ArticleTranscultural Psychiatry 48(3) 284–298 ! The Author.docx

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Transcultural Psychiatry 48(3) 284–298 ! The Author(s) 2011
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DOI: 10.1177/1363461511402867 tps.sagepub.com
Cooperation and contention in
psychiatric work
Seth D. Messinger
University of Maryland, Baltimore County
Abstract
This article discusses the social organization of psychiatric
work in the psychiatric
emergency department of a public general hospital located in
New York City, based
on ethnographic research conducted from 1999 to 2001. Case
studies of the care of
two patients with ambiguous symptoms are discussed. The
analysis applies the ‘‘differ-
ences approach’’ developed by Mol and colleagues which
focuses on the way different

professions provide divergent explanations and ontologies for
symptoms and illness.
The cases illustrate the ways in which social structural
constraints are compelling psy-
chiatry to become a multidisciplinary specialty.
Keywords
cities, political economy, psychiatry, public hospitals, social
organization of work
Many patients who present to psychiatric emergency
departments in large urban
centers in the US have multiple problems, which go beyond the
disciplinary range
of psychiatry and require the services of other occupations that
thus far have served
in positions subordinate or ancillary to psychiatrists (Freidson,
1988). These prob-
lems include co-morbidity of mental illness and drug or alcohol
dependence, and
problems including unemployment, poverty, homelessness, and
other social ills.
The presence of this wide variety of co-morbidities coupled
with a relative scarcity
of hospital inpatient beds has altered the social landscape of
psychiatry. Once
ancillary occupation groups, like addiction counseling, now
have a claim on the
provision of beds which are key hospital resources as well as
access to networks of
placements through outpatient substance abuse rehabilitation
programs. This gives
members of these ancillary groups greater professional

authority, creating the con-
ditions where they are able to reorganize their working
relationships with
Corresponding author:
Seth D. Messinger, Department of Sociology and Anthropology,
University of Maryland, Baltimore County,
1000 Hilltop Circle, Baltimore, MD 21250, USA.
Email: [email protected]
http://crossmark.crossref.org/dialog/?doi=10.1177%2F13634615
11402867&domain=pdf&date_stamp=2011-07-08
psychiatrists. At times, these collaborative efforts can be
described as cooperation.
Alternatively, these once ancillary clinical occupational groups
can thwart the
efforts of psychiatrists to diagnose and admit patients to the
inpatient unit, causing
contention. In this article, I will illustrate these processes
through a close reading of
two patients’ experiences in the psychiatric emergency
department.
The argument that I present here claims that in order to
understand how
psychiatry is practiced in settings where a variety of pressures
such as social
service cuts, scarcity of beds and other resources, along with
challenges facing
indigent and largely underserved patients, we must investigate
this practice not

as a singular profession but as a multidisciplinary one. Berg and
Mol’s (1998)
‘‘differences approach’’ emphasizes on how different clinical
specialties can focus
on the same organ or dysfunction yet have ontological
distinctions that critically
shape their practice. This approach is particularly useful in
understanding the
challenges faced by clinicians in the psychiatric emergency
department, in which
psychiatrists work to understand their patients’ distress as
products of endoge-
nous disorders, while addiction counselors, social workers and
psychologists
view this distress as a product of the patients’ entanglements in
a complex
social world. These two groups of clinical workers negotiate
diagnoses and
treatment plans through their cooperation, or alternatively,
through intense
debates over the key question: ‘‘what is wrong with the
patient’’ (Luhrmann,
2000).
The ‘‘differences’’ approach is concerned with how different
clinical specialties
approach the disease or bodily organ from distinct ontological
perspectives, as well
as with how multidisciplinary clinical programs approach
complex therapeutic
challenges (Berg & Mol, 1998; Mol, 1998, 2003). Two examples
of this approach
to the study of clinical work are germane to the issues I discuss
in this article. Mol
(1998, 2003) investigates the different modes of diagnosis and
clinical understand-

ing when various medical specialties identify atherosclerosis.
She traces the distinc-
tions in ways of knowing atherosclerosis across different
medical specialties
illustrating how this disorder is enacted by practitioners in
relation to a shifting
terrain that is dependent on the context of where atherosclerosis
is observed (in the
thickened walls of the artery by a pathologist or in a patient’s
complaint by an
outpatient physician).
Gremillion’s (2003) ethnographic work on a treatment unit for
adolescents
with anorexia nervosa provides an example of how conflict
emerges between clini-
cians where different professional perspectives exist uneasily.
In an account of a
debate between a psychiatrist and a pediatrician over whether a
particular
patient could be discharged from the unit, the pediatrician
staked her position
on the basis of the patient’s weight, arguing that it was still
dangerously low.
The psychiatrist agreed about the low weight but argued that the
patient had
developed increased insight into her situation and had
strengthened her determi-
nation to eat. Here the anorectic patient is perceived in two
distinct ways: the pedi-
atrician is addressing the biomedical problem of an underweight
individual who is
at risk for malnutrition. In contrast, the psychiatrist is looking
at the complex
Messinger 285

transformation being wrought by the patient and endorsing an
emerging will to eat
that should be supported despite continuing low weight
(Gremillion 2003, p. 65).
Among the psychiatrists in the Urban Hospital psychiatric
emergency depart-
ment, mental illness was understood along strict biomedical
lines. Disorders and
diagnostic criteria were laid out in weekly seminars where
attending psychiatrists
taught residents how to identify symptoms and to understand
their relationships to
each other and to specific disorders. In contrast during morning
report and in other
conferences members of the ancillary professions, including
addiction counselors
and social workers, added a more complex perspective,
discussing patient symp-
toms in terms of their drug use, family situations, employment
status and social
networks (among other factors). The realities of specific
patient’s experience of
distress were constructed in ways that reflected the ontological
positions con-
structed from the standpoint of these different professions.
These ontological dis-
tinctions set the stage for the forms of cooperation and
contention that I will
describe.
Setting

This study was conducted between 1999 and 2001 at Urban
Hospital, a public
hospital in New York City. Urban serves a primarily low
income population of
African Americans, Latinos, a sizable immigrant community
originating in the
Caribbean and Africa, as well as substantial numbers of
undocumented
immigrants.
Urban Hospital is a major institution for the neighborhood. The
hospital has
been the site where generations of community residents have
been born, treated for
illnesses, and died. However, by the year 2000, many
community members felt the
hospital was surviving on borrowed time. Adding to their
anxiety, a new ambula-
tory care unit was built raising fears that a shift in the
hospital’s mission was
imminent and that the number of beds might soon be reduced.
People from the
hospital and the neighborhood were also concerned that Urban
Hospital’s rela-
tionship with two private medical centers was a harbinger for its
transformation
from a community hospital to a research center.
Urban Hospital was connected to a network that included two
private hospitals.
These private hospitals were in a much stronger position to
control their flow of
work. In busy periods their psychiatric emergency departments
could go ‘‘on diver-
sion,’’ which meant that ambulances transporting patients were
directed to alter-

native hospitals, often Urban. During my fieldwork, Urban’s 16
bed psychiatric
emergency department frequently would have over 20 patients.
These patients
would be placed on beds in the hallway or were placed in
reclining chairs that
were made up as beds in a patient lounge area. In these
situations, which occurred
when the inpatient psychiatric units were filled or overfilled,
psychiatrists and
addiction counselors and social workers would huddle together
working out dis-
positions to the community’s network of substance abuse
rehabilitation agencies or
286 Transcultural Psychiatry 48(3)
to longer-term state psychiatric facilities. As Rhodes (1991)
pointed out in her
ethnography of a psychiatric acute care center, the scarcity of
inpatient beds and
the challenge of locating an open admission slot for a difficult
patient provides a
constant struggle for clinicians. The end result in a place like
Urban Hospital is that
the ability to locate or reserve admission slots confers a
significant amount of
prestige and influence.
Urban Hospital’s psychiatry department, like many of its other
clinical depart-
ments, is largely made up of physicians who trained in foreign
medical schools and
immigrated to the United States, often after several years of

medical work abroad
(Katz, 1992).
1
Nearly all the resident psychiatrists accepted a slot in the
residency
program because it was available, not because it was a first
choice. Most had also
applied to internal medicine or some other non-surgical
specialty. The fact that
many of the residents are ‘‘accidental’’ psychiatrists makes
Urban a compelling
place to conduct a study of issues of training, professional
socialization, and the
practice of psychiatry. Urban’s status as a public hospital means
that it serves a
very diverse array of patients. As a public hospital Urban would
presumably have
the largest diversity of psychiatric illness to treat, making it a
rich training envi-
ronment for the residents (cf. Mizrahi, 1986).
Methods
Using participant observation in the context of an ethnographic
investigation of
the social organization of work, training environments, and
clinical practice, I
collected data on a daily basis between 1999 and 2001. The
research involved
observation of emergency department practices and interviews
with the clinical
staff members. I was able to attend morning report meetings and
had access to
all the clinicians. I also had access to the patient areas of the

emergency department
and was able to observe patients when they were not being
physically examined or
receiving treatment. However, if a patient had signed a consent
form I was able to
sit in with them on some meetings with psychiatrists or other
clinicians after receiv-
ing oral permission from both the patient and the clinician. In
this article all names
are pseudonyms (including the hospital name). Measures to
ensure confidentiality
included anonymous codes and pseudonyms that were provided
as a rule.
2
The
study was approved by the Institutional Review Board (IRB) at
both Teachers
College, Columbia University and at the hospital site. All
participants were
informed about the objectives and gave informed consent.
Results
While Urban Hospital kept a sequential log of admissions to its
psychiatric emer-
gency department it did not collect data tracking repeat
admissions, admissions by
diagnoses, or other historical information. That said, during the
period of my
Messinger 287

research it appeared that the majority of patients treated in the
Urban Hospital
psychiatric emergency department had a history of previous
psychiatric contact.
These patients were generally regarded as easy to diagnose and
were generally
perceived as offering little challenge in the development of a
treatment plan. This
was because in most cases their existing diagnoses were
reapplied and their links to
outpatient care were reestablished. In contrast, the two patients
that I discuss
below had no record of contact with Urban Hospital’s
psychiatric department
and they did not report being treated at other facilities. As I will
illustrate these
patients are more likely to engender the kinds of inter-clinical
debate which lead to
cooperation or contention among the various clinicians in the
emergency depart-
ment. The two cases that are the focus of this paper represent
the common dis-
tinctions made between patients without a psychiatric history.
The first case is
representative of patients who present with psychiatric
symptoms and a positive
toxicology screen for alcohol and/or drugs. The second case
represents patients
with symptoms that have unclear origins and which do not lend
themselves to
existing psychiatric disorders and which ultimately are seen to
fall under the cat-
egory of ‘‘problems with living.’’
Cooperation

