Category: Academic Writing

Cannabinoids & Metabolism

Much attention has been paid to the emotional and cognitive effects of marijuana. However, we believe that these effects can only be understood in the context of the endocrine interactions which are initiated by marijuana’s ingestion. In this article we will examine the function of both endogenous and exogenous cannabinoids with an emphasis on metabolic functioning.

We will review evidence which points to endocannabinoids as critical components of the body’s energy balance apparatus, and implicates endocannabinoid dysregulation in the development of metabolic syndrome, type 2 diabetes, and mental illness. Finally, we will suggest that cannabis extracts may be useful in the treatment of metabolic dysregulation, and that illicit use of marijuana may in many cases constitute a form of self-medication for the emotional effects of metabolic disorder.

The Metabolic Disorder

The metabolic disorder is a constellation of prediabetes symptoms now recognized by the International Diabetes Federation. Its symptoms include central obesity, hypertension, fasting hyperglycemia, decreased HDL cholesterol, and elevated triglycerides. The metabolic syndrome is associated with the development of type 2 diabetes, gout, non-alcoholic fatty liver disease, polycystic ovarian syndrome, and an irregularity of skin pigmentation known as acanthosis negricans (IDF, 2006).

The etiology of the metabolic disorder is unclear and appears to be extremely complex. Some have argued that insulin resistance brought about by excessive dietary carbohydrate may be a primary cause of the metabolic syndrome, while others have pointed to obesity, chronic inflammation, or excessive uric acid levels caused by dietary fructose.

The Endocannabinoid System

Interest in the biological activity of cannabis sativa and its primary constituent, Delta(9) Tetrahydrocannabinol (THC), led to the discovery of an endogenous cannabinoid system. The endocannabinoids are natural phospholipids which bind to a pair of G-protein coupled cannabinoid receptors known as CB1 and CB2. THC primarily activates CB1 receptors, which are found in the hypothalamic nuclei, the mesolimbic system, and in peripheral tissues including fat cells and gastrointestinal organs (Pagotto, Vicennati, & Pasquali, 2005).

The hypothalamic nuclei is involved in regulating energy balance and body weight, and so it is believed that CB1 plays a role in up- and down-regulating the body’s metabolic rate in order to adjust to the amount of energy available. The mesolimbic system is believed to be involved in regulating the incentive value of food, and so is important for increasing and decreasing appetite as necessary. The peripheral tissues represent the final link in this chain of metabolic regulation, and are responsible for the absorption and release of nutrients. Because CB1 receptors are concentrated in these biological regions, and because THC administration is associated with increased appetite, the endocannabinoids have long been thought to be involved with regulating appetite (Pagotto, Vicennati, & Pasquali, 2005).

Biochemical Effects of Cannabinoids

The function of THC-activated CB1 receptors in adipose tissues has been clarified by laboratory experimentation. A recent study examined the biological effects of cannabis extract on both normal and insulin-resistant adipose tissue cultures. In cell cultures, THC increased insulin-induced glucose uptake, meaning that it essentially countered the effects of insulin resistance. These results support previous findings that smoking cannabis can reduce blood glucose in diabetics (Gallant, Odei-Addo, Frost, & Levendal, 2009). They also lend support to the hypothesis that cannabis and cannabis extracts may be useful in the treatment of type 2 diabetes and prediabetes metabolic disorders, which disorders are characterized by insulin resistance and consequent hyperinsulinemia.

The Metabolic Role of Cannabinoids

It appears that endocannabinoids play a central role in the metabolic process by mediating the effects of insulin and regulating the rate at which cells utilize insulin-induced nutrient uptake. For example, one study found that in healthy subjects who were not insulin-resistant, insulin reduced endocannabinoids levels. This effect was inversely proportional to the level of insulin resistance. (DiMarzo et al, 2009). The implication of this finding is that the popular understanding of type 2 diabetes as a disorder of insulin sensitivity may be incomplete.

It is well established that endocannabinoids plays a major role in the control of appetite and peripheral metabolism. CB1, which is activated by THC, is responsible for most of these effects. A natural hyperactivation of the endocannabinoid system results in a chronic positive energy balance and obesity. Drugs designed to block endocannabinoid reception reverse this effect, producing not only a decrease in appetite but also weight loss in excess of what could be explained by the reduction in caloric intake. In short, high levels of endocannabinoid activity induce energy storage while low levels induce energy expenditure (Despres, 2007). Further evidence for this relationship can be found in the characteristic accumulation of intra-abdominal fat that is seen in patients with type 2 diabetes and cardiovascular disease. CB1 reception appears to specifically mediate this effect (Cote, 2007).

Emotional Effects of Glucoregulatory Disorders & THC

Emotional distress has been identified as one of the two primary motives for marijuana use in young adults (Brodbeck, Matter, Page, & Moggi, 2007). However, the mechanisms by which marijuana alleviates emotional distress have remained mysterious. A study of high school students found that, among students with high rates of truancy, emotional distress was significantly associated with dysregulation of blood sugar levels. Students with hyperglycemia reported higher levels of distress (Iwatani et al, 1997). Since hyperglycemia is a result of insulin resistance, this study tells us that prediabetic conditions are significantly associated with subjective feelings of emotional distress.

Recent studies have demonstrated that metabolic syndrome is associated with the onset of depression (Takeuchi et al, 2009) and post-traumatic stress disorder (Jin et al, 2009). It is very possible that susceptibility to these disorders may be a result of endocannabinoid dysregulation, and could be treated by cannabis extracts. It is furthermore possible that chronic illicit marijuana use may represent a form of self-medication for metabolic dysregulation and its associated emotional effects.

Conclusion

As we have seen, the endocannabinoid system is intimately involved with the regulation of metabolic functioning. Cannabinoid receptors mediate insulin-stimulated glucose uptake, cellular lipogenesis, and energy balance. Type 2 diabetes and metabolic disorder are brought about by hyperinsulinemia, which in turn brings about insulin resistance and insensitivity to the effects of endocannabinoids.

Cannabis extracts, and specifically THC, exert a direct effect on insulin sensitivity and glucose uptake, resulting in lowered blood sugar. They also result in the alleviation of subjective feelings of emotional distress, although the mechanism for this effect remains unclear. Because the literature increasingly suggests a connection between metabolic dysregulation and emotional distress, we conclude that metabolic correction may be the means by which cannabis extracts provide relief from emotional distress.

Our conclusion is novel. Although others have suggested that cannabis may sometimes be used to self-medicate for symptoms of anxiety or ADHD, we are aware of no other researchers who have connected illicit cannabis use with self-medication for metabolic disorder. Nonetheless, we believe the evidence is compelling enough to warrant serious speculation and to prompt additional research. The evidence we have reviewed in this paper suggests that cannabis extracts may be effective treatments for metabolic syndrome, and may help to moderate the negative physiological, neurological, and psychological effects of glucoregulatory disorders.

The evidence furthermore suggests that treatment programs focusing on chronic marijuana use should give special attention to the medical and dietary implications that this drug use may have. It is possible that certain cases of marijuana dependence may be better conceptualized and treated if full metabolic assessments were performed concurrently with psychological assessments. This may be particularly true of those cases in which the reported reasons for marijuana use relate to emotional distress. The literature provides increasing evidence for mind-body interaction, and therefore suggests that quality of care will improve as medical and psychological treatment programs become more fully integrated.

References

1. Brodbeck, J., Matter, M., Page, J., & Moggi, F. (2007). Motives for cannabis use as a moderator variable of distress among young adults. Addictive Behavior, 32(8), 1537-1545.
2. Côté, M., Matias, I., Lemieux, I., Petrosino, S., Alméras, N., Després, J.P., & Di Marzo, V. (2007). Circulating endocannabinoid levels, abdominal adiposity and related cardiometabolic risk factors in obese men. International Journal of Obesity, 31(4), 692-699.
3. Després, J.P. (2007). The endocannabinoid system: a new target for the regulation of energy balance and metabolism. Critical Pathways in Cardiology, 6(2), 46-50.
4. Di Marzo, V., Verrijken, A., Hakkarainen, A., Petrosino, S., Mertens, I., Lundbom, N., Piscitelli, F., Westerbacka, J., Soro-Paavonen, A., Matias, I., Van Gaal, L., & Taskinen, M.R. (2009). Role of insulin as a negative regulator of plasma endocannabinoid levels in obese and nonobese subjects. European Journal of Endocrinology, 161(5), 715-722.
5. Gallant, M., Odei-Addo, F., Frost, C.L., & Levendal, R.A. (2009). Biological effects of THC and a lipophilic cannabis extract on normal and insulin resistant 3T3-L1 adipocytes. Phytomedicine, 16(10), 942-949.
6. International Diabetes Federation (2006). The IDF Consensus Worldwide Definition of Metabolic Syndrome. Retrieved from http://www.idf.org/webdata/docs/IDF_Meta_def_final.pdf on November 24, 2009.
7. Iwatani, N., Miike, T., Kai, Y., Kodama, M., Mabe, H., Tomoda, A., Fukuda, K., & Jyodoi, T. (1997). Glucoregulatory disorders in school refusal students. Clinical Endocrinology, 47(3), 273-278.
8. Jin, H., Lanouette, N.M., Mudaliar, S., Henry, R., Folsom, D.P., Khandrika, S., Glorioso, D.K., & Jeste, D.V. (2009). Association of posttraumatic stress disorder with increased prevalence of metabolic syndrome. Journal of Clinical Psychopharmacology, 29(3), 210-215.
9. Pagotto, U., Vicennati, V., & Pasquali, R. (2005). The endocannabinoid system and the treatment of obesity. Annals of Medicine, 37(4), 270-275.
10. Takeuchi, T., Nakao, M., Nomura, K., Inoue, M., Tsurugano, S., Shinozaki, Y., & Yano, E. (2009). Association of the metabolic syndrome with depression and anxiety in Japanese men: a 1-year cohort study. Diabetes/Metabolism Research And Reviews, 25(8), 762-767.

The Individual Psychology of Alfred Adler and his successors has always purported to have implications for career choice and satisfaction. The techniques of Adlerian lifestyle analysis, such as the assessment of psychological birth order and the interpretation of early recollections, provides a great deal of information about an individual’s motivations, preferences, and general orientation towards self, other, and the world at large. In this paper we will examine the ways that this information can be used to develop an expedient and comprehensive view of our clients’ career paths and to assist them in making choices that will satisfy their conscious needs as well as their unconscious private logic.

Overview of Adlerian Theory

The basic premise of Individual Psychology is that all individuals strive to transform their perceived inferiorities into perceived superiorities. The specific types of inferiority that an individual perceives originate in his or her relationship to the early environment. Elements of this environment include what is called the family constellation, or the arrangement of parents, siblings, and other family members in relation to the individual. For example, the order in which a child is born into his or her family will tend to exert a strong influence on the types of opportunities and expectations that he or she experiences while growing up, and so will influence the development of the individual’s personality and style of living across the lifespan (Watkins, 1993).

Another major premise of Adlerian assessment and counseling is that behaviors of all kinds, including emotional and cognitive behaviors, are teleological. In fact, Individual Psychology holds that the purposive nature of each behavior can be fit within the framework of an individual’s overarching final goal, of which he or she is unlikely to have any conscious knowledge. The pattern of behaviors which build up in support of this final goal, in turn, constitute the individual’s style of life (Watkins, 1993).

Finally, Individual Psychology holds that the individual is inseparable from his or her social environment. Because the individual’s perceptions and purposes are seen to emerge from the social situation in which the individual is positioned, all of the actual and perceived problems of life are seen as social problems, The well-adjusted individual, therefore, experiences a strong sense of connection with his or her social environment. Adlerians refer to this sense of connectedness as the community feeling or the sense of social interest (Watkins, 1993).

Overview of Adlerian Assessment & Counseling

 

Adlerian assessment is fundamentally an assessment of the individual’s manner of relating to the world around him or her. One way in which this relationship can be understood is through an examination of the early social environment in which the individual’s style of life originated and developed. Because the individual is seen as an active force in his or her world from the very beginning, the lifestyle assessment focuses on the ways in which the young individual began to make a place for himself or herself within the family unit.

