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Edward Eid

#: 032
Dr. Omar Al-Dewachi

A Cultural Approach for a Truly Global Mental Health


Due to the incessant influx of money into the rapidly evolving global
health field, a number of paradigm shifting notions sprung (and continue to
spring) from the ever expanding literature to challenge conventional
principles. Of late, the subject of mental health rose to prominence as a
result of epidemiological research carried out globally. Prince et al. estimate
that approximately 14% of the global burden of disease is accredited to
neuropsychiatric disorders with the lions share of this percentage due to
depression (1). On their website, the WHO found that over 400 million
individuals worldwide suffer from depression, 60 million from bipolar
affective disorder, 21 million from schizophrenia, and 35 million from
dementia (2). Low and middle income countries mired in poverty and
political instability prioritize the more tangible issues of infectious diseases,
maternal, and child health over mental health, which is considered to be an
altogether independent issue (1). However, mental disorders have been
found to act as risk factors in developing a variety of communicable and noncommunicable diseases as well as facilitating the transmission of infectious
diseases by individuals with mental disorders (1). Thus, in response to the

quantitative and qualitative aspects discussed above, the Global Mental


Health (GMH) movement came into existence. Prince and Patel have defined
GMH as being an Area of study, research and practice that places a
priority on improving mental health and achieving equity in mental
health for all people worldwide (3). While the goals of the movement
were unanimously lauded by global health scholars, the foundations on
which the movement was built were fertile ground for debate. The fields
nearly exclusive biomedical western approach was accepted by some as
being globally appropriate while others decried the marginalization of
sociocultural factors specific for each target population.
According a more central role to the conventionally overlooked
sociocultural aspects increases the GMH movements application to nonWestern cultures and ameliorates the GMH movements quest to achieve
mental health on a global scale. In what follows, I will be dissecting the GMH
field using social theory and mounting a defense for a more culture-based
approach to mental health. In a section of the paper, I will be using PTSD as
a representative of the mental disorders targeted by GMH.
The GMH field is imbued with the inclinations and notions of Western
thought. It is common knowledge that high income countries, such as those
considered part of the Northern divide (those located in North America and in
Western Europe) have more funds, personnel, and facilities to carry out
research than those of low and middle income countries. As such, their
contributions to the GMH field are vastly more significant than those of other

countries. These Western scholars are themselves influenced by a biomedical


approach that advocates diagnostics of the various mental disorders in line
with those observed in studies where population samples were exclusively
taken from the west. In terms of treatment, pharmaceutical drug usage is
considered a central tenet. These specific preferences and inclinations come
to define the field and its various aspects. The aforementioned is a brilliant
example of the social construction of knowledge as it depicts how cultural
nuances such as reliance on a pharmaceutical approach can dictate what is
deemed as an appropriate treatment. Another paragon of the social
construction of reality theory is the Diagnostic and Statistical Manual of
Mental Disorders (DSM), a mainstay of the GMH field. Up until 1973, the DSM
lumped homosexuality with other mental disorders. As the sexual revolution
gathered pace during the 1960s, Western societies began shifting their views
on homosexuals. These social pariahs were finally deemed socially
acceptable. Consequently, subsequent versions of the DSM from 1973
onwards omitted homosexuality from the list of mental disorders (4). A
further instance of the social construction of reality theory lies in the
medicalization of certain subjective experiences, whereby these experiences
are reformulated into medical conditions such as PTSD and clinical
depression (4). This springs out of a typically western tradition of
institutionalizing medical norms (4), whereby ideas, actions, experiences
are converted into a transmissible truth giving rise to knowledge (medical in
this case). As we have seen concerning homosexuals, vertical differences in

a culture across time can force a shift in the GMH field by the reevaluation of
DSM definitions. It is thus reasonable to assume that horizontal differences
across cultures should also be critically assessed and integrated into the
foundations on which the GMH field was built if a holistic approach to dealing
with mental health issues worldwide is to be attained.
Due to the monopolization of the GMH movement by western thought
and practices, its application in non-western conditions has been met with
vehement opposition. Under urgent situations, such as tsunamis,
earthquakes, civil wars, etc , western psychologists deployed by UN
agencies and NGO assign the psychological dimensions of the problem at
hand as well as the method of carrying out interventions and treatment with
negligible consideration to local practices (5). Marcella describes the
previously stated as a tyranny of western expertise whereby the dynamics
of the situation are orchestrated by subtle power struggles and the implied
assumption that western knowledge is superior to local knowledge (5).
Furthermore, by dismissing local treatments as primitive and irrational,
psychologists are inadvertently promoting GMH as a form of medical
imperialism or neo-colonialism (6). In support of her claims of
neocolonialism in GMH, Tribe describes how certain documents like the DSM,
a product of western thought, is applied uncritically as a de-contextualized
reference for appropriate research, diagnosis, and treatment of mental
disorders on the global stage (6). This homogenization of medical practice
runs the risk of abolishing hidden jewels of local knowledge that might be

