RESPONDING TO MENTAL DISTRESS : CULTURAL IMPERIALISM OR THE STRUGGLE FOR SYNTHESIS ?

This paper questions the appropriateness of some of the “help” that has already been given in mental health in the South, particularly Africa, and examines some of the complex ideological issues underlying different cultural understandings of the aetiology and treatment of mental illness. Some personal experiences, illustrating examples of the imposition of culturally inappropriate ideology in the teaching of psychiatry are described. In conclusion, some principles of good practice are suggested which could form the basis of a synthesis between cultures, and maximise the possibility of aid from the North in the area of mental distress being more culturally relevant. Mental illness and ideology Mental disorder is found and recognised in all societies. However, how it is shown in individual behaviour, what people think causes the disorder, and what treatment is considered appropriate, varies tremendously among cultures. Although some types of psychotic illness appear to have similar symptoms across cultures, other types of problems have been found to be “culture bound”. In other words they are found only in one particular culture and not in any other (Kirmayer, 1989; Munford, 1996; Patel et al 1995; Witzum et al. 1996). However, even when symptoms appear similar, how they are understood is totally dependent on the cultural context. In any culture, the predominant approach to mental illness is inseparable from the particular “world view” held by that society, the ways that are considered acceptable for making sense of human experience. Ideological issues cannot be discussed in depth here, but they are of paramount importance, as it is a particular world view that is being exported North to South, not value free “help” (Gronemeyer, 1992). Although there may be dissent among professionals in the North in the mental health field, the predominant model in psychiatry in the North is that used in medicine: the “medical model”. This has, as its basis, the classification of symptoms into particular diagnostic entities, the identification and labelling of those conditions, and the application of treatment, most often in the form of medication. The medical model is directly rooted in the North’s emphasis on science as the preferred mode for understanding the world. Stemming from this medical model and scientific framework, a great deal of cross cultural research in mental illness has been devoted to applying the West’s classification system to other cultures in an attempt to validate a “universal” diagnostic system for mental disorder (Ben Tovim, 1985; Kirmayer, 1991; Littlewood, 1992; Sartorius et al, 1993; Weis et al, 1995). In researching the literature, it is surprising that this endeavour has been so persistent, in spite of increasing awareness of culture bound syndromes and the reservations of researchers who have attempted to use standardised classification systems (Edgerton & Cohen, 1994; Littlewood, 1992: Susser et al, 1995; Weis et al, 1995). Approaches to mental distress: what can the North offer? Can approaches developed in the North offer anything useful and non damaging to very different cultures? In medicine there is at least a broad consensus about the causation of physical disease and how it can be treated. Though there is debate, it is generally agreed that people’s bodies contain the same parts and work in the same ways! However, there is much less consensus in the North about the treatment of mental distress. Many of its basic tenets, i.e. the biological basis of schizophrenic conditions are completely rejected by other professional workers in the field (Marshall, 1999; Boyle, 1996). Those who are being treated and who are in distress often remain confused as to how to understand what is the matter, given the lack of a unitary model among professionals. These disagreements in the North continue unabated and show little sign of resolution. Given the fragmented and disjointed nature of psychiatry and mental health services in the North, what seems to have been exported to “less developed” countries so far? What might the contribution of psychiatry be now that mental health is very much on the international aid agenda? The literature reveals many studies on the incidence of mental illness in other cultures, and on validating measuring tools, but there appears to be very little about specific ways of working and what is actually happening. I will review some of my own experience, while recognising that the situation in other countries may be very different, and that changes may have occurred. Personal observations The primacy of the Primary Health Care Team (PHCT) as a model of care in “less developed” countries is now well established. It is generally recognised that providing health services in the same way as the North is not either practically or financially possible. Thus it falls to nursing staff to work at village level – dispensing medicines, training village health workers, conducting health education programmes, and operating as the essential foundation for all services, including mental health. Thus it seems of paramount importance to consider their role and to review what kind of training they are receiving.