Family Therapy in Developing Countries Primary Care Alain Quinet1, Sarah Shelmerdine2, Patrick Van Dessel3 and Jean-Pierre Unger3*
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Quinet et al. J Fam Med Dis Prev 2015, 1:2 ISSN: 2469-5793 Journal of Family Medicine and Disease Prevention Research Article: Open Access Family Therapy in Developing Countries Primary Care Alain Quinet1, Sarah Shelmerdine2, Patrick Van Dessel3 and Jean-Pierre Unger3* 1Independent Psychiatrist, Belgium 2Independent Consultant, UK 3Department of Public Health, Institute of Tropical Medicine, Belgium *Corresponding author: Prof. Jean-Pierre Unger, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, B-2000 Antwerpen, Belgium, Tel: +32-3-247.62.54, Fax: +32-3-247.62.58, E-mail: [email protected] Abstract Introduction Purpose: Mental health and psychosomatic problems are both Mental health and psychosomatic problems are both widespread widespread and disabling in low and middle-income countries and disabling in low and middle-income countries (LMIC) settings (LMIC). There is a clear need for strategies to strengthen first line [1-3]. Up to 30% of patients attending primary care facilities in LMIC services for their treatment. Family (‘systemic’) therapy has been shown to be effective in this setting but there is a dearth of research present with common mental disorders [4-6]. In addition, many investigating its use. other pathological conditions known to be made worse by mental Methods: A family therapist, psychiatrist by training was interviewed factors (e.g. psoriasis, eczema, stomach ulcers, high blood pressure, by a public health doctor specialized in health services organization, and heart disease) require bio-psychosocial treatment [4]. Consider to derive concepts useful for GPs and nurses working in LMIC first an asthma crisis in a child: like a regulatory shunt in an overloaded line services to handle the relational and emotional component of electric circuit, it often occurs when there is a need to diffuse tension bio-psychosocial care. The interview was supplemented with a between the parents. literature review. Results: Concepts in systemic therapy conditions dealt with by However, in LMICs, mental health (for instance depression [7]) systemic therapy are detailed together with basic concepts in receives little attention [8,9] and scant resources [10]: systemic approach e.g. symptom persons, family homeostasis, neurotic vs. psychotic families, therapeutic resources, circular - In most LMICs less than 1% of the total health budget is allocated questioning, reframing, paradoxical injunctions, therapy steps, to mental health [10]; strategies to accompany changes, and required organization features. - There is no more than one psychiatrist and one psychiatric nurse Conclusions: First line professionals can be involved in the per 100,000 people; treatment of psychic and relational disorders without in-depth - There are even fewer psychologists and social workers working preparation. Family/systemic therapy appears more effective than psychoanalytical techniques in LMIC because there is limited in the mental health field [11]. tradition of introspection in LMIC, and families in LMIC remain There is thus a clear need for strategies to strengthen LMIC first strongly structured and a key social safety net. line services for the treatment of mental health problems and for the Systemic therapies can have an important impact on quality promotion of bio-psychosocial care [12,13]. of care where health professionals have no tradition of properly handling bio-psychosocial disorders and improve doctor-patient A patient-centered perspective in primary care practice is barely communication. However, more experience is needed to define the conditions for its optimal utilization in LMIC. reflected in medical curricula. Doctors in LMICs have rarely been exposed to concepts useful in the handling of individual psychological Keywords and family relationship disorders. Many tend, at the first opportunity, Family medicine, Mental health, Health systems strengthening, to refer any mental disorder to a hospital or a psychiatrist without Family therapy, Systemic therapy, Low and middle income having tried to solve the problems themselves. Because they lack countries the related concepts and practical tools, communication is rarely Abbreviations perceived as an intellectual challenge, even less an indispensable AIDS: Acquired Immune Deficiency Syndrome, GP(s): General therapeutic tool [1]. This is true, despite established links between Practitioner(s), LMICs: Low and Middle Income Countries, NGO(s): patient-centered care and positive outcomes of healthcare delivery, Non-Governmental Organization(s), TB: Tuberculosis, WHO: including patient