. We examined explanatory models of West African patients with schizophrenia in a communitycentred department of psychiatry in Mali, West Africa. Methods.- Patients and experts volunteered to be interviewed in the Department of Psychiatry of the University Hospital, Pont G, in Bamako, the capital of Mali. We used semi- structured interviews to explore key psychotic symptoms and explanatory models of psychosis in fi ve experts and fi fteen patients with schizophrenia. All interviews were analysed using computer assisted content- analysis with the program Atlas.ti. Results.- African patients displayed key symptoms of schizophrenia such as commenting and imperative voices, inserted thoughts and other phenomena of alien control, which were often subjectively explained as obsession by witches or jinns. Explanatory models differed depending on occidental migration experience and age. The involvement of family members in the treatmentsetting facilitates inclusion and recovery. Experts emphasized the need to integrate traditional and ethno- pharmacological approaches and modern medicine to treat their patients in a culture sensitive manner. Discussion.- Our data suggests a strong infl uence of illness concepts on the experience of psychotic symptoms, treatment expectations and health- related behaviour. © 2012 Elsevier Masson SAS. All rights reserved. which explains how expectations and experiences of the causes, symptoms and consequences of disease are infl uenced by subjective illness concepts. According to the model, illness signals are recognized and linked with mental representations. This association helps to create cognitive representations of a problem and is accompanied by specifi c emotions. They include the subjective view towards a patient’s illness symptoms, causes, consequences, duration of the illness, treatment effi cacy, personal infl uence and disease- related emotions [25]. Some authors suggest to use the theoretical concepts of “explanatory models” rather than “subjective illness” concepts, because the fi rst explicitly considers the sociocultural context and thus refl ects social and cultural differences in illness experience and explanation [3,19,20,21,32]. According 08_Napo.indd S44 14/06/2012 14:44:49
to Kleinman, explanatory models consist of the illness and disease concepts of a single person in a given illness episode in interaction with his/her cultural context and sociocultural environment (e.g. caregivers including experts, family members etc.). The research by Williams & Healy, 2001 [41] suggests to apply the term “explanatory map” as an alternative to “explanatory model”, because the term “map” refl ects the diversity and complexity that can be found in conceptions of illness and disease [41]. That implies that “explanatory models” do not consist of a coherent set of beliefs, but a multiplicity of illness and disease explanations constructed in specifi c sociocultural settings, which may be infl uenced by time and “historical development of traditional cultural knowledge” [33,4]. It has been suggested that the way patients feel to be understood and accepted in the process of treatment has an important infl uence on the compliance and the experience of therapeutic relationships [26,5,18,35]. Explanatory models and concepts also play an important role in terms of beliefs and estimations of the social consequences of a disease and the social role of a patient. This can include aspects of social stigmatisation and ideas about the participation of the patient in social life or the working environment [9]. In the African context, illness is very often regarded as a family affair, i.e. a collective experience of different subjects [32]. The infl uence of cultural knowledge (social rules, rituals, traditions, symbolisation, communication styles) and (collective) narratives thus plays an important role in the constructions of “explanatory models” or “explanatory maps”. Research on explanatory models of schizophrenia in Afríca is complicated by the history of psychiatric explanations of psychosis. For example, Bleuler termed the word “schizophrenia” when closely cooperating with Freud, and assumed that schizophrenic thought disorder refl ects a loss of evolutionarily higher cognitive functions and a return to a “primitive” mode of wishful (autistic) thinking that characterizes both children and “the Negro” (in singular! ) [2]. Bleuler suggested that ideas in the mind are normally connected in a logical way and this connection is enforced by the experience of ‘reality’. He claimed that a pathological destruction of the connections can lead into psychosis. If the logical connections between ideas are lost, the psyche splits up into incoherent ideas, and the only force which regulates their manifestation is desire. This split up of the mental process gave the disease its new name – schizophrenia [15]. During colonialism, Western psychiatrists claimed that healthy Africans resemble Europeans after lobotomy (a destruction of prefrontal cortex function), which was supposed to explain symptomatic differences in mental disorders between Europeans and Africans [6]. However, in the 1950ies and 60ies, the “race” concept was increasingly rejected, because it wrongly assumes categorical genetic differences between populations when indeed only gradual differences in allele frequencies are observed [27]. In psychiatry, Lambo showed that differences in psychotic symptoms in Nigerian patients are strongly infl uenced by their individual upbringing, with subjects from traditional backgrounds displaying mainly polymorphic psychoses and subjects with Westernized socialisations reporting “classical” key symptoms of schizophrenia such as certain acustic hallucinations or passivity phenomena [24,37]. Using such symptoms F. Napo et al. / European Psychiatry 27 (2012) / supplement n°2 / S44-S49 S45 as diagnostic criteria, the World Health Organization later observed comparable frequencies of schizophrenia in different countries around the world, including Nigeria [36]. While these data falsify hypothesis that suggest fundamental differences in mental disorders between Africans and Europeans, cultural and religious differences in e.g. concepts of “the soul”, “the self” or the existence of supernatural beings and their impact on human life and experience may cause profound differences in illness experience. Therefore, the goal of our study was 1) to assess key psychotic symptoms and explanatory models/maps of West African patients and their caregivers, and 2) to investigate how psychotic patients are treated in a Malian community- orientated psychiatric context. We tried to focus not only on symptoms and impairments but to also assess how salutogenetic resources of the patients are taken into consideration in local treatment settings [1]. 2. The setting Our investigation was based in the Department of Psychiatry of the University Hospital, Point G, in Bamako, Mali. The inpatient service is organized as a communal treatment setting. Since the 1980ies, a reform movement in Mali has focused on changing the classical view and associated stereotypes of psychiatric treatment [23]. This movement is interested in minimizing social stigmatisation and tries to give patients a voice to integrate the families into the therapeutic process, and to facilitate reintegration into society. The movement intends to overcome treatment models in which patients are isolated from their social reality, placed in the passive role of an “ill patient” and treated nearly exclusively with medication [23]. In 1984, the Ministry of Health developed treatment guidelines including the demand for an amelioration of treatment conditions. Since then, patients who are treated in the so- called “psychiatric village” at the University Hospital in Bamako are only admitted when accompanied by a family member [10]. The family and patients live together in small houses on the compound and they share the social reality of the patient during the whole therapeutic process. The patient and his/ her companion live together, cook together and sleep in the same house, similar to their home environment. The centre of the therapeutic village is the “Toguna”, a small round house where the experts hold clinical consultations with the patients and their families. The architecture of the small house has a therapeutic meaning: on the one hand the “Toguna” is constructed in a round form to include all professionals, relatives and patients during the consultation, and the “Toguna” has a very low ceiling. Thus, a person who becomes angry during the expert consultation is not able to stand up, which, in the experts’opinion, calms the anger of the person and suppresses aggression. A patient’s companion can play an important (salutogenic) role for the healing process. The family member who accompanies the patients during the whole therapeutic process acts as a mediator. The role of the mediator is to clear the way for the communication between the experiences of the patient and the socio- culturally constructed realities of the family members. Proofs 08_Napo.indd S45 14/06/2012 14:44:50
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Page 7 and 8: health of Turkish woman in Germany:
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Page 23 and 24: were then scrutinized independently
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Page 73 and 74: Acknowledgments We are very gratefu
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Page 85 and 86: Epilogue A. Kleinman Esther and Syd
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