Thursday, December 18, 2014

The Role of the Health Belief Model on the Medicalization of Refugee Life - Svyatoslav “Slavvy” Petrov

Introduction –
The Link between the Health Belief Model & Medicalization -
Over the last two decades, studies of non-Western refuges and asylum-seekers, seen in clinics in Western countries, have proliferated in the cross-cultural mental health and public health literature (14, 31). Not surprisingly, most studies (e.g. 21) indicate a high prevalence of refugees who are diagnosed with posttraumatic stress disorder (PTSD) (14). 
However, a critical analysis of the PTSD model reveals that there is a poor distinction "between the physiology of normal distress and the physiology of pathological distress, so that overdiagnosis is easy" (30, 31). When refugee experiences of distress are reduced to a pathological entity, trauma becomes psychopathology and a refugee life takes on a medicalized form. This dominant ideology arises from the globalized discourse of trauma solidified by humanitarian organizations such as UNICEF, universalist claims in Western psychiatry that mental disorders are the same everywhere, reductive biomedical training curriculums, and an overdependence on the core assumptions of the Health Belief Model (HBM) (14, 31). 
As mainstream medicine, psychiatry, and public health become more objective, the socio-political and historical contexts of illness become secondary to prevention, diagnosis and treatment. Positivist medical and public health behavioral models, such as the HBM, make it challenging to understand, assess, and treat non-Western and racialized peoples when the focus of health behaviors is zoomed in on the individual and the historical and socio-cultural elements of health-related decision-making are neglected (34). When illness or a health behavior is de-contextualized, the link between models of illness, symptom presentation and treatment becomes blurred.
The disconnect between individual and culture in the HBM is a significant problem in cross-cultural refugee care and especially in refugee mental health needs-assessment and services. Frequently, refugee identities amount to patients inflicted with "post traumatic stress" (31). This, as Summerfield argues, occurs because there is "a missed identification between the individual and the social world, and a tendency to transform the social into the biological (the mere machinery of the body)" (31). By reducing the refugee experience to visible symptoms "inside a person (between his or her ears)," the social context and current needs are ignored both in medical and public health interventions (31).
More importantly, the medicalization of refugee life may be a major barrier to effective physician-refugee-patient relationships. To ensure effective preventive and/or therapeutic encounters with refugees, medical providers and public health practitioners must take a holistic approach; identify the socio-cultural aspects that influence refugee health behavior and illness presentation; address the current social situation and needs of refugee groups and raise clinical and needs-assessment questions that go beyond symptomatology and notions of “perceived susceptibility,” “perceived severity,” and “perceived benefits” (9, 10, 26). To accomplish this, modern medical and public health workers must be willing to resist both the drivers of medicalization and the common assumptions instilled by the HBM.  
What is Medicalization?: Origins & Modern Drivers - 
The term medicalization emerged in the 1970s. Its application was mainly used to critique emerging medical definitions for previously non-medical issues. Explicitly, medicalization refers to the "process by which nonmedical problems become defined and treated as medical problems, usually in terms of illnesses or disorders" (5). In his 1992 article, "Medicalization and Social Control", Conrad expounds upon the social origins of medicalization (5).
Analysts have long pointed to the social factors that have encouraged or abetted medicalization: the diminution of religion, an abiding faith in science, rationality, and progress, the increased prestige and power of the medical profession, the American penchant for individual and technological solution to problems, and a general humanitarian trend in western societies [to pathologize distress and "trauma" in order to galvanize access to public support and sponsorship].  
Despite the multiple aspects that reify medicalization, the "organization and structure of the medical profession has an important impact" (5). “Professional dominance and monopolization have certainly had a significant role in giving medicine the jurisdiction over virtually anything to which the label "health" or "illness" could be attached (8).
To complicate things, the modern engines that drive medicalization expand beyond the clinical (interactional) level and into the realm of biotechnology (i.e. pharmacology, psychotropic drugs), consumers (i.e. patient choices, elective care), and managed care (i.e. HMOs, coverage of once non-medical problems) (6).
Conrad argues that modern pharmaceutical and biotechnology industries are becoming major facilitators of medicalization (6).