The first case study provides an example of multi-disciplinary
cooperation in which
clinicians came together to address the particular challenges in
developing a diag-
nosis, treatment plan and disposition. These challenges include
the opacity of the
patient’s symptoms in the context of chronic drug and alcohol
use as well as his
unstable housing situation and intangible elements of his
personality that made
him difficult to place in an inpatient bed or treatment facility.
Late one evening, an African American man in his 40s arrived
at the locked
doors of the Urban Hospital psychiatric emergency department.
He was let into the
triage area where he was initially searched by a hospital police
officer. After waiting
a few moments he was interviewed by a psychiatric resident
accompanied by a
nurse who measured his blood pressure and his temperature.
During the interview
the man, who said his name was Avery, gave a complex and
detailed account of a
series of interpersonal conflicts that had frightened him enough
to seek help. He
had first gone to the medical emergency department around the
corner and they
had suggested he come here.
Avery described a series of escalating conflicts with his
neighbors and with the
building superintendent in his apartment building. These
conflicts stemmed from
his separation from his girlfriend. According to Avery they had
broken up and she

had moved into the basement of the building. He said that she
then had a series of
sexual encounters with neighbors and the building
superintendent, and that when
these men had discovered that she had HIV they blamed Avery
for their exposure.
Avery said that he thought they were planning to assault him
and that he could
hear them planning it through the walls and the floor of his
apartment. He also said
that he was being watched all the time because he heard voices
describing his
activities. For example, when he was brushing his teeth he
could hear a voice saying
‘‘now he is brushing his teeth’’ or when he was walking through
his apartment he
could hear a voice saying ‘‘he’s going from the kitchen to the
living room.’’
In order to help Avery feel more calm, the resident who
interviewed him gave
him an injection of a standard medication combination often
administered at
Urban Hospital that was referred to as ‘‘a five and two’’
meaning five milligrams
of haloperidol (a neuroleptic) and two of lorazepam (an
anxiolytic). After he was
‘‘medically cleared’’ through a brief physical examination,
Avery had blood drawn
in order for the psychiatrists to get a toxicology screen. Avery
was assigned to a bed

and promptly fell asleep. After I left, the resident wrote up his
notes to present
Avery’s case to the team the next day at morning report.
The morning report is the most elaborate ‘‘rounds’’ presentation
of the day in
the psychiatric emergency department. In attendance are the
attending psychia-
trists, two or three psychiatric residents, Dr. Maye the
psychologist, Ms. Crusoe,
the addiction counselor, one of the social workers, and one of
the nursing staff. In
addition, medical students, physician assistant students,
psychology and social
work interns, case managers from outside agencies (who may
have clients in the
emergency department). The morning after Avery came to the
emergency depart-
ment the admitting resident Dr. Oba, presented the details of his
case to the assem-
bled team. Overnight the hospital lab returned the results of
Avery’s bloodwork
showing the presence of heroin. Furthermore, in a subsequent
interview with him
conducted by a nurse it was reported that he was a habitual
heavy user of cocaine
and heroin as well as alcohol.
The discussion of Avery in morning report, which took about 15
minutes,
ranged across several diagnostic possibilities. Dr. Oba took
Avery’s belief that he
was going to be assaulted as evidence of a paranoid delusion.
He also presented
Avery’s report of hearing his neighbors angrily talking about
him and describing

his activities as two forms of auditory hallucination, which were
clear evidence of
schizophrenia (American Psychiatric Association [APA], 2000).
Ms. Crusoe disagreed with Dr. Oba and told the group that the
patient had
‘‘talked about cocaine and alcohol use both of which could be
responsible for the
hallucinations.’’ The attending psychiatrist also supported her
position reminding
Dr. Oba that, ‘‘While you’re right. . . the commenting voices
are a powerful sign of
schizophrenia, until we know more about him I agree with Ms.
Crusoe. Alcohol
alone has been associated with auditory hallucinations including
those that seem to
be commenting or describing the patient’s activities.’’
At the conclusion of the discussion, the morning report team
agreed that the
diagnosis for Avery could only be ‘‘substance induced
psychotic disorder.’’ This led
to a brief discussion of the various disposition options. One
possibility was to
admit Avery to the inpatient unit at Urban Hospital, but the
social worker men-
tioned that, in light of Avery’s report about conflict with his
neighbors and building
superintendent, they might have to consider Avery as unstably
housed or homeless,
which meant that he could not be discharged without a home or
a residential
facility to go to. This led to a brief renewal of the possible
diagnosis discussion
Messinger 289

because the choice of problem to emphasize (psychiatric
disorder versus substance
dependence disorder) would have implications for where Avery
could be sent.
Over the rest of that day and the following I was able to talk to
two psychiatric
residents and to Ms. Crusoe (the addiction counselor) about
Avery and about what
would likely happen to him. The psychiatric residents continued
to argue that
Avery likely had schizophrenia, pointing to the commenting
hallucination as well
as to the persistence of his delusional belief that there was a
plot to assault him.
Added to this, the daytime resident, Dr. Randolph, argued that
Avery had a delu-
sional denial of illness which was further evidence of a primary
psychotic disorder.
In contrast, Ms. Crusoe argued that Avery was a drug addict and
that his
symptoms needed to be understood in that context. She was
determined to have
Avery admitted either to the inpatient unit or to a residential
treatment facility
because, in her view, only in a secured, structured institutional
setting could Avery
receive the kind of care he needed.
Although, Ms. Crusoe agreed with the psychiatrists that Avery
had a mental
illness, she disagreed over the specifics, seeing it as an

addiction disorder rather
than a psychotic disorder, but she had no doubt that it was
persistent and intrac-
table. What distinguished her position from the psychiatrists
was that she did not
locate the disorder in Avery’s body or brain but in the social
context within which
he lived. Interestingly, while she defined his problem as one
stemming from social
factors, her notion of social context was limited to immediate
behavioral conse-
quences. She did not identify poverty, unemployment, or other
more obviously
social structural factors in her analysis of Avery’s situation. She
advocated admit-
ting Avery to the hospital or to a similar setting because, in her
professional view,
he needed the structure to develop new habits and a new social
identity and net-
work that was based on being sober.
During the four days that Avery was in the emergency
department, Ms. Crusoe
and the psychiatrists negotiated his disposition. Avery also
became involved in
these decisions at least indirectly through his actions. While his
first day was largely
spent sleeping or being interviewed, over the next three days the
nurses found his
behavior challenging. He complained vocally about the food,
had loud arguments
on the pay phone, and was found smoking a cigarette butt in the
men’s room.
Ms. Crusoe bitterly joked that she was less inclined to accept
that Avery’s story
about being the target of an assault was delusional: ‘‘he’s a

tremendous pain in the
ass; I’d be looking to hurt him too.’’
Ms. Crusoe’s perspective about Avery’s diagnosis and the best
treatment options
available for him emerged as the predominate view held by the
team. This shift
from debate to cooperation was based on the evidence that the
team collected from
Avery’s narrative about his fears, the voices he heard, and his
description of his
drug and alcohol use, complemented by the laboratory
toxicology tests. One of the
residents mentioned that Avery’s behavior in the emergency
department had also
led him to change his mind. ‘‘There is something about how he
intrudes on the
nurses, what he complains about, that does not seem like a
symptom of psychosis.
I’m not sure what is wrong with him in the whole picture, but I
don’t think a psych
unit is the right place for him.’’ The residents and physician
assistants sped up their
efforts with Avery, working with him on the proper medication
dosages to take as
well as running a number of physical tests to make sure he had
no health issues that
would obstruct his admission to a drug rehabilitation program.
Ms. Crusoe and her
social work colleagues started working through their networks
to find a place for

him. Despite these efforts, there were no available beds either
in the programs that
they contacted or, for that matter, in the hospital’s
detoxification unit.
The attending psychiatrist and Ms. Crusoe met with Avery and
encouraged him
to accept an admission to the hospital’s inpatient psychiatric
unit to begin the
detoxification process, pending the availability of a bed in a
residential treatment
facility. Avery agreed to this and was admitted to one of the two
inpatient units.
However, according to the attending psychiatrist assigned to the
inpatient unit,
Avery immediately requested to be discharged and provided his
apartment address
as his home. He was released and did not go to a residential
drug rehabilitation
program. I draw attention to this in order to point out that the
kind of interdis-
ciplinary cooperation that I am describing does not
automatically entail a desirable
clinical outcome, rather it illustrates the fluid and distributed
nature of authority
that can influence both diagnosis and treatment planning.
Patients like Avery are increasingly present in psychiatric
emergency depart-
ments (Larkin, Claassen, Emond, Pelletier, & Camargo, 2005).
They often present
with a combination of symptoms of psychiatric disorders and
drug and alcohol use.
These patients fall between the discrete boundaries of specific
clinical occupational
groups like psychiatry and addiction counselors. As in the case

