Clinician experiences of managed mental health care: a rereading of the threat.

The threat mental health professionals perceive in managed care, as indicated by their writings on the subject, is re-examined in light of evidence from an ethnographic study. Fieldwork focusing on clinician experiences of managed care was carried out at an urban community mental health center. Existing explanations of "the threat"--the possibility of deprofessionalization and the potential for deterioration in the quality of care--proved inadequate to account for the power it wielded at this site, perhaps because its full impact had yet to be felt at the time of data collection. A "rereading" suggests the meaning of managed care for this group of clinicians lies in the prospect of being gradually, unknowingly, and unwillingly reprofessionalized from critics into proponents simply by virtue of continuing to practice in a managed care context, and in losing a moral vision of good mental health treatment in the process.

The place of culture in DSM-IV.

This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV and outlines recommendations to improve future diagnostic systems. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed. Although a step forward has been taken to introduce cultural elements in DSM-IV much remains to be done. Further culturally informed research is needed to ensure that future diagnostic systems incorporate a genuinely comprehensive framework, responsive to the complexity of health problems in increasingly multicultural societies.

Chronic illness of the temporomandibular joints as experienced by support-group members.

PURPOSE: For temporomandibular disorders, the clinical situation is one of considerable etiologic, diagnostic, and therapeutic uncertainty. Using interview data, this report describes this condition and the search for care from the perspective of sufferers who are support-group members. PARTICIPANTS AND METHODS: Thirty-two individuals participated; all were members of a support group for individuals with long-term problems attributed to the temporomandibular joints and/or the surrounding masticatory muscles. Using a structured, open-ended interview format, this study investigated how individuals understand and give meaning to their symptoms, their patterns of care seeking, and the consequences of the illness on their lives. The participants also completed several structured questionnaires. RESULTS: For these support-group members, symptoms extended beyond the jaw and surrounding area, with extensive musculoskeletal involvement and resulting dysfunctions that have far-reaching consequences for the sufferers' lives. Primary care physicians are often consulted, especially early in the illness history. They also provide ongoing care and are asked for guidance when patients seek specialized treatment. A striking aspect of the findings from the interviews is the complex and costly pattern of health care seeking. This extended search for effective treatment is examined with reference to culturally based understanding, shared by patients and clinicians, about the nature of illness.

In the subjunctive mode: epilepsy narratives in Turkey.

Careful analysis of transcripts of interviews we conducted with a sample of persons identified as suffering epilepsy or seizure disorders in an epidemiological study in Turkey revealed not only that life stories of illness have an overall narrative structure but that the interviews were composed as a corpus of shorter stories. Analytic concepts from reader response theory bring attention to aspects of both the overall life story and the stories told about illness. In particular, we identify 'subjunctivizing tactics' present in the narrative representation of illness that allow sufferers and their families to justify continued care-seeking and to maintain hope for positive, even 'miraculous,' outcomes. In particular, these narratives maintain multiple perspectives and the potential for multiple readings, suggesting alternative plots about source and outcome of illness, and they represent potency and the possibilities for healing through stories of encounters with the mysterious.

Oncology and narrative time.

Oncologists encounter the uncertainty of time horizons in their patients' lives. Although American oncologists are given a cultural mandate to instill hope in the therapeutic narratives they create with patients, uncertainty leads them to expressions of time without horizons or of time with highly foreshortened horizons as they seek to create for patients an experience of immediacy rather than of chronology. The distinctiveness of the American pattern is highlighted through comparison with Japanese exemplar cases and stories of therapeutic practices in oncology. Concepts drawn from narrative analysis of temporality and the construction of the therapeutic plot are employed.

Oncologists vary in their willingness to undertake anti-cancer therapies.

