Reflections on Time Abroad

Both residents and faculty at Yale have rewarding experiences abroad exploring mental health throughout the world. Throughout Asia and Latin America to Africa, Yale psychiatrists are learning from other psychiatrists while bringing their own expertise to these regions. We have begun to highlight only a few of the may exciting Global Mental health experiences that have been possible here at Yale.

Changing Perceptions of Global Medicine

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"Through the CASE rotation as a second year resident, I had the opportunity to continue the work I started as a medical student, focusing on the mental health needs in the Kono District of Sierra Leone. Civil war raged in Sierra Leone between 1991 and 2002 and during that time, many children were raped repeatedly and forced to take drugs to reduce inhibitions against committing violent acts. One of the predominate drugs used to enforce these violent acts was brown-brown, a mixture of cocaine and gunpowder. As such, during my time in Sierra Leone I witnessed many young men, who currently still use this substance, portray symptoms consistent with psychosis. As a result of their substance use and associated symptoms, many were shunned away by people in the community. During my most recent visit in March 2013, I wanted to further characterize the symptoms of these individuals and understand the stigma surrounding mental illness in general, in hopes of developing strategies/treatments to integrate these young men back into the community. Through my experience, I really appreciated the desperate need for skilled clinicians to work in areas were people are too often neglected and in crucial need for help. As there are no practicing psychiatrists in the country, many people have taken liberties in treating the mentally ill. It was not uncommon that I encountered men tied to trees or locked in rooms for months without outside contact, to prevent 'evil' spirits from running loose. I had to do away with my Western ideas/teachings of mental illness and understand the perspective of the Sierra Leonean community. By approaching many people without judgement and motivated by the need to genuinely help, I relied on my expertise thus far, to not only diagnosis, but treat the young men afflicted with the 'evil' spirit.

"As the stigma attached to both mental illness and substance use is so intense, I often found myself making house calls in the middle of the night or early morning to prevent others from noticing the "white woman," who visited the house. Oh yes, I am in fact Black American, however I quickly learned that any person from the US/Europe, based on their style of dress and dialect was considered a white woman! Not only did I experience a true cultural shift, much different from anywhere else in the world I've visited, but my usual understanding of how I perceive myself as Black woman in society was challenged. Overall, the experience in the global mental health project in Sierra Leone, has undoubtedly changed my life and worldview, not only on how psychiatry is practiced, but how medicine on a whole is approached throughout the world. I look forward to continuing my project this upcoming January 2014, as it is sure to be an unforgettable and worthwhile experience. Psychiatry indeed is a life long experience in learning and I am so grateful to have been able to participate in my Sierra Leonean project. I am now convinced my clinical practice and research endeavors, will undoubtedly include some facet of global work!"

Dr. Ayana Jordan, Yale Psychiatry Resident

Practice at the Forefront of Global Health

Yale Global Mental Health ProgramDr. Guillermo Valdes Montemayor, psychiatry resident, in Chiapas Mexico. Photo by Eva Quesada for Shoot4Change, with verbal permission of subjects.
Dr. Guillermo Valdes Montemayor, psychiatry resident, in Chiapas Mexico. Photo by Eva Quesada for Shoot4Change, with verbal permission of subjects.

"Traveling to Chiapas, Mexico was a marked experience in my professional and personal lives. Meeting and connecting with the local residents and working with young men and women that practice at the forefront of Global Health prompted me to engage in a constructive and reflective process. Also, learning about a completely different system of care, in which a copious amount of urgent needs forces you to be mindful of available resources and to work on new ways of approaching problems, has given me a new perspective about the health care system in the United States. Today, I feel confident about focusing my non-clinical interests in community psychiatry and policy making."

Dr. Guillermo Valdés, Yale Psychiatry Resident

Analyzing Data on Mental Health Delivery and Recovery

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During the summer of 2012, I spent 6 weeks at London School of Hygiene and Tropical Medicine working as a research collaborator with the PRogramme for Improving Mental health CarE (PRIME) on a study looking at best strategies to integrate mental healthcare with primary care in Nepal . My prior experience in anthropology and global mental health was centered on data gathering and fieldwork, but I did not have any experience doing data analysis or writing up my findings. This project not only allowed me to develop these skills, but gave me the opportunity to become a part of a research community dedicated to developing culturally appropriate mental health services based on needs and input of local stakeholders.