with the clinical
occupational groups discussed by Mol and others, these patients
straddle the onto-
logical divide between the biomedical psychiatric model of
mental illness being in
the head, and the addiction counseling model, which sees these
pathologies as
rooted in social systems. Beyond the diagnostic difficulties and
limited treatment
options, there are substantial constraints on the broader hospital
and residential
treatment facilities that make it increasingly difficult to find a
place for patients in
these situations. Whether a consequence of
deinstitutionalization or a byproduct of
recent neoliberal innovations throughout municipal governance,
there is both a
decline in fiscal support for the expansion of public hospital
psychiatric inpatient
beds as well as an increased push to close or privatize public
hospitals. Psychiatric
departments have had to adjust to face these new circumstances.
One way in which
they have adjusted is to distribute diagnostic and treatment
authority to previously
ancillary clinical occupational groups, in part out of recognition
that non-medical
and non-psychiatric treatment approaches can be effective for
the patients who are
increasingly looking to psychiatric emergency departments for
help.
Contention
This second case study provides an example of contention
between representatives

of clinical occupational groups. ‘‘Caroline,’’ like Avery, came
to the emergency
department with symptoms that led to divergent diagnostic
conclusions.
Messinger 291
However, the context of her symptoms again revealed a divide
between ways of
seeing and understanding psychiatric symptoms. In this case,
the resulting conten-
tion in practice led to a kind of diagnostic and therapeutic
stasis.
Early one evening Caroline, an 18-year-old woman, was brought
to the psychi-
atric emergency department by police officers, who were
accompanied by her
mother. According to her mother, Caroline had suffered a series
of emotional
losses in recent days. Her boyfriend of several months, who she
felt very strongly
about, broke up with her to go out with Caroline’s cousin, who
was also her best
friend. As a result of these events, Caroline became increasingly
withdrawn, never
leaving her apartment and rarely leaving her bedroom. She also
refused to eat.
According to Caroline’s mother, who was interviewed by the
social worker, after a
few days of this she encouraged Caroline to ‘‘get over it.’’
Caroline became inten-
sely angry. She began to ‘‘tear apart’’ the apartment, breaking
pictures, throwing

things around her bedroom and the family living room. When
she threw a clock
through the window looking out over the balcony her mother
called the police.
When the police arrived Caroline was standing on the balcony
amidst shattered
glass leaning out over the building court several floors below.
She did not resist the
entreaties of a police officer to come into the apartment. When
she did she was
handcuffed and brought down to the patrol car which took her to
Urban Hospital.
At the hospital, she was released from the handcuffs and was
interviewed separately
by a nurse, a social worker, and a psychiatric resident. She was
medicated with
lorazepam and given a bed.
During the next morning report, the psychiatric resident who
had admitted her,
Dr. Odinma, presented her case to the treatment team. He
reported the narrative
above, and added that during his interview with her she was
tearful. However, he
also said that her behavior was erratic, she would become
suddenly angry, then
suddenly laugh. She also gave evidence of being paranoid by
suggesting that her
cousin and her boyfriend had planned this in order to hurt and
humiliate her. The
resident explained he had given Caroline a provisional
diagnosis of brief psychotic
disorder (APA, 2000, pp. 329–332) with a rule out for
schizophreniform disorder.
When other clinical workers expressed surprise about this rule
out diagnosis, the

resident explained that coupled with Caroline’s violent outburst
in her apartment
and her labile mood during her interview she might be
exhibiting the schizophrenia
symptoms of ‘‘disorganized behavior’’ (APA, 2000, p. 314) and
‘‘bizarre thought’’
(APA, 2000, p. 324). Both of these symptoms need to be
recurring in order for the
diagnosis of schizophrenia, but at Urban Hospital it was
common practice for a
one-time occurrence leading to a hospital admission to be
sufficient for the
diagnosis.
After the morning meeting ended Dr. Maye, the psychologist,
interviewed
Caroline. The interview, which Dr. Maye described for me, led
her to discount
the violent behaviors that led to the patient’s admission to the
emergency depart-
ment. Dr. Maye preferred to elicit the patient’s own report
about her emotional
state during her recent interpersonal upheaval. During morning
report the next
day, Dr. Maye suggested that Caroline’s behavior needed to be
seen in the context
of her recent relationship losses. The psychologist argued that
the patient was
suffering from an ‘‘adjustment disorder’’ and was having
difficulty accommodating
her new interpersonal circumstances. Dr. Maye also suggested

that the patient
might have a personality disorder. She recommended that the
patient be taken
off her medications and referred to the outpatient program for
intensive psycho-
therapy, arguing that medication had little to offer in such a
situation. Dr. Maye
included her recommendation in Caroline’s chart. This
frustrated Dr. Odinma, the
resident, who afterward told me that the contradictory
recommendation in the
chart was ‘‘particularly vexing.’’ I asked him what it could
mean:
Probably it won’t matter, but if she sues us or if there is any
kind of investigation it
makes it possible to doubt the care. The chart is too serious to
meddle with because we
[members of the clinical team] disagree. We can change things
in the chart, but in
another way.
He explained that rather than have the dispute appear in the
chart, the diagnosis
could be shifted ‘‘as we developed our ideas.’’ He went on to
explain that he felt
particularly vulnerable given his status as a resident, and his
fear that nothing
should threaten his future plans to practice medicine.
Caroline’s case was as a continuing source of conflict between
the psychologist
and the psychiatrists. Both Dr. Odinma and Dr. Maye argued

that Caroline’s
problem was fleeting. Some clinicians were surprised that she
had even been admit-
ted and the reception to her was decidedly cool. One nurse
commented that ‘‘all she
needs is a smack.’’ When I asked why she thought that way the
nurse said, ‘‘Well,
it’s not really fair, but she seems kind of spoiled to me.’’ The
crux of the debate
between Dr. Odinma and Dr. Maye was whether Caroline’s
symptoms could be
explained with reference to her brain, for lack of a better word,
or to her situation.
For Dr. Odinma the evidence to diagnose Caroline as psychotic
stemmed from
her violent, disorganized behavior and ‘‘bizarre’’ delusions. Dr.
Maye saw
Caroline’s actions as being poorly described by a psychiatric
system of symptoms
and disorders.
3
Dr. Maye argued that Caroline’s behavior, although
inappropriate
and extreme, was an expression of frustration and humiliation at
being treated
badly by her boyfriend and cousin. Dr. Maye agreed that her
violent outburst
was problematic, but felt that in essence it was a temper tantrum
and to see it as
evidence of psychosis was out of proportion. ‘‘What’s next,
every time a kid flips
out because his parent won’t buy him a toy, we’re going to put
him on Haldol?’’

She argued that once you cross over into the emergency
department the question
becomes ‘‘what kind of crazy are you?’’ Instead, she said, they
should be open to
the possibility that some patients were brought to the emergency
department
by mistake. ‘‘Maybe she should have been arrested. I hope not,
but she doesn’t
belong here.’’
Physicians, in both their practice and in their training of
residents, inculcate the
idea that medical knowledge is a pre-eminent, real knowledge
and that other
knowledges, experiential in this case, are subordinate or
secondary knowledge
Messinger 293
(Taylor, 2003, p. 556). Dr. Odinma crafted a narrative of what
was wrong with
Caroline excluding both Caroline’s own account of the events
leading up to her
being brought to the emergency department, and the latent or
experiential story
that Dr. Maye invoked. Dr. Odinma’s narrative served to
establish his authority as
a representative of medical science, as well as to address his
perceived vulnerability
to challenges to his status as a physician and as a competent
professional.
4

