Papers by Dr. Liana E . Chase
The Lancet Psychiatry, 2020
Medicine Anthropology Theory, 2021
As 'psychosocial interventions' continue to gain traction in the field of global mental health, a... more As 'psychosocial interventions' continue to gain traction in the field of global mental health, a growing critical literature problematises their vague definition and attendant susceptibility to appropriation. In this article, I recast this ill-defined quality as interpretive flexibility and explore its role in processes of translation occurring at the frontlines of care in rural Nepal. Drawing from 14 months of ethnographic fieldwork among community-based psychosocial counsellors, I consider how the broad and flexible notion of the 'psychosocial problem' operates as a 'boundary object' in transnational mental health initiatives-that is, how it facilitates the collaboration of service users, clinicians, donors, and policymakers in shared therapeutic projects without necessarily producing agreement among these parties regarding the nature of the suffering they address. I suggest that psychosocial interventions may be gaining popularity not despite but precisely because of the lack of a unitary vision of the problems psychosocial care sets out to alleviate. In closing, I reflect on what distinguishes 'psychosocialisation' from medicalisation and highlight the limitations of the latter as a critical paradigm for the anthropology of global mental health.
Global Mental Health, 2018
Efforts to address global mental health disparities have given new urgency to longstanding debate... more Efforts to address global mental health disparities have given new urgency to longstanding debates on the relevance of cultural variations in the experience and expression of distress for the design and delivery of effective services. This scop-ing review examines available information on culture and mental health in Nepal, a low-income country with a four-decade history of humanitarian mental health intervention. Structured searches were performed using PsycINFO, Web of Science, Medline, and Proquest Dissertation for relevant book chapters, doctoral theses, and journal articles published up to May 2017. A total of 38 publications met inclusion criteria (nine published since 2015). Publications represented a range of disciplines, including anthropology, sociology, cultural psychiatry, and psychology and explored culture in relation to mental health in four broad areas: (1) cultural determinants of mental illness; (2) beliefs and values that shape illness experience, including symptom experience and expression and help-seeking; (3) cultural knowledge of mental health and healing practices; and (4) culturally informed mental health research and service design. The review identified divergent approaches to understanding and addressing mental health problems. Results can inform the development of mental health systems and services in Nepal as well as international efforts to integrate attention to culture in global mental health.
Background: The World Health Organization's 'building back better' approach advocates capitalizin... more Background: The World Health Organization's 'building back better' approach advocates capitalizing on the resources and political will elicited by disasters to strengthen national mental health systems. This study explores the contributions of the response to the 2015 earthquake in Nepal to sustainable mental health system reform.
Methods: We systematically reviewed grey literature on the mental health and psychosocial response to the earthquake obtained through online information-sharing platforms and response coordinators (168 documents) to extract data on response stakeholders and activities. More detailed data on activity outcomes were solicited from organizations identified as most active in the response. To triangulate and extend findings, we held a focus group discussion with key governmental and non-governmental stakeholders in mental health system development in Nepal (n = 10). Discussion content was recorded, transcribed, and subjected to thematic analysis.
Results: While detailed documentation of response activities was limited, available data combined with stakeholders' accounts suggest that the post-earthquake response accelerated progress towards national mental health system building in the areas of governance, financing, human resources, information and research, service delivery, and medications. Key achievements in the post-earthquake context include training of primary health care service providers in affected districts using mhGAP and training of new psychosocial workers; appointment of mental health focal points in the government and World Health Organization Country Office; the addition of new psychotropic drugs to the government's free drugs list; development of a community mental health care package and training curricula for different cadres of health workers; and the revision of mental health plans, policy, and financing mechanisms. Concerns remain that government ownership and financing will be insufficient to sustain services in affected districts and scale them up to non-affected districts.
Conclusions: Building back better has been achieved to varying extents in different districts and at different levels of the mental health system. Non-governmental organizations and the World Health Organization Country Office must continue to support the government to ensure that recent advances maximally contribute to realising the vision of a national mental health care system in Nepal.
Clinical guidelines in refugee mental health increasingly advocate phased approaches to intervent... more Clinical guidelines in refugee mental health increasingly advocate phased approaches to intervention that foreground the provision of pragmatic and social support in contexts of ongoing instability. However, the impact of such interventions has rarely been explored from the perspective of refugees themselves. We conducted ethnographic research on the experiences and perceptions of users of an intervention embodying this approach: a community Day Center for asylum seekers in Montreal. Data comprising 15 interviews and field notes from 50 participant observation visits were analyzed using an established theoretical framework to identify mechanisms supporting self-perceived wellbeing among users in the domains of safety, social networks, justice, identity/roles, and existential meaning. Results shed light on how this nonspecific buffering intervention responds to the threats and pressures asylum seekers themselves identify as most salient in the immediate postflight context. These findings are discussed in relation to emerging theoretical frameworks in refugee mental health that emphasize agency, justice, and the role of local ecologies. We conclude that the Day Center shows significant promise as an innovative early stage mental health intervention for precarious status migrants and merits further research and evaluation.
