The Biomedical Model v. Biopsychosocial Model
The Biomedical Model
In the Clinical Psychology Review one of the authors, Brett J. Deacon, explains that the biomedical model proposes that mental disorders are brain diseases and asserts pharmacological treatment to target presupposed biological abnormalities. The biomedical model has dictated American healthcare for three decades and during that time psychiatric medications has sharply increased; hence, mental disorders have become commonly regarded as brain diseases caused by chemical imbalances that are corrected with disease-specific drugs. Although the biologically-focused approach has urged the developments of psychological treatments for several mental disorders, the model does have its flaws. For example: it has neglected treatment process, inhibited treatment innovation and dissemination, and divided the field along scientist and practitioner lines.
The Biopsychosocial Model
On the otherhand the biopsychosocial model argues that the mind and body aren’t not to be looked at seperately. The biopsychosocial approach builds on the biomedical approach incorporating biological, psychological, and socio-environmental factors. The complex interactions of these three factors will then help mental health/clinical health providers understand a patient’s subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care.
Which One is Better?
It isn’t about which model is better or worse, but which model is more effective when treating specific cases. The field of psychology is vast, therefore, one model may be more effective when researching in a specific category of psychology. For example, neuropsychology might find it more beneficial to use the biomedical approach as its area of focus is on the mind and brain; whereas, in abnormal psychology the biopsychosocial model is better because abnormal psychology studies the emotional, physical, and mental effects of disorders which can look different for each patient depending on the the three factors of the BPS model.
The Globalization of The American Psyche:
As mentioned in my introduction video the book Crazy Like Us by Ethan Watters planted my curiosity about how America is homogenizing how the world goes mad. Specifically, chapter two, The Wave That Brought PTSD to Sri Lanka, helped me focus my project on the mental disorder PTSD. In 2004 a tsunami hit Sri Lanka killing over a quarter of a million people. In response, Western therapists and traumatologists went into the country thinking cases of PTSD were sure to increase. Mental health workers went on to conduct Critical Incident Debriefing,” to train local people in identifying PTSD and to encourage survivors of the tsunami to “open up” about their experience in order to properly heal. They also used PTSD checklists that were developed by the controversial Diagnostic and Statistical Manual of Mental Disorders, therefore ignoring the culturally distinct reaction to traumatic events and specific methods of healing in Sri Lanka. Watters further proved that the Sri Lankans’ experience of trauma differed from that of Americans in two ways. First, Sri Lankans reacted to disaster “as if they had experienced a physical blow to their body” meaning a more common symptom of PTSD in Sri Lankans was physical pain (Watters 91). Second, Sri Lankans did not report to experience symptoms such as anxiety, fear, or numbing. Instead, they reacted to trauma in terms of the damage it did to their social relationships. For example when a boy was asked what made him feel better when he gets worried about the violence in his community and he answered: “when his mother promises him that if they are attacked and killed that they would all die together” (Watters 92). Thus, Watters concludes that in Sri Lankan culture “emphasis on the social over the psychological” is crucial when considering how one might properly heal from tragic events (Watters 93).
My other focus besides PTSD was that of resettling refugees in America. Therefore when considering how to treat refugees the BPS model is ideal because these displaced persons are coming from diverse backgrounds that need to be taken into considerations as they may not be used to dealing with mental illness through the biomedical approach. The extent of the stigma of mental illness as well as how mental health is talked about looks different around the world. Therefore, when thinking about treating resettling refugees with PTSD in the U.S. moving away from the biomedical model and towards the biopsychosocial approach is more appropriate. So, the question is how can western nations better treat PTSD— specifically in refugees— with the understanding that the cultural context of these individuals plays a role in discovering how to properly heal one from traumatic events?
Post Traumatic Stress Disorder (PTSD)
What is PTSD?
Post-traumatic stress disorder is a psychological reaction that can manifest itself after a traumatic event. Some examples of traumatic events include accidents, assaults, military combat, natural disaster, war, etc. PTSD symptoms often co-exist with other conditions such as substance use disorders, depression, and anxiety Statistically, women are twice as likely to experience PTSD than men.
Symptoms of PTSD According to the National Alliance on Mental Illness (NAMI):
- Re-experiencing type symptoms, such as recurring, involuntary and intrusive distressing memories, which can include flashbacks of the trauma, bad dreams and intrusive thoughts.