By the second day in the emergency department, the attending
psychiatrist pre-
sented Caroline with the option of going into the inpatient unit
or leaving with a
referral to an outpatient program. She rejected both options and
left without a
prescription to continue the antipsychotic medication that she
had been given while
in the emergency department. The chief of the emergency
department was not
disappointed to see her go. He wrote in her chart that she was
discharged rather
than that she had left ‘‘against medical advice.’’
Discussion
The ‘‘differences’’ in medical practice perspective offers
important insights into the
social organization of clinical work. Medical workers from the
different clinical
occupational groups in Urban Hospital’s psychiatric emergency
department are
engaged in practical questions over how to treat the suffering of
patients and
this work leads to ongoing efforts to interpret what is wrong
with patients. The
question of where mental illness comes from, the mind and body
of the patient, or
the social system in which he or she acts, is as salient as ever in
debates between
psychiatrists and members of other clinical occupational groups.
This debate often
pits psychiatrists using a biomedical perspective against
clinicians from social
work, addiction counseling, occupational therapy, and others
who emphasize the

social context.
Patients who come into Urban Hospital present a variety of
symptoms, which
emerge from mental distress and from substance use. This basic
issue is widely
agreed upon by the clinical team members. But where
psychiatrists perceive mental
distress to have its origin in the brain, a psychologist may seek
the cause of mental
distress in the maladaptive social interactions in which patients
are embedded, and
addiction counselors may see its roots in a toxic social system
involving drugs and
crime. These perspectives are not strictly occupational
differences but are also
ontological ones. The ‘‘differences’’ approach encourages
researchers to see this
kind of conflict as a sort of clinical politics with shifting
coalitions and resources
coming into and out of play.
The ‘‘differences’’ perspective offers the possibility of a new
model of psychiatry
as a multidisciplinary medical specialty. The other clinical
occupational groups
offer understandings of illness and logics of care that directly
impinge on patients’
experience. Medical workers from the so-called ancillary
clinical occupational
groups like addiction counseling and psychology are all
concerned with the way
that patients fit into the larger social system beyond the
hospital. They offer a more

widely elaborated psychiatry, which provides the possibility of
confronting the
messy realities of social life as causal factors in mental
disorders.
This article provides an example of how the ‘‘differences’’
approach to under-
standing the social organization of medical work can be applied
to the ethno-
graphic study of a psychiatric emergency department. This
study foregrounds the
plural nature of psychiatry more generally as displayed in
episodes of cooperation
and contention between physicians and non-physicians in the
negotiation of deci-
sions about diagnosis, treatment plan, and disposition.
The differences approach to the study of the social organization
of clinical work
presents a new way to understand psychiatric practice in local
clinical settings.
However, recognizing the distribution of clinical authority to
diagnose, develop
treatment approaches, and arrange dispositions, to previously
subordinate groups
also creates new possibilities for psychiatry as a discipline. This
possibility
addresses Luhrmann’s concern that the biomedical research
agenda, which inves-
tigates organic causes for mental illness has led psychiatry to
diminish its potential
to ‘‘meaningfully encounter psychic suffering’’ (Lakoff, 2006;
Luhrmann, 2000).

Allowing previously subordinate clinical occupational groups to
oversee all aspects
of patient care creates an approach to recognize the subjective
and ‘‘essential’’
(Luhrmann’s term) way that suffering occurs as part of
experiencing a particular
affliction.
Successful psychiatric work could benefit from this complex
form, while provid-
ing numerous avenues of research. For example, studying
‘‘difference’’ helps us to
illuminate a paradox of contemporary psychiatric practice as it
occurs in general
hospitals. This paradox is that even as psychiatry as a discipline
turns to strict
interpretations of biomedical models of illness, the continuing
effects of deinstitu-
tionalization and the rise of managed care, as well as the
reductions in spending on
social services at all levels of government, have created
conditions where psychia-
trists must confront a renewed responsibility for managing
social ills reminiscent of
the age of the asylum; that is, poverty and social
marginalization translated into
symptoms of mental illness.
Conclusion
In this article I have described an example of what can be called
a ‘‘differences’’
approach to the study of the social organization of medical
work. Differences is a
way of investigating medical work developed in part by Mol and
others who seek

to illuminate the ontological distinctions in perceiving
pathology in different clin-
ical specialties whose work overlaps through their encounters
with organs, patients,
or disease and disorders. For instance Mol (2003) describes the
incommensurate
ways that pathologists diagnose atherosclerosis (through
identifying thickened
arterial walls) and primary care physicians who ‘‘see’’ this
disorder in the presen-
tation of the signs and symptoms of patients they encounter in
their examination
rooms. Gremillion (2003) describes how debate, or contention
as I have described it
in one of the examples included in this paper, intrudes on the
discharge planning
Messinger 295
associated with a particular patient in an eating disorder
inpatient unit. In this
example anorexia is understood in two fundamentally different
ways. The psychi-
atrist is concerned with the patient’s progress towards gaining
insight into her
disorder, developing the will to overcome it, and creating
healthy eating habits.
The pediatrician is concerned with the patient’s malnourishment
and continuing
low weight. Anorexia, as a disorder, is split into a mental and
physical disorder by
these clinical specialties.
The research I present here supports the importance of the

differences approach.
Here I present two patients who are representative of the kinds
of patients that are
flowing into psychiatric emergency departments, particularly
those of public hos-
pitals. Where my research takes the differences approach into
new areas, is in my
focus on the contrasts between psychiatrists and non-physician
clinical staff.
Psychiatrists, particularly residents, at Urban Hospital approach
the reports of
their patients’ symptoms through an understanding that fixes
mental illness in
the brain. Symptoms are seen, by the residents, as reflecting the
diagnoses that
they are being trained to identify. In contrast to this, the
addiction counselor, the
psychologist and the social workers and nurses understand that
the symptoms
described by the patients can often have their roots in the
complex social worlds
that these individuals inhabit, which are often a nexus of
poverty, substance abuse
and dependence, as well as interpersonal disruptions. The
ontological distinction is
between a psychiatric understanding of mental illness as
something in the body
(specifically the brain) and this alternative approach, which sees
mental illness, or
perhaps better termed, emotional upheaval, as something in the
social system or
community.
The two cases that I discuss, while quite different share a key
similarity: they
presented in the psychiatric emergency department with opaque

or ambiguous
symptoms that could lead to a variety of potential diagnoses. In
both cases the
psychiatric residents considered their symptoms in light of
psychotic disorders,
particularly schizophrenia. In contrast non-physician clinicians
posed alternative
theories that were grounded in the social context inhabited by
these patients. In the
case of Avery, his long-term drug and alcohol use were
considered in light of his
auditory hallucinations and delusional beliefs. In the case of
Caroline, her emo-
tional upset and destructive behavior in the context of
experiencing humiliation
around the loss of her significant other was contrasted with the
psychiatric resi-
dent’s impression that her upset and behavior could be seen as
emerging from the
spectrum of symptoms of psychosis. In the first case, the
clinicians drew together in
their understanding of Avery’s problem as they collaborated on
developing a diag-
nosis and treatment plan for him. In the second case the
psychiatric residents were
pitted against the psychologist and the nursing team. The result
was that they were
not able to negotiate a diagnosis or treatment plan leading to
Caroline being
discharged with little if any follow up planned.
Looking at these cases through the lens of what I have termed
‘‘the differences
approach’’ is important for three reasons. The first is that it
acknowledges a reality
of practice in Urban Hospital’s psychiatric emergency

department, which is that
psychiatry is increasingly a multidisciplinary specialty drawing
together the efforts
of physicians and non-physician clinicians. Second, this
approach recognizes the
complexity of the lives of the patients who seek care in the
emergency department.
They present with a mix of symptoms that are, on the one hand,
evidence of
psychiatric illness and on the other hand push beyond the
boundaries of discrete
psychiatric disorders requiring complex interventions. Last,
these complex inter-
ventions are located both inside of and outside of the hospital.
They require psy-
chiatrists to work closely with addiction counselors and social
workers to find
placements in an array of programs that are paradoxically
diverse and scarce;
they do not merely rely on the question of what is the
appropriate or ‘‘right’’
psychiatric diagnosis. The contributions of non-physician
clinical workers are an
important feature of psychiatric practice and without their input
as we can see in
the case of Caroline the proper disposition and treatment plan
may never fully be
reached. It is only through a deeper understanding of the
ontological distinctions
that separate clinical from ancillary groups that we can begin to
gain insight into

the problems faced by their shared patients.
Funding
This research received no specific grant from any funding
agency in the public, commercial
or not-for-profit sectors.
Notes
1. See, Katz, 1992, p. 365. Katz’s work looked at international
medical graduates (IMG)
who practiced psychiatry in the Maryland State psychiatric
hospitals. Her conclusions
were that culture issues generated both by the region of origin
of the IMG psychiatrists
and the culture of the state mental health system contributed to
a lower standard of care
than offered by US medical graduates.
2. To protect confidentiality, there was no audio-recoding and
interviews were recorded by
hand. Thus, except for brief quotations, I describe talk rather
than reproduce it verbatim.
3. See Horwitz and Wakefield (2007) for a discussion on the
transformation of normal
emotion into psychiatric disorder.
4. Barrett (1996) describes a similar process in his book on the
narrative construction of
schizophrenia in an inpatient unit.

References
American Psychiatric Association (APA). (2000). Diagnostic
and Statistical Manual of
Mental Disorders (4th ed. text rev.). Washington, DC: APA.
Barrett, R. A. (1996). The psychiatric team and the social
definition of schizophrenia: An
anthropological study of person and illness. New York, NY:
Cambridge University Press.
Berg, M., & Mol, A. (Eds.). (1998). Differences in medicine:
Unraveling practices, techniques,
and bodies. Durham, NC: Duke University Press.
Freidson, E. (1988). Profession of medicine: A study of the
sociology of applied knowledge.
Chicago, IL: University of Chicago Press.
Gaines, A. (1992). Ethnopsychiatry: The cultural construction
of professional and folk psy-
chiatries. Albany: State University of New York Press.
Messinger 297
Gremillion, H. (2003). Feeding anorexia: Gender and power at a
treatment center. Durham,
NC: Duke University Press.
Horwitz, A. V., & Wakefield, J. C. (2007). The loss of sadness:
How psychiatry transformed
normal sorrow into depressive disorder. New York, NY: Oxford

