[Revisiting the notion of treatment in mental health from the perspective of consumers and stakeholders of alternative community treatment resources: the issue of subjectivity]. / Revisiter la notion de traitement à partir de récits de personnes usagères, d'intervenants et de responsables de ressources alternatives en santé mentale: la question de la subjectivité

This article examines the importance of subjectivity and its complexity in psychiatric and mental health care. The question of subjectivity appears quite marginalized in current debates, especially in North America. The authors question the tendency to disregard subjectivity in mental health care and treatment. Results of a qualitative study with consumers and stakeholders of non institutional organizations identified as alternative community treatment resources, show that point of views meet regarding comprehension of treatment, thus increasing the interest and the scope of this study's findings.

An anthropologic study on strategies for addressing health problems among the elderly in Bambuí, Minas Gerais State, Brazil.

This paper explores the contribution of anthropological perspectives for clarifying the mechanisms through which socioeconomic circumstances influence the strategies developed by elderly for addressing their health problems in a small Brazilian city. Interviews with 20 key-informants explored the community's broad perception of the health situation of the elderly. Life histories collected from 30 elderly women examined their own perception of their health status and their health strategies. Narratives converge in emphasising the important role played by financial factors in accessing health services and medication. Life histories also describe some damaging strategies resorted to by the elderly to deal with their lack of resources. Elderly women emphasize the crucial support they receive from their family and/or neighbours to overcome health problems. Thus, the issue of poverty is not only a matter of socioeconomic circumstances, but also the poverty of broader social networks.

An anthropologic study on strategies for addressing health problems among the elderly in Bambuí, Minas Gerais State, Brazil / Um estudo antropológico sobre as estratégias para resolver problemas de saúde entre idosos de Bambuí, Minas Gerais, Brasil

This paper explores the contribution of anthropological perspectives for clarifying the mechanisms through which socioeconomic circumstances influence the strategies developed by elderly for addressing their health problems in a small Brazilian city. Interviews with 20 key-informants explored the community's broad perception of the health situation of the elderly. Life histories collected from 30 elderly women examined their own perception of their health status and their health strategies. Narratives converge in emphasising the important role played by financial factors in accessing health services and medication. Life histories also describe some damaging strategies resorted to by the elderly to deal with their lack of resources. Elderly women emphasize the crucial support they receive from their family and/or neighbours to overcome health problems. Thus, the issue of poverty is not only a matter of socioeconomic circumstances, but also the poverty of broader social networks.

Este artigo utiliza a abordagem antropológica para examinar mecanismos por meio dos quais a situação socioeconômica influencia as estratégias desenvolvidas por idosos residentes em uma pequena cidade brasileira para enfrentar seus problemas de saúde. Entrevistas com vinte informantes-chave visaram à percepção da comunidade acerca da saúde do idoso. Entrevistas com trinta senhoras idosas objetivaram a percepção que elas possuíam da saúde e estratégias adotadas para resolver tais problemas. As análises mostraram que as narrativas dos dois grupos convergem na ênfase do papel desempenhado por fatores financeiros no acesso aos serviços de saúde e aos medicamentos. As histórias de vida descreveram algumas estratégias prejudiciais à saúde para fazer frente à falta de recursos. As senhoras também destacaram a importância do apoio da família e/ou de vizinhos para superar problemas relacionados à saúde. Assim, a questão da pobreza não é só econômica, mas também a pobreza das redes sociais de apoio.

Dr Ravi L. Kapur (1938-2006): a psychiatrist at the crossroads of multiple worlds.

This article reviews the life and work of Dr Ravi L. Kapur, a seminal figure in the fields of social and community psychiatry in India. Kapur made significant contributions to the understanding of the role of spirituality in psychology and psychotherapy and the psychological dynamics of sectarian violence.

The process of recovery of people with mental illness: the perspectives of patients, family members and care providers: part 1.

BACKGROUND: It is a qualitative design study that examines points of divergence and convergence in the perspectives on recovery of 36 participants or 12 triads. Each triad comprising a patient, a family member/friend, a care provider and documents the procedural, analytic of triangulating perspectives as a means of understanding the recovery process which is illustrated by four case studies. Variations are considered as they relate to individual characteristics, type of participant (patient, family, member/friend and care provider), and mental illness. This paper which is part of a larger study and is based on a qualitative research design documents the process of recovery of people with mental illness: Developing a Model of Recovery in Mental Health: A middle range theory. METHODS: Data were collected in field notes through semi-structured interviews based on three interview guides (one for patients, one for family members/friends, and one for caregivers). Cross analysis and triangulation methods were used to analyse the areas of convergence and divergence on the recovery process of all triads. RESULTS: In general, with the 36 participants united in 12 triads, two themes emerge from the cross-analysis process or triangulation of data sources (12 triads analysis in 12 cases studies). Two themes emerge from the analysis process of the content of 36 interviews with participants: (1) Revealing dynamic context, situating patients in their dynamic context; and (2) Relationship issues in a recovery process, furthering our understanding of such issues. We provide four case studies examples (among 12 cases studies) to illustrate the variations in the way recovery is perceived, interpreted and expressed in relation to the different contexts of interaction. CONCLUSION: The perspectives of the three participants (patients, family members/friends and care providers) suggest that recovery depends on constructing meaning around mental illness experiences and that the process is based on each person's dynamic context (e.g., social network, relationship), life experiences and other social determinants (e.g., symptoms, environment). The findings of this study add to existing knowledge about the determinants of the recovery of persons suffering with a mental illness and significant other utilizing public mental health services in Montreal, Canada.

