Latin American and Spanish-speaking perspectives on the challenges of global psychiatry. Renato D. Jair J. The multi-faceted phenomenon known as globalization has a particular impact on the conceptual and practical development of mental health disciplines in general, and psychiatry in particular, across different world regions.
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The multi-faceted phenomenon known as globalization has a particular impact on the conceptual and practical development of mental health disciplines in general, and psychiatry in particular, across different world regions. To be theoretically and functionally effective, global psychiatry requires an integration of its different components. These may constitute supportive elements of an instrumental inter-regional bond in the present and future of our discipline.
Globalization is, without a doubt, one of the most frequently mentioned and debated terms in the contemporary world. The term became fashionable in the past 2 or 3 decades, driven by a variety of sociodemographic, geo-political, economic, and techno-scientific factors.
Not surprisingly, the concept has been perceived, elaborated, and utilized differently by groups positioned in favor of or against its implications.
Thus, politicians and economists may see in globalization immense opportunities for growth and greater income for individuals, families, communities, and nations. Social communicators consider it a platform of total access to, and massive dissemination of information across the world.
The notion of a universal language, away from the failed experiment of Sanskrit, now witnesses an almost unstoppable reality of English playing precisely that role. Finally, pertinent debatable areas and conclusions are proposed. In , the total world population reached 7. By the year , rural populations are expected to reach 3. In , there were cities with more than one million inhabitants each, a number that will grow at least three times in the next 3 decades.
By , 41 mega-cities with more than 10 million inhabitants each are anticipated; currently, this number is A recent review on homicides and suicides in megalopoles shows the impact of economic indicators, ethnic conflicts, social inequalities, and religious and cultural differences: a disorganized process of urbanization and the marked differences between wealthy and marginalized sectors become high risk factors for a normal emotional development.
Religious clashes, leading to wars in several parts of the world, are also a response to what is perceived as the threatening hegemony of subordinating, authoritarian powers. Thus, the burden of social neglect, family erosion, handicaps, and disadvantages grows, fueled by deficits in nutrition, financial income, job markets, genuine affection, solidarity, or support.
In the strictly clinical field, an increased prevalence of highly disabling mental disorders, comorbidities of different kinds, and the scarcity of diagnostic and therapeutic resources render the psychiatric and mental health needs of the globalized world a rather complex set of problems and uncertainties.
In turn, each cultural group, although in possession of its unique value system, finds itself struggling over the survival of such values, open as they are to both dialogue and conflict. And, considering the historical and cultural perspectives, there are different ways to get ill, to express or explain symptoms, to seek help, or to respond to treatment among patients from different geographic or national origins.
This process also involves moral and ethical perspectives, since, even with the acceptance of universal precepts and norms, ethical judgment is always exercised within a particular frame of circumstances. Psychiatry has evolved differently in different parts of the world.
It is clear that while its historical origins reside in Eastern civilizations and regions, the most structured and most productive source in modern times 18th century on came from Europe, particularly its Western territories.
Currently, psychiatry from Western continental Europe and its Anglo-Saxon counterpart may be said to share significant features. Thus, continental European psychiatry is best characterized by descriptive and phenomenological approaches inspired by German and French pioneers, such as Jaspers, the Schneiders, Kretschmer, Ey, and many others and particularly oriented to a solid initial diagnosis.
A big platform for theoretical debates, 37 , 39 , 40 this branch of psychiatry seems to be, however, free of rigid school- or doctrine-based rules. It advocates the active use of varied clinical resources and modalities, and an overall combination of medical approaches, empirical or scientific postulates, and humanistic principles. Continental European psychiatric practice also emphasizes diversity, with predominance of social or so-called universal coverage of mental health services.
Also, this emergence, in the context of growing U. Since World War II, four areas have clearly come to reflect the interaction between globalization trends and the developments in the theory and practice of psychiatry. The first relates to attempts at establishing nosological taxonomies with universalistic aspirations. The second front is that of treatments. The third area, planning, financing, and delivery of care, has faced more difficulties, even though it has also tended to reach global dimensions.
