Research and training of medical doctors in intercultural mental health care in rural Chiapas, Mexico

Ten years ago, the World Health Organization launched the mhGAP programme in order to improve mental health care in low-income countries through training of primary health care workers in management of the most prevalent mental health conditions. In 2014, an MTb edition was dedicated to this topic, and the main message was that, in order to be effective, the mhGAP programme needed to be adapted to local and cultural contexts.[2]

In Mexico, neuro-psychiatric diseases are responsible for most of the healthy life years lost due to disability. [3] However, although the country ratified the United Nation’s Convention on the Rights of People with Disabilities in 2007, no successful strategies have yet been implemented to improve mental health care services in rural settings.

In Chiapas, a southern Mexican state with more than 4 million inhabitants, there is only one ambulatory mental health care centre, situated in the capital city. Other than that, psychiatric care is concentrated in a few regional hospitals and the private sector. The Health Secretary recently organized a few mhGAP training sessions for primary health care workers. [4] However, in socio-culturally diverse Chiapas, where traditional healers are an important part of the local health care system, the challenge is to offer training that takes into consideration the large local variety of illness perceptions and healing practices.

Mental health research in hospital san carlos

Hospital San Carlos (HSC) is a rural, private, not-for-profit hospital in Chiapas that serves 80% of the indigenous population, principally Tzeltal speaking people of Mayan descent. [5] Mental health problems rank sixth in the list of most frequent diagnoses at the HSC outpatient clinic: mostly anxiety and depressive disorders.[6] In 2014, the hospital started a mental health project with the aim of providing primary mental care according to the mhGAP programme, including psychological and psychiatric services. Patients who present at the outpatient clinic and are referred to a psychologist or a psychiatrist are first seen by a general practitioner.

In an attempt to strengthen sociocultural understanding and communication during clinical encounters with mental health patients, we carried out a qualitative research study in 2017 on patient illness experiences. [7] Eight patients of Tzeltal origin were interviewed using the McGill Illness Narrative Interview (MINI) method, which has been validated for the Spanish language. [8] We also interviewed medical doctors working at HSC in order to obtain information about their perceptions of the illness experiences of their patients. To triangulate data, a focus group discussion was held with the medical doctors to discuss the results of the interviews. In addition, 20 randomly selected clinical encounters with mental health patients were observed. Our most important findings are presented below.

Understanding the patients’ suffering from a sociocultural perspective

Patients and medical doctors both stated that doctors often do not make the correct diagnosis. The doctors’ explanation for this is that, during medical consultations, Tzeltal speaking patients usually mention only their somatic condition. They rarely see a causal relation between physical symptoms and adverse life events which they may have experienced. Moreover, patients who suffer from mental disorders, which in local language may be called susto or nervios, believe they require costumbre* or need to visit a traditional healer. They consult a medical doctor only for the treatment of physical problems. From patient narratives, however, it became clear that mental suffering and somatic expressions are embedded in their social environment and can be understood as a way of coping with certain adverse social situations.

The two examples below illustrate some of the socio-cultural explanations cited by patients with mental disorders and make it clear that physical symptoms can be seen as an expression of social adversity.[9]

* Susto: illness caused by a traumatic experience, such as an accident, an attack by a dangerous animal, or near drowning
** Costumbre: ritual or religious actions undertaken in the community to treat and prevent disease, for example praying, using herbal teas, or rituals performed by a traditional healer

Juan, aged 28, homosexual and as a result not accepted by his family and community, battles with the question whether homosexuality is a disease or not. He says: ‘My head feels like a mill that twists me, and my blood jumps strongly. It is as if my veins where the blood passes are going to tear apart.’ Juan’s anxiety symptoms are an expression of suffering from his socially not accepted homosexuality. His symptoms also seem to be part of the ‘micro politics’ of his social interaction, as Juan presents them to his social surrounding as an explanation of his homosexuality as a disease that might be cured. [10]

