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Mental Health and Alcoholism Melanie de Luna Renzo Rosales Jennifer Avery Globalization, Nutrition, and Health Monteverde Institute June 24 to July 21, 2001
Introduction Our team consists of Melanie de Luna, a medical student with an interest in public health research; Renzo Rosales, a graduate student in Cultural Anthropology at the University of Florida with an interest in globalization, migration, and community development and; Jennifer Avery, a graduate student in Applied Anthropology at the University of South Florida with a growing interest in public health. We were interested in the topic because we felt that mental health is a significant component of any culture in relation to its overall health status. Furthermore, the community expressed an interest in this topic; these issues are increasingly important, particularly as the area is in a state of transition from a rural, enclosed society to one that is progressively under the influence of cultural and economic globalization. Historical and Social Context According to the most recent community health analysis (EBAIS 2000 Equipo Bsico de Atencin Integral de Salud), the principal causes for consultations in the clinic related to mental health are signs of depression and anxiety resulting from emotional stress. The majority of these cases are women who are victims of some form of aggression. The major intervention strategies implemented for these cases are: a) workshops and talks about domestic violence; b) coordination of counseling sessions with the Social Work department; and c) promotion of healthy life styles during the various consultations. The most common mental disorders are: depressive syndromes, anxiety, schizophrenia, mental retardation, and learning disabilities. The social problems of highest priority in the area are: interfamilial and social violence, the lack of recreational activities, and the abuse of alcohol and drugs. This locally produced document further asserts that Monteverde, formerly a traditional and conservative community, has experienced the influence and mixing of Anglo and European cultures as a result of increased tourism. This increase, combined with a lack of outlets for healthy recreation, has brought on a related increase in the consumption of different types of drugs (alcohol, tobacco, marijuana, cocaine, and others) among both adult and youth populations. The community is becoming increasingly aware of these problems, although it has not been able to mobilize the resources to address them adequately. The EBAIS document reports that the existence of places where drugs are sold is well known to the community, as well as places that sell liquor and cigarettes to minors. The sector contains three bars, two discos, and ten bar restaurants. These figures do not include hotels with restaurants in which alcohol is sold. At the national level, Mata and Rosero (1988) assert that the impacts of drug and alcohol abuse Include effects on family economics and well being, prostitution, child abuse, and vagrancy. The authors define an alcoholic as a person exhibiting any of the following symptoms: inability to abstain from drinking, inability to stop drinking, or withdrawal symptoms. An excessive drinker is one who drinks two more times a month with an absolute alcohol intake of 120ml for males and 60ml for females in one sitting (this is the equivalent of approximately 3 6 shots of liquor). This report also claims that alcoholism in Costa Rica is perpetuated by the ambivalent attitude of the state. The Fbrica Nacional de Licores, controlled by the government, produces the bulk of hard spirts, including guaro, rum, and gin. The Costa Rican government began producing the national guaro in 1986 after
prohibiting the production of contraband guaro, which is laden with toxic impuri ties. In addition, the state facilitates importation of inexpensive foreign liquor to further discourage bootlegging. Research Methods The research questions designed by the group, based upon both the expressed interests of the com munity and background information, are: What is the incidence of mental health problems in the community, including the use and abuse of alcohol and drugs? What types of problems are most common? How does the community perceive its own problems with drug and alcohol use and mental health issues? Who drinks? How much? To what extent is alcoholism a problem? What are the consequences of alcohol and drug abuse? How does alcoholism/drug addiction relate to issues of domestic violence and depression? How have these problems evolved over the last five to ten years? How are gender differences, age, socio economic status, and education related to these issues? What resources are available to the community in regards to drug/alcohol, and mental health problems? How accessible are these resources? Are they being utilized? Are they sufficient? What other resources are desired by the community? What are the cultural traditions (thoughts, beliefs, perceptions, behaviors) that influence these issues? The research methods employed to address these questions include archival research, unobtrusive observation, participant observation, and informal, semi structured and structured interviewing. Given the sensitive nature of the topic and the lack of previous research, available references, and community readiness, the researchers felt that the subject would best be approached through the comprehensive use of qualitative methods. Further, given the limited time and resources available for our research and the broad scope of the topic, the use of rapid, anthropological methods was most appropriate. Resources that facilitated this research included the most recent annual EBAIS report, public medical records, contacts with community leaders and other community members, and communication with local professionals. Key ethical considerations involved protecting the confidentiality of our research subjects and excluding some content that could violate the privacy of our informants and others. Our logistical problems relate largely to the controversial nature of our research subject. We were unable, unlike other research groups; to acquire large amounts of quantifiable data through surveys because were intent on respecting the privacy and comfort of the respondents. Given the intimate nature of our topic, however, such questionnaires were unlikely to elicit valid and reliable information. Moreover, the time period in which we conducted our research was insufficient for comprehensive coverage of the topic. Finally, we felt that our informants deserved something tangible to be gained by them from our research, and, with all of our constraints, we were apprehensive about what we would be able to provide them. Our research team had several positive experiences throughout our work. Firstly, almost all of our informants were highly cooperative and, moreover, seemed appreciative of our interest in the subject and in them. Our
