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Title: Medicine, Psychiatry and Process Work: Individual and collective dimensions of working with embodied experiences and mental states


1
Medicine, Psychiatry and Process Work Individual
and collective dimensions of working with
embodied experiences and mental states
  • Pierre Morin, MD, PhD

2
Main Points
  • Studies over the last 25 years have found
    significant relationships between inequality in a
    society and various health outcomes.
  • Processes of social marginalization, rank
    relative poverty in populations may be a critical
    risk factor for physical and mental health.
  • Psychology, including the way we process or
    internalize cultural dynamics has a big impact on
    our health.

3
Health is both an individual and a cultural or
group process
  • What makes us healthy or sick depends both on
    individual and social factors. Research shows
    that social conditions the jobs we do, the
    money were paid, the schools we attend, the
    neighborhoods we live in are as important to
    our health as our genes, our behaviors and even
    our medical care.

4
Medical Models
  • Bio-medical model
  • Social determinant model
  • Bio-psycho-social model
  • Balance/Holism model
  • Psychodynamic model
  • Positive psychology (Seligman), Positive health
    model (Antonovsky)
  • Indigenous model
  • Recovery/Self-management model

5
Current Roles/Polarities
  • Victim Healer/Expert
  • Nature Nurture
  • Biology/Genes Society
  • Body Mind
  • Pathology Positive Health
  • Disease management Recovery
  • Evidence based Care
  • Efficiency

6
Health Disparities
  • Available studies show the US to have the most
    mental illness, of any country.
  • Trends show mental distress increasing in the US
    over the last decades.
  • Studies over the last 25 years have found
    significant relationships between inequality in a
    society and various health outcomes, including
    self-assessed health, mortality measures, teenage
    birth rates. It also correlates with rates of
    violent crime.
  • Relative poverty in populations may be a critical
    risk factor for mental health.
  • The escalating rates of mental illness observed
    may represent an adaptive response to the
    increasing hierarchy in the US.

7
Health Disparity
  • Relative poverty
  • Disparity between the rich and the poor High gap
    correlates with poor population health.
  • Social comparison Feelings of humiliation,
    resignation and shame affect our stress
    physiologies.

8
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9
Wilkinson 1992 BMJ
10
Somebodies and Nobodies
  • Sense of being a nobody in social comparison to
    others.
  • Loss/lack of status/rank because of
    marginalizing processes.
  • Sense of shame and humiliation, loss of respect
    and dignity.
  • Independent of individual psychology.
  • Power of internalized social values.

11
Competition outcomesthrough dominance /
attraction
Dominance upperness
fight
Lack of control
POWER
HEDONIC
AGONIC
flight
Social Integration approach closeness friendlines
s ingroup orientation (insider) love
attractiveness
Social Isolation withdrawal distance hostility ou
tgroup orientation (outsider) hate
AFFILIATION
co-operation
withdrawal
Control
yielding
Submission lowerness
Stevens 1996
12
Social Position/Rank
Occupational status
Income, wealth
Common physical and mental disorders
Education
Biological and psychological factors/powers
13
Social Position
Psychosocial Resources -mastery/self-efficacy sel
f-esteem
Health Outcomes - mental - physical
  • Stress
  • life events
  • chronic strains
  • daily hassles
  • early adversities
  • Social Support
  • emotional
  • instrumental
  • social integration

Stress Process Model (Pearlin 1989)
14
SES, Social Class, Inequality
  • Gender, age, race, SES, sexual orientation,
    health are sources of inequality that form
    inter-locking webs of disadvantage
  • power, resources are differentially distributed
    within and between these status positions
  • we do not occupy single status categories
  • Double or Triple Jeopardy Hypothesis

15
Marginalization
  • Overt or covert trends within societies whereby
    some qualities/behaviors/traits are given more
    centrality and those perceived as deviating from
    the group norms tend to be excluded by wider
    society.
  • Marginalized groups racial or ethnic minority
    groups, the poor, the elderly, the sick, the
    disabled, the obese, homosexuals etc

16
Levels of Influence
  • Dispositional/personal power/rank an
    individuals capacity to influence their actions
    or those of others
  • Psychological
  • Spiritual or transpersonal
  • Social
  • Situational/contextual power/rank derives
    from ones momentary roles in a given situation
    as a teacher, health care provider, parent, bank
    teller etc....
  • Systemic power/rank the complex of
    powerful forces that create situations/envi
    ronments

17
Rank
  • Rank reflects the underlying power differences of
    the many hierarchies we use on a daily basis to
    compare ourselves (Fuller, 2003).
  • Conscious or unconscious, social or personal
    ability or power emerging from areas of
    socio-cultural influence, personal psychology,
    and/or spiritual ties (Mindell, 1995) .

18
Subjective Rank and Health
19
Relative Poverty
  • "When everyone is poor together, there is no
    shame in being poor." (Gilligan)
  • "A house may be large or small as long as the
    surrounding houses are equally small, it
    satisfies all social demands for a dwelling. But
    if a palace rises beside the little house, the
    little house shrinks into a hut" (Karl Marx)

20
Process Work Approach
  • Individual FIELD Community

Process Consensus Reality Dreaming Essence Physi
cal Symptoms Mental States Dreams Conflicts/Group
Process
21
Opportunities for Public Health InterventionsA
Social Determinants Framework
Social Health Determinants

Targeted Protection
Primary Prevention
Secondary Prevention
Tertiary Prevention
Equity and Social Justice
Reduces Vulnerability
Disability and Death
A Safe, Healthy Population
Vulnerable Population
Diagnosed, but with no complications
Clinical complications requiring treatment
Societal Resources
Creates Vulnerability
Adverse Social Conditions
The Physical Environment
Upstream Approaches Social Cohesion, Social
Equity, Social Capital
Downstream Approaches Provision of Clinical
Services
Adapted from Milstein B, Homer J. The dynamics of
upstream and downstream why is it so hard for
the health system to work upstream, and what can
be done about it? CDC Health Systems Workgroup
Atlanta, 2003.
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