An Opportunity to Create a New Narrative of Mental HealthVivian Khedari, Field Guide for Barefoot Psychologists Principal Investigator
Khedari is a Ph.D. candidate at the New School and is one of the principal investigators on the Field Guide, leading the charge on the neuropsychology elements of the study. Also, she wrote a chapter of the Guide as well as some of the self-care exercises.
As we strive towards a global increase in mental health awareness by celebrating World Mental Health Day, it is inevitable to think about cultural differences around how we understand wellbeing and what each of our communities label as mental illness. We are all from different families, in different towns, in different cities, states and countries and within each of our nested contexts we have acquired a lens through which we see the world and navigate it. We have different ways of expressing distress and those around us have different ways to help us cope with it. Often the most effective way to overcome our distress will be the way which is most compatible with the “illness narratives” our communities have construed around what causes our pain and how we can overcome it. For example, the distress that in a Western setting might be expressed as “depression” in the way the American Psychiatric Association defines it and that has been stereotyped in film and modern literature might best be healed through psychotherapy; whereas similar distress for a Hmong, an ethnic group in East and Southeast Asia, might be indicative of a lost soul and require a ritual involving the community coming together around the afflicted person to heal them. On the other hand, if our distress leads to troubles in regulating our emotions we could instead be accused of being rude and short-tempered by those closest to us and find ourselves alone without a community-sanctioned pathway towards healing.
As a clinician, whenever I work with somebody from a culture different from my own, I spend considerable time learning my client’s own theory of why they struggle with a symptom, presenting my own understanding, and negotiating a common ground. I find that it is through a consensus on language, tone and approach that my clients and I make the most progress towards their treatment goals. I keep this in mind when considering refugee-related work. When we think about mental health for forcibly displaced people, we are immediately thinking of people who are in a new place, different from the one in which their illness narrative originated.
Given that the number of forcibly displaced people surpasses the number of clinicians available to give them the time and attention needed to reach the compromises I aim to reach with my clients, we must invest in self-paced or community-led interventions like psychoeducation, providing education and information to those seeking or receiving mental health services, which have the advantage of reaching a lot of people at low cost and without the need of an expert. However, we must keep that if the self-help material being disseminated is too discrepant from the illness narrative of whoever receives it, it will be largely ineffective. One way to address this concern is by focusing the interventions on that which is universal – which is not how we express distress but how it impacts our body. However, the most recent science explaining the impact of traumatic experiences on the body exists mainly for an elite audience of academics familiar with the jargon and concepts being discussed in peer-reviewed publications. As it stands, this knowledge is largely inaccessible to a group of people whose very label implies the experience of trauma: the growing number of forcibly displaced people around the world.
The Field Guide for Barefoot Psychologists, a psychoeducation intervention for refugees and migrants, is meant to increase individuals’ capacity for self-care and caring for others by (1) building knowledge regarding why and how experiences of forced migration affect the brain and body and (2) providing specific and self-teachable exercises to improve emotion regulation. The Field Guide introduces the psychoeducation content by grounding it in stories that are relatable to their audience. Currently, we are testing a version which focuses on people affected by the Syrian Civil War. For example, the first section introduces the reader to the basics of the brain and the nervous system while later on, it presents the neurophysiological processes underpinning grief and loss, guilt and shame, and despair and hopelessness. I believe that through the use of storytelling, The Field Guide manages to do what I strive to do in sessions with my clients: engagement that comes from identifying with the story and relating to it that establishes common ground. Then, there is a new illness narrative introduced through a compromise that does not contradict the reader’s own notions of mental illness or health. The Field Guide does not challenge expressions of distress – culturally sanctioned or not- but instead provides the reader with a new illness narrative that can explain the origin of the distress and the many ways we express it.
If we revisit the examples above, an American and a Hmong might both learn, from reading the Field Guide, how negative emotions we feel during depressed states can increase cortisol levels, and that other chemicals our bodies produce – like oxytocin – can decrease cortisol levels and enable us to feel calmer. Both the American and the Hmong can continue to pursue the healing strategies that most match their illness narrative and they can also learn to practice self-soothing exercises to help stimulate the production of oxytocin. At the same time, somebody who feels ashamed of the way they have behaved due to their feelings of depression might find in the body-based explanation a validating statement that is less stigmatizing and provides them with access to healing pathways through the exercises in the Field Guide.
I believe what the Field Guide aspires to is a model for what the pursuit for improved global mental health should look like: an effort to make information accessible to a lay audience, that has a right to the most recent knowledge of the symptoms they experience without imposing unyielding constructs or definitions that might not translate across cultures or illness narratives.
Follow the conversation on Twitter: @Beyond_Conflict