research methodology enabled us to experience the local culture on a personal level; our connections with the community made our research a more gratifying experience. Findings Detection of Mental Health, Alcohol, and Drug Abuse Problems Detection of the community problems we researched appears to occur at three levels: the medical professional, self detection, and peer detection. At the level of the medical professional, symptoms of mental health disorders, which are largely connected to cases of domestic abuse, are frequently manifested as a series of unrelated somatic ailments. Diagnosis is also made in an intuitive manner as medical professionals working with a small community may sense that certain patients, often the ones who return week after week, may have more issues to discuss than the physical conditions they present to the doctors and nurses. These cases, if merited, may be referred to a psychologist or social worker. Diagnoses may also be made at the individual level, as a person may recognize his or her own symptoms of mental distress. The local bookstore has a large collection of self help books that may assist the individual by providing education about their condition. These individuals may also seek the assistance of the social worker, who comes to the area once a week. Lastly, diagnoses are made by concerned peers and members of social support networks, who recognize emotional and behavioral changes in close acquaintances and suggest various patterns of resort. Tourism As noted in the 2000 EBAIS report, the impact of tourism on mental health and alcohol/drug abuse issues is widely recognized. Informants contend that tourism has had the effect of modifying the principal sources of income in the community. A community that was once accustomed to the schedule necessitated by an agriculturally based economy has adjusted to a lifestyle associated with tourism. Traditional values are being thwarted by the influx of new money, values, and experiences. One example is the growing involvement of women in the tourist industry and their resulting increase in economic independence from their husbands. Such cultural transitions may be related to higher incidence of such mental health conditions as alcoholism, depression or anxiety. The rise in population and diversity may also place community ties at risk for disintegration. For instance, the economic prosperity of the area reinforces the trend observed in the rest of the country of the migration of Nicaraguans. From the perception of many of our informants, Nicaraguans are conceived of as violent, aggressive or not as socially integrated as the Ticos. Further, tourists contribute directly to drug and alcohol abuse issues through their demand for drugs and alcohol through both legal and illegal means. The influence of mass media may popularize this lifestyle, especially among the younger residents of the Monteverde area. Finally, tourism indirectly promotes the intensification of alcohol and drug consumption by locals working in the tourist industry as they make a good living compared to other areas of employment and reportedly spends a substantial percentage of their income on alcoholic beverages in bars and discos. These establishments also attract local youth not directly involved in the tourist industry and promote further drinking and drug use among this population.
Motivation/Causes for Drinking Several explanatory factors for drinking in Monteverde were provided by our informants. Primary among these was the lack of alternative recreational resources. The EBAIS reports only one recreational sports field in the area and, with the exception of bars and discos, no establishments cater to the recreation of locals. Youth organizations are few, and a local business that showed current films has recently closed down. The lack of available recreational outlets the tendency for youth to experiment with alcohol and drugs at an early age as young as eleven and twelve. Several respondents also noted low levels of parental control over their children; they are unable to deter this undesirable activity. Drinking is also reported to be a kind of social institution, and respondents do not hesitate to assert that people like to drink. Alcohol is readily available in the community through local commercial establishments, including supermarkets, hotels and restaurants, as well as bars and discos, places where social activity and mingling with others is facilitated. In addition, the people in the area are hard working, and diversion is a necessary component of daily activity. Drinking is perceived as a primarily male activity. It may provide men a socially acceptable means by which they can share their feelings, vent personal frustrations, and transcend daily life. However, women, partly because of their increased economic independence, are now participating more in the consumption of alcohol. Woman also may be turning to alcohol as a coping method for personal or familial problems. Community members who are not experiencing the economic benefits of the tourist industry are also able to drink in less expensive establishments and may be consuming large quantities of hard liquor, such as guaro, and beer at home. Finally, drinking is explained in two ways relating to familial factors. One is the perception that alcoholism is genetic. The other is that such behavior is learned in the household, especially by young males, as an expected aspect of adult behavior. Economic challenges are among the most frequently mentioned consequences by our respondents. Although responses vary, the typical amount of money spent drinking on a given night can range from 2000 to 13000 colones, or 4 to 20 beers. Excessive drinkers or alcoholics may consume up to 30000 colones worth of alcohol, including shots of hard liquor such as guaro and tequila. It is customary for a patron to purchase rounds of drinks for friends or others in the bar without being cognizant of the amount of money being spent. Money spent in bars is presumably diverted from other household expenses, and respondents report that children may lack food or other necessities as a result of expenditures on alcohol. For example, one informant, in explaining a case of anemia in a young girl, asserted that her father was an alcoholic and spent a considerable portion of the family income on alcohol rather than on food. This type of spending may prompt women and children to begin working to compensate for the money lost. Further, many residents subsist on very low incomes, ranging from elderly pensions of 10500 colones to minimum salaries of 20000 per month. Such income levels, related to the