satisfaction [14], resolution of patients’ concerns World Health Organization and health outcomes [15,16] in both high and low and middle- income countries [17]. In industrialized countries, many patients with mental problems Citation: Quinet A, Shelmerdine S, Dessel PV, Unger JP (2015) Family Therapy in Developing Countries Primary Care. J Fam Med Dis Prev 1:006 ClinMed Received: April 11, 2015: Accepted: July 19, 2015: Published: July 23, 2015 International Library Copyright: © 2015 Quinet A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. respond best to a combined approach. Experienced clinicians usually for the system within which the suffering individual is located. One draw on various counseling theories and techniques to design such approach is family/systemic therapy [31,32]. Systemic therapy interventions that fit a patient’s problem. The format of therapy (e.g., is one of the main schools of thought in psychotherapies, alongside individual, couple, family, or group) will vary with each patient: psychoanalysis, transactional analysis and behavioral psychology. Systemic therapy focuses on how relationship dynamics influence the - Psychoanalysis offers interpretations of the meaning of the presenting problem and the therapist aims at altering these dynamics, patient’s free association of ideas and feelings. rather than focusing on the behavior (as in behavioral psychology) Brief psychotherapy attempts to achieve behavioral or attitudinal or internal dynamics (as in psychoanalysis) of the individual. Family change and the clinician makes recommendations based on an counseling, for example, brings the entire family or relevant key understanding of the situation and the reasons for resisting change. members together to discuss specific problems of one or more family This form of therapy employs empathy, suggestion, persuasion, members, including marital discord, drug abuse, or relationship education, reassurance, and insight. Supportive psychotherapy is problems. used to reinforce a patient’s defenses, but avoids the intensive probing The “systems” to which “systemic therapy” refers are essentially of emotional conflicts employed in psychoanalysis and intensive families, extended or not, according to the relevant situation. psychotherapy. However, they may include religious or community leaders, friends, It is not, however, so simple a matter as being able to transport other relatives, traditional healers, and already or potentially involved strategies found to be effective in high income countries to LMICs health professionals and health services. [4,18]. This is largely because of socio-cultural and ideological While there is a dearth of research investigating the use and differences [19] and because of differences in the range of barriers effectiveness of this technique in LMICs, this paper aims to sketch out to addressing mental health issues faced by high and low income a broad professional orientation in systemic therapy for GPs, nurses, countries. Furthermore, classical forms of psychotherapy have been medical assistants and their supervisors working in LMIC settings. found to be less effective in LMICs than in high-income settings (see, for example, Patel et al. [20]). This is thought to be because Methodology psychotherapy reflects the (Western) culture in which it was developed [2]: in its traditional form, it is based on talk about the self, A family therapist, psychiatrist by training and experienced conceptualized in individualist terms. The constructions implicit in in Belgium, Senegal, Congo and Vietnam, was interviewed by a this approach do not fit well with LMIC’s more socio-centric cultural public health doctor specialized in health services organization. frameworks, which often conflict with Western understandings of the The purpose of the interview was to derive from the psychiatrist’s person, his/her illness and the extended family structure [21,22]. 30 years professional experience concepts useful for GPs and nurses working in LMIC first line services to handle the relational A few researchers have shown that group therapy, rather than and emotional component of bio-psychosocial care which they are individual counseling, is more compatible with local understandings expected to deliver under the primary health care strategy [33]. In a in many LMIC settings. Patel et al. [20], for example, showed, in a series of four one hour interviews, the therapist was asked to discuss randomized control trial, that group therapy had significant effects key methodological issues related to his clinical and supervision in the treatment of depression in India, as compared with individual experiences in systemic therapy. The interview was supplemented therapy, which had no greater effect