otherwise pertinent in dealing with and treating certain local mental


conditions.
When it comes to PTSD, advocates of the current GMH method of
applying DSM and other western documents worldwide call attention to the
physiological similarities shared by the whole human species. They point to
the shared neurological responses implicating the hypothalamus-pituitaryadrenal axis (HPA) among other endocrine organs; moreover, cultural
relativism would rattle the disease model of psychiatry, which posits solid
symptomatology listings for the various mental disorders and fixed treatment
protocols (5). Given the homogeneous response to trauma, this viewpoint
would preclude consultation with target populations (7). While these
advocates viewpoints on the homogeneity of human physiology is
scientifically sound, this view dangerously borders on genetic determinism. It
is too simplistic to assume that the biological factors are the sole
determinants of the human experience; biology only draws half of the
picture. Each individual is a product of a complex interplay of biological and
environmental factors. These environmental determinants include but are
not limited to sociocultural considerations like religion, traditions, art, etc. As
such, mental states under normal and pathological conditions are
significantly influenced by culture. In line with the social construction of
reality theory previously discussed, Marcella eloquently paints cultural
constructions as spectacles that frame our view of reality, constantly
guiding us as we seek to make meaning of the world around us (5).

Consequently, PTSD symptomatology listed in the GMH-adopted DSM can fail


to encompass the multitude of culture-specific symptoms exclusively
manifested in response to trauma. In his book, Watters mentions multiple
cultural specific symptoms that evaded recognition by DSM symptomatology
listings. For example, Salvadorian women refugees following the civil war
have been known to experience calorias, a sensation of a dramatic rise in
temperature in their body not found within DSM symptoms, while failing to
reveal elevated startled responses in response to trauma symbols as
expected by DSM symptomatology (7). Other non-DSM symptoms are
impregnated with cultural beliefs like the dramatic distress suffered by
Cambodians that claim they were visited by vengeful spirits. When quizzed
on these symptoms, Cambodian sufferers attributed them to their inability of
performing burial rites for their dead (7). Some symptoms lack an equivalent
in English and are language-bound such as asabi, a type of nervous anger,
and fisha-e-bala, the sensation of internal stress or pressure (7). Trauma
perception was also seen as being different among cultures. In Watters
book, Fernando observed that Sri Lankans had the tendency to relate
distorted psychological states to the social disruption brought forth by the
tsunami like death of a family member or a friend; both social and
psychological were interwoven. On the other hand, Western sufferers of PTSD
tend to suffer personal psychological damage that translated later on to
social damage (7). In terms of treatment, local knowledge has been known to
treat conditions that have proven elusive to western practices. Sudden

unexpected death syndrome is the name of a condition where Southeastern


Asian individuals, most notably male Laotian-Hmong refugees, die in their
sleep after sleep paralysis. Survivors of these traumatic dreams report fear
of evil spirits brought on by their failure in performing rites (8). In order to
prevent the disease from striking in prone individuals, shamans, the
equivalent of priests and sheikhs in Christianity and Islam respectively, were
employed to perform the traditional rituals and alleviate stress (8).
In conclusion, GMHs current approach to diagnosing and treating
mental disorders is a product of Western thought. Embedded in its system is
a belief in the supremacy of the Western biomedical model over other local
non-Western culture-specific models. In effect, the threat of neo-colonialism
looms large with the relegation of non-western models to inapplicable,
primitive cultural artefacts. However, we have seen, using PTSD as our
model mental disorder, how local cultural beliefs can have a significant and
central role in defining and treating mental conditions. The GMH movement
requires critical reassessment where sociocultural considerations should play
a more central role or suffer the loss of humanitys rich cultural heritage. The
Global in Global Mental Health should not be defined as the
universalization of one model at the expense of others; on the contrary,
Global should be defined as the inclusion of the various cultures and their
separate systems under the common goal of ensuring equity when providing
proper mental health to all parts of the world.
References

1. Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M., &
Rahman, A. (2007). No health without mental health. The Lancet,
370(9590), 859-877.
2. Mental disorders. (n.d.). Retrieved May 16, 2015, from
http://www.who.int/mediacentre/factsheets/fs396/en/
3. Patel, V., & Prince, M. (n.d.). Global Mental Health: A New Global Health
Field Comes Of Age. JAMA: The Journal of the American Medical
Association, 1976-1977.
4. Hanna, B., & Kleinman, A. (2013). Unpacking Global Health. In
Reimagining Global Health. University of California Press.
5. Marsella, A. (2010). Ethnocultural Aspects of PTSD: An Overview of
Concepts, Issues, and Treatments. Traumatology, 16(4), 17-26.
6. Tribe, Rachel. "Culture, Politics and Global Mental Health." Disability
and the Global South (2014): 251-65. Print.
7. Ethan Watters, The wave that brought PTSD to Sri Lanka, 2010.
8. Madrigal, A. (2011, September 14). The Dark Side of the Placebo
Effect: When Intense Belief Kills. Retrieved May 18, 2015, from
http://www.theatlantic.com/health/archive/2011/09/the-dark-side-ofthe-placebo-effect-when-intense-belief-kills/245065/

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