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239 12 WomanwithPsychosis A Case Story Bao Ly, a sixty-one-year-old widow with a history of psychosis, was brought by her stepson to see her psychiatrist because she was much worse.For several weeks she had talked about demons incessantly, stating that the spirits were living in her body, eating her liver, and telling her to kill people. She had threatened her stepson and his family with a knife and then turned the knife on herself, saying that she wanted to kill the evil spirits living in her liver. Sometimes she spoke in a language the family did not understand, and sometimes she talked with people who were not there, such as her dead husband and his dead wives. Seeking a cure, her stepson had arranged for several shaman ceremonies to protect her from the evil spirits. After each ceremony she was better, but only for several days. Her stepson was trying to arrange for a very powerful shaman to come from Laos to exorcise the evil spirits. Before he could pay for the trip, Mrs. Ly became more violent, and he sought the psychiatrist’s help. The psychiatrist knew that Mrs. Ly, a widow for two years, had been the fourth wife of a man who had had five wives. In Southeast Asia, her husband had been married to three wives concurrently. Two wives had died, and one wife had run away. By the time he married Mrs. Ly, he was a single man with six daughters. Childless herself, Mrs. Ly raised the six daughters as her own. Many years later, she and her husband decided that he would marry a fifth wife so they could have a son who would take care of them in their old age. Mrs. Ly had not known how she would react when the beautiful fifth wife gave birth to a baby boy. Enraged and jealous, she hired a sorcerer to curse the younger wife, who subsequently died in the process of giving birth to her second child, a daughter. Mrs. Ly’s subsequent regret and guilt had fueled her depression for years. As she talked with the psychiatrist at this visit, it was apparent that she was convinced that the fifth wife was taking revenge. She felt helpless and hopeless and was convinced she would be killed by the dead fifth wife or by the evil spirits or that she would kill herself. Against her wishes, the psychiatrist admitted her to the hospital, placing her on a seventy-two-hour hold to protect others and herself and to treat her psychosis. An interpreter came to the locked in-patient psychiatric unit for thirty minutes 240 Mental Illness every day, but otherwise there was no one who could speak Hmong with her. She complained to her stepson that she could not stay there and begged him to take her home. She refused to take the medications, maintaining that she was not crazy (vwm) but rather was possessed by spirits. The psychiatric team explained that the medicines would protect her body and mind from the evil spirits until her stepson could arrange for the definitive shaman ceremony. She reluctantly agreed, and over the next two weeks, she improved. Before she was released, her family members expressed gratitude for the care and help she had received, but they also expressed their anger about her being called crazy and their frustration that there was no English translation for the spiritual problem causing her suffering. Questions for Consideration Questions about Culture Typically, how are mental illnesses such as psychosis understood and treated by the Hmong? How does this approach differ from the views and practices of U.S. psychiatrists? What is the significance in Hmong culture of placing a curse on someone? What are the Hmong social norms and expectations regarding men married to multiple women? What impact has Western psychiatry had on the Hmong understanding of, and openness to, the medical treatment of psychiatric disorders? Questions about Cross-Cultural Health Care Ethics How (if at all) should the care of this woman differ from the usual Western approach to treating patients with her disorder? How can Western psychiatrists explain psychosis to a family who holds different beliefs about the cause and nature of such problems? Questions about Culturally Responsive Health Care What does this case reveal about disclosure and communication skills with Hmong patients? What cultural considerations should a psychiatrist take into account before ordering a seventy-two-hour hold, over a family’s...

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