Developing a model of recovery in mental health.

BACKGROUND: The recovery process is characterized by the interaction of a set of individual, environmental and organizational conditions common to different people suffering with a mental health problem. The fact that most of the studies have been working with schizophrenic patients we cannot extend what has been learned about the process of recovery to other types of mental problem. In the meantime, the prevalence of anxiety, affective and borderline personality disorders continues to increase, imposing a significant socioeconomic burden on the Canadian healthcare system and on the patients, their family and significant other 1. The aim of this study is to put forward a theoretical model of the recovery process for people with mental health problem schizophrenic, affective, anxiety and borderline personality disorders, family members and a significant care provider. METHOD AND DESIGN: To operationalize the study, a qualitative, inductive design was chosen. Qualitative research open the way to learning -- the inside -- about different perspectives and issues people face in their process of recovery. The study proposal is involving a multisite study that will be conducted in three different cities of the Province of Québec in Canada: Montréal, Québec and Trois-Rivières. The plan is to select 108 participants, divided into four comparison groups representing four types of mental health problem. Each comparison group (n = 27) will be made up of 9 units. Each unit will comprise one person with a mental health problem (schizophrenia, affective anxiety, and borderline personality disorders. Data will be collected through semi-structured open-ended interview. The in-depth qualitative analysis inspired from the grounded theory approach will permit the illustration of the recovery process. DISCUSSION: The transformation of our Health Care System and the importance being put on the people well-being and autonomy development of the person who are suffering with mental problem This study protocol follows-up on earlier theory-building process that begun with the work of Noiseux 2. The contribution of the present study is to increase the comprehension of the concept of recovery and to enhance the body of knowledge in that domain. Very few studies have examined recovery and the one that did used a descriptive approach which did not take into account the perspective of the family members and the caregivers of the recovery process.

Training researchers in cultural psychiatry: the McGill-CIHR Strategic Training Program.

OBJECTIVES: The authors aim to summarize the pedagogical approaches and curriculum used in the training of researchers in cultural psychiatry at the Division of Social and Transcultural Psychiatry at McGill University. METHOD: We reviewed available published and unpublished reports on the history and development of the McGill cultural psychiatry programs to identify the main orientations (conceptual and methodological), teaching methods, curriculum and course content. Student evaluations of teaching were reviewed. Follow-up data on research and other academic activities and employment of trainees who graduated from the program was obtained by e-mail questionnaire. RESULTS: The McGill program includes a Master of Science program, an intensive summer school, annual Advanced Study Institutes, and the McGill-CIHR Strategic Training Program in Culture and Mental Health Services Research. The interdisciplinary training setting emphasizes the cultural history and embedding of psychiatric knowledge and practice; the social construction of ethnicity, race, and cultural identity; the impact of globalization, migration, and ideologies of citizenship on individual identity and the configuration of cultural communities; and the integration of quantitative and qualitative ethnographic methods in basic and evaluative research. CONCLUSION: This critical transdisciplinary approach provides researchers with conceptual tools to address the impact of the changing meanings of culture and ethnicity difference in the contemporary world on mental health services.

Insight and psychosis: comparing the perspectives of patient, entourage and clinician.

BACKGROUND: The construct of insight in psychosis assumes congruence between patient and clinician views of the meaning of symptoms and experience. Current definitions and measures of insight do not give systematic attention to the impact of interpersonal, cultural and socio-economic contexts. AIMS: We hypothesized that socio-cultural factors influence insight in patients with schizophrenia. METHODS: We tested this hypothesis through comparison of insight in 18 triads, each composed of a patient, a family member and a clinician. The sample consisted of patients who were first diagnosed with psychosis in the last two years, and who were either immigrants from Africa or the Caribbean Islands, or Canadian born. Insight was assessed by analysis of narratives collected from patients, family members and clinicians for a research project on the negotiation of treatment. Each narrative was scored for insight along multiple dimensions with the Extracted Insight Scale (EIS), developed for this project. RESULTS: There was a significant correlation of insight on the EIS between patients and family members (r= 0.51, p= 0.03) but not between patient and clinician or family and clinician. The mean levels of insight across the three groups were comparable. Qualitative analysis of the illness narratives suggested that insight was based on the meanings constructed around psychotic experiences and that the process of interpreting and attributing psychotic experiences reflected each person's cultural background, life experiences, and other social determinants, especially stigma. CONCLUSION: Forms of insight can occur in the context of discordance or disagreement with the clinician's opinion. We present a testable model of the sociocultural determinants of insight that can guide future studies.