For my project, I conducted a thematic analysis of qualitative data on mental health delivery and recovery. Data was collected in Chitwan, Nepal and consisted of interviews with focus groups and key informants, including health professionals, traditional healers, community leaders, religious leaders, policy makers and service users. When I returned to New Haven, I wrote up the findings, which contributed to a report on the Results of Qualitative Study among Stakeholders in Nepal, to share our methods and findings with other members of PRIME. The ultimate goal of our work is to use the findings to develop mental health programs in Nepal that improve health and socio-economic outcomes. I cannot wait to visit Chitwan and see our work put into action.

Dr. Anna Fiskin, Yale Psychiatry Resident

An Externship to Thailand Teaches Important Lessons and Expands a Doctor's Perspective

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Dr. Christina J. Lee shared the experience of her international psychiatry externship in Bangkok, Thailand:

"'Sawasdee,' a traditional Thai salutation meaning both 'hello' and 'goodbye', continues to echo through my head each time I think about my international psychiatry externship during my 2nd year of residency. My stint in Bangkok, Thailand was one of the best experiences of my residency training and I continue to have fond memories of the month I was lucky enough to rotate at the Chulalongkorn Hospital and work with some of the friendliest, most gracious people I have ever met.

"While there, I trained under Dr. Rasmon Kalayasiri, (a substance abuse researcher who collaborates with Yale's own Dr. Robert Malison), and shadowed Chulalongkorn child psychiatry residents as they completed their daily clinical duties and didactics. Needless to say, the experience was both incredibly fun and enriching. I was fascinated to get a glimpse of how psychiatry practice and training differ from their counterparts in the United States. Thai-unique, non-American elements, including the open air design of the hospital, traditional white nurse's uniforms (complete with caps), purple patient uniforms/gowns, and the emphasis on exercise for the patients were just a few of the many interesting things I witnessed.

"All of the psychiatry residents were young (in their early 20s) and the majority of them lived together in spare quarters near the hospital. As a result, the kinship among the residency class was similar to that of a large family, namely in the closeness that can develop, but this 'family' was not at all exclusive; I was warmly embraced into their group, and any hesitation I had about traveling so far by myself disappeared upon my meeting these people.

"Highlights of my trip included singing group karaoke, staying in a traditional Thai house in a remote part of the country, exploring a floating market, and visiting some of their homes. I was delighted to spend my evenings with the residents as they poked fun at my exuberant appetite for their delicious cuisine; on weekends they were my personal tour guides as I visited all the spectacular sights in Bangkok.

"With regard to the research component, I had the opportunity to visit multiple substance abuse rehab facilities. One rehab center, which was particularly memorable, was run by Buddhist monks and open to anyone with a substance use disorder, including international clientele. The patients I met there described drinking a concoction of herbs prepared by one elderly monk (apparently the sole proprietor of the recipe) to facilitate their detoxification. Patients at this center were taught how to meditate, to listen to their bodies, and to acquire strength and inner peace. They would awaken early in the morning and perform chores to keep the facility clean and well-maintained. Art was used therapeutically, and the patient artwork on display included an array of stunning sculptures and paintings.

"Indeed, the opportunity to learn about one's specialty through a different culturally lens is one that I heartily recommend seizing. Just as recreational travel always has the remarkable effect of expanding one's perspective, traveling for educational gain stretches the scope of learning while invigorating, rather than enervating. I have made friends as well as professional contacts in Bangkok, and look forward to reuniting with them someday declaring: 'Sawasdee!'"

Dr. Christina J. Lee, Yale Psychiatry Faculty

Investigating the Use of Pharmacologic and Behavioral Treatments in Malaysia

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During her CASE rotation, Dr. Emily Tejani worked with Drs. Richard Schottenfeld and Marek Chawarski as part of their research group investigating the use of pharmacologic and behavioral treatments for opioid dependence in Malaysia. As part of this project, she spent a month in Malaysia learning about the heroin and HIV epidemic in the region, and participated in meetings with their collaborators in order to better understand the unique aspects of conducting a clinical trial internationally.

Dr. Tejani was also able to develop an independent project, which involved describing methods of heroin and amphetamine administration in Malaysia and investigating how these have changed over time since the introduction of heroin to the country. She was fortunate to attend a regional conference on opioid use and to learn from clinicians and researchers throughout East Asia and the South Pacific.

She remarks, "I came away with a deeper understanding of substance abuse issues in the region and a level of compassion and commitment to those struggling with these disorders that would not have been possible without this experience."