A major component of this adaptive process can be surmised from the individual’s ordinal and psychological birth order. A first-born child, for example, is often cherished and expected to fulfill the wishes of his or her parents, and so is likely to tend toward conventionality and conscientiousness. The second-born enters the environment several years behind his or her older competitor and is therefore unable to match the elder sibling’s skill in fulfilling the parents’ wishes. This child will therefore often learn to demand attention and recognition through originality and rebellion, and by developing skill in areas where the elder sibling has not excelled. A key point in the consideration of birth order is that it is the child’s experience of his position within the family that is important, rather than the actual order in which the child was born. A second-born who is five or six years older than the elder sibling may feel and behave as though he or she were a second-born, an only child, an eldest child, a middle child, or any combination of the four, depending on the interactional dynamics of the family as a whole (Leong, Hartung, Goh, & Gaylor, 2001).

A key projective technique of Adlerian assessment is the interpretation of early recollections. Because the individual is seen as an active participant in the creation of his or her environment, the memory itself is seen not as a passive storage of past events but rather as an active recreation which serves to reinforce the individual’s private goals. Therefore, by scrutinizing an individual’s recollections of early life, the clinician can get a sense for the private logic that emerged from the early situation and the ways in which it may be maintained in the present day.

From these techniques the individual’s style of living can be deduced. This lifestyle consists of the individual’s attitudes toward him or herself, toward others, and toward the world at large. It is through the exploration and evaluation of these attitudes that Adlerian counseling and psychotherapy aim to assist the client in cultivating an increased sense of interconnectedness with his or her social environment. It is precisely this social interest which is, in Individual Psychology, seen as the essence of health and adaptation.

Implications of Lifestyle for Career Assessment

An individual’s choice of career can be seen as an extension and expression of his or her total style of life. As Watkins (1993) explains:

It is saying, “This is who I am,” “This is how I see myself vis-a-vis others,” “This is how I see myself vis-a-vis the world at large.” For example, the person whose life-style is oriented around helping and assisting others might gravitate toward such jobs as counseling, nursing, or some other helping profession. The person whose life-style is oriented around knowing (to know, find out) might gravitate toward such jobs as science or academics. Further still, the person whose life-style is oriented around getting and acquiring (to have and to hold) might gravitate toward jobs that emphasize collecting, buying, and investing (p. 357).

There is some limited research to support these notions and to connect them with other, better-studied models of career conceptualization. A 1978 study compared the predictive power of Holland’s Self-Directed Search (SDS) against Mosak’s lifestyle typology. This study found that life style type was “essentially as effective as SDS in such predictions.” A study published in 1980 also supported a relationship between vocational orientation and lifestyle type. This study compared Thorne’s Life Style Analysis measure against Holland’s Vocational Preference Inventory and found a number of significant correlations between indices on the two measures. In particular, the authors of that study noted strong correlations between Holland’s Enterprising scale and the Aggressive-Domineering and Domineering-Authoritarian lifestyle configurations. Mosak’s Conforming lifestyle type also correlated positively with Holland’s Conventional scale and negatively with his Artistic scale (Watkins, 1984).

As self-selected representations of the life-style, early recollections can therefore be used as an expedient tool for collecting information about individuals’ vocational motivations as well as their individual vocational needs. A series of early recollections provides the skilled Adlerian counselor with a wealth of information about the client’s way of learning, of motivating him or herself, of approaching work as a basic task of life, and of relating to others in both collegial and authoritative capacities.

Lifestyle and Career Counseling

According to Watkins (1984), “the more consistent the person’s life style is with the realities and demands of an occupation, the greater the likelihood that the person will be satisfied in the occupation.” He further explains that the compatibility of an individual’s own lifestyle with those of his or her coworkers will be a great importance, due to its effect on the individual’s ability to find a place for him or herself within the interpersonal dynamics of the workplace. These ideas are not at all dissimilar from other theories of career congruence, such as Super’s “life-span, life space” model (Anderson, 1995).

One Adlerian approach to career counseling, called the “Career Goals Counseling” process and developed by McKelvie & Friedland (1978, as cited in Watkins, 1993) focuses on assessing and modifying clients’ personal goals, assessing and intervening with the obstacles that impede those goals, and assessing or modifying the strategies that clients are using to meet their goals. When we speak of personal goals in this context, it should be noted that we are speaking not only of situational or intermediate goals, but also of Adlerian final goals, or the basic strivings which characterize the client’s lifestyle. Such goals might be along the lines of “being good” or “being superior” (Newlon & Mansager, 1986, as cited in Watkins, 1993).

Likewise, the obstacles that an individual faces may not only be objective in nature, such as discrimination, lack of education, lack of information, and so on. Individuals also carry with them their own set of personal, internalized limitations that impede their ability to select and succeed in career that they will ultimately find fulfilling. These include “irrational ‘shoulds,’ ‘oughts,’ and ‘musts’ that we maintain” (Watkins, 1993).

Strategies, then, are the patterns of behavior that individuals engage in in order to advance their goals. These strategies are reflective of the unique manner in which an individual attempts to implement his or her lifestyle. While two workers might share the goal of “advancing,” one might seek to do so through consistent and conscientious work while another seeks to accomplish the same goal by finding fault with and criticizing co-workers (Watkins, 1993).

In order to discover a client’s unique system of goals, obstacles, and strategies, the McKelvie-Friedland approach calls for a complete lifestyle assessment interview. This procedure is a standard practice in all types of Adlerian counseling and psychotherapy, and it involves taking a detailed psychosocial history, including information about the client’s family constellation and a set of early recollections. In this model of career counseling, the counselor concentrates on helping the client to gain insight into vocationally-relevant psychosocial dynamics in his or her own life. For example, the client might be led to consider the career ramifications of his or her life goal, and to consider more effective choices given his or her current life situation and direction (Watkins, 1993).

The main shortcoming of the McKelvie-Friedland approach, according to Watkins (1993), is that it is essentially a direct translation of the standard Adlerian counseling approach into the area of career counseling. As noted, it involves a complete lifestyle assessment interview, which is often quite lengthy and may include elements which, Watkins argues, the average career counseling client will have trouble relating to because of its abstract, “experience-distant” orientation.

Watkins finds a more creative reinterpretation of Adlerian clinical technique in the work of Savickas, who states “…much of the data gathered with the Life Style Inventory [or interview pertains to career-adjustment counseling, that is, helping clients cope with problems at work. Although enlightening, data about family constellation and early recollections are not needed for career-choice counseling” (1989, as cited in Watkin, 1993). Savickas refers, then, to a “career-style counseling” method that fits within the framework of Individual Psychology.

Savickas’ career-style counseling utilizes an abbreviated “career-style assessment” designed to gather lifestyle information that is directly applicable to vocational choice in an experience-near fashion. In this assessment process, clients are first asked to describe their role models in order that the counselor can begin to understand their values and potential ambitions. Next, clients are asked about their favorite books and magazines, thereby gathering further information about role models and valued characteristics as well as preferred environments and types of interactions.

Clients are next asked leisure activities they enjoy; this line of inquiry provides insight into the clients’ interests, ways of self-expression, and coping strategies. Questions about clients’ preferred school subjects next provides the counselor with information about “work habits, work attitudes, and preferred work environments” (Watkins, 1993). Savickas’ model directs counselors to next inquire about clients’ favorite mottoes or sayings. Personal mottoes are likely to directly reflect pertinent lifestyle information and so provide insight into the client’s basic heuristics for evaluating situations.

The next step in the career-style assessment is to ask clients to share their “occupational daydreams” as well as the ambitions that their parents had for them. These questions will provide insight into the internalized meanings that occupational roles hold for clients. Finally, clients are asked about an important decision that they made, and the process whereby they came to make the choice that they made. This final line of questioning allows the counselor to understand what steps will need to be taken to assist the client in reaching a decision.

Conclusion

While the ideas and methods of Individual Psychology certainly seem to have a lot to offer to the career counselor, there are two major problems with each of the Adlerian approaches that we have examined: lack of empirical support, and lack of a clear model for intervention. Although there is some very limited research indicated significant correlations between Adlerian constructs and more widely accepted career development and assessment models, this research derives from only a handful of relatively small studies which have been spread out over significant periods of time.

Likewise, Adlerian career counseling has not yet found a clear model for intervening in the career development of clients. The available literature speaks to the value of Adlerian projective techniques such as lifestyle analysis and early recollections, but makes no mention of specifically Adlerian methods for making use of this information. This lack may reflect Individual Psychology’s psychoanalytic roots, pointing to an underlying assumption that insight into the causes and dynamics of psychological and practical difficulties will ultimately provide the client with more and better behavioral choices. However, this assumption is far from explicit in the available literature and would be surprising given Adlerian counselors’ reliance on concrete tactics and strategies in psychotherapy sessions (Mosak & Maniacci, 2006).

Therefore it is more likely that Adlerian career counseling methodologies are simply under-researched and poorly developed at this time. This is not to say that standard techniques of Adlerian counseling and psychotherapy could not be effectively adapted to the career counseling situation, but simply that doing so would require experimentation on the part of the practitioner. Individual Psychology has been enjoying a minor resurgence in the United States over the last five or ten years, and so the problem of Adlerian career counseling may be one that will yet be adequately addressed.

References

1. Anderson, K.J. (1995). The use of a structured career development group to increase career identity: An exploratory study. Journal of Career Development, 21(4), 279-291.
2. Leong, F.T.L., Hartung, P.J., Goh, D., & Gaylor, M. (2001). Appraising birth order in career assessment: Linkages to Holland’s and Super’s models. Journal of Career Assessment, 9(1), 25-39.
3. Mosak, H.H., & Maniacci, M.P. (2006) Tactics in counseling and psychotherapy. Mason, OH: Thomson Brooks/Cole.
4. Watkins, C.E., Jr. (1993). Psychodynamic career assessment: An Adlerian perspective. Journal of Career Assessment, 1(4), 355-374.
5. Watkins, C.E., Jr. (1984). The Individual Psychology of Alfred Adler: Toward an Adlerian vocational theory. Journal of Vocational Behavior, 24, 28-47.

Stigmatizing attitudes toward mental illness, individuals suffering from mental illness, and psychological service utilization are widespread. They result in social isolation, reduced opportunities, and outright discrimination against affected individuals (Gaebel, Zäske, Baumann, Klosterkötter, Maier, & Decker et al., 2008). The negative effects of stigma also extend to the families of individuals with mental illness, their close relationships, and even the professionals who work with them (Goffman, 1963; Sadow & Ryder, 2008). This stigma is associated with treatment underutilization, treatment delay, and premature termination (Masuda et al., 2007; Gaebel et al., 2008; Gould, Greenberg, & Hetherton, 2007; Corrigan, 2004).

Definitions & Understandings of Stigma

In his classic text on stigma as “spoiled identity,” Goffman (1963) describes stigma as a visible or invisible ‘mark’ that disqualifies its bearer from full social acceptance. Mental illness marks affected individuals as having “blemishes of individual character,” the acquisition of which “spoils” their identities and removes them from their place within the social hierarchy. While some argue that stigma should be clearly distinguished from discrimination, others define stigma as a multilevel interaction between affective, cognitive, behavioral, and contextual aspects. Campbell & Deacon (2006) elaborate:

The failure of individual-level approaches to effect widespread stigma reduction has led to an alternative focus on the links between stigma and wider macro-social inequalities (e.g. gender, ethnicity). Such analyses suggest that stigma is not something that individuals impose on others, but a complex social process linked to competition for power, tied into existing mechanisms of dominance and exclusion (Parker and Aggleton, 2003). Macro-social analyses imply that interventions such as anti-discrimination legislation or poverty-reduction will assist in stigma reduction. But taking this view can mean that researchers pay little attention to the individual psychological dimensions of stigma (2006, p. 412).