Speaking about culture in multiple voices.

As a mark of gratitude to Alexander Leighton, this article engages him in a dialogue, reopening several debates that were enriched by his research and reflections on ethics, the 'aesthetic dimension' of the research enterprise, the processes that mediate between collective and individual variables, and his strong distrust of theory. The authors discuss some of the features of Leighton's perspective that they have retained and transformed in their own work on community responses to chronic mental illness in rural Quebec, on the course of schizophrenia in India, and on culture and psychosis in clinical settings in Montreal. The challenge remains the one that Leighton identified: how can findings derived from different disciplines be made to co-ordinate? The authors argue that this question must be answered from within the centre of each discipline rather than from their frontiers or zones of interface.

Shadows of culture in psychosis in south India: a methodological exploration and illustration.

Transcultural studies suggest a possible influence of culture on the course and outcome of schizophrenia. However, the notion of culture remains ill-defined in these studies; most often, hypotheses regarding protective factors seem to derive more from stereotyped visions of cultural differences than be empirically based. Explorative studies conducted in south India consider subjective experience as a key mediating variable between culture and course and outcome in schizophrenia. They explore patients and relatives experience and its evolution and aim at identifying the explicit and implicit references to culture throughout the narratives. Ethnographically oriented data collected through an open-ended Turning Point/Period Interview systematically reconstructs the perceived evolution of signs, coping, explanations, reactions and help-seeking from different perspectives. This paper examines the degree of convergence and divergence between narratives collected from a small sample of female schizophrenic patients and one of their relatives. A high degree of convergence at the level of symptoms and differences in their narrative construction are observed.

A qualitative study of religious practices by chronic mentally ill and their caregivers in South India.

BACKGROUND: Socio-cultural explanatory factors for mental health problems determine help seeking behaviors. The study aimed to understand the reasons mentally ill patients and their families in India choose to seek help from a religious site. MATERIALS AND METHODS: Persons with mental illness and their families were interviewed at religious sites using a guideline questionnaire. Issues such as significant life events, explanations for perceived abnormal behavior and reasons for choosing a specific religious site for 'treatment' were explored. DISCUSSION: Seeking religious help for mental disorders is often a first step in the management of mental disorders as a result of cultural explanations for the illness. This behavior also has social sanctions.

A theoretical and empirical analysis of context: neighbourhoods, smoking and youth.

Numerous studies are currently addressing the issue of contextual effects on health and disease outcomes. The majority of these studies fall short of providing a theoretical basis with which to explain what context is and how it affects individual disease outcomes. We propose a theoretical model, entitled collective lifestyles, which brings together three concepts from practice theory: social structure, social practices and agency. We do so in an attempt to move away from both behavioural and structural-functionalist explanations of the differential distribution of disease outcomes among areas by including a contextualisation of health behaviours that considers their meaning. We test the framework using the empirical example of smoking and pre-adolescents in 32 communities across Québec, Canada. Social structure is operationalised as characteristics and resources; characteristics are the socio-economic aggregate characteristics of individuals culled from the 1996 Canadian Census, and resources are what regulates and transforms smoking practices. Information about social practices was collected in focus groups with pre-adolescents from four of the participating communities. Using zero-order and partial correlations we find that a portrait of communities emerges. Where there is a high proportion of more socio-economically advantaged people, resources tend to be more smoking discouraging, with the opposite being true for disadvantaged communities. Upon analysis of the focus group material, however, we find that the social practices in communities do not necessarily reflect the "objectified" measures of social structure. We suggest that a different conceptualisation of accessibility and lifestyle in contextual studies may enable us to improve our grasp on how differential rates of disease come about in local areas.

[Recovering after a psychosis; Opening a path? Finding one's own voice?]. / Se rétablir après une crise psychotique : ouvrir une voie? Retrouver sa voix?

The author questions the meaning of the very notion of recovery from the perspective of people who have gone through a psychotic episode. Results of two studies are briefly presented under the angles of "social reintegration" from the perspective of discourses and practices of patients; the other on the place and significance of alternative community groups in mental health in regards to consumers' life trajectory and suffering. Narratives illustrate that recovery does not mean a return to what was "before". Recovery is organized around various themes that are intertwined: finding words, taming daily life, recovering control, reopening movement, naming the exceptional character of the experience and having it acknowledged. Recovery implies the possibility of building a significant inner space and reorganizing relationship to others and the world at the same time, according to one's own rythm.

[Integration of services and practices: the test of experience.]. / L'intégration des services et des pratiques. L'épreuve de l'expérience.

The authors explore how integration of services takes shape in specific contexts according to data of a research on discourses and practices of mental health workers and consumers of community groups. The analysis aims at understanding how the models prevailing on the level of organization of services impact on one hand, on the rules of work organization of professionals and their concept of problems and interventions and on the other hand, on the climate of organizations and the daily lives of consumers, the relationship between themselves as well as with mental health workers and the place given to consumer's words, projects and wishes. The authors thus examine how organizational models and their implications affect the possibilities offered to consumers and the paths opening or not to improve their lives.