Dr. Emily Tejani, Yale Psychiatry Resident

A Cross-Cultural Experience in the Psychiatric Wards of Changsha, China

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During her second year CASE rotation Dr. Amelia Villagomez visited psychiatric wards in Changsha China (Hunan province). She shared this description of her experience:

"The experience provided me the opportunity to see how similar and yet how varied psychiatric presentations and treatments are across the globe. In Xiangya hospital, drug company pens and tissue boxes filled the busy outpatient attending's office who had multiple medical students hovering around a patient in distress -- a familiar sight. Yet not so recognizable was an almost entire hospital with patients experiencing first break psychosis (given limited resources, most beds were allocated to first break patients) or mania and the absence of a requirement to obtain consent to speak with family members (physicians there found it peculiar that we would require such consent given that it was in the patient's best interest to have collateral information). The experience in China helped broaden my Western-centric view and provided me with recognition of the similarity of psychiatric symptoms despite a significantly different cultural backdrop. I am extremely grateful to the residency program for helping to arrange this cross-cultural experience; without help from the program in securing funding and collaboration with the Yale China Association this trip would not have been possible."

Dr. Amelia Villagomez, Yale Psychiatry Resident

A Resident's Experience in Learning Stress Resilience

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"I still remember the moment when I first learned of the earthquake in Sichuan, China on May 12, 2008. Sichuan is my home province . The deadly earthquake took more than 80,000 people’s lives. Fortunately my family survived, but I cannot possibly imagine how much they were traumatized by this unbelievable disaster. When I heard many school students died in the earthquake, I decided to go back home to help. With support from former program director Dr. Kirwin and present director Dr. Rohrbaugh, I took a three-week vacation to go back to Sichuan with Dr. Heather Goff, an assistant professor at YPH. We decided to hold workshops for 'school-based post-trauma intervention' in three cities with the most severely damaged areas. Workshops were sponsored by Professor Lin Chen, the director of the National Key Laboratory of Cognitive Science in the Chinese Institutes of Academy.

"We fortunately had support from well-known PTSD experts at Yale, Dr. Southwick and Dr. Marans, in the Child Study Center. Taking their advice and guidance, Dr. Goff and I constructed the syllabus for the workshop. Our goal was to help school teachers understand the psychological needs for their students, normal and abnormal reactions to earthquake, and basic counseling skills. Our team included one coordinator from Professor Chen’s lab, local government staff and two voluntary translators. One of them was a third-year medical school student from Cambridge University in London who came back home for summer vacation. In three weeks, we had trained a total of 268 middle school and high school teachers. At the beginning of each workshop, we asked everyone to say a few words about themselves. Without exception, everyone talked about their experience during the earthquake. Although I learned much information from the media before I went back to China (my parents compiled two volumes of earthquake news from a variety of newspapers and magazines), I was still shocked by the magnitude of the tragedy. I was deeply moved by stories told from people’s own experiences. One day, when we were in a workshop, several teachers suddenly jumped up. Neither Dr. Goff nor I realized that it was an aftershock until someone shouted 'Earthquake! Earthquake!' Desks and lamps were shaking for seconds. Nobody left, the workshop continued. Heather and I used it as an example to teach feelings, thoughts, and behaviors.

"Three years passed by since my trip to Sichuan. Many people and their stories are still in my mind. The person whom I miss the most is a 7 year-old elementary school girl. This little girl survived from the school building collapsing. However, some of her friends died. She came to the workshop with her mother and quietly sat in the classroom playing with her mother’s cell phone. During the break, her mother told us that her daughter had changed to a different person since the earthquake. Prior to the earthquake, she was very happy and outgoing, the most popular girl in the school. She became quiet, shy and fearful, and could not be alone for any second after the earthquake. Her mother had to take her to the workshop. She asked her mother to buy her a bottle when they were shopping together, which made her mother worrisome. We did not get a chance to talk to her or her mother as we tried to cover as many subjects as we could. The next day, the little girl, wearing a bright yellow skirt, came with her mother again. By the end of the workshop, she told her mother, 'Mom, I am normal. I am not crazy. I just acted younger than I am.' She approached Dr. Goff and I and asked to take a picture together. Before I went back to Sichuan, I doubted whether or not I could help people who were deeply traumatized and suffered so much from their loss. This little girl gave me courage to complete our mission. She taught me that people, even as young as 7 years old, could be resilient.

"It was an unforgettable experience from my residency training and my professional life. I learned more from those earthquake survivors than any textbooks and papers that I have read. I am always grateful to everyone who helped me accomplish this workshop. My thoughts are with those dedicated teachers and their young brave students."

Dr. Ke Xu, Yale Psychiatry Faculty