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Where Is the Family in Global Mental Health?

Our Kosovar Albanian hosts began orienting us to their country as soon as we stepped off our flight. Our group of American mental health professionals had arrived in 1999 hoping to aid a people traumatized by war and ethnic cleansing. A University of Pristina faculty member's first statement was, "In Kosova, a person is a family member, not an individual." He explained how strong families and family clans had preserved Kosovar culture during 500 years of Ottoman Turk occupation, followed by a century of Serbian occupation (Griffith et al., 2005).

In the world's low- and middle-income countries (LMIC), a person's identity is often located more within the family, clan, or tribe than the individual (Hofstede, 2011; Helman, 2007, pp. 281-285). Throughout history, strong families have protected vulnerable individuals, nurtured children, and gathered resources for the common good. In many low- and middle-income countries, this social unit extends beyond the nuclear family to include the extended family with grandparents, aunts, uncles, and cousins.

It is notable that neither family therapy nor family medicine has placed insistent attention upon the centrality of the family in the mental health of LMIC, given the expertise in family centered care that each discipline has to offer. Global mental health seeks to reduce inequities, within and between countries, to access evidence-based interventions for the prevention and treatment of mental health problems. Global mental health has introduced innovations in mental health service delivery to achieve these aims with efficiency and effectiveness. As discussed in this volume by Patterson and Edwards (2018), these include integration of mental health services into primary care; task-sharing and task-shifting strategies; and stepped-care health service delivery. Families are often the most plentiful resource available to global mental health programs in impoverished LMIC. Families can be major contributors to resilience against trauma and loss (Patel, 2012, p. 9; Yarns, 2015, p. 129). We believe that the family should move to the forefront of global mental health clinical research, mental health policy, and human rights advocacy.

A stepped-care model can provide a point of entry for family therapists and primary care physicians to contribute to the global mental health mission (Patterson, Abu-Hassan, Vakili, S., & King, 2018; Patterson, Edwards, & Vakili, 2018). Stepped-care is a population health care strategy in which a patient population is provided education on health behaviors and self-care. Those still symptomatic receive an additional basic, manualized level of care that is often provided by a nurse or a nonprofessional health care worker. Those individuals with severe or persistent symptoms are then referred to specialists for individualized treatment. Stepped health care delivery has been demonstrated to be effective for anxiety and depression, as well as psychosocial care of chronic medical disorders (Bower & Gilbody, 2005; Eaton, De Silva, Rojas, & Patel, 2014; van Straten, Hill, Richards, & Cuijpers, 2015). Stepped-care can expand the scope of global mental health interventions in LMIC by adding multiple family members to treatment programs and by drawing upon the natural organizational strengths of families. In typical family centered stepped care for a target population care is intensified, as needed, across a series of tiers:

* First tier. Family psychoeducation about common mental health problems, schoolbased parenting classes, and family strengthening programs would be provided for all families across the target population (Kumpfer & Alvarado, 2003).

* Second tier: Specific screening for mental health problems would occur as a routine component of patient visits to primary care clinicians, both for sake of efficiency and to reduce stigma. During patient encounters, primary care clinicians could administer brief resilience-building interventions alongside medical treatment when patients are struggling to cope (Griffith, 2018).

* Third tier: Primary care screening that identifies specific mental health problems, such as depression, anxiety, or posttraumatic symptoms, would prompt a referral to a nurse or mental health worker with focal training in resilience-building psychotherapeutic interventions and basic family therapy skills. Resilience-building psychotherapeutic interventions can be drawn from hope modules (Griffith, 2018) or resilience-building cognitive-behavioral psychotherapy (Padesky et al., 2012). Requisite family therapy skills are those needed to build a therapeutic alliance with the family and to engage family members in an action plan where each person has a role (Sprenkle, Davis, & Lebow, 2009). Validated methods have been developed for selecting nurses and mental health workers with sufficient empathy, relational skills, and emotional awareness to fulfill this role competently (Kohrt et al., 2015).

* Fourth tier: A mental health professional or primary care clinician with family therapy expertise would support the nurse or mental health worker with clinical supervision, case consultations, and referral of complex cases. Complex cases include either patients with severe symptoms or problems that failed to resolve at the third tier level. Mental health problems that are primarily because of dysfunctional family processes or abuse, neglect, or exploitation of vulnerable family members often require a fourth tier specialist (Rohrbaugh, Kogan, & Shoham, 2012).