While physicians are still the gatekeepers for many drugs, the pharmaceutical companies have become a major player in medicalization. In the post-Prozac world, the pharmaceutical industry has been more aggressively promoting their wares to physicians and especially to the public.
Additionally, Summerfield (31) argues that evidence suggests that the pharmaceutical industry has the power to set research agendas and to endorse unaffordable treatments for non-medical problems.
Industry strategies include casting ordinary processes as medical problems (e.g. baldness), casting mild functional symptoms as portents of serious disease (e.g. irritable bowel syndrome), casting personal or social problems as medical ones (e.g. social phobia), casting risk factors as actual diseases (e.g. osteoporosis), and using misleading disease prevalence estimates to maximize the size of a medical problem (e.g. erectile dysfunction) (22).
Further, as the American medical system changes and provides more choices (e.g. elective cosmetic surgery) consumers (i.e. patients) of healthcare play a significant role in the process of medicalization (6).
As health care becomes more commodified and subject to market forces, medical care has become more like other products and services. We now are consumers in choosing health insurance plans, purchasing health care in the marketplace, and selecting institutions of care [and] hospitals and health care institutions now compete for patients as consumers.    

In our current medical age, consumers have become increasingly vocal and active         in their desire and demand for services. Individuals as consumers rather than patients help shape the scope, and sometimes the demand for, medical treatments for human problems.
In relation to managed care, Conrad (6) suggests that HMOs have assumed an important role in increased use of psychotropic medications in adults and children. He argues that lack of coverage for certain interventions (e.g. talk therapy) forces providers to prescribe treatments that are only covered by patients' insurance plans. This can proliferate medicalization. “It seems likely that physicians prescribe pharmaceutical treatment for psychiatric disorders knowing that these are the types of medical interventions covered under managed care plans, accelerating psychotropic treatments for human problems” (6).
All in all, these, largely Western, forces of medicalization construct positivist schemas and facilitate reductionist practices in refugee care. Common paradigms of medicalization allow mental health professionals and public health providers to conflate natural responses to "trauma" with psychopathology. In other words, refugee experiences are conceptualized through an objective lens that zooms in on the individual and his or her pathology, but neglects more pressing, subjective refugee needs. Taking this into account, the discourse of medicalization and the universality of the HBM in the refugee care context is in need of critical assessment.
Rethinking "Trauma" & PTSD -
In "The Invention of Post-traumatic Stress Disorder and the Social Usefulness of a Psychiatric Category," Dr. Derek Summerfield makes four crucial points about modern conceptualizations of trauma and distress. He argues that 1) "a psychiatric diagnosis is not necessarily a disease, 2) distress or suffering is not psychopathology, 3) PTSD is an entity constructed as much from socio-political ideas as from psychiatric ones, and 4) the increase in the diagnosis of PTSD in society is linked to changes in the relation between individual personhood and modern life" (30).
These arguments are critical of "the global spread of the [PTSD] diagnosis by humanitarian programmes" (30, 31). The greatest shortcoming of this understanding of trauma is that the "misery and horror [experienced by refugees] is reduced to a technical issue tailored to Western approaches to mental health" and interpreted via a largely Westernized HBM (3, 28, 30, 31). In this vein, refugees' background culture, current situation, and subjective meanings brought to the lived experience are narrowed to a singular diagnosis (30). This is the crux of the problem. Approaching an individual refugee outside of a historical and/or socio-cultural context can create a misjudged classification that all refugees experience and need mental health screening and services. 
Furthermore, the liberal application of the PTSD diagnosis reaffirms its natural, objective place in the world as a universal category. Summerfield warns against this and states that "PTSD may be seen as a Western culture-bound syndrome" (32). In this sense, indiscriminant merging of traumatic experiences with a psychiatric disorder is problematic. As Young (35) accentuates,
             The disorder is not timeless, nor does it possess an intrinsic unity. Rather, it is glued together by the practices, technologies, and narratives with which it is         diagnosed, studied, treated, and represented and by the various interests,          institutions, and moral arguments that mobilized these efforts and resources          (cited in 30).   
To drive the point home, Summerfield (31) argues that human experiences should not be categorizes as objective signs of "trauma." Refugee experiences are not universal, and their responses to traumatic events are not always indicative of a mental disorder. 