Previous studies have shown that groups of cancer sub-specialists differ in their stated willingness to undergo treatment for diseases lying within their area of expertise. In order to learn whether oncologists feel similarly about other forms of cancer, medical, radiation, and surgical oncologists were asked to fill out a questionnaire indicating whether they would be willing to undergo either chemotherapy or radiation therapy for a variety of common malignancies, or recommend them to a spouse or sibling. Subjects were also asked whether they would undertake an experimental therapy (interleukin-2) for any of three malignancies, or recommend such treatment to a spouse or relative. Fifty-one oncologists (14 radiation oncologists, 14 surgical oncologists, and 23 medical oncologists) were recruited from the staff of four university teaching hospitals. Although they agreed about accepting or declining therapy for some examples, there was considerable heterogeneity in their responses. In only 37% of the 30 cases involving standard therapies did greater than or equal to 85% of the oncologists agree that they would accept or refuse therapy. Only some of the variation of the responses could be attributed to the sub-specialty orientation of the oncologists. Physicians were as willing to recommend standard therapies for themselves as a spouse or sibling. Physicians were also divided in their opinion about whether they would accept a particular experimental therapy if diagnosed with one of three neoplasms. They were significantly more likely, however, to recommend it for a spouse or sibling than to accept it for themselves. Variation in the proportion of patients who receive anti-cancer therapies may relate, in part, to differences in opinion concerning the worth of such therapies among oncologists or primary physicians. This study shows that oncologists are quite heterogeneous with regard to their personal preferences for anti-cancer treatments for a variety of malignancies. Further studies are required to learn if such attitudes (among oncologists or primary physicians) directly affect the administration of such therapies.

A critical review of epidemiological studies of Puerto Rican mental health.

Through a review of the epidemiological literature on the mental health of Puerto Ricans and other Hispanics, the authors argue that lack of attention to cultural issues in epidemiological studies leaves many questions unanswered and raises concerns about the validity of studies in this area. The authors point out that the mental health status of Puerto Ricans in New York City is still poorly understood after 30 years of research. The roles of cultural response styles and of culturally meaningful expressions of distress in shaping responses to research interviews should be central concerns in developing research in cross-cultural psychiatry.

American oncology and the discourse on hope.

From the perspective of medical anthropology and comparative research, American oncology appears as a unique variant of international biomedical culture, particularly when contrasted with oncological practice in societies such as Japan and Italy. Based on interviews with 51 oncologists in Harvard teaching hospitals, this paper argues that American oncological practice draws on distinctive cultural meanings associated with "hope" and is infused with popular notions about the relationship between psyche and soma, the progressive efficacy of biotechnical interventions, truth-telling, and the nature of the physician-patient relationship.

Telling the diagnosis of cancer.

Although a concensus has emerged in this country that patients should be told when cancer is discovered, no data is available to indicate how and where patients are currently told that they have cancer. Fifty-five patients undergoing anticancer therapy were therefore interviewed to learn how this process occurs. The majority of patients were told by surgeons (74%) and only a minority by primary care physicians (11%). Most were told in a traditional medical setting (42% in the doctor's office, 17% in a hospital room), but 23% were told over the telephone and 19% in the recovery room. Two indicators of patient satisfaction with the telling process suggested that different sites of telling were not equivalent. Patients told over the telephone or in the recovery room were more likely to describe the telling in negative terms and less likely to describe their doctors as being helpful in understanding their illness than those told in a doctor's office or in their hospital bed. This pilot study indicates considerable variation in this aspect of patient care and suggests directions for future research. To determine whether interviews that explore these issues with cancer patients are unpleasant or stressful, patients' reactions to being subjects in this study were sought. Patients asked directly at the completion of the interview or surveyed 2 to 4 months later said the interview had been helpful and/or a positive experience. None expressed negative feelings about participating. Concerns about the psychological harm resulting from such study of this patient group do not appear to be warranted and should not impede future research.

Disabling practitioners: hazards of learning to be a doctor in American medical education.

Ongoing work with first and second-year medical students suggests that American medical culture is characterized by a juxtaposition of notions of "competence" and "caring," and that the training of students to be competent physicians requires a reconstruction of "common sense" views of the patient, of sickness, and of the personal boundaries of the medical student. Contradictions that arise from efforts to maintain qualities of caring while undergoing these changes are highlighted.

Ritual, the state, and the transformation of emotional discourse in Iranian society.

This paper explores the social and cultural organization of Iranian emotional discourse and its transformation in post-revolutionary Iran. First, the Moharram dramas we participated in during field research are described, indicating how these performances organized a 'prototypical' view of the social order, the self, and the passions. Using Kapferer's distinction between "transcendental" and "transformative" rituals, we argue that these dramas were traditionally organized as "transcendental" rites. Second, data on grieving rituals and depressive illness among Iranians is introduced, focusing on the "transformative" qualities of mourning rites and suggesting an interpretation of depression as a failure of the "work of culture." Third, the appropriation of these symbolic forms of society, self, and the emotions by the current Iranian Islamic state and the role of the state in defining the meaning and legitimacy of emotions and their expression is analyzed.

Do patient attitudes influence physician recognition of psychosocial problems in primary care?

