understanding the stakes in children’s idioms of distress ria reis · 2017-11-22 · in...
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Understanding the stakes
in children’s idioms of distress
◊Ria Reis
Leiden University Medical Centre
University of Amsterdam
University of Cape Town
Bergen, Norway, 13-10-2017
Background
Research focus:
- Children and Youth’s health perceptions and strategies
- Trans-generational transmission of vulnerabilities in contexts of inequality
- Supporting (mental) health interventions for populations affected by inequity, epidemics, disasters, conflicts and violence.
- Children’s cultural idioms of distress (IOD)
Aims
Discuss
relation between culture and children’s expressions of distress.
children’s stakes when they show cultural idioms of distress.
Example
Epidemics of mass dissociative illness in schools
Distress and Culture
Psychological distress:
Unpleasant feelings or emotions that interfere with functioning. Sadness, anxiety, and symptoms of mental illness are manifestations of psychological distress.
Culture
Shared and intergenerationally transferred
framework of ideas, perceptions, beliefs, values,
dispositions, norms, rules, and customs that
shape and give meaning to people’s lives
The work of culture in the body/mind
- Culture provides people with guidelines how to deal with
- bodily and emotional sensations and experiences.
- Culture plays a role in determining what is important:
- learn to pay selective attention to certain meaningful processes in the body/mind
- Culture is about ideas and norms:- differences in what is allowed to be felt and
expressed (Kleinman 1980)
- Culture’s work is mostly unconscious:- we experience our body/mind as natural
Learning a language of distress
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DSM 5*: cultural concepts
Considerable differences in the way people perceive or express their distress
may complicate patient-caregiver interaction and hamper effective diagnostic and treatment trajectories
Cultural competences (knowledge, attitudes, skills) needed for accurate diagnosis and adequate referral.
Cultural templates to express suffering and distress.
Cultural Syndromes
Cultural Explanations
Cultural Idioms of Distress
* Diagnostic and statistical manual of mental disorders
DSM V: cultural concepts
Cultural syndromes
clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts and that are recognized locally as coherent patterns of experience.
Cultural explanations
labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress.
DSM V: cultural concepts
Cultural Idioms of distress
Alternative modes of expressing and communicating distress that make sense and invite action in the context of specific complexes of personal and cultural meaning’
Nichter, M., 1981
Shared, culturally distributed sets of symbols, behaviors, language or meanings that are used by people to express, explain and/or transform their distress and suffering.
Hollan, D., 2004
DSM V: cultural concepts
Cultural Idioms of distress
Ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns.
DSM 5
Critique: every expression of distress is cultural, makes the concept superfluous.
Cultural Idioms of distress
an embodied symbolic language for psychosocial suffering that derives its legitimacy from its shared metaphors, meaning and understanding in a group.
due to its multilevel and multi-interpretable nature and its use of condensed symbols it allows the individual to express and communicate suffering caused by different types of stressors
that cannot be expressed in the local socio-cultural-political context due to its inherent threat to the dominant values and structures’
De Jong, J.T. & R.Reis, 2010, Kiyang-yang, a West-
African post-war idiom of distress. Culture, Medicine
& Psychiatry 34: 301-32.
Empirical example Outbreaks of spirit possession in
schools
Case description
1. One child feels unwell
2. From vague physical complaints to violence
3. Seeing/hearing things others can’t see/hear
4. Children’s behaviour installs fear of occult
5. Mounting to collective panic
6. Other children fall prey
Outbreaks occur every year, in different schools
Behaviour known from ritual contexts
Expression of distress - cause of distress
Perspectives and interventions
Heated debates about accountability, related to involvement in the occult
Spiritual interventions backfire
Involvement of parents, community, health & religious services, leadership, media
Children sent home, school closed
No school psychological/psychiatric services, no support in aftermath
Causes are not addressed
Outbreaks continue as (underground) bushfire
Step 1
An embodied symbolic language for psychosocial suffering that derives its legitimacy from its shared metaphors, meaning and understanding in a group
Behaviour is recognised and experienced as meaningful
Violent agency expressed confirms the spirit hypothesis for onlookers
“children are not themselves’
Therefore children are not accountable for the expression of negative emotions
Step 2
Due to its multilevel and multi-interpretable nature and its use of condensed symbols it allows the individual to express and communicate suffering caused by different types of stressors ...
Identification of underlying social causes causing distress by involving children as social actors:
Making sense of and intentionally acting upon themselves and the world
Step 2
Vignette study:
“I don't think they came from a happy family … Because the demons attacked mostly those who came from under privileged families so that it helps them out with their needs … I think the ones that are attacked by demons are the ones that stay with guardians and not their real parents and you find that they abuse them … When you don't stay with your parents, the people you live with sometimes beat you for nothing … “
(focus group, Swaziland, translated from siSwati).
Step 2
Due to its multilevel and multi-interpretable nature and its use of condensed symbols it allows the individual to express and communicate suffering caused by different types of stressors ...