The fundamental relativity of human experience, even in extreme conditions, and the primacy of the subjective appraisal and social meaning, means that there can be no such thing as a universal trauma response. Human responses to aversive experiences such are not analogous to physical trauma: people do no passively register the impact of external forces (unlike, say, a leg hit by a bullet) but engage with them in an active and problems-solving way. Suffering arises from, and is resolved in, a social context, shaped by the meanings and understandings applied to events (and which may evolve as the context evolves).
With this in mind, public health practitioners must be careful not to generalize and assume that there is an inherent connection between a refugee identity and mental health. What is key here is that public health practitioners must conduct screenings and interventions that are grounded not only on the traditional HBM but also expand the current HBM by integrating cultural interpretation and understanding of a what is important to specific refugee groups. This can be achieved through a systematic review or meta-analysis of existing cross-cultural literature and in-depth interviews with refugee patients in order to elicit the role of culture on refugee health behaviors, understanding, and help-seeking.
"Pathologizing" Refugees -
Despite lay and clinical ideologies that attempt to naturalize posttraumatic stress as a biological response to distressing events, critical perspectives within the mental health professions suggest that natural responses to traumatic experience should not be agglutinated with pathology (2, 3, 27, 31). In lieu of this criticism, Richman (25) cautions against the pathologising of refugees:
            It is often assumed that all refugee[s]... are 'traumatized' by their experiences,    and need specialist treatment, but in practice few refugee[s]... require specialist      treatment, and distress can often be relieved without recourse to specialists.
To further the critique, mental health and public health providers question the cultural appropriateness of Western therapeutic interventions with refugees groups. Specifically, in non-western cultures, distress is conceptualized in terms of external factors and social experiences rather than internal emotional processes (29). In "The Social Experience of War and Some Issues for the Humanitarian Field", Summerfield argues that psychiatric therapy and counseling may not be practices familiar to refugees, and sharing one's personal feelings outside the family unit may be considered atypical (27).
In light of these complexities, Summerfield urges that refugees' distress should not be seen in Western terms as PTSD, but should be interpreted as "a normative and adaptive communication" (30). However, Summerfield and others do not disqualify the devastating side-effects of traumatic experiences. They acknowledge that all refugees are entitled to support systems. With this in mind, "support needs to be practical, educational and social, bolstering refugees' resilience rather playing on vulnerabilities" (1, 13, 25). Additionally, Burnett (4) notes that the skills of some refugee community members may be valuable for providing the most culturally appropriate, counseling-like interventions.
Considering the complex and culture-specific refugee responses to "trauma," Hek (13) provides important advice: 
What is significant is striking an appropriate balance between ensuring that...refugees have access to emotional and psychological support that makes sense to them, does not make them feel stigmatized and takes into account cultural issues, whilst not immediately assuming that all...refugees will need such input (19, 24). The key, as with all service provision, is to see each [refugee] as an individual who is likely to have some similar experiences to others in similar circumstances, and some different experiences; to build on their strengths; promote positive factors in their lives and engage them in the discussion of what they think they need.
Essentially, refugee experiences are social, political, personal, and situational. In this sense, clinical assessment of refugees should be holistic. Unfortunately, biomedical and psychiatric paradigms of distress have a tendency to reduce these experiences to pathology and neglect more pressing refugee concerns. Mainstream clinical and public health discourse places value on objectivity and the traditional HBM, and tends to medicalize distress, making consideration for social realities and culture an afterthought. 
Medicalizing Idioms of Distress -
As mentioned earlier, concentration on the psychological status of refugees has enlivened a growing body of research on trauma and PTSD. Nonetheless, scholars (e.g. 23, 27-32) dispute the validity of the term “trauma” as an explanatory model for distressing events. These scholars call PTSD a pseudo-condition, arguing that PTSD and trauma are socially constructed and medicalized.
Summerfield (28) indicates that Western psychiatric communities medicalize distress refugees convey. This occurs because psychiatric models of causation apply biological constructs to the lived experiences of refugees. However, in non-western cultures, distress is not an internal emotional phenomenon (29, 31). Refugees conceptualize distress as external social experiences rather than biological symptoms (15).