Research has yielded consistent evidence of high levels of psychiatric morbidity and psychosocial problems among primary care patients, and recent studies have focused on improving physician recognition. These studies are based on the unexamined assumption that patients want their physicians to treat psychosocial disorders; thus, underrecognition is examined by analyzing characteristics of physicians and medical settings. Patient characteristics, particularly attitudes about the appropriateness of seeking help for psychosocial problems in primary care, have not been examined in relationship to underrecognition. This study directly focuses on patient attitudes about appropriateness of requesting care for psychosocial difficulties, the extent to which patients discuss difficulties with their physicians, and the degree to which physician recognition is explained by these patient characteristics. The study sample of 883 adult patients was drawn from 23 primary care practices. Over 70 percent of patients find it appropriate to turn to their primary care physicians for help with emotional distress, family problems, life stress, behavioral problems, and sexual dysfunction; however, only one fifth to one third of patients who have experienced difficulties have discussed these problems with their primary care providers. Attitudes about appropriateness are significantly related to physician recognition of psychiatric symptoms and family difficulties but account for limited variance in levels of recognition.

Patient requests in primary health care settings: development and validation of a research instrument.

The development of the Primary Care Patient Request Scale and factor analytic and validation data from four diverse clinic samples are reported. The factor analysis yielded five plausible request dimensions: Treatment of Psychosocial Problems, Medical Explanation, Supportive Communication, Test Results, and Ventilation and Legitimation. The construct validity of the instrument was tentatively supported by the ability of the factor scales to discriminate consistently among the nature of the presenting complaint, the type of primary care clinic, and the marital status of the patient. Establishment of the clinical and research utility of the Primary Care Patient Request Scale awaits further efforts at cross-validation.

Reflexivity and countertransference in a psychiatric cultural consultation clinic.

A Mexican-American woman who complained of persistent head pain and a bothersome "voice" was seen by a team consisting of a psychiatrist, social scientists, and spiritualist healers in a Cultural Consultation Clinic of a Psychiatric Consultation Liaison Service. This single case is analyzed to provide an understanding of the interpretive dimensions of psychiatric practice. It is argued that a hermeneutic analysis of clinical phenomena focuses attention on three distinct aspects of interpretation: on the interpretation by clinicians and clients of the discourse of the other in terms of their own clinical models; on the influence of deeply embedded personal meanings on this interpretive process; and on the role of the observer in clinical ethnography. It is argued that to sustain a hermeneutic analysis of psychiatric practice, an account of transference and countertransference in terms of interpretation theory will have to be developed.

Diagnostic profile of a family practice clinic: patients with psychosocial diagnoses.

A 10 percent random sample of all active patient charts in the Family Practice Clinic at the University of California, Davis, Sacramento Medical Center was analyzed for age, sex, occupation, marital status, and number of clinic visits in the previous 12 months. Diagnoses and treatments for each visit were also recorded. Thirty-six percent of all adult female patients and 26.5 percent of all adult male patients were diagnosed as having psychosocial problems. Patients with psychosocial diagnoses made more visits for both acute and chronic illnesses and were more frequently diagnosed with illnesses in every diagnostic category than were other patients. Women, patients in blue-collar occupations, and patients who had never married or were divorced were most likely to have psychosocial diagnoses. Of the patients with psychosocial diagnoses, 18.8 percent were treated with antidepressants, 16.0 percent with pain medications, and 11.1 percent with tranquilizers.

Social status and fertility: A study of a town and three villages in Northwestern Iran.

Summary Studies of the relationship between social status and fertility in developing societies have shown diverse results. This study suggests that such findings result in part from problems in the conceptualization of social stratification and social status. In developing societies such as Iran the differentiation of modern and traditional cultural (and occupational) groups within social classes has resulted in the emergence of a dual hierarchy. Measures of social status must therefore reflect these conceptually distinct hierarchies, rather than be limited to linear scales. Figures from a study in a town and three villages in northwest Iran undertaken in 1973 are analyzed. Findings indicate that for women in towns, as social status increases within both traditional and modern occupational hierarchies (husband's occupation) and as measured by income, education and index of modern items, there is a general and almost monotonic decrease in the number of living children, children ever-born, and ideal number of children, with an increase in age at marriage and contraceptive use. The social and cultural homogeneity of the village sample is reflected in the relatively small variations in fertility-related behaviour and attitudes; however, fertility differences between landed and landless villages appear similar to the pattern found in the urban samples. The differences in the fertility behaviour of village and urban women of similar income and educational status indicate that fertility behaviour is related partially to class and partially to status distinctions between urban and rural communities.