physical and mental well being of the family, are more frequently associated with low levels of education and higher incidences of mental health conditions. Other consequences of excessive drinking are reported cases of physical, verbal, and sexual abuse directed toward wives, children, and also the elderly. A number of informants repeatedly connected the issue of alcohol abuse with domestic violence. These issues are related to other economic issues as well. A portion of the population is not experiencing the economic benefits of the tourist industry. Arguments over money may exacerbate the problem of domestic violence. Other family level consequences attributed to alcohol abuse include emotional instability, infidelity, and emotional and physical separation between spouses. Health consequences include cases of hepatic cirrhosis, and compromised nutrition as a result of replacing meals with alcohol. Some informants contend that alcohol use leads to experimentation with illegal drugs. Despite the perception that there are a high number of excessive drinkers in the community, however, our informants in the medical field assert that no medical emergencies involving overdoses of alcohol or drugs have been reported. Cultural Contributions to the Maintenance of Alcohol/Drug Use Informants note several culturally proscribed belief and behaviors that mitigate the perceived severity of the problem. For example, drinking and drunkenness is more tolerated in appropriate contexts. Bars and soccer games are the social situations in which the consumption of alcohol is not suppressed. On special occasions, such as community or family fiestas, social rules may be relaxed, and public drunkenness is tolerated. Further, several of our informants assert that there is a stigma, especially for men, in admitting that one has a problem with alcohol. Also, the community describes itself as hard working, and alcohol is not held to interfere performance at work. Such cultural traditions may conceal or diminish the perceived extent of the problem. Resources for the Community When questioned about the resources available to a person with alcohol/drug abuse or other mental health issues, respondents most often cited the priest and medical doctors. The former is a prominent community leader as well as a psychologist who speaks fluent English. As such, he is a valuable resource for many community residents. He has claimed, however, that he does not have enough time to counsel all those who seek his assistance. Despite these limitations, he has developed several youth initiatives, one of which includes a soccer league, retreats, and workshops to deter the abuse of alcohol and drugs by young people. He has also supported the development of a DARE program, an international and educational outreach initiative, within the community. As previously noted, people with alcohol, drug abuse, or mental health problems often seek out the help of medical doctors in the clinic. The doctors may refer serious cases to the psychologist, social worker, or the Vida Familiar program at the Monteverde Institute. Although the latter is often cited as a resource by our informants, the social worker and psychologist are less frequently mentioned and often only when probed. This trend is not
surprising in the case of psychologist, who was reported to have come to the area only twice last year. A private psychologist has recently been recruited to the area, but has not been utilized to full capacity due to her hourly fee of 9000 colones. The social worker, a more accessible resource in that her services are available to the community once a week, may also experience time constraints. The amount of time that she is available to the community is not sufficient to address all the people who seek out her help. Her lack of availability may further reduced residents incentive to visit her. The dispersed arrangement of the community and the difficulties associated with transportation make it difficult for people to access her services at the clinic and constrain her ability to make sufficient house calls. Other available resources include a local chapter of Alcoholic Anonymous, which meets twice a week in Santa Elena. Several informants have reported that women are not made to feel comfortable at these meetings. As a result, most attendees are men, who may occasionally bring their wives. A chapter of Al Anon, an organization for relatives of alcoholics, also exists and consists mostly of women. The group, however, is quite small, so meetings are irregular if they occur at all. An informal but widely used support network is the womens cooperative, or CASEM. This organization has developed over the past ten years, and its growing membership has facilitated communication between women dealing with drug/alcohol abuse and mental health issues in themselves or other family members. Other womens organizations perform similar functions for their members. An informal but widely used support network is the womens cooperative, or CASEM. This organization has developed over the past ten years, and its growing membership has facilitated communication between women dealing with drug/alcohol abuse and mental health issues in themselves or other family members. Other womens organizations perform similar functions for their members. Some infrequently utilized resources also exist in Puntarenas. These include a resident psychologist and Hogares CREA, a religiously affiliated rehabilitation center. These resources, however, are a three hour bus ride away from Monteverde and, as a result, are not commonly mentioned as available resources by the community. Finally, doctors may also refer patients to a psychologist in San Jose, but this necessitates missing days from work and waiting up to three months for an appointment. Discussion Our short term findings confirm several points established in the 2000 Monteverde EBAIS report. These include the idea that the lack of viable recreational options for adults and especially young people has contributed to the intensification of drug and alcohol abuse. We can also confirm that the community does not feel that it has sufficiently mobilized the resources to combat these problems. Further, our research supports the notion, emphasized in this most recent EBAIS report that the growth of the tourist industry has contributed to the increased presence of drugs and alcohol in the community.