To explain the asymmetry between clinical and indigenous explanatory models of distress, Summerfield (29) provides one compelling reason:
            Western cultural trends – accelerating in the twentieth century – towards the    medicalization of distress, and the rise of talk therapies, provide the             backdrop to the discourse of ‘trauma’. Medicine and psychology have replaced            religion as the source of descriptions and explanations of human experience, and individual psychology has come to be seen as the core human nature             everywhere.
Ironically, while Western medical communities solidify distress and trauma as somatic symptoms requiring therapy, “there is little evidence that those affected [by traumatic experiences] anywhere in the non-Western world have seen their mental health as an important issue apart, and wanted treatment specifically for this” (31).
Although refugees commonly have traumatic histories and sometimes need psychiatric assistance, indiscriminant application of medicalized paradigms of trauma overlooks their pragmatic or culture-bound concerns. Refugees may see doctors for mundane ailments as well as exotic ones, and their concerns may be social and economic, not just biological and psychological. A sole focus on the biological and behavioral ramifications of distress via a reductionist HBM perspective facilitates the medicalization of refugee life itself.
Medicalization of Refugee Life: A Mixed Blessing? -
Frequently, biomedical conceptualizations of trauma become synonymous with refugees' lived experiences. The Western, culturally-bounded understanding of experiences of violence has a tendency to shift the conversation towards emotional and psychological trauma. Biomedicine and public health follow a similar logic. If traumatic stimuli existed in the past, it must have visible repercussions in the present. In other words, trauma can be pinpointed in a refugee's biology. Such thinking makes it easy to conceive refugees as patients in need of psychiatric assessment. Sometimes, this is a dangerous logic. It amounts to a biomedical generalization that neither considers the context nor the social realities of refugees. A hyperactive medical gaze overlooks the immediate needs of refugees. 
This is not to say that refugees do not need emotional or psychiatric support, but often it is the last thing they seek (31). Correspondingly, Summerfield argues that “there may be risks that the host society offers refugees a sick role rather than what is really sought: opportunities for meaningful citizenship as part of rebuilding a way of life, [learning the host country’s language, finding a place to live or seeking employment opportunities]” (32). Specifically, the biomedical gaze “may reduce still evolving experiences, meanings and priorities of [refugees] to a single category – trauma – so that refugee suffering is too routinely attributed to pre-flight events, neglecting current factors” (32). 
Furthermore, evidence suggests that asylum seekers whose immediate needs are met tend to do better on the social and psychological levels. For example, Dahoud and Pelosi's (7) study of Somali asylum seekers in London revealed that insecure housing, not experience of war, torture or death of relatives, was the predominant variable predicting those who would report mental health issues (cited in 32). Additionally, Gorst-Unsworth and Goldenberg's (12) study demonstrated that in Iraqi asylum seekers in London, poor social support was significantly linked to low mood or depression rather than a history of torture (cited in 32).
However, despite the pitfalls of modern medicine and psychiatry to address the social realities of refugees, the medicalization of refugee life may be a mixed blessing. Considering that qualification for asylum or refugee status is a complex legal process, attaining a PTSD diagnosis "has become the means by which people seek victim status-and its associated moral high ground-in pursuit of recognition and compensation" (14, 31). In other words, "...a biomedical category has to be used in order to get things done" (14). Likewise, for refugee and asylum seekers, a PTSD diagnosis functions as a legitimizing tool; it is "the royal road to [services and protection] for victims of many different sorts of violence...and until a better system can be devised it would be wrong...and surely be unjust to block off this road" (14).
In this way, although the medicalization of "trauma" reduces refugee experiences to a single illness category, a PTSD diagnosis may be the only way refugees or asylum seekers receive legal authorization to remain in the host country. Additionally, this authorization allows for easier access to needed social and medical services.
Indeed, it is paradoxical that objective conceptualizations of "trauma" and the individual-based principles of the HBM can be transformed into a critical asset necessary for legitimation and "moral exculpation" (30). Ironically, the stakeholders of this legitimation are biomedical providers and public health practitioners who adhere to the naturalized PTSD discourse and the traditional HBM (5): “Physicians [and public health personnel] may function as gatekeepers for benefits that are only legitimate in organizations that adopt a medical definition and approach to a problem, but where the everyday routine work is accomplished by nonmedical personnel.”