Those individual psychological dimensions, it is argued, have their basis in a universal human need to project fears of uncertainty and danger onto stigmatized ‘out-groups.’ The universality of this need can be seen in the separation and stigmatization of out-groups across cultures—the targets of stigma vary widely based on local power differentials, but the process of stigmatization can be seen anywhere (Joffe, 1999). For example, the stigmatization of HIV/AIDS sufferers in late-twentieth century United States culture helped to reinforce “middle American” morality through its association with marginalized out-groups who failed to meet prevalent social expectations: intravenous drug users, homosexual men, and prostitutes (Crawford, 1994). While applications of this principle to the stigma currently associated with mental illness can certainly be surmised, no research on the moral bases of mental health stigma could be found.

Why Mental Health Stigma is a Problem

Regardless of its causes, mental illness stigma has been found to pose a major barrier to some of the most basic tasks of life, such as establishing and maintaining friendships, employment, and housing. Stigma has also been found to significantly interfere with access to and outcomes for both psychological treatment and general medical treatment (Sadow & Ryder, 2008). Through shame, humiliation, and damage to the affected individual’s sense of self, stigma negatively impacts the likelihood of service utilization and treatment compliance. Consequently, patients who score higher of measures of stigmatizing attitudes are at higher risk for negative outcomes (Gould, Greenberg, & Hetherton, 2007; Corrigan, 2004). Stigmatizing attitudes have also been observed among students and professionals from many segments of medical and psychological service. As a result, people diagnosed with mental illness receive fewer medical services and a reduced range of insurance benefits; (Sadow & Ryder, 2008).

Review of Interventions for Mental Health Stigma

Corrigan & O’Shaughnessy (2007) list three main avenues for addressing the stigma associated with mental illness: protest, education, and contact. While each of these avenues has some degree of validity on its face, the efficacy of interventions based on any of these principles leaves much to be desired. Of the three, only direct contact has shown any effectiveness in reducing stigmatizing attitudes toward mental illness over an extended period of time.

Protest Interventions

Protest tactics involve directly challenging negative or stigmatizing representations of mental illness in the popular media in order to undermine the cultural maintenance of those representations. The primary means of protesting stigmatization in popular media is by way of economic boycott. Organized boycotts and threats of boycott from advocacy groups targeting the producers, distributors, and advertisers responsible for entertainment commodities have been successful in removing stigmatizing materials from public view in at least two instances.

An ABC television series called Wonderland depicted a person with mental illness behaving in a violent and sadistic manner. After intense targeting from mental health advocacy groups directed both at the network and the show’s advertisers, the show was discontinued after just a few episodes. Another instance cited by Corrigan & O’Shaughnessy (2007) is the advertising campaign leading up to the release of the comedy film Crazy People. Advocacy groups threatening Paramount Pictures with potential economic consequences convinced the company to remove movie posters depicting a large cracked egg with arms and a caption reading “Warning: Crazy people are coming.”

Despite these apparent successes, no empirical research has demonstrated that such efforts have a positive impact on the general public’s prejudices toward individuals with mental illness. In fact, the opposite may be true; some research suggests that protest strategies may produce an “attitude rebound.” The negativistic nature of protest interventions, which fail to provide positive alternatives to the attitudes they seek to undermine, seems to inspire an overall worsening of the public’s stigmatizing attitudes (Corrigan et al., 2001).

Educational Interventions

The educational approach, on the other hand, seeks to cultivate accepting attitudes toward mental illness by disseminating accurate information and dispelling myths about mental illness, such as the popular beliefs that persons suffering from mental illness are more likely to commit violence, or that mentally ill individuals are unable to be productive in the work force (Corrigan & O’Shaughnessy, 2007; Corrigan et al. 2001). The basis for this approach rests on a number of studies that have found individuals who are more knowledgeable about mental illness to hold fewer stigmatizing attitudes. Additionally, educational strategies for reducing stigma tend to be attractive to both researchers and policy-makers because they are affordable and easily reproducible. Some educational instruments that have been used in this way in the past include public service announcements, flyers, books, and informative videos.

Educational approaches are also the most-studied form of intervention for reducing mental health stigma. Unfortunately, the research seldom supports their effectiveness. Many studies have found significant reductions on stigmatizing attitudes through exposure to college courses or informational sessions, but the magnitude and duration of the effects tends to be very limited. Furthermore, the effects of educational interventions correlate to participants’ knowledge of mental illness prior to participation in the educational programs, indicating that the effects of education-based interventions may primarily reflect the attitudes of participants who had already agreed with the programs’ messages (Corrigan & O’Shaughnessy, 2007).

One notable implementation of the educational approach to stigma reduction has been the UK Royal Navy’s trauma risk management (TRiM) program, which seeks to improve recognition of and response to PTSD by reducing the stigma associated with the diagnosis. The TRiM program trains nonmedical personal in basic assessment of trauma risk and the administration of psychological first aid. The training encompasses only traumatic stressors and seeks only to facilitate early referral to appropriate counseling services. According to Gould, Greenberg, & Hetherton (2007), “the aims for participants are to understand PTSD and stress reactions, so that negative representations of mental illness are modified, and the problems associated with other posttraumatic management strategies (e.g., PD) are addressed” (p.507).

While the TRiM program does encourage individuals to share their experiences of stress and stress-related problems in order to reduce stigma, the program’s primary intervention is to provide education about the effects of traumatic stress and ways of assessing for risk and symptoms of PTSD. A brief longitudinal study of personnel who volunteered to receive this training found both significantly improved attitudes toward stress-related ailments and increased help-seeking. However, in light of evidence that attitudinal effects are unlikely to be maintained over the long-term, the study was severely limited by lack of follow-up. Additionally, the authors note that highly stigmatizing individuals tend to be those least likely to volunteer to attend educational packages, further weakening the evidence for this intervention’s effectiveness. In spite of these shortcomings, the study’s authors argue that the tightly integrated structure of the military organization makes it more susceptible to real-world improvements as a result of this type of intervention than the population at large (Gould et al., 2007).

Direct Contact Interventions

Among the general population, the most effective methods of reducing stigma appear to be those which facilitate direct contact between individuals with mental illness and members of the general population. Researchers have consistently found that greater levels of personal familiarity with mentally ill individuals tend to equate with fewer prejudicial attitudes toward mental illness. Additionally, while some reduction of stigmatizing attitudes can result from the disclosure of popular figures such as celebrities who disclose their experiences with mental illness, greater effects result from the disclosures of individuals perceived to be more similar to the recipient of the message, people “just like me” (Corrigan & O’Shaughnessy, 2007).

One program that has sought to reduce stigma using this direct-contact approach is the National Alliance for Mental Illness (NAMI) In Our Own Voice program, in which mentally ill individuals share their history and experiences with treatment in a workshop format. Audience members are encouraged to asked questions and interact with the presenters. Preliminary research has shown good initial responses from program participants along with promising reductions in stigmatizing attitudes several weeks after their participation in the program (Corrigan & O’Shaughnessy, 2007).

There are several difficulties in implementing contact-based interventions, not least of which is that they require disclosure from individuals living with mental illness. This type of disclosure puts the mentally ill participants at risk to experience the exact stigma which the interventions would hope to circumvent. While much greater reductions result from programs which put mentally ill individuals in contact with members of the general population, the effect may be insufficient to warrant this added risk. Furthermore, there is some evidence that the segments of the population who hold the most stigmatizing attitudes are also the least likely to become involved in this type of program (Corrigan & O’Shaughnessy, 2007).

One area in which this risk may be both minimized and justified is in the training of future health professionals. Sadow & Ryder (2008) have performed a number of studies aimed at decreasing stigmatizing attitudes towards mental illness among this group, typically with poor results. Various educational efforts that did not include personal contact with mentally ill individuals, including training programs which utilized videos of presentations by such individuals were not effective in reducing stigma among nursing students. However, when personal presentations by individuals with mental illness were presented in the classroom and followed by an opportunity to process the experience with a psychologist, stigmatizing attitudes were significantly decreased among this group. This is an important finding given our previous discussion of the dangers of mental health stigma among healthcare providers.

In their review of contact-based interventions to reduce stigma among schoolchildren, Pettigrew & Tropp (2000) identify five factors which they see as necessary for optimal stigma-reducing contact: equal status between majority and minority groups; a shared goal between members of both groups; a cooperative, rather than competitive, framework for accomplishing the common goal; institutional support for the interactions between members of each group; and minority members who moderately disconfirm the prejudicial stereotypes about their group. However, the efficacy of these school-based programs has been disappointing, with most studies showing mixed results or no differences in stigmatizing attitudes among the exposed children. On top of this, the risk of amplifying stigmatization is increased when working with children, as Corrigan & O’Shaughnessy (2007) argue:

The threat of “coming out of the closet” once again becomes a key factor in realising this kind of contact. Decisions need to be made as to whether children with mental illness will disclose their group status in order to facilitate contact effects. This means that some parents of children with mental illness, who are rightfully concerned about their child’s socialisation and education, must risk their child being stigmatised to attempt this kind of friendship building. Moreover, the mother and father must risk experiencing family stigma that suggests, for example, that bad parenting produced their child’s mental illness (p. 94).

Another notable shortcoming of contact-based approaches to reducing stigma is that they may be limited in the scope of attitudinal change they can realistically effect. While contact with mentally ill individuals helps to undermine beliefs that such individuals pose an immediate physical danger, it is less likely to affect other types of stigmatizing thoughts and feelings, such as overall anxiety and thoughts about “us versus them” (Masuda et al., 2007).

A Large-Scale Combined Interventive Approach

The World Psychiatric Association (WPA) has been working to implement a combined program including all three of the discussed strategies for stigma reduction through their “Global Program Against Stigma and Discrimination Because of Schizophrenia — Open The Doors.” In cooperation with the German Research Network on Schizophrenia, this program has been implemented as a large-scale controlled trial throughout Germany since 2001. Anti-stigma intervention programs, schizophrenia awareness intervention programs, and a no-intervention control condition were each assigned to two German cities. Cities were relatively homogenous in terms of population, with each city being home to a university-affiliated department of psychiatry and offering free psychiatric services to the community (Gaebel et al., 2008).

Several strategies were employed in the anti-stigma intervention cities. Educational programs were targeted at influential groups such as health professionals and educators, and direct-contact programs were initiated. These consisted of “lectures at adult education centers, art exhibitions, cinema events, readings, theatre events, and charity concerts. Most events included panel discussions with mental health professionals as well as people who were affected by mental illness as participants. Prior to the events, press conferences were held and/or press mailings were distributed. Furthermore, press workshops about schizophrenia and its misconceptions in the public were conducted to improve the reporting in the mass media about schizophrenia and mental illness in general” (Gaebel et al., 2008, p.185) Protest actions were also orchestrated to discourage structural discrimination and stigmatizing messages.

The researchers hypothesized a reduction in total mental health stigma in anti-stigma intervention cities, with no comparable reduction in the cities receiving awareness programs or no intervention. Stigmatizing attitudes were measured using pre- and post-testing of representative samples of each cities population via telephone survey. The results showed small but significant reductions in stigmatizing attitudes in the anti-stigma intervention cities, with most of the change relating to measures of perceived social distance in transient situations. The average citizen in these cities reported significantly more comfort having incidental day-to-day interactions with persons with schizophrenia in 2004 than in 2001, but was no more likely to be involved in repeated social or professional contact with these individuals (Gaebel et al., 2008).

An Alternative Approach: Cognitive Restructuring

A fourth method for reducing mental health stigma is the use of cognitive restructuring. For example, Sadow & Ryder (2008) describe a method of “turning the tables” on stigma within healthcare training programs by using the technique of “inspirational recruitment,” in which poorly paid and unpleasant work is elevated to the status of a noble cause. They cite a previous study in which this technique increased the rate at which psychiatry students were able to be recruited into otherwise undesirable positions working with severe mental illnesses in public health clinics.

Few other studies have utilized this more psychologically informed approach to stigma reduction, and we are aware of no studies which attempt to reduce stigma among the general population using similar techniques. However, modern understandings of perception and belief certainly make cognitive restructuring an attractive option, particularly in light of the previously cited evidence for its potential. This is a direction that stigma researchers should definitely be turning toward in the coming years, in both community psychology settings and clinical training programs.