The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social netw... more The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social networks and community supports in the ongoing resettlement process. This paper presents ethnographic findings on the role of informal care practiced by relatives, friends, and neighbors in the prevention and alleviation of mental distress in two Bhutanese refugee communities: the refugee camps of eastern Nepal and the resettled community of Burlington, Vermont, US. Data gathered through interviews (n = 40, camp community; n = 22, resettled community), focus groups (four, camp community), and participant observation (both sites) suggest that family members, friends, and neighbors were intimately involved in the recognition and management of individual distress, often responding proactively to perceived vulnerability rather than reactively to helpseeking. They engaged practices of care that attended to the root causes of distress, including pragmatic, social, and spiritual interventions, alongside those which targeted feelings in the ‘‘heart-mind’’ and behavior. In line with other studies, we found that the possibilities for care in this domain had been substantially constrained by resettlement. Initiatives that create opportunities for strengthening or extending social networks or provide direct support in meeting perceived needs may represent fruitful starting points for suicide prevention and mental health promotion in this population. We close by offering some reflections on how to better understand and account for informal care systems in the growing area of research concerned with identifying and addressing disparities in mental health resources across diverse contexts
In 2012 the Canadian government made significant cuts to its historically strong federal refugee ... more In 2012 the Canadian government made significant cuts to its historically strong federal refugee health coverage plan. While this policy had negligible effects on the level of coverage provided to asylum seekers in Quebec, there is evidence that this group nonetheless experienced reduced healthcare access during the period of polarized national debate that ensued. This study engaged the “candidacy” model of healthcare access to illuminate factors contributing to the observed gap between entitlement and access. Twenty-five semi-structured interviews were conducted with asylum seekers in Montreal to elicit narrative accounts of difficulties encountered in the pursuit of healthcare. Thematic content analysis in conjunction with a holistic examination of help-seeking trajectories revealed several important barriers to obtaining care, including widespread confusion and misinformation about refugee health coverage, cumbersome administrative procedures specific to asylum seekers, and long wait times. Feelings of marginalization and insecurity associated with precarious migratory status appeared to amplify the effects of these barriers to care such that even a minor access difficulty could have dramatic effects on future help-seeking and access outcomes. Demonstrating awareness of public discourses interrogating their deservingness of health coverage, participants often interpreted access difficulties as evidence of health professionals' unwillingness to serve them. Such interpretations conspired with fears associated with the asylum claim process to suppress self-advocacy, further help-seeking, and at times even information-seeking. This finding is particularly significant in that it suggests a mechanism through which hostile public representations of forced migrants–increasingly prevalent in Western host countries–can themselves endanger the physical, psychological, and social health of highly disadvantaged populations, even in the presence of strong entitlement policies. We close with reflections on how theoretical models of healthcare access might be adjusted to better accommodate the unique experiences of precarious status migrants.
The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social netw... more The recent rise in suicide among Bhutanese refugees has been linked to the erosion of social networks and community supports in the ongoing resettlement process. This paper presents ethnographic findings on the role of informal care practiced by relatives, friends, and neighbors in the prevention and alleviation of mental distress in two Bhutanese refugee communities: the refugee camps of eastern Nepal and the resettled community of Burlington, Vermont, USA. Data gathered through interviews (n=40, camp community; n=22, resettled community), focus groups (four, camp community), and participant observation (both sites) suggest that family members, friends, and neighbors were intimately involved in the recognition and management of individual distress, often responding proactively to perceived vulnerability rather than reactively to help-seeking. They engaged practices of care that attended to the root causes of distress, including pragmatic, social, and spiritual interventions, alongside those which targeted feelings in the “heart-mind” and behavior. In line with other studies, we found that the possibilities for care in this domain had been substantially constrained by resettlement. Initiatives that create opportunities for strengthening or extending social networks or provide direct support in meeting perceived needs may represent fruitful starting points for suicide prevention and mental health promotion in this population. We close by offering some reflections on how to better understand and account for informal care systems in the growing area of research concerned with identifying and addressing disparities in mental health resources across diverse contexts.
Published in: Himalaya, 34(1): Article 19
Anthropology & Medicine, 2010
Illness narratives and explanatory models have been a research focus for the discipline of medica... more Illness narratives and explanatory models have been a research focus for the discipline of medical anthropology for decades. In recent years, standardized qualitative research tools have been developed to elicit illness narratives as a means of conducting socio-cultural analysis and as a springboard for health-related interventions - particularly with reference to communities experiencing rapid socioeconomic transition or those in which trauma has been experienced. Nevertheless, gaps persist in terms of the latent methodological and epistemological challenges of translating and transplanting such research tools to new contexts. This paper chronicles the adaptation of the McGill Illness Narrative Interview (MINI) for use in the culturally Tibetan region of Mustang, Nepal. This analysis is based on 44 in-depth interviews using an adapted version of the MINI to elicit narratives about experiences of illness. The MINI proved to be a compelling research tool, particularly in terms of engaging research assistants in the field. Yet its deployment in a context where distinctions between individual and social suffering can be blurred, where the dichotomization of 'religion' and 'medicine' makes little sense, and where understandings of causality are rooted in the concept of karma, revealed the extent to which the MINI - and, by extension other such qualitative research tools - emerges from particular models of narrative construction and assumptions about the relationships between self and other, cause and effect. Concluding recommendations are made regarding the adaptation of this tool to other settings.