- Avoidance, which can include staying away from certain places or objects that are reminders of the traumatic event. A person might actively avoid a place or person that might activate overwhelming symptoms.
- Cognitive and mood symptoms, which can include trouble recalling the event, negative thoughts about one’s self. A person may also feel numb, guilty, worried or depressed and have difficulty remembering the traumatic event. Cognitive symptoms can in some instances extend to include out-of-body experiences or feeling that the world is “not real” (derealization).
- Arousal symptoms, such as hypervigilance. Examples might include being intensely startled by stimuli that resembles the trauma, trouble sleeping or outbursts of anger.
PTSD Within the Refugee Community
Who are refugees?
The Migration Policy Institute defines refugees as individuals who are unable or unwilling to return to their country of origin or nationality because of persecution or a well-founded fear of persecution. Refugees are eligible for protection in large part based on race, religion, nationality, membership in a particular social group, or political opinion. The 1996 Illegal Immigration Reform and Immigrant Responsibility Act expanded this definition to include persons forced to abort a pregnancy or undergo a forced sterilization, or who have been prosecuted for their resistance to coercive population controls.
In the United States what sets apart refugees from other groups like immigrants and asylum seekers are:
- Refugees are usually outside of the United States when they are screened for resettlement.
- Admissions process and agency responsible for reviewing refugee applications differ from asylum seekers and immigrants.
Causes of PTSD Specific to Refugees
According to The National Child Traumatic Stress Network (NCTSN) children are quite resilient—the capacity to recover from trauma in the case of PTSD—however when talking about refugee children they experience more trauma than the average.
For example, when in their country of origins refugee children may experience traumatic events such as:
- Violence (as witnesses, victims, and/or perpetrators)
- Lack of food, water, and shelter
- Physical injuries, infections, and diseases
- Forced labor
- Sexual assault
- Lack of medical care
- Loss of loved ones
- Disruption in or lack of access to schooling
Once displaced, refugees may also face the same or new traumatic events which includes:
- Living in refugee camps
- Separation from family
- Loss of community
- Uncertainty about the future
- Harassment by local authorities
- Traveling long distances by foot
All the traumatic events above can be experienced by not only children but all demographics of refugees as well.
The Challenge of Treating Refugees With PTSD in the U.S.
The bad news is that with all the research that I’ve done there isn’t enough sufficient treatment-outcome research to inform intervention for refugees. Another challenge is that there have been numerous problems with the overall assessment of refugees’ psychological distress. For instance, varied methodologies and range of measures employed have made it difficult to draw conclusions across studies. Researchers’ abilities to draw conclusions from literature is also limited as several evaluation measures haven’t been adequately translated into the refugees’ native languages and are insensitive to the refugees’ cultural norms. The information that has been collected is controversial because connecting back to the biomedical model v. the BPS model relief workers and doctors disagree at times as to who needs mental health services and what type of mental health care is needed.
According to the National Center of PTSD there are some straightforward, reliable, and culturally validated screening instruments of trauma exposure and psychiatric distress in a variety of refugee communities.
Examples of Trauma Screens:
- Harvard Trauma Questionnaire (has been validated across a wide variety of cultures and in many different languages).
- Resettlement Stressor Scale
- War Trauma Scale.
Examples of measures of psychological distress:
- Hopkins Symptom Checklist-25
- Beck Depression Inventory
- Impact of Event Scale
- Posttraumatic Symptom Scale-30
The National Center of PTSD claims that some appropriate treatments may include offering group treatment to refugees who have experienced broadly similar events, having psychosocial interventions focus on strengthening the community and providing support to large groups through population-wide psychoeducation campaigns or the management of therapeutic activity centers. However, to counter these treatments in the second chapter of Crazy Like Us, the same scenario of treatments were used on Sri Lankans, yet the conclusion was that those treatments were ineffective and culturally insensitive.
The alternatives provided by the National Center of PTSD suggests that treatment is enhanced by targeting psychosocial risk factors. For instance, in an assessment of a sample of Cambodian refugees, there was a significant relationship between work status and depression; hence suggesting that providing employment in refugee camps would likely reduce rates of depression. Further, researchers such as Mollica have found that refugees involved in religious activities were one-third less likely to meet criteria for PTSD than respondents who participated in few or no religious activities. Additional protective factors include the presence of extended family, educational opportunities, the presence of human rights organizations, the availability of self-help groups, small camps, and the opportunity to engage in traditional cultural practices. I think targeting psychosocial risk factors is more effective because by doing so builds understanding for what type of treatments work for a specific group of refugees and the treatment plans would also take into account where psychological distress lies in specifc cultures.