The fact, however, almost two decades later, is that such approaches have neither been fully demonstrated nor generally accepted. And so, other traditions have emerged, with geography, a main referent, and language, a pivotal feature in any culture, as unifying factors. These traditions encompass, of course, the two large continents of Asia and Africa; but, for the purposes of this work, the case of Latin American psychiatry including Portuguese-speaking Brazil and the broader Spanish-speaking psychiatry, including Spain, 69 - 72 will be examined.
The remaining portions of the article will examine the role of this psychiatry in a world carrying the ambiguous label of globalization. We will briefly examine its three geo-demographic and sociocultural components, their history, value endowments, achievements, and contributions to a globalized world. On its side, Portugal colonized the territory that formed Brazil, today the second largest country in the Americas. At the time of conquest and colonization, there were more than native or aboriginal cultures and communities in what is now Latin America.
The treatment armamentarium in those cultures included the use of shamanistic or magical approaches and religious rituals with elaborated nosological explanations and a large paraphernalia of management practices. Paradoxically, during this colonialist period, an intense religious zeal also submitted many mentally ill persons by summary trials and swift executions, through the actions of the Tribunals of the Sacred Inquisition.
The trajectory of Latin American psychiatry has reflected to some extent the paths followed by psychiatry in other latitudes and regions of the world. In the twentieth century, contributions from the phenomenological-existential, biological, psychodynamic, social, and community camps were incorporated. This sequence outlines four developmental periods in the history of Latin American psychiatry post-colonial subordination, selective import of ideas, critique and sedimentation, and synthesis , leading to the contemporary delineation of a still debatable, yet unique identity.
As a result of these approaches, Latin American psychiatry has been characterized by three features: mestiza , social, and critical. The second characteristic, its social scope, is dictated not only by demographic and economic realities, but also by traditions that enhance sociocentrism or communalism, friendship- and family-based practices, hierarchically-inspired respect for parental as well as elderly and other types of authority, and persistence of some rural life habits.
The third characteristic of Latin American psychiatry is its critical stance. Thanks to the work of leading academicians, educators, and scholars, many of the concepts coming from both Europe and the United States have been and are processed, analyzed, and critically examined before they are either taken in or, more frequently, adapted. Significant contributions to phenomenology, psychopathology, clinical diagnosis, psychodynamics, medical psychology, folkloric psychiatry, clinical epidemiology, and cultural psychiatry, substantiate the trajectory of Latin American psychiatry.
The Latin American population is not a uniform, monolithic entity. Different ethnicities, languages, and subcultures persist, in some cases practically untouched by European-inspired civilization, or the actual globalization forces.
Attention to the mentally ill in Spain had a religion-inspired, asylum-based nature before the institutionalization of psychiatry as a medical practice. Some historians maintain however, that hospital assistance to mentally-ill individuals existed earlier in Granada and Barcelona. Later on, many asylums in Spain became physically or administratively associated with general hospitals, thus generating a tradition that also absorbed the significant input of religious congregations. Psychiatric associations and journals were created at the beginning of the 20th century.
The strong influence of German psychiatry at the beginning of the 20th century made it possible for Spanish psychiatry to absorb both phenomenological and humanistic approaches.
The Spanish Civil War forced into exile a good many Spanish psychiatrists from both the psychoanalytic and neurobiological fields. Most of these exiles ended up in Latin American countries, particularly Mexico, Chile, and Argentina.
It is clear that Spanish psychiatry embraced and expanded the contributions of continental Europe and Anglo-Saxon scholarship. The role of Spanish psychiatry in the European continent was enhanced while, at the same time with reciprocal immigration waves beginning in the s being a decisive factor , favoring an increasingly closer contact with other segments of Spanish-speaking psychiatry.
An important event during the early s was the start of a profound reform in the organization and provision of psychiatric care in Spain. This process eliminated the old asylums, which were replaced with well-structured care-providing networks, closely connected with primary care practitioners. In the last three decades, advances in neurobiological and epidemiological research have produced a vast critical mass of young investigators, already competitive in the international field.
The downside of this reality, however, is that Hispanics as a group find themselves at the bottom of the economic totem pole, mostly in low-paying jobs particularly in the agricultural area , living below poverty levels in terms of housing, income, nutrition, and other parameters.