University Press.
Katz, P. (1992). Conflicts of cultures in a state mental hospital
system. In A. Gaines (Ed.),
Ethnopsychiatry: The cultural construction of professional and
folk psychiatries. Albany:
State University of New York Press.
Lakoff, A. (2006). Pharmaceutical reason: Knowledge and value
in global psychiatry. New
York, NY: Cambridge University Press.
Larkin, G. L., Claassen, C. A., Emond, J. A., Pelletier, A., &
Camargo, C. A. (2005). Trends
in U.S. emergency department visits for mental health
conditions, 1992–2001? Psychiatric
Services, 56(6), 671–677.
Luhrmann, T. M. (2000). Of two minds: The growing disorder
in American psychiatry. New
York, NY: Knopf.
Mizrahi, T. (1986). Getting rid of patients: Contradictions in the
socialization of physicians.
New Brunswick, NJ: Rutgers University Press.
Mol, A. (1998). Missing links, making links: The performance
of some atherosclerosis.
In M. Berg & A. Mol (Eds.)., Differences in medicine:
Unraveling practices, techniques,
and bodies. Durham, NC: Duke University Press.
Mol, A. (2003). The body multiple: Ontology in medical
practice. Raleigh, NC: Duke

University Press.
Rhodes, L. A. (1991). Emptying beds: The work of an
emergency psychiatric unit. Berkeley:
University of California Press.
Taylor, J. (2003). Confronting ‘‘culture’’ in medicine’s
‘‘culture of no culture.’’ Academic
Medicine, 78(6), 555–559.
Seth D. Messinger is an associate professor of anthropology at
the University of
Maryland, Baltimore County. His research interests include the
social organization
of medical work in psychiatric and physical medicine and
rehabilitation settings.
Currently he is conducting ethnographic research on the
connections between post-
traumatic stress disorder and mild traumatic brain injury
afflicting veterans of
the Wars in Iraq and Afghanistan. Address: Department of
Sociology and
Anthropology, University of Maryland, Baltimore County, 1000
Hilltop Circle,
Baltimore, MD 21250, USA. [Email: [email protected]]
Word limit = 1000 words
Watch an episode of Q and A (Monday nights on the ABC) and
discuss the following:
· Date of program
· Identify the social issues discussed on the program.
· Identify one social policy debate reflected within the program

and what underpins the views of the panel members?
· Discuss your own views in relation to one issue discussed on
the program?
· How would you attempt to influence this social policy and
why?
It is essential that students complete the readings and material
provided.
· Development of argument supported by literature (5 references
APA 6th )
· Critical analysis and originality
· Grammar/structure/academic writing
Episodes link of Q and A =
https://www.abc.net.au/qanda/2019-11-03/10868566
https://www.abc.net.au/qanda/2019-04-03/10838558
C O M M E N T A R Y
Changes in the Conceptualization of Personality Disorder:
The DSM-5 Debacle
Thomas A. Widiger
Published online: 6 October 2012
� Springer Science+Business Media New York 2012
Introduction

Lanier, Bollinger, and Krueger (2011) provide an overview
of proposed changes to the diagnosis and classification of
personality disorders to appear in the forthcoming fifth
edition of the American Psychiatric Association’s (APA)
Diagnostic and Statistical Manual of Mental Disorders
(DSM-5). They are correct that the proposed changes to the
personality disorders section are fundamental, and in some
respects may represent a true paradigm shift in how a
mental disorder is conceptualized and diagnosed. As
expressed by the Chair of the DSM-5 Personality and
Personality Disorders Work Group (PPDWG), ‘‘the work
group recommends a major reconceptualization of per-
sonality psychopathology’’ (Skodol 2010, ‘‘Reformulation
of personality disorders in DSM-5,’’ para. 1). I do not
myself disagree with some of the more radical proposals
that are being made, but a difficulty I do have is the sur-
prisingly liberal threshold that has been accepted for
making any such revisions (Frances 2009; Widiger 2011).

In addition, one point of strong agreement with Lanier et al.
is that the construction of DSM-5 is in a state of ‘‘flux,’’ to
the point that it is frankly difficult to predict or anticipate
what may in fact happen to the diagnosis of personality
disorders.
Lanier et al. state that the proposals for DSM-5 consist of
four major changes (see Table 1 of Lanier et al.): (1) a
change to the definition of personality disorder to require the
presence of a pathology of identity integration, integrity of
self-concept, and self-directedness in order for a diagnosis to
be made; (2) an assessment of level of self and interpersonal
dysfunction; (3) the deletion of five diagnoses; and (4) the
inclusion of a six domain (37 trait) dimensional trait model.
However, since this paper was written, there have been quite
a few significant changes to these (and other) proposals.
Prototype Matching
Missing from the Lanier et al. list of changes was a deci-
sion by the PPDWG to abandon diagnostic criterion sets

for prototype matching (Skodol 2010; Skodol et al. 2011).
One of the, if not the, major innovation of the third edition
of the APA diagnostic manual (i.e., DSM-III; APA 1980)
was a shift away from the unreliable prototype matching to
the requirement that a mental disorder diagnosis include a
systematic and comprehensive assessment of a specific and
explicit set of diagnostic criteria (Spitzer et al. 1980). The
criterion sets of DSM-III increased dramatically the ability
of researchers to conduct reliable, replicable, and valid
research. As expressed recently by Kendler et al. (2010),
‘‘the renewed interest in diagnostic reliability in the early
1970s-substantially influenced by the Feighner criteria-
proved to be a critical corrective and was instrumental in
the renaissance of psychiatric research witnessed in the
subsequent decades’’ (p. 141). One of the benefits of this
renaissance was the highly published Collaborative Lon-
gitudinal Studies of Personality Disorders (CLPS), which
used as its primary measure a semi-structured interview

that systematically assessed the DSM-IV personality dis-
orders’ specific and explicit criterion sets (Skodol et al.
2005).
Nevertheless, the PPDWG proposed to abandon diag-
nostic criterion sets for prototype matching, in which one
matches one’s perception of a patient with a 10–17
T. A. Widiger (&)
Department of Psychology, University of Kentucky, Lexington,
KY 40506-0044, USA
e-mail: [email protected]
123
Clin Soc Work J (2013) 41:163–167
DOI 10.1007/s10615-012-0419-9
sentence paragraph description of a prototypic case
(Skodol 2010; Westen et al. 2006). ‘‘To make a diagnosis,
diagnosticians rate the overall similarity or ‘match’
between a patient and the prototype using a 5-point rating
scale, considering the prototype as a whole rather than

counting individual symptoms’’ (Westen et al. 2006,
p. 847). Rather than require a researcher or a clinician to
spend 2–4 h carefully assessing each diagnostic criterion,
with prototype matching ‘‘clinicians could make a com-
plete Axis II diagnosis in 1 or 2 min’’ (Westen et al. p. 855)
because one does not assess each individual sentence
within the narrative description. Instead, the clinician
matches their perception of the patient with the overall
gestalt. The diagnosis is reduced from a systematic
assessment of each of the nine diagnostic criteria for DSM-
IV-TR borderline personality disorder (or each of the 13
sentences within the DSM-5 narrative description of a
prototypic case) to simply a single judgment: whether the
patient’s personality appears to match the set of sentences,
considered together as a unified whole.
This proposal was made despite the fact that there is a
considerable body of research to document the poor reli-
ability and validity of prototype matching (Widiger 2011;

Zimmerman 2011), a considerable body of research to
support the reliability and validity of specific and explicit
criterion sets (Zimmerman 2003), and no research that has
compared directly the reliability or validity of indepen-
dently administered prototype matching with specific and
explicit criterion sets. Skodol (2010) cited in support of
prototype matching studies conducted using the Personality
Assessment Form (PAF). However, the authors of these
studies in fact acknowledged that they used prototype
matching only because at the time their study began semi-
structured interviews to assess the DSM-III criterion sets
were not yet available (Shea et al. 1987). Pilkonis et al.
(2011) have since indicated their significant concern that
prototype matching permits diagnosticians to ‘‘interpret
each prototype narrative in potentially different ways,
opening the door to a host of known problems with cog-
nitive heuristics, such as salience and availability biases’’
(p. 73).

The only empirical support beyond the early PAF
research was a validity study by Westen et al. (2006) and
an interrater reliability study by Westen et al. (2010), both
of which included fundamental methodological flaws. For
example, in the case of the validity study, the clinicians
who provided the prototype ratings also provided the cri-
terion diagnoses, the latter even provided prior to their
provision of the prototype ratings. Frankly, using this
methodology, it would be difficult to obtain weak results,
as the clinicians were simply confirming their own recently
made judgments. If this criterion contamination was not
problematic enough, the ratings were provided for patients
the clinicians already knew extremely well (in treatment on
average for 16 months), which is not the situation in which
diagnostic criterion sets are typically used. With respect to
the reliability study, these prototype ratings were obtained
in the course of a 4.5 h standardized interview, inconsistent
with the purported method of prototype matching. In

addition, there was a clear possibility that the assessments
were again not in fact blind to one another. The clinicians
who provided the ratings were graduate students working
together within a psychological clinic. It is not uncommon
in such a setting for student clinicians to discuss amongst
themselves their diagnostic impressions of new clients (and
in some cases initial clients are discussed together at formal
case meetings).
In response to the critiques of prototype matching
(Widiger 2011; Zimmerman 2011), the PPDWG was com-
pelled to abandon their proposal for prototype matching and
to include instead diagnostic criterion sets (Siever 2011). In
sum, it now appears that this major innovation for DSM-5 has
been rejected. However, rather than work from the diag-
nostic criterion sets that were developed for DSM-IV-TR and
have since been used in a substantial body of empirical
research (e.g., Skodol et al. 2005), the PPDWG has appar-
ently decided to construct brand new criterion sets by arbi-