A stepped care model is justified by its low costs and breadth of impact. Depending upon level of need, everyone within a target population can be reached. Nurses and mental health workers are more plentiful and less costly than mental health specialists in LMIC. Engaging families in a strength-based approach avoids stigma that often limits access to mental health care by individuals.

A cultural readiness for family centered stepped care may exist in any LMIC where family or clan identities predominate. Recently, the Jordanian Ministry of Health engaged our "Global Mental Health Initiative in the Middle East" (1) to provide 10 days of training in mental health services for 30 of their general practitioners who worked in Ministry of Health primary care clinics. These general practitioners' medical educations consisted of 6 years medical school plus 1 year of general medical postgraduate training. No training in mental health care had been included in their medical education. In their primary care clinics, these general practitioners typically treated 30 patients a day, commonly in 5-10 min office visits. In one of the training exercises, attendees presented "difficult cases" in a role-played interview. The following case consultation was typical for the cases presented:
Ms. Aqilah is elderly and suffers from depression and diabetes. She
spends her day sitting silently. Ms. Aqilah's diabetes has been
difficult to control and now is impairing her vision. For years, she
had devoted her life to her three sons with personal sacrifices that
included work outside the home for extra income. Now her sons have all
grown up, completed education, and begun successful careers in another
city. Her husband mostly stays in his room. Ms. Aqilah had consoled
herself by reading the Qur'an, but now her poor vision interferes. She
seems to be just waiting do die. How can she be helped?

It stood out that this Jordanian physician did not simply present the facts of a case. Implicit in her description was a well-developed formulation organized around a developmental crisis in Ms. Aqilah's family, precipitated by her sons' departures into adult life. Also notable were responses of other group members when asked to brainstorm possible interventions. Within 5 min other general practitioners were recommending interventions based upon this family formulation:

1. Insufficient funds had been put forward as the reason that visits by the sons had not already taken place. Contact the sons to pool their money so they could take turns visiting their mother.

2. Organize a ceremony attended by family and friends that would honor Ms. Aqilah's parenting and personal sacrifices that reared three sons from childhood into mature adults who were living lives of integrity.

3. Meet with the husband to enlist his assistance in helping his wife to better adhere to care for her diabetes.

These physicians responded naturally to this family formulation based upon their personal experiences and knowledge about Jordanian families and culture. They were already "thinking family," unlike in the United States where trainees often feel they are learning a new language when asked to "think family" (Fogarty & Mauksch, 2017).

Unlike in North America, patients in Jordan and other LMIC often live long lives in close proximity with their families, with little voluntary geographic movement or social dislocations. Despite the brevity of 5-10 min clinical encounters, physicians come to know their patients and their patients' families well over time. This vignette shows how family centered care may find a natural fit with the clinical thinking of primary care clinicians in LMIC than for their North American counterparts.

Family centered health care fits well within the global mental health mission to reduce health care inequities in LMIC. Engaging families in treatment requires no additional health care expenditures. Families are plentiful in LMIC as an untapped resource for healing and illness prevention. Helping build family centered stepped delivery of health care in LMIC holds promise as an exciting new frontier for family therapy and family medicine.


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James L. Griffith, MD

The George Washington University

Jessica Keane, BA

University of San Diego

James L. Griffith, MD, Department of Psychiatry and Behavioral Sciences, The George Washington University; Jessica Keane, BA, Marital and Family Therapy Program, University of San Diego.

Correspondence concerning this article should be addressed to James L. Griffith, MD, Department of Psychiatry and Behavioral Sciences, The George Washington University, 2120 L Street, NW, Suite 600, Washington. DC 20037. E-mail:

Received April 2, 2018

Accepted April 3, 2018

(1) The "Global Mental Health Initiative in the Middle East" is an academic consortium that includes the University of California, San Diego Department of Family Medicine and Public Health Division of Global Health, the University of San Diego Marriage and Family Therapy Graduate Program, and the George Washington University Department of Psychiatry and Behavioral Sciences.
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Title Annotation:COMMENTARY
Author:Griffith, James L.; Keane, Jessica
Publication:Families, Systems & Health
Date:Jun 1, 2018
Previous Article:An Introduction to Global Mental Health.
Next Article:Use of the WHO's Perceived Well-Being Index (WHO-5) as an Efficient and Potentially Valid Screen for Depression in a Low Income Country.

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