Familism, Marianism, close family connectedness, strong Catholic practices, a mix of conservative and liberal economic philosophies, and a general sense of self-protectiveness are the main cultural characteristics of the Latino population. Hispanic psychiatrists accounting for about 5, of the 35, Hispanic physicians in the U. The work of Hispanic mental health professional organizations in the United States, such as the American Society of Hispanic Psychiatry ASHP , founded in the late s, the Latino Behavioral Health Institute, the Hispanic Caucus of the American Psychiatric Association APA , and specialized centers in academic and clinical facilities, materializes in scientific and professional events, multidisciplinary encounters, specialized publications, and training events for young Hispanic clinicians and researchers.
This makes Hispanic psychiatry a vibrant, although relatively small, presence within Spanish-speaking psychiatry. Comparative, inter-ethnic including genetic research projects and publications, 97 with strong inquiries on the epidemiology of subpopulations, suicidal behavior, the impact of cultural factors on quality of life, illness experiences, acculturation, and risk and protective factors dominate the contributions of Hispanic psychiatrists in the United States.
The growth of Hispanic psychiatry is also reflected in the appointment of psychiatrists from this community to department head roles in academic centers around the country, as well as in their participation in national organizations such as the APA which has had three Hispanic presidents in the last 18 years , scientific and research agencies such as the National Institute of Mental Health NIMH , and international entities, such as the WPA, the World Health Organization WHO , and the Pan-American Health Organization PAHO.
The ethnic push, the arduous attention to particularities, may drown the ethical basis, made out primarily of moral universals. Furthermore, the practice of psychiatry implies a prudent balance between universal knowledge and local realities.
The nature of the knowledge that we call scientific includes an aspiration to universality. However, the history of medicine and of its basic sciences has consistently taught us that such aspiration cannot always be reached, since human beings, while physiologically similar, inhabit different sociocultural scenarios. There are diverse forms of humanity, and the processes acquire different meanings in the context of each culture. Psychiatry is, by definition, the most human and the most humanistic of medical specialties, and therefore it cannot renounce the imprint of this moral tension.
Even though in some parts of the world, it may take refuge in the technicality of what is scientifically universal, its ultimate purpose is to understand human suffering, help the sick, and accompany the incurable. One result of the analysis conducted in these pages is the amalgam of precious characteristics and achievements of the European and Anglo-Saxon brands of psychiatry and the inner essence of the Latin American and Spanish-speaking versions of the discipline.
Latin or Iberian American, Spanish, and U. Hispanic psychiatry can join forces, strengthen their ties not to play a competitive role in the international scene, but to assist in the generation of dialogues, the creation of sources of excellence for world psychiatry, on the basis of the genuinely syncretic discipline that it is today.
As said above, this role could be based on a combination of idealism and pragmatism, of acceptance and validation of what is possible vs. The resource constraints of the so-called developing countries can forge innovative mental health care strategies born out of both uniqueness and need , while developed countries can contribute to assess efficacy and measure outcomes.
Hispanic psychiatry in the United States and Iberian or Latin American psychiatry can work with Spanish psychiatry in that bridge-building role, beyond individualism closer to the Anglo-Saxon tradition or theoricism mostly ascribed to continental European psychiatry , with the virtues of a practical sociocentrism, looking at each and every person in any given community. Common cultural realities preceding colonization experiences, mestizaje processes, devotion to traditional descriptive, explanatory and healing practices provide flexible scenarios of historical understanding, mutual acceptance, and willingness to push cooperative efforts in clinical, teaching, and research terrains.
On the contrary, it can be the basis of stronger coalitions, educational efforts, social responsibility, and values that entail the possibility of a non-conflicting relationship between evidence-based and reason-based psychiatric practice. This constitutes a broadly educated mental structure, not one trapped in the diminishing frame of reductionism. Beyond any scientific foundation, world psychiatry constitutes a community of practices 83 that needs to be recognized in its historical development, its regional particularities, its sociocultural ingredients, 6 , 82 and its future multidimensional perspectives.
It can do it by: 1 retaining the imprint and the characteristics of its people, its culture and its history the whole notion of identity ; 2 describing and comparing its problems with those of the other regions; and 3 formulating potential solutions on the basis of an authentic universal, scientific language. Latin American and Spanish-speaking perspectives on the challenges of global psychiatry.
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Latin American and Spanish-speaking perspectives on the challenges of global psychiatry.
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