stigma and barriers to care - Uniformed Services University of the ...

Optimizing Access to Care 87
developed in specialty mental health. We need to know how that is going to come
together because we want to hold on to our evidence base. We do not want to throw
out those years and important efficacy trials.
The second principle, as we are building on access and meeting people where
they are coming to care, is engagement. For engagement I am going to try and bring
together two intellectual persons. We have had some wonderful talks by Sue Estroff
and other sociologists. Once upon a time I aspired to be an anthropologist, but was
not smart enough, so I went into medicine. I followed Arthur Kleinman’s work.
Much of the collaborative care model is founded in the illness perspective and meeting
the patient where they are at. Arthur has some fascinating studies of Taiwanese
shamans. The shamans have incredible retention rates because you come with any
problem and you can lay it out for the shaman and the shaman will deal with it;
marital conflict, death of a relative, a trauma. Those are some of the fundamental
aspects, actually, of care management. At a population level, if you are going to do
population-based medical phenomenology, you are concerned with the needs and
concerns of the population.
I will not get too much into Haiti, but I ended up in this mode with a population
that has profound religious and spiritual beliefs. I may not be a priest, but someone
may come to me and say, “My church is in rubble. My congregation is scattered
and I am having trouble praying, which is my primary coping mechanism.” I do not
know how to deal with that but I certainly can problem solve around, “Can you
find your congregation” I can deal with the general issue; I cannot help with the
actual prayer. What we are trying to do is to engage people with whatever needs
and concerns they have.
The third principle gets to what Chuck Engel now is doing 10 years later, which
is a stepped-care protocol. There is a very strong evidence base for this sort of intervention,
in which a care manager engages the patient in primary care and then steps
up the care to evidence-based CBT and medication for depression. There is much
less of an evidence base in PTSD. It is very hard to field the kind of trial that Art
Kleinman did in the Jerusalem trauma study, even in a day-to-day routine trauma
center context let alone in the chaos post disaster.
Going back to Kleinman, we have access, we have engagement, and we have
stepped care, all basic principles that can be applied across post-disaster settings.
Not much of this has been tested and we have STEPS-UP that is leading up to test
these principles in a military context. What about stigma As a frontline hardheaded
clinician, the cases we saw post 9/11 made a great deal of sense to me in terms of the
stigma of having nightmares, memories, and wanting to be seen in a primary care
clinic rather than a mental health specialty clinic. That makes intuitive sense to me.
Arthur and Joan Kleinman have written about how suffering can be biomedicalized.
If social scientists do not address frontline patient and provider concerns, we can
take what is happening in the clinic and make it too much of an abstraction so it is
not really relevant and does not get into clinical encounter.
What I think is important is that in these post-disaster contexts, stigma may be
important but there may be other concerns or competing demands that come first.
Again, we do not have the luxury of doing population-based clinical phenomenological
studies with every population. But as front line providers we need to learn
to taste what the different issues are and then engage around the key concerns. We
are moving inductively from clinical work and case studies, and we are trying to
think about theory. I agree with Sue Estroff, who said that theory is really important