Double orphan Deprivation Poverty & inequity Damaged social fabric
due to HIV/AIDS Weak mesostructures Insufficient & vertical
educational & health services
Step 2
Due to its multilevel and multi-interpretable nature and its use of condensed symbols it allows the individual to express and communicate suffering caused by different types of stressors ...
Sexual abuse Domestic violence Poverty & inequity Damaged social fabric
due to civil conflict Weak mesostructures Insufficient & vertical
educational & health services
Step 2
Due to its multilevel and multi-interpretable nature and its use of condensed symbols it allows the individual to express and communicate suffering caused by different types of stressors ...
Stressors were found on all ecological levels
Problems at macro- and exo-level (humanitarian emergencies) translate to problems at meso- and microlevel.
Step 3
stressors that cannot be expressed in the local socio-cultural-political context due to its inherent threat to the dominant values and structures’
Why do children enact a symbolic mode of expression?
To find answer: Direct our gaze to structural problems/tensions that cannot be directly addressed without endangering children’s stakes
Hypothesis: When suffering can be socially and politically addressed and solved, there is no longer a need for a symbolic mode of expression or IOD that will then dissipate
Step 3
Structural problems/tensions that cannot be directly addressed without endangering children’s stakes
Answer from children & adults:
experiences of abuse and parental neglect lead to anger, loneliness, anxiety, feeling downcast, distrust and disappointment in others.
expressing (strong) emotions by children in the presence of adults is discouraged / considered disrespectful.
To different extent re. gender, ethnic groups, class, family culture
Testifying suffering directly may endanger themselves and their loved ones
Logics of spirit possession
Social problems causing negative emotions
Keeping emotions
inside
Spiritual weakness
Spirit
attack
Logics of outbreaks
A permissive space
Physical, emotional & behavioral experiences as clues for interpretation: a spiritual presence.
Others act on these clues with (re)actions that confirm the interpretation
Reactions feed back into the anxiety of children
Other children’s mild dissociative experiences may also develop into possession trance
An outbreak is born.
Logics of spirit possession
Social problems causing negative emotions
Keeping emotions
inside
Spiritual weakness
Spirit
attack
Conclusion
Possession trance in schools can be analysed as a child idiom of distress
Behaviour that is believed to be caused by external agents is legitimate
Forbidden emotions (such as anger for girls) can be expressed
Children embody own/family/community distress
Children’s stakes are multileveled
Addressing them needs comprehensive interventions
Recommendations
See outbreaks as windows for understanding children’s social suffering and for social change
Help actors understand their role in process leading to outbreak
Do not confront but build on local understandings
Equip all actors with capacities to recognize and mitigate distress
Aim interventions not only at outbreak (spiritual / community/psychological) but focus on and address both individual and collective social suffering
Build structures that enable children to safely tell about their social suffering and enable effective responses
Build meso-structures around children (e.g. parents and teachers) and collaborate cross sectional (Health & Education)
Research template
Chose a case/pattern of (possible) collective expressions of distress
analyse it with three steps of CIOD concept
formulate hypothesis and/or research questions
Haunting spirits of the dead Uganda (cen)
Uppgivenhetssyndrom Sweden
Clusters of attempted suicide (Hindustani schoolgirls)
Binge drinking / substance abuse
Postnatal depression among migrant and refugee
women
Thank You
Literature references
Bronfenbrenner, U. (1979). The ecology of human development.
Cambridge, MA: Harvard University Press.
Hollan, D., 2004, Self Systems, Cultural Idioms of Distress, and the Psycho-bodily Consequences of Childhood Suffering. Transcultural Psychiatry 41(1): 62–79.
De Jong, J. T., & Reis, R. (2010). Kiyang-yang, a West-African post-war
idiom of distress. Culture, Medicine and Psychiatry, 34(2), 301–332.
Nichter, M. (1981). Idioms of distress: Alternatives in the expression of
psychosocial distress: A case study from South India. Culture,
Medicine and Psychiatry, 5(4), 379–408.
Reis, R. (2013). Child Idioms of Distress as a Response to Trauma:
Therapeutically Beneficial, and for Whom? Transcultural Psychiatry
50(5): 623 - 644.
Reis, R.,(2016), Children’s idioms of distress. In: Manderson, L., Cartwright, E. & A. Hardon (Eds), The Routledge Handbook of
Medical Anthropology, case study 2.1, pp. 36-42. Londen: Routledge.
Acknowledgements
Literature reviews and case studies in collaboration with
Joop T.V.M. De Jong
Navaraj Upadhaya & team Nepal (September 2012)
Kamla Nannan Panday-Jhingoeri & team Suriname (October 2012)
Jabulani Shabalala & team Swaziland (November 2012)
Heleen van de Brink & team Sierra Leone (March 2014)
Supported by (travel) grants from:
HCB program AISSR, University of Amsterdam
Foundation Peace Of Mind (POM)
PHEG /LUMC