trarily combining the self and interpersonal pathologies that
they think will be specific to each respective personality
disorder along with a list of traits they again think will likely
be diagnostic of each personality disorder.
Deletion of Diagnoses
The PPDWG also intends to delete half of the diagnoses;
more specifically, the dependent, narcissistic, paranoid,
schizoid, and histrionic personality disorders. The primary
reason for their deletion is to reduce diagnostic co-occur-
rence (Skodol 2010). Diagnostic co-occurrence has been a
significant problem for the categorical diagnoses (Widiger
and Trull 2007) but sacrificing fully half of them would
seem to be a rather draconian approach for addressing this
problem. In addition, it does not speak well for the credi-
bility of the field of personality disorder to be so willing to
sacrifice half of its coverage in order to address diagnostic
co-occurrence, as if half of what we have been diagnosing
and treating for the past 30 years was not worth the clinical

attention (Widiger 2011). Persons will still have dependent,
schizoid, paranoid, histrionic, and narcissistic personality
traits despite their diagnoses being deleted (if not, then it is
unclear why there is any need to include these traits within
the dimensional model). Lack of adequate coverage has
been a problem of comparable magnitude to diagnostic
co-occurrence (Verheul and Widiger 2004). This problem
will be magnified substantially in DSM-5.
164 Clin Soc Work J (2013) 41:163–167
123
In addition, significant questions have been raised with
respect to the rationale for which diagnoses to delete. There
does appear to be as much, if not more, empirical support
for the narcissistic and dependent personality disorders
(two diagnoses to be deleted) as there is for the avoidant
and obsessive–compulsive personality disorders (Bornstein
2011; Ronningstam 2011). Zimmerman (in press) suggests

that it is no accident that four of the five diagnoses being
retained (i.e., avoidant, obsessive–compulsive, schizotypal,
and borderline) were the focus of the CLPS project,
spearheaded by the Chair of the PPDWG (Skodol et al.
2005).
Skodol et al. (2011) provides a review of the literature
which they suggest indicates support for the decision to
delete the dependent and narcissistic personality disorders in
favor of the avoidant, obsessive–compulsive, antisocial,
borderline, and schizotypal. However, even if one confines
the decision to the studies cited by Skodol et al. one does not
discover much support for the decision (Mullins-Sweatt et al.
in press). For example, one of the reasons given for a
weakness in the validity of dependent personality disorder
was a difficulty in discerning its prevalence because the
prevalence purportedly fluctuates widely from study to
study. However, in the seminal review of epidemiology by
Torgersen (2009), cited by Skodol et al. the fluctuation in

prevalence was actually worse for the schizotypal (ranging
from 0.0 to 3.2 across the studies that were considered),
antisocial (0.0–4.5), borderline (0.0–3.2), avoidant
(0.4–5.0), and obsessive–compulsive (0.0–9.3), the five to be
retained, than it was for the dependent (0.4–1.8). Dependent
personality disorder was also said to be associated with only
moderate to low impairment in functioning, but its level of
impairment has been consistently higher than has been
obtained for the obsessive–compulsive in the studies con-
sidered by Skodol et al. (Mullins-Sweatt et al. in press).
Finally, Skodol et al. indicated that dependent was one of the
two least common personality disorders in the community,
according to the review by Torgersen. However, this was not
in fact the case. According to Torgersen’s review, with
respect to the median rate across the studies he considered,
dependent had a higher prevalence rate than schizotypal (and
higher than three other personality disorders), and, when
considering the pooled rate across these studies, a higher

prevalence within the community than either schizotypal or
borderline.
In any case, the decision of what to retain and what to
delete might in fact be moot, as it now appears that there
may not in fact be a personality disorders section, or at
least if there is one, it could very well be reduced to a
skeleton of its former self that is unlikely to survive any
future harsh winter. Siever (2011) indicates that a repre-
sentative of the PPDWG agreed with representatives of the
schizophrenia disorders work group to move schizotypal
personality disorder out of the personality disorders section
into a new class of schizophrenia-spectrum disorders. Its
primary coding will be as a schizophrenia-spectrum dis-
order, not as a personality disorder (the latter will only be
noted parenthetically for historical purposes). A similar
proposal is being pushed heavily for a shift of antisocial/
psychopathic personality disorder into a new class of (child
and adult) disruptive behavior disorders, wherein it would

also receive its primary diagnostic coding and noted only
parenthetically that it used to be classified as a personality
disorder (Siever 2011). If these new proposals are enacted,
the personality disorders section will be left with just three
diagnoses (i.e., avoidant, obsessive–compulsive, and bor-
derline), and it is difficult to imagine that the section could
then survive (Widiger 2011).
Dimensional Trait Model
It is evident that the diagnosis and classification of person-
ality disorder is shifting toward a dimensional trait model
(Widiger and Simonsen 2005). It has in fact been suggested
that the primary contribution of DSM-5 will be a shift of the
entire diagnostic manual toward a dimensional model of
classification (Regier 2008). This will be most clearly evi-
dent with the personality disorders, which will include a 6 (or
5) dimensional model of maladaptive personality, including
37 (or 25) lower-order traits that can be used to provide an
independent description of each particular patient and/or be

part of the diagnostic criterion sets for each respective per-
sonality disorder. Lanier et al. (2011) describe well many of
the benefits and advantages of this shift.
Lanier et al. (2011) also document well how this proposal
is well aligned with the five-factor model (FFM) of general
personality structure. An integrative dimensional model of
normal and abnormal personality offers quite a few benefits
(Krueger and Eaton 2010; Widiger and Trull 2007). It
addresses the many fundamental limitations of the categor-
ical model (e.g., heterogeneity within diagnoses, inadequate
coverage, lack of consistent diagnostic thresholds, and
excessive diagnostic co-occurrence). It provides a more
comprehensive and individually specific description of each
patient’s normal and abnormal personality structure, thereby
facilitating more precise and informative research concern-
ing etiology and pathology, and more specific and distinct
treatment decisions (Widiger and Mullins-Sweatt 2009).
Finally, it transfers to the psychiatric nomenclature a wealth

of knowledge concerning the origins, childhood antecedents,
stability, and universality of the dispositions that underlie
personality disorder (Widiger and Trull 2007).
Lanier et al. also indicate, however, that the authors of the
DSM-5 dimensional trait model disavow some of the con-
nection with the FFM; more specifically, that compulsivity is
Clin Soc Work J (2013) 41:163–167 165
123
not a maladaptive variant of conscientiousness and oddity or
peculiarity is not a maladaptive of openness (Clark and
Krueger 2010; Krueger et al. 2011). The rationale for this
position is unclear, as there is a considerable body of
empirical research that supports the relationship of com-
pulsivity to conscientiousness and oddity to openness
(Widiger 2011). In addition, failing to acknowledge this
continuum results in a model that lacks coherence or
consistency, as if some dimensions of maladaptive per-

sonality are on a continuum with general personality
structure (i.e., emotional instability or dysregulation,
antagonism, detachment, and disinhibition) whereas others
(i.e., compulsivity and oddity), are for no apparent reason
qualitatively distinct from general personality structure.
This has not been the position held previously by the
proponents of dimensional models of personality disorder,
including the authors of the model for DSM-5 (e.g., Clark
2007; Markon et al. 2005).
There are, however, important ways in which the
dimensional trait model proposed for DSM-5 is different
from the FFM. First, it does not actually include any nor-
mal personality traits, thereby failing to provide a truly
integrative model. The DSM-5 proposal is confined to
maladaptive personality traits, and thereby will not be able
to identify the normal variants of the traits could in fact be
quite useful, if not important, for treatment planning, such
as openness that can suggest a responsivity to insight,

reflective, and dynamic therapies, agreeableness and
extraversion that can suggest a receptivity to group, mari-
tal, and other forms of interpersonal therapy, and consci-
entiousness that can suggest a willingness and ability to
withstand the rigors of dialectical behavior therapy
(Widiger and Mullins-Sweatt 2009). In addition, the model
is entirely unipolar, failing to recognize the bipolarity of
personality structure that has been empirically very well
supported (Markon et al. 2005; Widiger 2011). The
absence of this bipolarity contributes to the failure of the
proposed model to recognize a number of important mal-
adaptive personality traits, such as the glib charm and
fearlessness of psychopathy (low neuroticism), gullibility
and meekness of dependency (high agreeableness), and
closedness to feelings of alexithymia (low openness).
In fact, like almost everything else for DSM-5, the
dimensional model has apparently changed since the paper
by Lanier et al. was accepted for publication. The model

proposed at this current moment in time is a 5 domain
model (emotional dysregulation, detachment, antagonism,
disinhibition, and peculiarity), with 25 lower-order trait
scales. The basis for this shift appears to be due simply to a
recent factor analysis conducted by member(s) of the
DSM-5 PPDWG (Siever 2011), rather than being guided by
the considerable body of existing research. This may reflect
the wider tendency of the DSM-5 process (Frances 2009) to
allow work group members to rely on their own prefer-
ences and their own studies rather than seeking a more
consistent historical continuity guided by a wider scientific
literature.
Conclusions
In sum, Lanier et al. are indeed correct that DSM-5 per-
sonality disorders are likely to be much different than the
DSM-IV-TR personality disorders. Some of these signifi-
cant changes could reflect major improvements in how
disorders of personality are conceptualized and diagnosed.