Acceptance and Commitment Therapy As a Stigma Intervention

A similarly oriented approach is the use of Acceptance and Commitment Therapy (ACT) to reduce stigma. This approach addresses stigma only indirectly; ACT “uses acceptance, mindfulness, and value-directed behavioral change strategies in order to increase psychological flexibility” (Masuda et al., 2007, p. 2765). According to Masuda et al., research has supported the idea that increased self-acceptance produces increased empathy. While contact-based education only undermines beliefs about danger, ACT addresses the overarching avoidance of discomfort by increasing acceptance.

For example, in a study on substance abuse counselors, multicultural training reduced stigmatizing attitudes toward racial and cultural groups immediately after the intervention, but not at three-month follow-up. On the other hand, an ACT intervention which encouraged counselors to reflect on the automatic nature of judgmental processes and the “paradoxical effect of deliberate attempts to eliminate both self-stigma and stigmatizing attitudes” (Masuda et al., 2007, p. 2766) showed much better results. The ACT intervention reduced both stigmatizing attitudes among the counselors as well as measures of workplace burnout at follow-up.

Refocusing on more general factors like mental flexibility as contributors to stigma can also help to clarify the mixed results typically seen when other tactics are used. One study subjected college students to a single 2 1/2 hour ACT workshop focused on stigmatizing attitudes toward mental illness. Prior to the intervention, it was found that students with a lower level of general mental flexibility were more stigmatizing than their more flexible counterparts. The ACT intervention reduced stigma in both flexible and inflexible individuals, and in fact showed a particularly high comparative effectiveness for psychologically inflexible study participants. The authors speculate:

This pattern of results suggests that some forms of stigma may reflect uninformed attitudes about legal, cultural, and institutional practices related to mental illness. In more experientially avoidant individuals, however, stigmatizing views may become entangled in psychologically avoidant processes linked to the perceived threats of the stigmatized condition (Goffman, 1963) and to the inability to deal with the thoughts and feelings that arise as a result. These differences might help explain the somewhat inconsistent results for education in the stigma literature (Masuda et al., 2007, p.2769).

Conclusions

There has been much research on the effects of mental health stigma, but quite a good deal less research has examined potential interventions for reducing its presence or impact. This area of study is also significantly less ideologically sophisticated at present. None of the primary avenues for reducing stigma have proven satisfactory, although direct-contact programs have shown some promise and education programs have been effective within controlled social contexts such as military organizations.

A greater level of psychological savvy is needed in developing interventions for this purpose. Along these lines, some preliminary research on cognitive restructuring efforts and ACT-based interventions have shown a great deal of promise. It is unlikely that these early efforts cannot be bested by additional consideration for individual, social, and community psychological understandings.

While stigmatizing attitudes among the general public have been fairly well-studied, self-stigma and mental health service users’ reactions to stigma are more poorly understood. Bagley & King (2005) argue that the success or failure of expensive public campaigns to reduce the stigmatization of mental illness should be measured by the resulting feelings and experiences of the individuals affected by the stigma. To this end, they argue that primary interventions for newly-diagnosed cases of mental illness should include counseling aimed at mediating the effects of and improving responses to stigmatizing interactions.

Alternatively, an argument could be made for a more general measurement of the efficacy of anti-stigma efforts. The success or failure of these programs should hinge on the increased utilization of services and increased effectiveness of services utilized. This latter goal is likely to be too heavily confounded to be adequately measured as an effect of anti-stigma interventions. Therefore, future anti-stigma research should use the likelihood of the general public to utilize services, along with actual service utilization, as measures of outcome for anti-stigma interventions.

References

• Bagley, C. & King, M. (2005). Exploration of three stigma scales in 83 users of mental health services: Implications for campaigns to reduce stigma. Journal of Mental Health, 14(4), 343-355.
• Campbell, C., & Deacon, H. (2006) Unravelling the contexts of stigma: From internalisation to resistance to change. Journal of Community & Applied Social Psychology, 16(6), 411-417.
• Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614–625.
• Corrigan, P.W. & O’Shaughnessy, J.R. (2007). Changing mental illness stigma as it exists in the real world. Australian Psychologist, 42(2), 90-97.
• Corrigan, P. W., River, L., Lundin, R. K., Penn, D. L., Uphoff-Wasowski, K., & Campion, J. (2001). Three strategies for changing attributions about severe mental illness. Schizophrenia Bulletin, 27, 187–195.
• Crawford, R. (1994). The boundaries of the self and the unhealthy other: Reflections on health, culture and AIDS. Social Science and Medicine, 38(1), 1347–1365.
• Gaebel, W., Zäske, H., Baumann, A.E., Klosterkötter, J., Maier, W., Decker, P., & Möller, H. (2008). Evaluation of the German WPA “Program against stigma and discrimination because of schizophrenia — Open the Doors”: Results from representative telephone surveys before and after three years of antistigma interventions. Schizophrenia Research, 98, 184-193.
• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall.
• Gould, M., Greenberg, N., Hetherton, J. (2007). Stigma and the military: Evaluation of a PTSD psychoeducational program. Journal of Traumatic Stress, 20(4), 505-515.
• Joffe, H. (1999). Risk and the other. Cambridge: Cambridge University Press.
• Masuda, A., Hayes, S.C., Fletcher, L.B., Seignourel, P.J., Bunting, K., Herbst, S.A., Twohig, M.P., & Lillis, J. (2007). Impact of acceptance and commitment therapy versus education on stigma toward people with psychological disorders. Behaviour Research and Therapy, 45, 2764-2772.
• Pettigrew, T. F., & Tropp, L. R. (2000). Does intergroup contact reduce prejudice: Recent meta-analytic findings. In S. Oskamp (Ed.), Reducing prejudice and discrimination (pp. 93–114). Mahwah, NJ: Lawrence Erlbaum & Associates.
• Sadow, D., & Ryder, M. (2008) Reducing stigmatizing attitudes held by future health professionals: The person is the message. Psychological Services, 5(4), 362-372.

The transformational model of leadership has gained considerable traction among leadership theorists and researchers over the past few decades. It appears to be a fairly reliable and unitary construct referring to a set of leadership behaviors which are associated with a variety of positive organizational outcomes. In this paper we will briefly detail the behaviors included within the transformational leadership model. We will review some of their benefits for organizations in general and health care organizations in specific. Finally, we will argue that a transformational leadership model offers unique benefits in the field of mental health, and should therefore be considered best practices for mental health service administrators. Throughout our discussion, we will attempt to make the subject matter directly applicable to mental health administrators by suggesting similarities to existing psychological concepts and opportunities for implementation in a mental health setting.

Overview of Transformational Leadership

Under a transformational leadership model, the leader focuses on creating positive change in followers through behaviors which help them to “transform” into more motivated, satisfied, and harmonious members of the organization. Transformational leadership is generally characterized by four types of leadership behaviors, often referred to as the four ‘I’s: idealized influence, intellectual stimulation, individual consideration, and inspirational motivation (Fisher, 2009).

Idealized Influence

 

The concept of idealized influence is similar to what might generally be thought of as charisma. Although the vast majority of literature on charismatic leadership focuses on the potential for negative social consequences, there is also an argument to be made that charisma is a component of highly effective transformational leadership (Aaltio-Marjosola & Takala, 2000). In this sense, the exertion of idealized influence refers to a “leader’s ability to generate enthusiasm and draw people together around a vision through self-confidence and emotional appeal” (Fisher, 2009, p.362).

At a more tangible level, a leader can become a more idealized influence by modeling desirable role behaviors within the organization and culture. By positioning him or herself as a positive role model, a leader can thereby engender the trust, respect, and even admiration of subordinates. In mental health terms, this has similarity to what clinicians refer to as ‘fostering transference’ with their clients. By exhibiting the types of behaviors that one would expect from a leader in a given situation, one can generally assume that they will be automatically afforded greater deference within that situation.

Intellectual Stimulation

Transformational leaders help to provide intellectual stimulation for their subordinates. In practice this means that transformational leaders foster more democratic working environments than other types of leaders, because they are frequently engaging their team members in creative and innovative problem solving (Fisher, 2009). This may be a key reason for the significant association between transformational leadership and feelings of psychological empowerment among subordinates (Fuller, Morrison, Jones, Bridger, & Brown, 1999).

Psychological empowerment is a state of increased intrinsic motivation. Empowered individuals have a sense of agency in their work roles; they feel as though they are doing their jobs in ways that they choose and for reasons that they choose (Fuller et al, 1999). It is easy to see how engagement in problem-solving tasks related to the work situation itself would help to instill this sense of agency and improve personal investment in the workplace, because individuals are being actively recruited as collaborators in shaping their own organizational culture.

Individual Consideration

This leads naturally into the next aspect of transformational leadership, which is individual consideration. This refers to the ability of the leader to ‘get to know’ team members and show them individual respect and concern. If team members are being recruited as intellectual collaborators in organizational problem solving, their personal needs and preferences will naturally emerge.

Leaders can further the sense that individual consideration is being by regularly assessing their followers’ personal goals and working to create new opportunities which match those goals (Fisher, 2009). Monitoring followers’ progress and providing mentoring along the way will help to enhance this effect while also bolstering the leader’s position as an idealized influence. The leader’s requests will be more likely to be perceived as in the followers’ best interests, and so should be more likely to be fulfilled with enthusiasm.

Inspirational Motivation

Finally, a transformational leader “moves team members toward action by building their confidence levels and generating belief in a cause” (Fisher, 2009, p.362). This is highly compatible with the previously discussed aspects of transformational leadership. Through individualized consideration and mentoring, individuals are led to work toward improving themselves and their status within the organization. By providing a positive role model, individuals are given direction and momentum for guiding their own role behaviors. And by providing intellectual stimulation and making individuals active participants in their workplace, they are led to see how their own growth and development corresponds to the growth and development of the organization as a whole.

This latter effect is the key ingredient in inspirational motivation. Transformational leaders put this into practice by drawing team members around a vision of what the organization can be in the future. By setting high expectations for the organization as a whole and behaving in ways that are congruent with those expectations, transformational leaders are able to inspire their subordinates to hold similar expectations and to work toward realizing those expectations.

Benefits of Transformational Leadership

Transformational leadership behaviors have been associated with a variety of positive organizational outcomes across industries and across cultures. They are positively associated with overall leader effectiveness (Jung, Yammarino, & Lee, 2009). Employee effectiveness is also positively affected, with extra perceived effort, organizational citizenship behaviors, and job satisfaction all being associated with transformational leadership (Fuller et al, 1999). In this section we will discuss three effects of transformational leadership that may be particularly important for mental health care administrators: group cohesiveness, psychological well-being, and creativity.

Group Cohesiveness

Group cohesiveness is a concept that is well-known to mental health workers providing group therapy services. When there is cohesiveness among group members, each individual member is propelled by the group to accomplish more than could be done alone. The same is true of work teams.

According to Wang & Huang (2009), group cohesiveness among work teams results in more and better group interaction, stronger group influence, and greater individual involvement in the group. Studies have shown that group cohesiveness is associated with emotional intelligence, and this is a quality that mental health workers should exhibit relatively high levels of due to the demands of their profession. However, the primary mediating factor between emotional intelligence and work team group cohesiveness is transformational leadership (Wang & Huang, 2009).

Particularly in service agencies where turnover rates are high because of provider burnout, higher levels of group cohesiveness may serve as a protective factor by increasing the level of support that workers receive from one another. The higher levels of group interaction that cohesiveness brings about should also increase consultation between colleagues, resulting in a higher quality of services.

It is also pertinent that group cohesiveness induces higher levels of personal involvement with the group. A study of health care organizations found that employees’ personal involvement in their organizations was negatively correlated with their stress levels (Skela Savic & Pagon, 2008). In that study, the single greatest predictor of successful individual involvement was transformational leadership.

Psychological Well-being

Psychological well-being is the subjective experience of being in a positive state of mental health. Several studies have found that a leader’s behavior can affect the mental health of his followers, but there has been little research examining the possible mechanisms for this interaction. Arnold, Turner, Barling, Kelloway, & McKee (2007) noted that there is an established connection between transformational leadership and the sense that one’s work is meaningful. Since deriving meaning from events has been called a “fundamental human motive,” they hypothesized that the positive effects of transformational leadership on psychological well-being could be accounted for by this enhancement of meaningfulness. In their two studies of Canadian health care workers, they found that after controlling for humanistic beliefs about their work, the relationship between transformational leadership and psychological well-being was fully mediated by workers’ perceptions that their work was meaningful.

