By Carla Pezzia
University of Texas at San Antonio
As I initially developed my dissertation project, I asked several people in Panajachel, Guatemala, what would be a worthwhile study regarding health and, more specifically, regarding mental health. Various ideas were presented, but one topic was echoed by all: alcoholism. There appeared to be a united front promoting a study on anything that was related to alcohol abuse and dependence in the region. Given my five years of experience with brief alcohol intervention research, it seemed like a perfect match.
I decided to focus on understandings of alcoholism within a broader context of mental health, and then explore the experience of recovery from mental health disorders, specifically alcoholism. To this end, I have interviewed over 30 community members, various political and religious leaders, ten local and regional health professionals, and several nongovernmental organization representatives. I have also collected over 300 community surveys of mental health concerns in the area. In a preliminary review of my data, there is clear consensus that mental health disorders are abundant and in need of further study. Yet there is also a clear disconnect between the general and the leadership populations on how to manage the care of mental health disorders. In this article, I will present some of these differing views. I will end with a discussion of my own role as an applied anthropologist in helping community members negotiate their mental health care.
The Popular Support
While the biomedical model has become the overwhelming approach to healthcare by Panajachelenses, biomedical mental healthcare resources are limited. As such, mental healthcare appears to reside within the more traditional spiritual/religious realm. In fact, anthropologists have often cited the Evangelical church to be the Guatemalan Highlands version of Alcoholics Anonymous (e.g., Goldin and Metz 1991; Nash 1960). However, much like Alcoholics Anonymous, the “success” rate of “treatment” in the Church is debatable.
When I first met Tobias (names have been changed), I was overwhelmed by the physical sensation of defeat that he exuded. His daughter, Maria, has been struggling with schizophrenia for over ten years, and in her most severe states has been physically violent toward several of her family members. Tobias and his wife had tried everything for Maria. They had gone to non-specialized biomedical professionals, traditional healers, and religious leaders. The last time they went to a religious leader at one of the largest Evangelical churches in Panajachel, they were told that Maria would never get better because Tobias and his wife were sinners and did not have a real relationship with God. Since they had always considered themselves to be good Christians, Maria’s parents were stunned and driven further into desolation. Maria was eventually put on psychotropic medications that curb her violent tendencies, and while her parents still identify as Christians, they no longer seek religious support for their healthcare.
Overall, based on survey results and community member interviews, there is an overwhelming amount of support for further mental health studies and professional intervention development, particularly amongst people who either are mentally ill themselves or have mentally ill family members. “Professional” in these cases refers to psychiatric and/or psychological services. Often times, mothers are the ones to note recent changes in the view of mental healthcare. They acknowledge that what has been done traditionally has never been sufficient, and they are ready to test out different healthcare modalities in order to ensure the emotional well-being of, at the very least, their children.
The Official Stance
Throughout Latin America, both human and material resources for healthcare, in general, are limited, and even more limited for mental healthcare specifically. Political leaders say that the available resources are good enough, and there are no plans for developing more services. There is a psychiatrist at the Department of Sololá national hospital, which is about a 20-minute bus ride away from Panajachel. However, since the heavy rain in the rainy season of 2010 washed out part of the road leading to the hospital, this road has been closed on several occasions for varied lengths of time, making the trip to the hospital more costly both monetarily and in travel time. Moreover, the psychiatrist is only there Monday through Friday in the mornings, and a patient has to arrive no later than 10AM and wait for hours to be seen, making it difficult for the patient, or an accompanying family member, to take time off from work. For alcoholics, there are two chapters of Alcoholics Anonymous in town. That is all they need, according to a state level medical leader. Religious leaders claim that all that is needed for any issue is going to church.
Yet in November of 2010, two community leaders arranged for two counseling graduate students to conduct their practicum in Panajachel. They had specifically wanted these students to group counsel children who had experienced a shock from the recent mudslides due to the heavy rains and were having troubles sleeping at night. On the first day, there was a strong showing of roughly 20 children. The following day, the counselors cajoled the parents into staying and receiving counseling as well. The following week, no one showed. This was taken to mean by the community leaders that people were not interested in receiving services. They had heard one woman refer to a poster announcing the sessions as something “para locos” (for crazy people).
An Anthropologist in the Middle
Before even starting my fieldwork, I knew my topic was going to be difficult to study. I had the general trepidations of a typical graduate student compounded by the fact that I was dealing with a potentially extremely sensitive issue. Of course, I was ethically bound to put in some safeguards to ensure that anyone in an active crisis could receive some kind of medical attention. Most IRBs really only require that a list of referral numbers be presented to a study participant. While I did develop a list, I felt it was necessary to take things a step farther.
As an act of reciprocity, I worked with interested participants in seeking out and negotiating the services they desired. When the counseling students were here, I talked to the community leaders about having the students counsel other people. They shot me down saying no one would be interested, and the proof was that people had stopped attending by the second week. From my personal perspective, the issue was not lack of interest but lack of advertising, but the community leaders would have none of it. Eventually, I was able to get around the community leaders and go straight to the graduate students. They agreed to meeting with people as a side service, and I was able to fill their available time completely. Unfortunately, by that point, they were finishing up their practicum hours, only coming once a month, and most of their days were consumed with providing support sessions for adolescents learning English competing for a scholarship to study in the US.
While the opportunity with the graduate students was a positive negotiation for mental health care, it is more often than not a negative negotiation. As a lone anthropologist without any major funding support, I fall back on previous case management experience where I try to connect individuals with more established organizations, be they governmental or non-governmental. As already mentioned, the governmental services are limited, and the non-governmental organizations are not that much better equipped. While there is one NGO that often pays for an alcoholic/drug addict to go to a rehab center near Guatemala City for a month, this service is ultimately mediocre at best when the individual returns to Panajachel to the same exact environment they were in before. People like Maria are often turned away because program managers do not believe that donors will be as willing to give to help her over some young child in need of shoes and a primary school education, which is both understandable and disheartening at the same time.
I have three more months in the field, and I would like to say that there is some kind of light at the end of the tunnel in terms of applying my data to benefit the mentally ill in Panajachel on a broader level. With a community divided, there is no clear mechanism to promote more extensive mental healthcare in a culturally appropriate and sustainable manner, yet only time and continued effort will really be able to tell. For the time being, individual study participants find some relief in being able to tell their stories.
Goldin L.R., and B. Metz. 1991. An Expression of Cultural Change: Invisible Converts to Protestantism among Highland Guatemala Mayas. Ethnology 30(4):325-338.
Nash, June 1960. Protestantism in an Indian village in the Western highlands of Guatemala. Alpha Kappa Delten 49-53.