However, the proposals vary considerably in the extent to
which they have compelling empirical support. Even a
member of the DSM-5 PPDWG has opined that ‘‘the DSM-
5 proposal is a disappointing and confusing mixture of
innovation and preservation of the status quo that is
inconsistent, lacks coherence, is impractical, and, in places,
is incompatible with empirical facts’’ (Livesley 2010,
p. 304), characterizing the overall effort as an expression of
‘‘incoherence and confusion’’ (p. 304). The major accom-
plishment of the fourth edition of the APA’s diagnostic
manual was not in the development of surprising new
content but rather in the careful, cautious, and systematic
method with which it was constructed. The authors of the
forthcoming fifth edition may have turned this priority on
its head, emphasizing instead radical changes without first
conducting careful, systematic, thorough, or objective
reviews of the scientific literature.
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Author Biography
Thomas A. Widiger is the T. Marshall Hahn Professor of

Psychology
at the University of Kentucky. He was the Research Coordinator
for
DSM-IV and the 2010 recipient of the Distinguished Scientist
Award
by the Society for a Science of Clinical Psychology.
Clin Soc Work J (2013) 41:163–167 167
123
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posingFiveSpecificPersonalityDisorderTypes.aspx
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International Journal of Mental Health, 45: 135–153, 2016
Copyright #�Taylor & Francis Group, LLC

ISSN: 0020-7411 print/1557-9328 online
DOI: 10.1080/00207411.2016.1167489
A Model of Deinstitutionalization of Psychiatric Care
across 161 Nations: 2001–2014
Christopher G. Hudson
School of Social Work, Salem State University, Salem,
Massachusetts, USA
Abstract: Deinstitutionalization has been ongoing since the
1950s and is a trend that has been
molded by diverse sociocultural conditions and competing
ideologies. Key questions from the
literature include its extent and the drivers motivating it,
political and financial dimensions, and
consequences in such domains as homelessness, nursing home
care, and the criminalization of
the mentally ill. This study specifically addresses questions
about the extent of deinstitutionalization
internationally, and the salience of competing explanations of
this trend for understanding the extent
of availability of psychiatric beds.
This study employs a secondary analysis of data from the four
editions of the World Health
Organization’s Mental Health Atlas, as well as supplemental
international databases. It uses a
regression methodology to examine rates of change of
psychiatric beds during 2001–2014 in 161
nations. Predictors include key geographic, demographic,
socioeconomic, political, cultural, and
service system conditions.
The study reveals deinstitutionalization of inpatient care is far

from universal, characterizing
almost a half (45.1%) of the world’s nations. That the overall
decline in inpatient beds is close to half
of one percent (−0.41%) per year indicates this is a modest
reduction, notwithstanding dramatic
changes in both directions in subsets of nations. The regression
model accounts for 55.7%�of the
variation of deinstitutionalization, using several significant
predictors. Deinstitutionalization is
associated with income inequality, racial and ethnic diversity,
low population density, a high Human
Development Index, psychiatric commitment laws, high
incarceration rates, among other conditions.
Keywords deinstitutionalization; psychiatric hospitalization;
geography of mental health; community
mental health
The deinstitutionalization of psychiatric beds reflects a long-
term and pervasive restructuring of
mental health service systems, both local and national. It is a
term that has been used to refer to
various phenomena, ranging from the depopulation of public
psychiatric hospitals to changes
that include the development of community mental health
services [1]. In the United States,
it is a trend that began in 1955, but in many nations it did not
emerge until the 1990s or later.
Given the long history and ideological debates surrounding
deinstitutionalization, it should
be noted that research on this trend has rarely advanced beyond
the use of uncontrolled descrip-
tive statistics, case studies, and other descriptive
methodologies. And it has only been since the
1990s that this trend has been examined in an international

context. Much of this work has been
Address correspondence to Christopher G. Hudson, School of
Social Work, Salem State University, 352 Lafayette
Street, Salem, MA 01970, USA. E-mail: [email protected]
http://dx.doi.org/10.1080/00207411.2016.1167489
mailto:[email protected]
noncumulative, addressing questions that range from the causes
and drivers of deinstitutionali-
zation, to its political dynamics and financial dimensions, and
its consequences in such areas as
homelessness, nursing home care, and the criminalization of the
mentally ill.
The purpose of this article is not to present a comprehensive
review of the considerable
literature on deinstitutionalization, since there are already many
excellent reviews [2–6].
Instead, it aims to describe this trend on an international scale
and explore potential predictors
of levels of deinstitutionalization of psychiatric care across the
world during the 2001–2014 per-
iod. Whereas its detractors often argue that financial savings
has been a central motivation [5],
advocates emphasize the ideal of improving community care and
assuring the human rights of
psychiatric patients [7]. Commentators have proposed a variety
of theories about the drivers of
this trend, which typically include some combination of
historical, geographic, cultural, socio-
economic, political, and service system explanations. Most
hypothesize that there is a complex
combination of drivers, applicable differentially in varying

contexts. Thus, this study aims to
develop an exploratory and descriptive model of conditions that
are potentially explanatory
of the extent of deinstitutionalization across all nations for
which data is available. It does
this through the use of existing data sources collected by the
World Health Organization
(WHO) [8–11] and other international organizations. This study
also examines the question
about the extent to which deinstitutionalization has continued to
take place on a global scale
during the initial years of the 21st Century (2001–2014).
BACKGROUND
The deinstitutionalization of psychiatric care has taken place
primarily in the mental health sys-
tems of developed, usually westernized nations, ones that have
experienced a preceding period
involving the building of psychiatric hospitals. For instance, in
the United States, a dramatic
expansion in inpatient psychiatric beds took place between 1840
and 1955, from 1 per
100,000 population to 338.9 per 100,000 (calculated from [12]).
The trajectories of deinstitutionalization have varied
dramatically, depending not only on the
nation or state considered, but also the type of data examined.
Unlike in the United States, in
many parts of the world deinstitutionalization did not begin
until the 1970s, ranging into the
1990s or later. In the United States, as a whole, if we consider
the number of annual psychiatric
hospital episodes, the population rate of those in public
institutions in the United States declined
by 96%�between 1950 and 2010, to the same level as 1850 [13–

15]. Nonetheless, reports indi-
cate that in many parts of the world, the mental health systems
are still dominated by inpatient
care. A study of 42 low- and middle-income nations, that
employed the World Mental Health
Atlas data, found that 80%�of mental health resources continue
to be devoted to inpatient care
and little to community mental health [16]. Despite the recent
availability of data relevant to
deinstitutionalization from WHO sources, the extent of the
phenomenon on a worldwide basis
has not yet been systematically analyzed and reviewed.
Theoretical Perspectives on Deinstitutionalization
Several explanations have been proposed for the contraction in
availability of psychiatric beds,
ones for which there is mixed support. In several nations, early
drivers include the exorbitant
136 HUDSON
cost of maintaining antiquated hospital systems; the
introduction of the first generation of
psychotropic medications in the early 1950s; and a combination
of journalistic exposés of
horrible conditions in public psychiatric hospitals, along with
the development of alternative
service ideologies and approaches that emphasize short-term
care in community settings.
Concurrent with these changes was the development of formal
policies aimed at replacing
institutional care with community mental health, such as the

Community Mental Health Act
introduced in the United States by President John F. Kennedy in
1963 [17]. Such changes were
only associated with modest declines in institutional care in the
1955 to 1965 period. Some of
the greatest declines, however, took place in the following
decades, primarily during the 1965 to
1980 period [13]. Two of the most significant factors introduced
during this period involved a
new emphasis on civil rights, particularly, the protection of the
civil and procedural rights of
mental patients including the restriction of commitment criteria
to the requirement that patients
be dangerous to self or others before they could be involuntarily
committed [18]. In addition,
the introduction of a variety of financial incentives to support
patients outside of the hospital
is believed to have accelerated the discharge of mental patients
to nursing homes, other com-
munity facilities, as well as acute units in general hospitals. In
recent years, the introduction
of increasingly stringent cost-containment controls, mainly in
the private managed care
insurance market, has also served to minimize length of stay,
resulting in the decline of inpatient
hospitalization in specialty psychiatric settings as well as in
general hospitals [19].
Even as psychotropic medications and financial incentives are
often cited, several other expla-
nations have also been advanced for deinstitutionalization.
Novella [8] includes some of these in
his review, emphasizing the role of ideology, specifically the
anti-psychiatry and related critiques
of the conventional explanation that focuses on the introduction
of psychotropic medications. He

notes that several of these explanations, such as that of anti-
psychiatry, professionalization, and
decarceration [2], emphasize the changing power relationships
between treaters (primarily psy-
chiatrists) and their clients, and the change to a community
context of care as a means of preser-
ving social control relationships and professional hegemony.
Novella [5] points out that such
explanations minimize the role of changing cultural and
socioeconomic conditions. Other expla-
nations that Novella [5] reviews include the expansion of
psychiatric rehabilitation, including
transinstitutionalization in which costs are seemingly reduced
by shifting care to community
institutions such as shelters, nursing homes, and prisons. For
example, several researchers
[20, 21] have attempted to advance what has come to be known
as the Penrose Hypothesis
[22], either that the social controls inherent in psychiatric
hospitalization are replaced with those
of jails and prisons, leading to the criminalization of the
mentally ill, or that social control is
alternatively pursued either through inpatient mental health care
or through prisons.
Although the relative salience of these accounts are debated,
especially given their scarce
empirical support, it is clear that some combination of the
critique of large institutions, financial
incentives, changing treatment ideologies, and especially a
growing focus on the civil rights of
patients have all driven the transition of patient care to
community contexts, and that official
policies, such as the Community Mental Health Act (1963) in
the United States, may have
played only a secondary role in highlighting and legitimizing