It is notable that these studies were carried out among health care workers, as most people would agree that this work—like mental health—is intrinsically meaningful. Yet it is not uncommon to hear workers in mental health service organizations describe their work experience in terms of a progressive loss of meaning. High case loads, inadequate funding, and arduous paperwork all contribute to the type of personal crisis that leads to burnout. It is the sense that one is simply making no difference in the world by continuing on with his or her work.

By directly enhancing the sense that there is meaning in the work that mental health care providers are doing, transformational leadership has a potential to strongly affect worker satisfaction and reduce burnout. And because this effect improves psychological well-being, it may also help clinicians to exercise a higher level of clinical judgment than they would otherwise be capable of. This improves the quality of services that are provided and so circularly enhances the sense that meaningful work is being done.

Creativity

We have discussed the possibility that transformational leadership could improve clinical judgment, but most mental health workers would agree that a high degree of creativity is also required for their clinical work. Interventions must frequently be designed on-the-fly, and should ideally be tailored for each individual on the basis of their present behavior considered alongside their full history. There is some evidence to suggest that transformational leadership may increase creativity at both the individual and organizational levels.

Gumusluoglu & Arzu (2009) performed a study on transformational leadership in another field requiring a high degree of creativity: software research and development. They studied Turkish personnel and managers from organizations of various sizes in order to determine whether transformational leadership had an effect on creative output. They found that the most creative workers were those whose managers exhibited the most transformational leadership behavior. In examining possible mechanisms for this association, they found that psychological empowerment was the strongest mediating factor.

Whether by creating a culture of psychological empowerment within the organization or through some other mechanism, this effect seems to also be true at the organizational level. In a study of 50 Taiwanese electronics and telecommunications companies, a positive relationship was found between overall organizational innovation and transformational leadership behaviors from the CEO (Jung, Wu, & Chow, 2008).

Although neither of these studies were performed within the mental health industry, it seems likely that similar effects could be found among mental health care providers and administrators. Higher levels of personal investment, psychological well-being, and support from other employees should reasonably be expected to enhance the individual creativity of clinicians and to foster a culture of creative clinical intervention.

Transformational Leadership is a Natural Fit for Mental Health Administrators

Fisher (2009) has pointed out that adherence to any leadership model tends to produce better results than leadership which is not guided by any model at all. Therapists have long held a similar view of theoretical orientation as it applies to the psychotherapy situation. When a therapist or leader operates in accord with a coherent theoretical model, it provides a consistency and predictability. This helps people to feel safe and affords them an understanding of their situation which they could not otherwise have. This may be why both transformational and transactional leadership styles are associated with providers having positive attitudes toward adopting evidence-based practices (Aarons, 2006).

Regardless, there is some reason to believe that the transformational leadership model may be a natural fit for the social service fields, including mental health. For example, a study of social service supervisors found that they generally tended to use transformational leadership techniques spontaneously, whether or not they consciously identified themselves as doing so (Arches, 1997).

Mary (2005) found similar results in a survey of members of the National Network for Social Work Managers and the Association of Community Organization and Social Administration. When asked to think of a leader they had worked with and to rate them on the Multifactor Leadership Questionnaire, she found that the leaders discussed generally operated in a manner consistent with the transformational leadership model. In addition, transformational leadership qualities were positively correlated with leader effectiveness, satisfaction with the leader, and extra effort on the part of workers. These results match those of Gellis (2001), who found that transformational leadership factors in social service administrators were positively correlated with similar positive organizational outcomes. Social workers were more likely to engage in requested activities and reported feeling more satisfied with their leader when more transformational leadership qualities were present.

Conclusion

There is substantial evidence that the transformational leadership model produces organizational outcomes which mental health administrators would generally find desirable. By providing a practical means for generating positive role identification, intrinsic motivation, personal investment in the workplace, motivation and resiliency, transformational leadership promises to enhance the quality of services provided while reducing negative effects on workers. Because provider burnout is such a widespread and troublesome phenomenon in social service agencies, the benefits of transformational leadership may prove particularly compelling in this industry.

As we have seen, transformational leadership is already prevalent among social service organizations. Furthermore, the degree to which it is practiced corresponds to leader effectiveness, among other positive organizational outcome variables within these types of agencies. It results in better group cohesiveness, which will help workers to feel better supported and to feel more personally involved in their agencies. It also results in lower stress and greater psychological well-being for health care workers.

Transformational leadership also increases individual creativity and organizational innovation among workers in some creative fields, and this benefit may also apply to mental health workers. More creative workers will be more capable of adapting their skills and techniques to the needs of individual patients, thereby resulting in a higher quality of services and better clinical outcomes. For all of these reasons, the transformational leadership model is a natural fit for the mental health field, and its implementation should be considered an integral part of best practices for mental health administrators.

References

1. Aaltio-Marjosola, I. & Takala, T. (2000). Charismatic leadership, manipulation and the complexity of organizational life. Journal of Workplace Learning, 12(4), 146-164.
2. Aarons, G.A. (2006). Transformational and transactional leadership: Association with attitudes toward evidence-based practice. Psychiatric Services, 57(8), 1162-1169.
3. Arches, J. L. (1997). Connecting to communities: Transformational leadership from Africentric and feminist perspectives. Journal of Sociology & Social Welfare, 24(4), 113–124.
4. Arnold, K.A., Turner, N., Barling, J., Kelloway, E.K., & McKee, M.C. (2007). Transformational leadership and psychological well-being: The mediating role of meaningful work. Journal of Occupational Health Psychology, 12(3), 193-203.
5. Fisher, E. (2009). Motivation and leadership in social work management: A review of theories and related studies. Administration in Social Work, 33, 347-367.
6. Fuller, J.B., Morrison, R., Jones, L., Bridger, D., & Brown, V. (1999). The effects of psychological empowerment on transformational leadership. The Journal of Social Psychology, 139(3), 389-391.
7. Gellis, Z. D. (2001). Social work perceptions of transformational and transactional leadership in health care. Social Work Research, 25(1), 17–25.
8. Gumusluoglu, L. & Arzu, I. (2009). Transformational leadership, creativity, and organizational innovation. Journal of Business Research, 62, 461-473.
9. Jung, D., Wu, A., & Chow, C.W. (2008). Towards understanding the direct and indirect effects of CEOs transformational leadership on firm innovation. The Leadership Quarterly, 19, 582-594.
10. Jung, D., Yammarino, F.J., & Lee, J.K. (2009). Moderating role of subordinates’ attitudes on transformational leadership and effectiveness: A multi-cultural and multi-level perspective. The Leadership Quarterly, 20, 586-603.
11. Mary, N. (2005). Transformational leadership in human service organizations. Administration in Social Work, 29(2), 105–118.
12. Skela Savic, B. & Pagon, M. (2008). Individual involvement in health care organizations: Differences between professional groups, leaders and employees. Stress and Health, 24, 71-84.
13. Wang, Y. & Huang, T. (2009). The relationship of transformational leadership with group cohesiveness and emotional intelligence. Social Behavior and Personality, 37(3), 379-392.

The most current Diagnostic and Statistical Manual of Mental Disorders (APA, 2000) provides only a single gambling-related diagnosis: Pathological Gambling. This diagnosis requires that an individual meet at least five out of ten criteria which are representative of problem gambling among Western samples. However, even in the West, many individuals suffer significant financial and interpersonal consequences from gambling without meeting full criteria for this mental disorder. The literature typically refers simply to “problem gamblers,” a category which is inclusive of these subclinical cases as well as those which would meet diagnostic criteria (Raylu & Oei, 2004). In this paper we will follow the same convention, referring to problematic gambling behavior as that which is subjectively “out of control” for the gambler, whether or not it meets the Western diagnostic criteria. We will also see that conceptions of normative and problematic gambling vary across cultures, such that culturally-appropriate practices of diagnosis and treatment are called for.

In this article we will examine the differences in the ways that problem gambling is conceived of and presented within Chinese culture versus Western culture. We will review literature on the role that culture plays in the etiology and progression of problematic gambling behavior in general, as well as the specific cultural factors affecting its development among the Chinese people. We will see how the cognitive and emotional factors that lead to problem gambling in the Chinese are similar to and different from the factors that drive these behaviors in Western samples. Finally, we will examine whether our understanding of problem gambling among the Chinese may also inform our understandings of problem gambling in other Asian cultures.

We will conclude that, given the similarities between presentations of problem gambling across cultures, a cross-cultural model of gambling treatment which takes cultural differences into account may be possible. Because of the increasing size of immigrant communities in the West and the increasing intermingling between Eastern and Western cultures, such a model would be of inestimable value to clinicians now more than ever before. Regardless of whether a true cross-cultural model of gambling treatment can or will be developed, however, it is critical that clinicians consider both cultural and individual differences when designing and administering treatments.

The Role Of Culture In Problematic Gambling Behavior

Citing a significant gap in the literature on the role of culture in problem gambling, Raylu & Oei (2004) prepared a systematic review of the cultural variables involved in problem gambling and the cultural variations in problematic gambling behavior. They assert that gambling is a nearly universal human activity, with both problematic and non-problematic variations occurring in nearly every culture. Although there are not many studies investigating the prevalence rates of problem gambling across cultures, there is evidence that certain cultural groups are more vulnerable than others. The Western literature on gambling points to a number of significant genetic, social, and individual factors which contribute to problematic gambling. However, in order to develop better and more culturally appropriate treatments, the authors argue that these factors must be reexamined across cultures.

Cultural Prevalence of Gambling

Although there have been many anecdotal media reports that gambling problems are more prevalent among certain cultural groups, few systematic reviews currently support this notion. In the scientific literature, there is disagreement between studies as to which demographic characteristics predispose individuals to problematic gambling. Furthermore, most studies which have examined the prevalence of problematic gambling have done so within Western samples, while evidence suggests that cultural variations in the forms and functions of gambling may play a role in the initiation and maintenance of gambling behaviors. Even those studies which have attempted cross-cultural research on the topic have failed to explore the specific cultural factors which might influence gambling behavior. Raylu & Oei (2004) hold that this is a major limitation of the current literature on problematic gambling.

Many studies examining the prevalence rates of problem gambling have compared minority cultural groups such as indigenous peoples to the majority groups in the countries under study. Indigenous groups in the United States, Canada, New Zealand, and Australia have all been found to exhibit substantially higher rates of gambling behavior than the general populations of those respective countries. However, these studies have failed to investigate the relationship of problematic gambling with specific cultural factors such as norms, beliefs and values. It is therefore unknown whether culture is a significant determinant. Other factors such as socioeconomic status, unemployment, minority stress, or even genetic differences may very well be more important in generating this discrepancy (Raylu & Oei, 2004).

Cultural Perspectives On Gambling

In light of these limitations of the available literature, Raylu & Oei (2004) look to the cultural factors which have been implicated in other mental health concerns, and especially in substance abuse. They cite three primary, interrelated cultural factors which recur throughout the literature: cultural values and beliefs, acculturation effects, and attitudes toward seeking professional help. The authors hypothesize that these factors should also be important in the development and maintenance of problematic gambling.

Reylu & Oei (2004) argue that culture provides a framework by which individuals assess the desirability and risk of a given situation or behavior. These valuations are passed on by family members, respected community members, and through the social history of the community. According to the authors, each of these means of value transmission have been found to be relevant in the development of substance abuse disorders. They state that substance abuse is more common among individuals whose parents engage in and/or demonstrate positive attitudes toward substance use, as well as individuals living in communities where substance use is encouraged and considered normal.

This latter aspect is especially pertinent in the case of the Chinese, whose social norms and cultural history have portrayed gambling as “a way of life” for many generations, particularly among males (Reylu & Oei, 2004, p. 1096). Reylu & Oei offer that when one contrasts this Chinese cultural depiction of gambling with the historical condemnation of gambling among Muslim cultures, or the reserved approval that gambling has historically received in Western cultures, it becomes easy to see how the increased level of exposure and identification with gambling as a lifestyle and tradition could lead to increased gambling behavior among the Chinese. They argue that the collectivist orientation of Eastern cultures may further promote the retention of socially-endorsed gambling behaviors.