Feliciano, who is 33 years of age, suffers from anxieties caused by uncertainty around his mother’s and his own condition and his search for remedies. His mother became sick and they searched for the right treatment for three years. ‘We went to see doctors who did not detect what the problem was. We went to herb healers, but my mother didn’t get cured. We only spent money. In a laboratory, they found out that she had typhoid: it gives high fever and she felt as if she would die. She took pills, but that didn’t help much. They gave her some injections, but then she got gastritis and an ulcer. It got very complicated. She stayed in the city while I was working on the field, but then I fell sick as well.’ Feliciano suffered a herpes infection of his eye. Although he visited several doctors, including an ophthalmologist, he lost vision in one eye. Then he started to present anxiety symptoms: fast heart beating and chest oppression. As his frustrations accumulated because of his failed attempts to find help, his anxiety problem worsened. His symptoms were an expression of his personal internal suffering, partly caused by the ineffectiveness of the local health care system. Feliciano’s condition can be seen as an expression of his interaction with his social surroundings.

Training of medical doctors in interculturalism

Standard medical anamnesis may inhibit a practitioners’ understanding of the patient, as illustrated in the following dialogue.

Doctor: ‘I’m going to ask you some quick questions in order to know you better: Do you have any allergies?’
Patient: ‘They have given me a medication for spots that I got, but I got nose bleeding.’
Doctor: ‘Were you ever operated on?’
Patient: ‘No.’
Doctor: ‘Do you take medication?’
Patient shows a bag full of medications and comments: ‘I have many body pains.’
Doctor: ‘Has something happened in your life?’
Patient hesitates in answering.
Doctor: ‘Now I will examine you.’

If medical doctors in the intercultural setting of Hospital San Carlos had a more open and holistic attitude towards patients’ expression of suffering, patients would be more open, allowing doctors to obtain a better understanding of their patients’ condition. A clinical consultation must therefore be based on the patient’s perceptions that include somatic aspects as well as emotional experiences. An integrative approach to body and mind needs to be established when evaluating the patient’s condition. A shift has to take place in mental health care as well as in general practice to see the body as a symbol system on an individual, social and cultural level. To achieve this, Hospital San Carlos has implemented a cultural training programme for medical doctors that consists of Tzeltal language classes, training in open question interview techniques, and knowledge building of local culture by the team of medical practitioners, based on the collection and review of patient narratives.

CO-AUTHOR
JOSE ENRIQUE EROZA SOLANA, MEDICAL ANTHROPOLOGIST CIESAS SURESTE (CENTRO DE ESTUDIOS SUPERIORES EN ANTROPOLOGIA SOCIAL), SAN CRISTÓBAL DE LAS CASAS, MEXICO

References

I. World Health Organization (Internet) mhGAP. Mental Health Gap Action Programme: scaling up care for mental, neurological and substance use disorders; 2008. Geneva. Available from: www.who.int/mental_health/mhgap/en/

2. Netherlands Society for Tropical Medicine and International Health. Medicus Tropicus bulletin. Global Mental Health. Research, treatment and current issues. 2014; 52-2.
3. World Health Organization (Internet) Global Health Observatory Data; 2015. Country profile of environmental burden of disease; Mexico. 2009. Available from: www.who.int/gho/countries/mex.pdf (accessed 8 February 2018)
4. Organización Panamericana de la Salud (Internet) Curso Taller de las guias mhGAP en Chiapas; 2014. Mexico. Available from: www.paho.org
5. www.hospitalsancarlos.org (accessed on 15 July 2018)
6. Health Statistics, Hospital San Carlos 2014-2015.
7. Kruip H. Illness experience narratives with mental health patients of Tzeltal origin, Mexico. Royal Tropical Institute, Amsterdam. Master of International Health thesis. February 2018.
8. Groleau D, Young A, Kirmayer LJ. The McGill Illness Narrative Interview (MINI): An Interview Schedule to Elicit Meanings and Modes of Reasoning Related to Illness Experience. Transcultural psychiatry 2006 43(4): 671-691. Available from: https://www.mcgill.ca/tcpsych/research/cmhru/mini
9. Eroza Solana E. El cuerpo como texto y eje vivencial del dolor. Las narrativas del padecimiento entre los tsotziles de San Juan Chamula. México: CIESAS. Publicaciones de la Casa Chata; 2016. 396 p.
10. Rebhun LA. Nerves and Emotional Play in Northeast Brazil. Medical Anthropology Quarterly 1993; 7(2):131-151.