Mental Health in Guatemala

1. Mental Health in Guatemala A Comparative Study of Perceptions and Causes of Mental Illness

2. Research Statement • What do Guatemalans indentify as the most prevalent or pressing mental health concerns in their communities?  • What do Guatemalans consider to be the causes of these mental health problems? • Do “culture-bound syndromes” exist and, if so, among which groups of people? • How do ladino and indigenous populations differ in their articulations of mental health concerns? • Context: How might historical, political, and economic factors influence mental health and wellbeing? • Goal: Assess the mental health status of different populations to identify unmet needs and to develop appropriate interventions

3. Methods • Observation at field sites • Conversations with key informants, including: Spanish teacher, hospital workers, curandera, leaders in NGO/development organizations • Focus Group Discussion with members of Maya Works in AguasCalientes de Comalapa • In-Depth Interview with member of Maya Works in AguasCalientes de Comalapa

4. Ethical Considerations • Categorization of mental illness • Mental health as a taboo topic • Can diagnosing mental illness enable an unjust system? • Mental illness as coping mechanism

5. Literature Review Rubel has written about susto in Latin America, describing the beliefs about soul and body which underlie local understandings of this “folk illness.” He shows that an epidemiological lens can successfully be applied to folk illnesses. Rubel, Arthur. 1964. “The Epidemiology of a Folk Illness: Sustoin Hispanic America”. Ethnology, Vol. 3, No. 3: 268-283.

6. Literature Review Green has documented the experience of chronic fear among Mayan women in the altiplano. She suggests that people can be “socialized to terror,” simultaneously habituated to fear and yet living in a constant state of low-level panic. She also ties in the idea of social memory to examine the impact of a history of terror in constructing a “culture of fear.” As such, she argues that simply categorizing these women’s symptoms as PTSD or a culture-bound syndrome neglects to account for the socio-historical context producing these effects. Green, Linda. 1994. “Fear as a Way of Life”. Cultural Anthropology, Vol. 9, No. 2. 227-256.

7. Literature Review Foxen implicates globalization, gang violence, and food insecurity (among other factors) as playing a role in creating an environment of constant stress in present-day Guatemala along with the inheritance of the Violence. She argues, however, that investigations into the mental health status of Mayan communities should keep resiliency in mind rather than solely construing them as passive victims. Foxen, Patricia. 2010. “Local Narratives of Distress and Resilience: Lessons in Psychosocial Wellbeing among the K’iche Maya in Postwar Guatemala”. The Journal of Latin American and Caribbean Anthropology, Vol. 15, No. 1. 66-89.

8. Results: Susto • One of most common ailments treated by curandera in Comalapa • Also identified as a primary mental health problem in AguasCalientes de Comalapa • Symptoms: loss of color in the face, difficulty sleeping, loss of appetite • Treatment goal = reunite spirit with body • Place roses inside or beside pot containing water, say sick person’s name into the pot

9. Susto, continued • Susceptibility – curandera indicated that children are especially susceptible to episodes of susto • Causes • Frightening incident – e.g. earthquake, car accident, unexpected encounter with snake • Discrepancy • Curandera – psychological, not physical • Informant in AguasCalientes – more prone to get susto after frightening incident if do not have “sangrefuerte,” which depends in turn on nutrition

10. Results: Depression and Anxiety • Largely not categorized as “depression” • Hopelessness – La Limonada • “Worried thoughts” – AguasCalientes • Treatment • No prescription of psycho-pharmaceuticals (with possible exception of asylum in the capital) • Talk therapy • External consult at public hospital (?) • Private clinic • School counselor – uncommon, only at private schools

11. Depression and Anxiety, cont’d • Causes – family problems and local environment • Domestic abuse • Machismo • Women’s issues, e.g. education and reproductive rights • Alcoholism • Prostitution • Gang violence & narco-trafficking • “These youth turn to gangs after growing up in an environment without love – maybe their parents are separated, there was domestic violence, the mother has turned to prostitution. They join gangs because they know their lives are not worth anything, and they often take pride in their arrest and imprisonment.” (field notes, conversation with Spanish teacher)

12. Depression and Anxiety, cont’d • Causes – economic and political environment • “Sometimes people have many thoughts and cannot sleep at night because they are in debt or don’t have enough money to buy the things they need.” (IDI, AguasCalientes de Comalapa) • Government corruption and inefficiency

13. Interpretation • Comparison: ladino vs. indigenous populations • Susto only articulated by indigenous informants • Depression and anxiety experienced in both populations • Is there a link between economic insecurity and sustoamong Mayans in the highlands? • Perceived connection between susceptibility to susto and nutrition – could susto be prevented through improved food security? • Is susto an alternative expression of depression and anxiety? Can we justify separating the two?

14. Theoretical Approach: Culture-Bound Syndromes • “Syndromes from which members of a particular group claim to suffer and for which their culture provides an etiology, diagnosis, preventive measures, and regimens of healing” (Rubel 1964: 268)

15. Theoretical Approach: Explanatory Models • All explanatory models include: • Etiology (cause) • Timing and mode of onset • Physiological process • Natural trajectory and severity • Appropriate response • Problems arise when EMs of patient and healer do not coincide Kleinman, Arthur. 1978. “Concepts and a model for the comparison of medical systems as cultural systems”. Social Science & Medicine. Part B: Medical Anthropology 12: 87-8.

16. Susto as Explanatory Model • Etiology: frightening incident + vitamin deficiency • Onset: immediately following incident • Physiological process: body and spirit separate • Trajectory: loss of color in the face, trouble sleeping, loss of appetite • Treatment: bring back color with red roses, call the person’s name to reunite body and spirit

17. Hypothesis: Relationship between Explanatory Models and Resource Availability • Are EMs built around/ sustained or tossed aside according to available resources? • In AguasCalientes de Comalapa (population ~150), 3-4 women can perform treatment for susto • Limited access to biomedical treatments – ambulatory teams, frequently closed health post, pharmacies (potential cost barrier) • What mental health resources are available? • Top-down influence on subjective experience

18. Further Questions • Is susto experienced among ladino population, and what prevalence? • Do indigenous people feel that their mental health needs are being met with the resources currently available to them? • Will the incidence of susto decrease/ incidence of anxiety increase among indigenous groups with increasing modernization/ spread of alternative EMs?

19. Ethics Revisited • Claim: both populations experiencing some of same stressors, expressing in different ways • What is the danger of collapsing the two? • Can improving mental health resources actually increase incidence of mental illness/introduce new illnesses?

20. Questions?