Because culture provides a framework not only for the assessment of value but also the assessment of risk, Reylu & Oei (2004) posit that cultural factors should play a role in individuals’ determination of what types of gambling behaviors are problematic. They cite research indicating lower overall rates of help-seeking behavior among minority groups, as well as the specific reluctance of some particular groups to seek help for mental health problems. It appears to be those cultures where the shame associated with problematic gambling is greatest whose members are the least likely to present for treatment, even when facing greater material consequences. This includes Arabic cultures for whom gambling entails an inherent shamefulness, as well Asian cultures for whom the loss of internal balance that problematic gambling represents is seen as disgraceful.

Cultural Factors in the Treatment of Problematic Gambling

In turn, the problem of poor service utilization among these groups may be caused or exacerbated by a lack of cultural sensitivity in the available treatment models. Treatments for problem gambling tend to be based on Western treatment models and do not take cultural variables into account, according to Reylu & Oei (2004). Thus, the treatment approaches used for problem gambling may be incompatible with the nature and etiology of problem gambling as seen from within other cultures.

For example, Reylu & Oei (2004) cite one study of Hong Kong residents which found that the solutions to psychological disturbances tend to be attributed to internal actions on the part of the patient. This is quite different from the predominantly external attribution that psychological treatments are afforded in Western cultures. Perhaps as a result of this cultural difference, the Chinese have repeatedly been found to rely on self-help and support from primary social networks when attempting to overcome mental health problems, rather than seeking professional help.

Gambling And Problem Gambling Among Chinese People

In order to correct a lack of systematic reviews of gambling and problem gambling among Chinese people, Loo, Raylu, & Oei (2008) performed an analysis of 25 studies on gambling among the Chinese. The Chinese culture is uniquely steeped in gambling, with its history including the oldest recorded accounts of gambling worldwide more than 3000 years ago. In modern China, social gambling is a common and accepted form of entertainment and celebration. This is also the case for many Chinese immigrant communities. A recent New York Times article described what has become a Thanksgiving tradition for many American Chinese: spending the day and night at a casino (Buckley, 2009). Problem gambling is also commonly reported among the Chinese, yet there is an unmet need for prevention programs and interventions that are tailored to the unique needs of the Chinese culture.

For the Chinese, gambling is predominantly considered a social activity. Several studies have found social and entertaining forms of gambling to be much more popular among Chinese respondents than other forms, such as games of skill or betting on horse races. The rates of engagement in gambling activities are consistently higher among Chinese people “who consider gambling to be a form of entertainment rather than as ‘gambling’” (Loo et al., 2008, p.1154).

The reported prevalence of gambling among Chinese communities has varied widely between studies. This may be due to culturally-determined variations in self-report. Studies on Chinese-speaking populations in both China and Australia have shown that individuals in these groups tend to underreport their own gambling problems, compared to the third-party reports of their friends and relatives. Loo et al. (2008) conclude that this is an example of the characteristic reluctance of Chinese people to admit self-regulatory failures.

Loo et al.’s (2008) analysis suggests that acculturative, social learning, and gender differences may also play a significant role in the development of problematic gambling behaviors in the Chinese. For example, higher levels of gambling were associated with both greater age and less education. Additionally, the country of residence influenced the amount of gambling that took place within Chinese groups. Chinese individuals living in Taiwan, a country whose dominant culture and attitudes toward gambling are relatively similar to those of China, gamble significantly more than those living in Australia. Australian Chinese were also more likely to report feeling guilty about their gambling behavior and to conceal it from others. Finally, Chinese males tended to have a longer duration of problem gambling than their female counterparts, and were much less reluctant to acknowledge that gambling had become a problem.

These findings have clear clinical implications for Western clinicians working with Chinese individuals. The practitioner should remain mindful of the potential for under-reporting of gambling behavior, particularly with male clients and in communities where gambling is not as accepted as it might be in a predominantly Chinese community. Furthermore, the practitioner would do well to frame the issue in a way that is sensitive to the Chinese client’s need to maintain a sense of internal control.

Cognitive & Emotional Differences in Chinese Versus Caucasian Gamblers

Oei, Lin, & Raylu (2008) noted that a substantial literature has developed over the last decade implicating two primary variables in problematic gambling among Western populations: gambling cognitions and psychological states. Some common types of gambling-related cognitions override the rational controls that would otherwise help to maintain control over the behavior. The psychological states of anxiety and depression are also related to problem gambling, and may further depress the gambler’s capacity to evaluate and react to the gambling situation pragmatically. Several studies have shown that the reduction of these two factors through cognitive and behavioral interventions was “the most effective treatment for pathological gambling” (p. 148).

Gambling-related cognitive errors can be divided into three major categories: illusions of control, illusions of predictability, and inconsistent framing of gambling outcomes. The “illusion of control” refers to a gambler’s sense that he or she can exert an unrealistic level of control over the outcome. This often includes superstitious behavior such as carrying a rabbit’s foot or not associating with losing gamblers. By “illusions of predictability” we refer to an unrealistic sense that the outcomes of gambling events can be predicted based on factors such as the weather, hunches, or the sequence of past wins and losses. Finally, “inconsistent framing” refers to a gambler’s tendency to attribute wins to internal factors and losses to external ones (Oei et al., 2008).

However, Oei et al. (2008) note that knowledge of these gambling cognitions has resulted from the study of Western samples. Despite the frequent generalization of these findings to other ethnic groups, it is largely unknown whether these same cognitive and emotional factors apply to Chinese problem gamblers. Research has shown that individuals with a Chinese cultural background are exposed to different environmental and socialization pressures, maintain different values and beliefs, and exhibit psychobiological differences from Caucasian populations that are evidenced in early patterns of development. They may therefore also exhibit differences in cognitions and psychological states related to gambling.

One example suggested by Oei et al. (2008) is the greater prevalence of superstitious thinking within the Chinese culture. Superstitious evaluation of the potential outcomes of gambling events has frequently been implicated as a cognitive factor in the development and maintenance of problem gambling in Western studies. In Chinese gamblers, culture-specific beliefs about luck, fate, and spiritual influence on events may present an “insidious and profound” (p. 150) precursor to problematic gambling.

To fill this gap in the literature on cultural factors in problem gambling, Oei et al. (2008) conducted a study of 501 residents of Brisbane, Australia. Of those, 306 participants were identified as Caucasian and 195 were identified as Chinese. All participants were administered a problem gambling screening questionnaire, a measure of gambling-related cognitions, and a measure of depression, anxiety, and stress.

This study supported the hypothesis that the same cognitive and affective factors known to be related to problematic gambling behavior among Caucasians are also significantly related to problem gambling among Chinese Australians. Some differences of degree were found between the two study groups, however. Specifically, the Chinese participants had a significantly higher illusion of control over gambling events than their Caucasian counterparts, as well as a significantly lower perceived ability to stop gambling (Oei et al., 2008).

Clearly additional research is needed to confirm and expand upon these results. However, these findings suggest that similar clinical approaches may be effective with both Caucasian and Chinese problem gamblers. We are also given clues about how to design more culturally appropriate treatments for gambling problems. Interventions for problem gambling should target those cognitive and affective elements that are most culturally and individually relevant.

Applicability to Other Asian Cultures

As we have previously noted, many cultural similarities can be found between Asian peoples. This raises the question of whether our understandings of problematic gambling behavior among the Chinese might also apply to other Asian cultures. The literature on this topic is extremely sparse.

Emotional and Acculturative Factors in Vietnamese Women

One qualitative study of Vietnamese women living in Australia suggests that acculturative factors may play a substantial role in the development of problem gambling for female Asian immigrants, particularly those whose ethnic communities are very small (Chui, 2008). Loneliness and boredom are cited as primary reasons for taking up regular gambling activities. Some Asian immigrants feel that gambling is the only entertainment available to them in areas where they do not speak the local language. Study participants also discussed their reluctance to seek outside assistance for their problematic gambling. They described the same sense of shame and personal failure that we have seen to be associated with mental illness and help-seeking among the Chinese.

This study was too small for us to infer much about the larger Asian immigrant population. Additionally, the study participants were all women, while most studies of problem gambling have focused on men. Males in all cultures yet studied tend to be impacted more by cognitive errors than by emotional factors (Oei et al., 2008). However, the interviews described by Chui (2008) do underscore the necessity for clinicians to evaluate acculturative stress and culture-related resistance to treatment on an individual basis.

Cognitive Factors in Thai Lottery Gamblers

With regard to cognitive errors, we find a related quantitative study of lottery gamblers in Thailand (Ariyabuddhiphongs & Phengphol, 2008). This study examined the effects of superstitious thinking  by comparing two groups of regular Thai lottery gamblers. The first used superstitious methods to select their lottery numbers, such as searching for numbers at temples or divining numbers by dripping candle wax into bowls of water. The comparison group did not engage in any superstitious procedures to select their numbers.

The study found that lottery gamblers who used superstitious methods to select their numbers were also more susceptible to two particular cognitive errors: the “gambler’s fallacy” and entrapment. The gambler’s fallacy refers to the irrational belief that a particular gambling outcome is less likely immediately after it has taken place, and more likely when it has not taken place for some time. In the case of a lottery, the gambler’s fallacy leads players to believe that a number which has recently been drawn is unlikely to be drawn again. “Entrapment” refers to the escalation of commitment that occurs when a gambler has lost a substantial sum and feels that he or she is “close to winning” or has “gone too far to give up” (Ariyabuddhiphongs & Phengphol, 2008, p.296).

These cognitive patterns fit into the categories of gambling-related cognitive errors outlined by Oei et al. (2008). The gambler’s fallacy is based on an illusion of predictability, while entrapment seems based on a combination of attribution error and an illusion of control. Because it has been successfully applied to both Western and Chinese populations, and is a good fit with these findings from Thailand, Oei et al.’s basic model of gambling-related cognitive error appears to have cross-cultural applicability. This provides clinicians with a good starting point for evaluating individual cognitive factors which may encourage problematic gambling.

Conclusions

There is a relatively small amount of research on the cultural factors that affect problem gambling. However, based on the research we have reviewed, we believe there is sufficient evidence to conclude that cultural factors are significant. In order to provide culturally sensitive treatment to individuals with gambling problems, it is therefore important to take inventory of their cultural values and beliefs, acculturative experiences, and attitudes toward help-seeking.

Cultural factors are particularly salient when working with individuals from Chinese cultural backgrounds. Gambling is a heavily entrenched and widely accepted social activity in this culture. Superstitious beliefs about gambling outcomes, which have been associated with the development of gambling problems, are also more congruent with normative thought patterns in China than they are in the West. Oei et al. (2008) have suggested that psychoeducation targeting culture-specific superstitions about gambling outcomes may be of great benefit to the Chinese.

Individuals from Chinese cultural backgrounds also experience problematic gambling differently than those from Western backgrounds. They are more likely to attribute the problem to personal failures, are more likely to feel shameful as a result, and are more hesitant to seek help from outside their immediate social networks. This is an extremely important consideration for those working within Chinese communities, and indicates that preventive programs and community psychoeducational efforts may be very useful in these communities.

There are significant gender differences among Chinese problem gamblers that clinicians should also be aware of. Chinese females tend to be more heavily impacted by psychological factors such as anxiety and depression than their male counterparts. Conversely, Chinese males tend to be more susceptible to gambling-related cognitive errors.

Finally, although much more research is needed, it seems that cultural understandings of problem gambling among the Chinese may be largely generalizable to other Asian cultures. The current literature shows a broad overlap between the components of problematic gambling in Western cultures and those in China. The primary differences appear to lie in the degree to which particular cognitive and affective factors are expressed, rather differences in the types of factors that are present. This bodes well for the development of cross-cultural treatment models.

Discussion

How Changes in Chinese Culture May Affect Problem Gambling & Its Treatment

The articles which we have reviewed have not discussed the potential effects that changes in culture may have on the presentation and conceptualization of problematic gambling. However, neither mental illnesses nor their associated diagnoses are stagnant. They change based on new scientific understandings as well as cultural shifts which alter the range of what individuals consider to be possible within their cultural frameworks. The range of possibilities also varies widely from one individual to another even within an apparently unitary cultural framework.