Our research, however, enriches these ideas in various and subtle ways. For example, we gathered through our interviews that the tourist industry contributes to the problem of drug and alcohol abuse through several channels. These include the increased presence of establishment, including hotels, discos, and restaurants, in which alcohol is sold as well as the increased availability of high wage jobs in the tourist industry that enable residents to spend more money on alcohol. Also noted by the researchers is the probable impact that cultural disruptions over the last transitional decade can have on mental health. Our research further uncovered the recurrent theme of womens changing roles and their increased involvement with both drugs and alcohol. These changes are also related to the boom of the tourist economy and the growing financial independence of many women, including single mothers. We also must emphasize the growing presence of Nicaraguans in the community drawn here by opportunities in the tourist industry and the stigma placed upon them by locals. The most violent acts and excessive alcohol problems are largely attributed to them. In addition, the tourists are perceived to be the heaviest users of illegal drugs, which are easily accessible and sold at a relatively low cost. Finally, our research sheds light on the cultural factors that may contribute to problems with drug and alcohol abuse. The social ideal that personal problems should not receive public attention as well as the tendency for even the heaviest drinkers to fulfill their obligations in the work sphere may render community issues with alcohol abuse less obvious. In addition, the small size of the community results in a lack of privacy that may further deter people from exposing their personal problems. Such traditions are barriers that may have to be broken if these issues are to be adequately addressed. Recommendations At the methodological level, we recommend further studies that could validate or disprove some of our findings. Such studies should be long term and ethnographic, so that appropriate levels of rapport and trust can be developed between the researchers and the community. Further, better sampling procedures should be applied to ensure generalization of findings. Specialized studies should also be conducted. One such study may involve an examination of womens changing roles in the community, the increasing frequency of single mothers, the problem of domestic violence and how they do or do not relate to the consumption of alcohol. Another study may investigate patterns of youth behavior, their educational opportunities, and their changing roles in a transitional society as it relates to alcohol and drug abuse. Also, researchers may investigate the development of an underground subculture involved in both drug trafficking and use in this setting. Finally, more research should be conducted to discover the means by which community awareness and dialogue about these issues could be increased. During our interviews, community members also suggested some resources that they would like to be made available. These include a local rehabilitation facility, a resident psychologist and social worker covered by the Caja, preventative educational programs in schools, and increased dialogue about drug/alcohol use and abuse in the community. We cannot comment on the feasibility of addressing any of these requests, but they are the ones made by community members. In the case of the social worker, however, accessibility to her could be increased through improved road systems or transportation options.
To this end, our overarching recommendation is the mobilization of existing resources, such as the medical and psychological services at the clinic, the AA and Al Anon groups, the priest and church pastors, and the various educational institutions in an effort to promote a more open discussion and foster attention toward these issues. Such a collective network may have greater financial and human resources and be more holistic and synergistic in its response to the needs of the community. Also, it may be more able to put pressure at the district and national levels to secure adequate provisions, such as increased police presence and full utilization of the resources that the Caja guarantees its citizens. References Analysis de Situacin De Salud, 2000, EBAIS No. 9, Monteverde rea de Salud 3, Regin Pacifico Central CAJA Costarricense de Seguro Social. Mata, Leonard and Rosero, Luis, 1988. National Health and Social Development In Costa Rica: A Case Study of Inter sectoral Action. Technical Paper No. 13, Pan American Health Organization.
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de Luna, Melanie
Salud mental y alcoholismo.
Mental health and alcoholism.
Findings and recommendations for further studies on the incidences and causes of mental health issues and alcoholism.
Datos y recomendaciones para estudios adicionales en las incidencias y causas de temas de salud mental y alcoholismo.
Mental health--Costa Rica--Puntarenas--Monteverde
Community Health 2001
Scanned by Monteverde Institute
t Community Health