Ethical approval to work with human subjects was obtained from the Nepal Health Research Council.... more Ethical approval to work with human subjects was obtained from the Nepal Health Research Council. All interviewees were over eighteen years of age. Twenty-six interviewees were selected from a randomised list of households generated using the UNHCR database to represent major demographic groups in the camps; these interviewees were also administered the Brief COPE (see ). Four pilot interviews were conducted with individuals randomly approached in the camps. Key informants included representatives of all major communitybased organisations, two community health workers, leaders in camp administration and security, one shaman (dhami), and one astrologer (jyotisi).
A short article geared towards practitioners which summarizes my findings in the Bhutanese refuge... more A short article geared towards practitioners which summarizes my findings in the Bhutanese refugee community of Burlington, VT.
This ethnography addresses the experience and communication of psychosocial distress associated w... more This ethnography addresses the experience and communication of psychosocial distress associated with Bhutanese refugee resettlement as well as the way one refugee community has worked to foster resilience in the post-resettlement context. Many refugees have had experiences that predispose them towards diagnoses of “mental disorder,” including torture, sexual violence, and forced migration. Moreover, most resettled refugees continue to face psychosocial challenges as they adapt to daily life in a new country. A number of interventions have been developed to provide support during the transition to resettled life, yet these services are often inaccessible and/or poorly utilized due to a confluence of cultural, linguistic, financial, and other barriers. This study explores culturally sanctioned approaches to healing and adjustment, especially those that involve refugees as active participants in their conceptualization, development, and implementation. Specifically, this study is focused on the case of Bhutanese refugees in the US, an ethnically and linguistically Nepali group that lived in exile in eastern Nepal for nearly two decades before being subject to resettlement campaigns in the US and several other developed countries. A combination of participant observation, focus groups, and semi-structured interviews was used to illuminate a Bhutanese refugee ethnopsychology of wellness. In this pursuit, the author explored the relationship between language and concepts of psychological health and illness as well as social ecological influences on wellness.
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Papers by Dr. Liana E . Chase
Methods: We systematically reviewed grey literature on the mental health and psychosocial response to the earthquake obtained through online information-sharing platforms and response coordinators (168 documents) to extract data on response stakeholders and activities. More detailed data on activity outcomes were solicited from organizations identified as most active in the response. To triangulate and extend findings, we held a focus group discussion with key governmental and non-governmental stakeholders in mental health system development in Nepal (n = 10). Discussion content was recorded, transcribed, and subjected to thematic analysis.
Results: While detailed documentation of response activities was limited, available data combined with stakeholders' accounts suggest that the post-earthquake response accelerated progress towards national mental health system building in the areas of governance, financing, human resources, information and research, service delivery, and medications. Key achievements in the post-earthquake context include training of primary health care service providers in affected districts using mhGAP and training of new psychosocial workers; appointment of mental health focal points in the government and World Health Organization Country Office; the addition of new psychotropic drugs to the government's free drugs list; development of a community mental health care package and training curricula for different cadres of health workers; and the revision of mental health plans, policy, and financing mechanisms. Concerns remain that government ownership and financing will be insufficient to sustain services in affected districts and scale them up to non-affected districts.
Conclusions: Building back better has been achieved to varying extents in different districts and at different levels of the mental health system. Non-governmental organizations and the World Health Organization Country Office must continue to support the government to ensure that recent advances maximally contribute to realising the vision of a national mental health care system in Nepal.
Methods: We systematically reviewed grey literature on the mental health and psychosocial response to the earthquake obtained through online information-sharing platforms and response coordinators (168 documents) to extract data on response stakeholders and activities. More detailed data on activity outcomes were solicited from organizations identified as most active in the response. To triangulate and extend findings, we held a focus group discussion with key governmental and non-governmental stakeholders in mental health system development in Nepal (n = 10). Discussion content was recorded, transcribed, and subjected to thematic analysis.
Results: While detailed documentation of response activities was limited, available data combined with stakeholders' accounts suggest that the post-earthquake response accelerated progress towards national mental health system building in the areas of governance, financing, human resources, information and research, service delivery, and medications. Key achievements in the post-earthquake context include training of primary health care service providers in affected districts using mhGAP and training of new psychosocial workers; appointment of mental health focal points in the government and World Health Organization Country Office; the addition of new psychotropic drugs to the government's free drugs list; development of a community mental health care package and training curricula for different cadres of health workers; and the revision of mental health plans, policy, and financing mechanisms. Concerns remain that government ownership and financing will be insufficient to sustain services in affected districts and scale them up to non-affected districts.
Conclusions: Building back better has been achieved to varying extents in different districts and at different levels of the mental health system. Non-governmental organizations and the World Health Organization Country Office must continue to support the government to ensure that recent advances maximally contribute to realising the vision of a national mental health care system in Nepal.