Despite the mixed blessing of medicalization, Summerfield (30) challenges mental health professionals and public health practitioners to consider the ethical dilemma of categorizing and/or diagnosing people with mental conditions they may not have: might be timely for mental health professionals to review our definition of the disorder as a disease and decide whether it has sufficient robustness and explanatory power to apply to diverse uses to which it is now being put. Society confers on doctors the power to award disease status and social [and legal] advantages attached to the sick role. Current practice, which labels people as being mentally ill when they are not, calls this public duty of doctors into question. To conflate normality and pathology devalues the currency of true illness, promotes abnormal illness behavior, and incurs unnecessary public costs (20).
Taking the above discussion seriously, medical and public health providers must understand that their role permeates beyond prevention, diagnosis, and treatment and into the very fabric of refugee life and identity. Effective public health interventions and good provider-refugee-relationships may depend on providers' willingness to combine treatment with advocacy, social support, and cultural competency. For this to become a common practice, both concepts and discourse must change about the role culture plays on individual health behaviors.
Changing Concepts -
Commonly, "medicalization part of a doctor-patient interaction, when a physician defines a problem as medical (i.e. gives a medical diagnosis) or treats a "social" problem with a medical form of treatment..." (5). However, in order to ensure effective therapeutic interactions, providers must distinguish that refugees "are largely directing their attention not inwards, to their mental processes, but outwards to their devastated social world" (32). With this in mind, "health professionals have a duty to recognize distress, but also to attend to what the people carrying this distress want to signal by it" (32). To accomplish this, clinicians and public health workers must be attentive not only to health behaviors and/or symptomatology, but also to the social and material needs of their refugee clients (32):
Health professionals should beware the limitations of looking at the world through a medicotherapeutic prism. The idea that "recovery" from an aversive experience (or "processing" or "healing" or "closure") is a discrete thing is again a legacy of the Cartesian assumptions that launched psychiatry and psychology - that the mental world is separable from the material world and can be instrumentalised separately. In the real world "recovery" is even more slippery than "suffering", and as subject to sociomoral and philosophical considerations. Its setting is people's lives rather than they psychologies.
Taking this into consideration, liberal application of medicalized idioms of distress may create asymmetry within a physician-refugee-patient relationship. To avoid clinical misunderstanding, mental health professionals should integrate “indigenous” explanatory models of distress into assessment and treatment of refugee groups. Refugee experiences must not be narrowed to pathology. Providers must find a balance between clinical objectivity and real-world subjectivity. This would involve a reworking of the very premise of the HBM and showing culture equal priority when understanding health behaviors. To actualize this, there must be a change in the HBM-inspired biomedical and public health discourse. 
Changing Biomedical & Public Health Discourse -
Effective public health interventions and good physician-refugee-patient relationships may hinge on asking appropriate assessment questions. Before the turn of the eighteenth century, the question of - who are you? and what is the matter with you? - were common clinical inquiries. However, with time, the dynamics of recognition changed.
In The Birth of the Clinic (1994), Foucault addresses the historical and epistemological roots of objectification in the clinical setting. He analyzes how the emerging medical discourse led to the "medical gaze." The change in medical concepts and recognition was fundamental. Over the course of the eighteenth century, the question the physicians asked the patient changed from "What is the matter with you?" to "Where does it hurt?" (cited in 11). In other words, increased biomedical and public health objectivity that transformed how health professional see people.  In this sense, persons became patients and patients became carriers of illness. The priority shifted to treating the illness, not the patient in the holistic sense.
Nevertheless, despite this change in the pattern of recognition described by Foucault, qualitative evidence shows that modern physicians still ask, albeit implicitly, the "Who are you?", "How do you feel?", and "What is the matter with you?" questions in order to forge positive clinical relationships (11).
Additionally, in their seminal article, Kleinman and Benson recommend the use of explanatory models to elicit patients' illness experiences. The model consists of the following clinical questions (18):
What do you call this problem? What do you believe is the cause of this problem? What course do you expect it to take? How serious is it? What do you think this problem does inside your body? How does it affect your body and your mind? What do you most fear about this condition? What do you most fear about the treatment?