It will therefore behoove the culturally-sensitive clinician to pay attention to the phenomenological differences in clinical problems both within and between cultures. Depending on an individual’s level of exposure to Eastern or Western thoughts, ideals, and role models, he or she may exhibit attitudes toward gambling which are more or less congruent with the “Eastern” or “Western” attitudes which we have described. In a complicated and changing world, we must always be mindful of individual differences, no matter how scientifically grounded our preconceptions of a given culture may be.

Personal & Professional Importance of this Topic

The Chinese people comprise the largest ethnic group in the world, representing 22% of the planet’s population (Loo, Raylu, & Oei, 2008). Many millions of those live outside of mainland China, making it likely that the average clinician in just about any geographical location will encounter patients from Chinese cultural backgrounds. Unless clinicians are apprised of the unique cultural factors affecting these individuals, they will have difficulty providing them with high-quality services.

One of my own clinical interests is the treatment of impulse-control disorders. These disorders include substance abuse, problematic gambling, eating disorders, and compulsive behaviors. Behaviors which are subjectively involuntary and yet apparently volitional represent a fascinating interaction between conscious and unconscious processes. These include not only neurological, cognitive, and emotional factors, but cultural influences as well. As Castillo (2001) has argued, culture is a determinant of possibility, and so shapes the way in which both pathology and its resolutions are able to manifest.

Problem gambling is a fascinating topic for cultural study, because it is a rather pure form of impulse dysregulation. Unlike substance abuse or eating disorders, the problematic behavior is not tied to any physiological dependency. However, the manifestations of problem gambling often resemble substance abuse in both their inward and outward aspects. I was very interested to find such good research on this problem within the Chinese culture, and to find out the ways that cultural differences play into its etiology.

A Treatment Scenario

Clinical Vignette

We will now adapt a clinical vignette presented in Chui (2008, p. 277), in order to see how our understandings of culturally-appropriate treatment for Chinese problem gamblers might play out in clinical practice:

Ms. Choi, aged 39, is a divorced mother of four who is receiving a government pension as a single mother. She came from China to Australia in 1995 when her ex-husband sponsored her and the children. She was introduced to gambling by her friends who would drive her to the casino. Her ex-husband also encouraged her to gamble as a social activity because she stayed home most of the time. With limited English skills, she lacked vocational skills and felt dependent on her ex-husband. At the casino she would play card games, in particular blackjack. She would also watch other people play and bet her money on them (or “back” them). She believed that these other people had the “skill.” She would spend AUS$500-$600 a week on gambling and often borrowed money from her friends. She also felt obligated to financially support her family back in China.

Treatment Planning

This case exemplifies some of the cultural differences we have examined. The Chinese, as we have seen, tend to consider gambling a much more social activity than do individuals from Western backgrounds. In this vignette we see a lot of social encouragement for Ms. Choi to engage in gambling as a way to augment her social life and seek entertainment. An effective treatment plan for Ms. Choi will therefore need to help her to improve her social connections and find recreational activities outside of gambling.

The gender differences that we have seen described in Chinese gambling patterns also come into play in the case of Ms. Choi. Compared to Chinese men, cognitive errors related to gambling processes and outcomes play a relatively small role in the etiology of problem gambling. This appears to be the case for Ms. Choi, who engages in gambling primarily to fulfill emotional needs. It will therefore behoove the clinician to assess Ms. Choi for symptoms of anxiety and depression and to address these symptoms as needed. Based on the literature we have reviewed and on Ms. Choi’s clinical presentation, we will be surprised if these emotional factors do not underlie her loss of control over gambling behaviors.

Finally, we see in Ms. Choi’s presentation a combination of dependency and obligation that are almost certainly damaging to her self-concept under the present circumstances. Each of these feelings is related to gender roles that would be and most likely were adaptive for Ms. Choi during her life on mainland China, but which now are failing to serve her emotional needs. It will therefore be a major task of the therapy to assist Ms. Choi in becoming acculturated to her new environment. The therapist will need to help her critically evaluate the differences in cultural and personal expectations that face her in her new life in Australia.

References

• American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
• Buckley, C. (2009, November 26) A tradition that cherishes poker, not pumpkin pie. The New York Times, p. A28.
• Ariyabuddhiphongs, V. & Phengphol, V. (2008). Near miss, gambler’s fallacy and entrapment: Their influence on lottery gamblers in Thailand. Journal of Gambling Studies, 24, 295-305.
• Castillo, R.J. (2001). Lessons from folk healing practices. In Seng, W.S. & Streltzer, J. (Eds.), Culture and psychotherapy: A guide to clinical practice (pp. 81-101). Arlington, VA: American Psychiatric Publishing.
• Chui, W.H. (2008). True stories: Migrant Vietnamese women with problem gambling in Brisbane, Queensland. Journal of Social Work Practice in Addictions, 8(2), 276-280.
• Loo, J.M.Y., Raylu, N., & Oei, T.P.S. (2008). Gambling among the Chinese: A comprehensive review. Clinical Psychology Review, 28, 1152-1166.
• Oei, T.P., Lin, J., & Raylu, N. (2008). The relationship between gambling cognitions, psychological states, and gambling: A cross-cultural study of Chinese and Caucasians in Australia. Journal of Cross-Cultural Psychology, 39(2), 147-161.
• Raylu, N. & Oei, T.P. (2004). Role of culture in gambling and problem gambling. Clinical Psychology Review, 23, 1087-1114.

Although psychological and addictive disorders have come to be recognized as common and treatable conditions within the medical profession and even among the general population, the United States health care system is still lagging behind. Insurance companies do not provide equal coverage for mental health services, and most Americans lack access to even basic mental health care. The goal of interest groups campaigning for better mental health coverage has been to achieve “mental health parity,” meaning that that mental health services would be covered at the same level as general medical services and surgical procedures.

The first major victory is this campaign came in 1996, when Congress passed a law mandating equal annual and lifetime dollar limits for mental health benefits. A more recent piece of legislation has extended this parity in benefits to co-payments, deductibles, out-of-pocket limits, and caps on the number of inpatient or outpatient visits. The passage of this law is being hailed as a tremendous success by advocacy groups. However, the law has problematic limitations that may actually serve to increase systemic barriers to mental health treatment, particularly among the working poor and the lower middle class.

In this analysis we will examine the consequences of the present mental health parity law, and the structural barriers that continue to limit access to mental health services. We will examine the consequences of these limitations, both for the affected individuals and for the society as a whole. Finally, we will propose changes to the current policies which could remedy the problems we outline.

Why Mental Health Parity Is Needed

The Substance Abuse and Mental Health Services Administration (SAMHSA) conducted a comprehensive National Survey on Drug Use and Health in 2002, and found that more than five million individuals meeting criteria for serious mental illness “perceived themselves as having an unmet need for treatment in the year prior to the survey” (Bender, 2003). Of these, nearly 2.5 million severely mentally ill individuals cited insufficient financial resources as the primary reason that they were unable to receive appropriate treatments.

This means that, as of 2002, nearly 1% of the entire population of the United States is comprised of severely mentally ill individuals who want treatment but are unable to afford it (U.S. Census Bureau, 2003). This figure does not include individuals whose mental illnesses are distressing but not debilitating, who likely number in the tens of millions, nor does it include individuals suffering from substance abuse disorders, of whom there may be more still. The magnitude of the problems we face in ensuring treatment of psychological and addictive disorders constitutes a public health crisis.

This crisis reaches beyond the mental health system by putting an undue strain on the nation’s medical infrastructure. According to O’Donohue & Cucciare (2005), “research consistently shows that patients with psychological problems use more [medical] services than those without diagnosable psychological problems.” For example, one recent study tracked a sample of individuals admitted for inpatient treatment of various medical conditions. At four years, patients who demonstrated psychological factors such as depressive or aggressive tendencies had been readmitted for further medical treatment at a rate twice that of their counterparts with no psychological comorbidity. The total number of days of inpatient care utilized for the treatment of physiological conditions also doubled for these patients (Saravay, Pollack, Steinberg, Weinschel, & Habert, 1996).

The good news is that psychotherapeutic treatment reliably reduces medical service utilization. Mumford, Schlesinger, Glass, Patrick, & Cuerdon (1998) describe a history of research demonstrating that the delivery of mental health services is strongly predictive of decreased utilization of medical services across the board. They conclude that the evidence for a general cost-offset effect following outpatient psychotherapy is “widespread and persistent” (p. 85), with the most substantial savings coming from a decrease in inpatient service utilization.

Steps Toward Mental Health Parity Implementation

As we have mentioned, the first step toward mental health parity in the United States came with the passage of the Mental Health Parity Act of 1996 (MHPA). The act required that insurance policies which included mental health coverage do so at the same annual and lifetime dollar value as their coverage for general medical and surgical services (NASW, 2002). However, disparities between co-payments, deductibles, and out-of-pocket expenses were not affected by the bill, nor were any of the millions of insurance policies which provided no mental health coverage at all.

The U.S. Congress expanded on this effort to improve mental health coverage for Americans in 2008, by passing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The MHPAEA addressed a number our concerns regarding the MHPA. It required that employers whose insurance plans include mental health and/or substance abuse coverage eliminate any remaining disparity with medical coverage, including co-payment amounts, total out-of-pocket expense limits, deductibles, and annual limits on inpatient and outpatient visits (Bernstein, 2008).

However, the MHPAEA still placed no requirements on payees to provide mental health coverage to their beneficiaries. This means that, as before, only patients whose medical coverage includes optional mental health benefits will be able to benefit from the new law. Individuals’ whose insurance coverage does not include optional mental health coverage will remain without access, as will the millions of uninsured Americans (Jenkins, 2008).

Problematic Impacts of Mental Health Parity Legislation

Like the 1996 Act, The MHPAEA places a substantial financial burden on employers and other insurance payers without placing any additional regulation on insurance providers and managed care organizations. Opponents of comprehensive parity legislation have argued that any new regulations on the insurance industry would precipitate the loss of other, unprotected health care benefits in order to offset the cost (Carroll, 2004). However, placing the burden on employers will likely result in severe consequences for lower and middle class workers.

We can predict this because it is essentially what took place after the passage of the MHPA, which represented much less of an imposition on employers. According to the National Association of Social Workers, the “U.S. General Accounting Office reported in May 2001 that 86 percent of employers surveyed reported that they had complied with the requirements of the 1996 Act. Nevertheless, the vast majority of those employers substituted new restrictions on mental health benefits, thereby evading the spirit of the law” (NASW, 2002, Background and legislative history section, ¶ 10). With the new requirements being much more demanding, it is likely that many employers will simply see no benefit in continuing to provide mental health coverage, particularly for employees who are not considered valuable enough to warrant competitive benefits packages.

This means that by placing the burden of providing additional coverage on employers, the MHPAEA has essentially given employers an incentive to drop existing mental health coverage for low-wage employees. Workers who previously had inadequate access to mental health services are likely to see even their inadequate mental health benefits disappear. Such a change will disproportionately affect the working poor, a group whose high levels of external stress create a greater need for the very services they will be losing access to.

Meanwhile, advocacy groups such as the American Psychological Association are lauding this new law as a huge victory in the fight to end discrimination against sufferers of psychological illness (APA, 2008). What has actually taken place is the passage of federal legislation which effectively institutionalizes the medical discrimination which was already taking place within the insurance industry. Furthermore, the Act has freed the insurance industry from any responsibility for ending that discrimination, instead placing the burden on a group which has far less interest in the provision of those benefits to the individuals who need them most.

Solving The Problem Of Mental Health Parity

The laws that have been passed so far are out of line with the basic ideology underlying mental health parity, which is that mental illness is a medical condition. Based on this premise, it is reasonable that sufferers of mental illness be able to expect treatment comparable to that which they would receive for any other illness. Any medical service plan that excludes coverage for psychological conditions is therefore unfairly discriminating against sufferers of a particular set of conditions in a way that has been outlawed when it has occurred in the past.