The Inverted Pyramid
The Mental Health and Psychosocial Support Services (MHPSS) provided by Humanity Crew is implemented through the Inverted Pyramid. Notice that instead of approaching PTSD with one-on-one counseling that is usually a popular treatment option amongst Americans, individual sessions are actually the last step. More importantly, Humanity Crew places focus on the community as a whole, then group sessions. By following these steps they are able to understand (1) the social and cultural background of the refugees they are attending to (2) normalizing their experience so they are less avoidant of talking about their trauma. If the pyramid was flipped, refugees with PTSD would have a harder time being treated as one-on-one counseling could make the patient feel targeted and end up avoiding treatment even more. Moreover, Humanity Crew’s services are “designed to the refugees’ cultural background and are provided in their mother tongue”. Therefore, Humanity Crew is knocking down the two challenges of treating PTSD in the refugee community: (1) understanding cultural context (2) language barrier. Excitingly, Humanity Crew is conducting research and raising awareness by sharing published reports in academic journals, at international conferences, and with the media. That is a step towards effective treatment for refugees with PTSD!
When researching what is being done locally within the city I reside in, Chicago, I decided to reach out and interview the non-for-profit organization Girl Forward. The Girl Forward mission is to provide “a community of support dedicated to creating and enhancing opportunities for girls who have been displaced globally by conflict and persecution”. They then go on to say why they serve refugee girls specifically:
Girls who receive resettlement in the United States face huge challenges: poverty, language barrier, limited or disrupted education, isolation, and trauma.https://www.girlforward.org/
Interview With Girl Forward
As a part of my research, I became interested in how my local community was helping refugees whether that be with resettling, providing safe spaces, or providing mental health care. Hence, I interviewed Ashley Marine who is the Deputy Director at Girl Forward and asked about how the programs at Girl Forward specifically help refugee girls with trauma. So far they have the Mentoring Program, Education Program, Safe Spaces Program, Media Development Program, and a Summer Program. I personally look forward to being more involved with this organization and hope to make a change in the social justice work that they do pertaining to refugee girls.
Mental Health Program
Ashley mentioned that Girl Forward was finally in the planning stages of starting a program for Mental Health and I wanted to know more about what that entailed. Based on my reading of the second chapter of Crazy Like Us , The Wave That Brought PTSD to Sri Lanka, I questioned what her thoughts were on the biomedical model when it came to diagnosing and treating refugees with trauma. She answered that the model is very much American and has its flaws such as not taking into account the cultural background and social environments of which these refugees are coming from. Although still in the planning stages Ashley explained that part of the program would include Social Emotional Learning or SEL. SEL will teach the girls at GF to find healthy coping mechanisms, develop self-awareness, self-control, and interpersonal skills that will help further acclamate these girls at their schools, work, and form positive relationships in their social life.
Ashely then emphasized that the biggest challenge is that GF has over 30 girls from over 30 countries, so trying to come up with a model for the Mental Health Program that will account for all the cultural and social backgrounds of the girls is impossible. Therefore, Ashely adds that GF has to work with what they’ve got, in some ways compromising with the biomedical model as clinical help is a resource that is already readily available and implemented in American society.
Western conceptions of mental illness may not be the way to go when treating resettling refugees with PTSD. We need to be culturally sensitive when treating any group as people come from diverse backgrounds, especially in America which is known to be a melting pot, and causes/symptoms of mental illnesses are unique to the person that has it. Despite the ambition to innovate and progress as a first-world country, the U.S. needs to be cautious of the ideas they are imposing because the consequences of such power are detrimental. The overarching consequence would be the eventual loss of diversity in indigenous forms of mental illness and healing.
What You Can Do
Things to keep in mind:
- Make an effort to get to know refugees around you and welcome them with helping hands.
- Build a strong support system for friends that are refugees as there are still many stressors for them even after being resettled.
- Don’t assume one treatment is more effective for a certain mental illness as that opinion is shaped by your cultural perception that may be different than that of others.
- Going off the last point, steer away from forcing an idea/concept of the country that refugee is resettling in.
- Finally, research and immerse yourself to different ways of healing to open up your perspective and change your view of what could be effective.
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