However, although such questions are highly applicable in "conventional" and multicultural clinical interactions, they are useful only to translate patient input into familiar biomedical discourse so that clinicians can arrive at a diagnosis and prescribe treatment. Taussig (33), "while applauding the emphasis which the new cross-cultural psychiatry gave to elucidating the patient's model of illness, nonetheless cautioned that the knowledge so obtained could allow the management of the patient to be all the more persuasive or coercive" (cited in 32).
Essentially, Foucault's description of the epistemological shift in clinical questioning and Kleinman's explanatory model approach facilitate the re-coding of lay or culture-bound expressions of illness into more tangible clinical information that can be analyzed and controlled. The goal here is to identify a disease category rather than address the social or material needs of patients. This mentality may not transfer well into refugee care. In this sense, the HBM model needs to be reassessed and reworked to include the concept of culture as a determining factor in health behavior. To start, caring for refugees and asylum seekers may require alternative points of clinical and public health inquiry.
Adjusting Points of Inquiry -
In chapter six of Ingleby’s volume, Summerfield (14, 32) tells a brief anecdote about a Somali asylum seeker (referred to him for psychiatric opinion) who once told him: “Your words are very fine, doctor, but when are you going to start to help me.” Here, the asylum seeker indicates that his distress signals his “focus on practical assistance and advocacy to help bolster [his] immediate social situation” rather than a pursuit of psychiatric therapy or a concern for a mental health problem (14, 32).
Such clinical realities signify that assessment of refugee experiences should “center on practical problems and direct attention to function-focused and problem-focused coping styles… rather than [only] the emotion-focus (14, 32). To step beyond psychopathology and identify actual refugee concerns that are linked to culture, the provider must ask different questions. Questions such as “How are you doing? And What do you need to do?” should prelude “How are you feeling?” (14, 32).
Asking such questions changes the focus of clinical discourse and adds an opportunity to incorporate a socio-cultural understanding of health to the HBM. It facilitates holistic diagnosis and challenges the universality of distress as a somatic symptom. In this vein, Kleinman (17) argues that although signs of distress (i.e. PTSD) can be identified globally, it is a fallacy to assume that distress carries identical meanings in every cultural context. Likewise, Kleinman and Good (16) claim that “describing how it feels to be grieving or melancholy in another society draws one into an analysis of radically different ways of being a person” (cited in 32). 
With this in mind, refugees "know that they will stand or fall by what they do in and about [their social] world" (31). Therefore, as discussed above, "for them the key questions [are] not ["where do I hurt?", or "what do I call this problem?", or] 'how am I feeling?' but 'what can I do to bolster my situation?'" (31). Unfortunately, if distress is perpetually relocated from the "social arena to the clinical arena" there is little promise that mutual clinical understanding, patient satisfaction, and healing will occur (31).   
If clinicians and public health practitioners become conscious of the socio-cultural determinants of health and look to immediate social realities refugees convey, there is hope that better symmetry may be achieved in screening and therapeutic interactions with refugee groups. Indiscriminant conflation of natural responses to traumatic experiences with psychopathology is the demise of effective clinical practices in refugee care. Likewise, assessment of refugee patients must not only be determined by technical and individual-based considerations or symptomatology, but also by the social, cultural, and humanistic parameters. To put this into practice, clinical concepts and discourse must permeate beyond singular, symptom-driven approaches of the prevailing HBM and address more pressing and practical refugee needs that are linked directly with a culture-bound understanding of health and health-seeking.   
Conclusion -
Refugee populations represent a noticeable proportion of patients providers and public health practitioners see. How providers and public health workers assess and treat refugee groups is essential to prevent illness, build new life, and achieve healing. Evidence indicates that best practices in refugee care hinge on providers' ability to recognize the socio-cultural determinants of health and understand the existing social realities of refugee groups. Likewise, effective physician-refugee-patient relationships depend on looking further than psychopathology and medicalized conceptualizations of refugee life. To put this into practice, clinicians and public health providers must challenge existing medical/public health dogma and discourse perpetuated by the narrow application of HBM, and adjust the focus of clinical inquiries to elicit refugees' cultural interpretations of health, practical problems and immediate needs.   

References – 
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