There are two main counter-arguments that can be made against this premise. The first is that mental illnesses are not medical conditions (Kershaw, 2008). However, as executive director of the Suicide Prevention Action Network USA in Washington Jerry Reed (2007) points out, a growing body of research has solidly established distinct physiological correlates of individual mental illnesses. Furthermore, mental illness results in a far greater number of fatalities each year than HIV/AIDS. There are nearly 30,000 mental illness-related suicides in the United States each year (Reed, 2007).

The second major counter-argument against our premise of mental health parity is that insurers should have the right to exclude certain classes of conditions as they see fit. As we have already discussed, legislative precedent contradicts this idea. Congress has already specifically outlawed this type of exclusion both for the elderly and for patients diagnosed with HIV/AIDS (Wellstone, 2002). This precedent takes on added weight when we consider that the level of fatality resulting from mental illness is much higher than that of the very disease for which Congress previously intervened.

Given, then, that the premise of mental health parity is sound, it becomes the duty of insurance providers to include mental health coverage as a part of basic medical benefit packages. Placing the burden of improving mental health coverage onto the individuals and organizations purchasing the coverage is not in keeping with the philosophy that mental illness and its treatments are equivalent and of equal importance to all other medical conditions and services. The way to implement that philosophy would be to require that insurance providers simply include mental health services under the existing terms of their coverage for general medical services.

Aside from being philosophically sound, this method of implementing mental health parity is also highly pragmatic. Insurers stand to benefit financially from offering better coverage for mental health services. Full mental health parity would represent a total cost increase of about 1.5% for most managed care organizations (Carroll, 2002). That increase would be more than offset within just a few years by the resulting reduction in general medical service utilization (Mumford et al, 1998). Employers, on the other hand, may stand to realize some increases in worker productivity as a result of better access to mental health services (see, for example, Wang, et al, 2007; Hartmann & Zepf, 2004; Hafner, Haug, & Kachele, 2004; Jordan, Grissom, Alonzo, Dietzen, & Sangsland, 2008), but ultimately have far less demonstrable interest in the provision of these services.

We therefore conclude that the most logical, feasible, and enforceable method of implementing mental health parity is to require insurance providers to include mental health treatments in their definitions of general medical treatments. By prohibiting the segregation of mental illness from physiological illness, equitable coverage is ensured without the substantial loopholes seen in the 1996 Parity Act and again in the 2008 Act. Furthermore, this method of enactment provides an ultimate financial benefit to the very organizations it holds responsible for implementation.

The problem in implementing this strategy is, of course, a political one. The insurance lobby is both exceptionally powerful and highly resistant to legislation which would increase its obligations. They have, unsurprisingly, supported legislation which offloads responsibility for mental health coverage onto businesses. For this reason, the business lobby seems like a natural ally in our attempts to redefine medical coverage to include mental health services. However, it is arguable that they have enough to gain to make substantial involvement worth their while.

The primary stakeholders in this redesignation seem to be healthcare providers and patient groups. Providers stand to gain from the opportunity to expand their mental health services, while patient groups have an interest in ensuring that comprehensive services are available. It may be possible to enhance the support of both groups by forming grass-roots organizations for individuals and families whose medical status has been affected by inadequate mental health care. These groups could act as emissaries between other stakeholder groups.

References

1. American Psychological Association (APA). (2008, October 3). Landmark victory: Mental health parity is now law [Press release]. Retrieved November 17, 2009 from http://www.apa.org/releases/parity-law1008.html
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Everybody “knows” what happened in Jonestown, Guyana in 1978. At the behest of their charismatic leader, all the members of the Peoples Temple religious cult—the residents of Jonestown—“lined up in a pavilion in front of a vat containing a mixture of Kool-Aid and cyanide” and  “drank willingly of the deadly solution” (Aronson, Wilson, & Akert, 2005, pp.4-5). That citation is taken from a popular Social Psychology textbook, and is a resounding demonstration of the phenomenon that this paper will attempt to explore: you see, the authors of that textbook feel so secure in their knowledge of the events surrounding the deaths in Jonestown that they feel no need to provide a reference for it. It is entered into the student consciousness as common knowledge. The fact that the popularly-accepted truth that Aronson, et al are parroting in this example is plainly false is almost beside the point, although this paper will provide a brief examination of some of the evidence which contradicts that accepted truth. The problem is much broader than the debunking of a single myth, and demands that some very important and difficult questions receive systematic evaluation: how is it that entire populations “know” things that contradict all available evidence, and what can be done to mediate this effect?

In considering the events of Jonestown, we might do well to start out by questioning our own credulity. What do we actually know about Jim Jones and The Peoples Temple, and from what sources? Does our understanding of the events stand up to logical scrutiny? Furthermore, as social psychologists, let us ask ourselves this very important question: In light of our current understanding of the power of social influence, do we believe it is plausible that 900 people took their own lives, simply because they were asked to? If so, are we willing to believe that we would behave in the same manner if subjected to similar social influences? As Aronson, et al (p.14) point out in their discussion of The Peoples Temple, “it is tempting and, in a strange way, comforting to write off the victims as flawed human beings. Doing so gives the rest of us the feeling that it could never happen to us.” The problem is that they use this rationale to imply that people would behave in a way that no empirical evidence has verified. Theirs is an argument from paranoia, having arisen out of its conclusion and stating as truism that which is both counterintuitive and unsupported. The idea here is not merely to pick on the authors of a textbook, but to pinpoint a mindset that is pervasive enough that it remains largely invisible in our society.

As Eileen Barker, the President of the Society for Scientific Study of Religions, has noted, “the belief in irresistible and irreversible mind-control techniques is so widespread that the democratic societies of Western Europe and North America appear to give ‘permission’ to citizens to carry out criminal attacks on someone merely on the grounds that he or she is a member of an unpopular religious group” (1996). Her research, however, does not support this belief. Furthermore, although there is very little research into the matter aside from her own, a small number of academics have taken up careers as “expert witnesses,” providing fervent yet unsubstantiated support to the idea. In the case of Jonestown, that man’s name was Dr. Hardat Sukhdeo. Jim Hougan writes:

Dr. Sukhdeo is, or was then, “an anti-cult activist” whose principal interests (as per an autobiographical note) are “homicide, suicide, and the behavior of animals in electro-magnetic fields.” His arrival in Jonestown on November 27, 1978 came only three weeks after he had been named as a defendant in a controversial “deprogramming” case. It is not entirely surprising, then, that within hours of his arrival in the capital, Dr. Sukhdeo began giving interviews to the press, including the New York Times, “explaining” what had happened.

Jim Jones, he said, “was a genius of mind control, a master.  He knew exactly what he was doing.  I have never seen anything like this…but the jungle, the isolation, gave him absolute control.”  Just what Dr. Sukhdeo had been able to see in his few minutes in Jonestown is unclear.  But his importance in shaping the story is undoubted: he was one of the few civilian professionals at the scene, and his task was, quite simply, to help the press make sense of what had happened and to console those who had survived.  He was widely quoted, and what he had to say was immediately echoed by colleagues back in the States. (1999)

The idea that a charismatic individual can completely overtake the decision-making power of random victims and use their mindless bodies to do his bidding even to the point of inciting a uniform mass suicide, with 600 adult individuals willfully—even joyously—killing themselves and their children is startling, anxiety-provoking, ambiguous, and enticing. It is, in short, good material for conversation. It is precisely the stuff of which rumors, gossip, and urban legends are made (Guerin & Miyazaki, 2006). It is not a realistic causal evaluation of plausible events, but is rather a good example of what is called “magical thinking,” the type of credulity typically associated with the pre-rational thought processes of young children. However, research indicates that as they mature, people tend to abandon magical beliefs in word only. “Indeed, in their general patterns of judgments, actions and justifications, adult participants seem to be prepared to respect both scientific and non-scientific causal explanations to an equal extent” (Subbotsky, 2001). By sharing rumors with amongst ourselves in the course of conversation and by receiving fantastical official versions through the media, this tendency toward fascination becomes manifest. Wherever mass media is the source of the information, we must also take into account the social component of individual judgement, which is a considerable influence (Joslyn, 1997). For, as McLuhan noted, sociality of mass media is profoundly experienced—when we watch television, we are influenced not only by the content of the programming but also by the knowledge that a large number of our peers are watching as well (1964).

This may help to explain why so many of us have accepted a version of the Jonestown events that are implausible. In addition to the psychological discrepancies we have already noted, let us observe that death by cyanide poisoning is a painful and grotesque affair. Central nervous system signals become scrambled, causing both voluntary and involuntary muscular systems to spasm violently. Twisted, contorted limbs and a terrible grimace known as cyanide rictus are typical of this cause of death (Jaffe, 1983 as cited in Judge, 1985). However, none of the more than 150 available photographs of the victims reveal these symptoms. Furthermore, the victims were laid out in neat rows, and some of the closer range photos reveal drag marks on the ground, indicating that the corpses were arranged in this way after their death. Based on an investigation that included the testimony of Dr. Leslie Mootoo, the top Guyanese pathologist who served as Chief Medical Examiner for the case and who personally examined many of the Jonestown bodies, a Guyanese grand jury concluded that only two of the 913 dead had committed suicide. Dr. Mootoo found fresh needle marks near the left shoulder blades of the vast majority of the victims he inspected, with some others exhibiting gunshot wounds or strangulation as the likely cause of death. The gun with which Jones himself is purported to have shot himself in the head was found lying nearly 60 feet from his body (Judge, 1985; Hougan, 1999; Schnepper, 1999). It is evident, then, that the supposed “mass suicide” was actually a massacre—but who would slaughter nearly a thousand U.S.citizens, nearly all of whom were African Americans, women, and underprivileged children?

There is a substantial body of evidence connecting Jim Jones and his Peoples Temple to the covert operations of the United States government intelligence community, not least of which are his longstanding ties with CIA operative Dan Mitrione, his adeptness at infiltrating and exploiting local governments, the suspicious circumstances surrounding the assassination of Congressman Leo Ryan in Guyana the evening before the massacre (whose escort was a high-ranking CIA officer), and the enormous cache of psychiatric drugs found on the premises of the Peoples Temple colony—all of the type being experimented with at that time under the CIA’s MKULTRA mind-control project (Judge, 1985; Hougan, 1999). Additional evidence of U.S.government involvement in the affair involves the self-proclaimed “anti-cult activist” psychiatrist Dr. Sukhdeo, whose own attorney has stated that his trip to Guyana was funded by the U.S. State Department.

The possibility exists that Jonestown, Guyana was indeed one of the many government experiments in mind-control of the 1970s. If it is, however, it would seem that the experimental subjects included not only the members of the Peoples Temple, but also the public at large. Regardless of intention, we have here a clear case of a governmental bureaucracy producing and disseminating misinformation for one reason or another, and the public—including the scientific community—accepting it without question, repeating it with authority, and even using it as a basis for social theory. The danger that this presents to free society is enormous, and the need for a concerted scientific effort to understand its limits and to develop safeguards is equally enormous.

References

1. Aronson, Elliot, Wilson, Timothy D., & Akert, Robin M. (2005). Social Psychology, 5^th Edition.New Jersey: Pearson Education, Inc.
2. Barker, Eileen (1996). “The Freedom of the Cage.” Society, Vol. 33 Issue 3, pp53-59.
3. Guerin, Bernard & Miiyazaki, Yoshihiko (2006). The Psychological Record, Vol. 56, pp.23-24.
4. Hougan, Jim (1999). ‘‘Jonestown. The Secret Life of Jim Jones: A Parapolitical Fugue.’’ Lobster, Vol. 37, pp.2-20.
5. Joslyn, Mark R. (1997). Political Behavior, Vol. 19 No. 4, pp.337-343.
6. Judge, John (1985). ‘‘The Black Hole of Guyana: The Untold Story of the Jonestown Massacre.’’ In Keith, Jim (Ed.), Secret and Suppressed: Banned Ideas and Hidden History.Portland,OR: Feral House.
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8. Schnepper, Jeff A. (1999). “Jonestown Massacre: The unrevealed story.” USA Today Magazine, Vol. 127 Issue 2644, p26.
9. Subbotsky, Eugene(2001). British Journal of Developmental Psychology, Vol. 19, pp.23-46.