such trends. Those who have
pointed out the injustices of premature discharge of patients to
the community have emphasized
the extent that deinstitutionalization perpetuates and aggravates
inequality. In contrast, others
argue that inequality is minimized by supporting the
reintegration of the seriously mentally
ill back into their communities (see [23]).
DEINSTITUTIONALIZATION ACROSS 161 NATIONS 137
National Studies of Deinstitutionalization
Very little systematic or comparable data is available on the
extent of deinstitutionalization
throughout the world. There are several scores of publications
on the experience in particular
nations and regions that have employed case studies, descriptive
statistics, and other
uncontrolled studies. In the United States, commentators
include Lamb [20] and others who
have highlighted the precipitousness of the process that the
depopulation of state and county
hospitals often occurred prior to the development of community
services, and that too much
emphasis has been placed on changing the locus, rather than on
improving the quality of care.
A pervasive theme in many nations has been the organizational
fragmentation of care due to the
split of responsibility for mental health between local and
national authorities that has resulted
in very uneven implementation of the policy.
In Europe, similar themes appear in the literature, especially the

slowness in developing com-
munity mental health services [24]. Ireland, for instance, has
been cited as a nation that started
out with some of the highest institutionalization rates in the
world, and has only slowly reduced
its hospitalization levels, albeit in a geographically uneven
manner [25]. In Germany, deinstitu-
tionalization was also reported in some areas in name only, with
the transfer of patients to
renamed sections of hospitals [26]. Others have complained that
in Scandinavia there has been
limited cooperation among the competing responsible
authorities [27]. One report from North
Finland indicates that smaller and less wealthy counties have
moved more quickly to
deinstitutionalize, compared to larger counties that have been
better able to afford ongoing hos-
pitalization for those in need [28]. Italy, in contrast, has seen
some of the most dramatic declines
in psychiatric hospital care in Europe, led by the Psichiatria
Democtratica movement inspired by
Franco Basaglia that emphasized the “de-psychiatrization” of
mental illness, the loosening of
commitment criteria, and the attempt to liquidate all psychiatric
hospitals [29]. Spain also is
reported to have achieved major advances with
deinstitutionalization, specifically, the develop-
ment of new decentralized forms of community mental health
care that are effectively integrated
with general medical care, but not without some inequities in
their geographic distribution [30].
In Australia and New Zealand, the progression of
deinstitutionalization has been slow but
steady, nonetheless, with complaints that the process has failed
to be associated with systematic

planning or adequate community support systems [31]. Inpatient
care in these nations has been
decidedly better than community mental health care [32].
In South America, it has only been in the last few decades that
deinstitutionalization has
started to be implemented [4]. Some of the greatest declines of
public inpatient care are reported
to have taken place in Uruguay and Paraguay, and to a lesser
extent in Chile, Brazil, Columbia,
Venezuela, and Peru [33]. In Brazil, these declines were
reported to have been made possible by
the development of acute inpatient units in private hospitals
[34].
Parts of the world that have deinstitutionalized the least include
Japan; East Asia in general;
and also, until the late 1990s, Israel. Yip [35] reports that in
Hong Kong care remains highly
institutionalized, and likewise, Kuno and Asukai [36] contend
that in Japan reductions in
inpatient care are unlikely, given both cultural factors, as well
as the low cost of hospitalization.
In Israel, in 2000 new rehabilitation legislation was enacted that
led to a dramatic shift in care to
community services [37]. Exceptionally little data is published
on the experience in Middle
Eastern, African, and many of the developing nations, in part,
because of the scarcity of
comprehensive mental health systems.
138 HUDSON
International Mental Health Policy Research1

It has only been in recent years that a body of empirical
research has emerged in the larger field
of international mental health policy, but only a small
proportion of these studies have focused
on deinstitutionalization. Editorials and commentaries have
emphasized dramatic disparities
between the mental health systems of developed and developing
nations. Discussions of the
sparsity of resources in the developing nations have repeatedly
urged the need for better
integration of mental health into the work of primary care
practitioners [38], given the very
low rates of mental health professionals in many developing
nations. Similarly, improved public
education has often been recommended, along with the more
creative use of nonprofessional
staff, and improved access to psychotropic drugs, all of which
have been viewed as cost
effective measures [39]. Finally, editorials regularly urge more
consistent and rigorous
collection of data on epidemiology, services, and outcomes
[40].
Single and comparative national case studies date back many
years, most notably to Kemp’s
compendium, International Handbook of Mental Health Policy
[41]. Studies such as Lurie’s
[42] that compares the systems in the United Kingdom, United
States, Canada, and New
Zealand highlighted themes of recovery, stigma reduction,
developing services for particular
client populations. Increasingly, governments are not being
expected to provide services, as
much as to fund and regulate them. A recent comparison of the
systems in Australia and China

emphasized the need for developing nations not to rely
exclusively on institutional services, and
to emulate those nations, such as Australia, which have moved
more aggressively toward the
creation of community service systems [44]. Particular barriers,
relevant to China, as well as
to many developing nations, include the lack of professionals
and services in rural areas, in part,
due to problems inherent in the poor economies of scale
associated with service development in
such sparse environments.
Since the World Development Report [45], the Global Burden of
Disease Report [46], and
other international reports, the WHO has increased its research
and advocacy efforts in mental
health. These have included the publication of the Mental
Health Atlas [8–11] dissemination of
the WHO Assessment Instrument for Mental Health Systems
(WHO-AIMS), and the launching
of the Mental Health Gap Action Programme (mhGAP) [47] and
the Movement for Global
Mental Health in 2008.
Of particular relevance for the current study, the World Mental
Health Atlas is a
compendium of data garnered through a descriptive survey of
the mental health systems in
192 countries, conducted most recently in 2014. Areas covered
by the survey consist of
questions on the presence of a (i) mental health policy; (ii) a
national mental health program;
(iii) mental health legislation; (iv) substance abuse policy; (v)
availability of psychotropic
drugs; (vi) the budget for any mental health program; (vii)
methods for the financing of mental

health services; (viii) mental health in primary care and
training; (ix) service availability, parti-
cularly, psychiatric beds; (x) rates of mental health
professionals; (xi) programs for special
populations; and (xii) information gathering systems. Official
reports of the results are limited
to simple tabulations, such as those of frequencies and means.
Substantial data is missing or
unavailable, particularly for developing nations. Although data
reported in the World Mental
Health Atlas [48] reveal that four-fifths of the world’s nations
have mental health programs,
1Portions of this section are adapted from [43].
DEINSTITUTIONALIZATION ACROSS 161 NATIONS 139
and seven-tenths (70%) have mental health legislation, with the
most pronounced inequities
involving budgets, services, and professionals. Unfortunately, it
has been the exception that
such inequities are considered in the context of underlying
disparities in mental health con-
ditions and needs. Yet, indicators of need are greater in Europe
than in Africa, where the rate
of neuropsychiatric conditions is 3,266 per 100,000 in Europe,
compared with 2,538 per
100,000 for Africa. North America, including the United States,
is closer to the European
experience, but falling short of Europe in its mental health
service coverage [43].
Since the initial dissemination of its World Mental Health
Atlas, WHO has continued to

refine its data collection instrument on national mental health
systems, and this is now known
as the Assessment Instrument for Mental Health Systems
(WHO-AIMS 2.2). It covers the six
domains included in the Atlas and is designed to facilitate
cross-country comparisons. As much
as this initiative represents an important advance in the study of
national mental health systems,
critics have emphasized the neglect of the political dimensions
of mental health policy devel-
opment, minimization of the role of culture in mental health
care utilization, and questionable
measurement validity [49].
The WHO World Mental Health Atlas initiative has succeeded
in stimulating several other
research efforts aimed at systematically understanding national
mental health systems. Most
notable has been the formation of the International Observatory
on Mental Health Systems
(IOMHS) at the University of Melbourne. The aim of this
institute is to monitor the mental
health systems in low and middle income countries, and to find
some way “to rationally classify
mental health systems at national and subnational (provincial
and district) levels. Along these
same lines, the Organization for Economic Cooperation and
Development (OECD) has been
developing a mental health monitoring systems for its 30
member states, one that looks not just
at services, but at outcomes [50].
With the accumulation of new descriptive data through the Atlas
and the WHO-AIMS instru-
ment, the possibility of correlational, specifically, quasi-
experimental research in this field has

opened up. Although there have been a variety of correlational
studies on the development of
social welfare and social security systems throughout the world,
this has not been the case with
mental health due to the lack of data. One of the earliest studies
of this type was that conducted
by Pillay [51] who demonstrated a simple but strong 0.84 zero-
order correlation between gross
national product (GNP) and rates of mental hospitalization
within nine of the OECD states. The
study also shows no significant correlation between GNP and
length of stay. Unfortunately,
such zero-order bivariate correlations typically raise more
questions than they answer, given
the very small sample size and lack of statistical controls.
To date, the development of the Mental Health Atlas data has
enabled several studies of
variations in national mental health policies. World
Development Report 1993: Investing in
Health by the World Bank [45] utilized the second wave of this
data (2006) to investigate
whether there were one or multiple dimensions characteristics
of the development of national
mental health systems, as well as which environmental
characteristics are most closely associa-
ted with such development. He found through a factor analysis
that three orthogonal or uncor-
related dimensions were identified that are characteristic of the
138 nations: (i) General Mental
Health Services (professionals and inpatient beds), (ii) Public
Mental Health Program; and
(iii) Community Mental Health that collectively accounted for
45%�of the variance in the data-
base of WHO predictors. Only one, General Mental Health
Services, was substantially explained

ArticleTranscultural Psychiatry 48(3) 284–298 ! The Author.docx

ArticleTranscultural Psychiatry 48(3) 284–298 ! The Author.docx

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