‘We have become not a melting pot but a beautiful mosaic. Different people, different beliefs, different yearnings, different hopes, different dreams.’
– Jimmy Carter
Western culture is taking over the world; from supermodels on television screens, to fashion accessories in shopping outlets around the world, to the movies made in Hollywood and disseminated worldwide online. Globalization has opened new doors. It has allowed us to build new relationships and learn about new cultures. It has opened our eyes to the worlds beyond our borders – to different languages, religions and beliefs. It has had an impact on every aspect of our lives, including medicine and healthcare.
The pathophysiology of most disease is similar throughout the globe. The diagnosis of a myocardial infarction will have similarities across different continents; an ECG that is normal in the UK will likely be deemed normal in the USA. But when it comes to our inner thoughts and our minds, a similar comparison cannot be made. The Western model of mental illness, of the divisions of neurosis, psychosis and personality disorders yields more than just mere categories. It also produces a set of values and beliefs – namely, that these thoughts and behaviours are outside the remit of social norms. Does a person with a diagnosis of Major Depressive Disorder in the USA show the same symptoms as someone in South Africa? Does this diagnosis hold the same meaning on the other side of the continent? My answer: no, it does not.
Mental health problems go beyond human anatomy and pathophysiology, and treating them like they do not leads to inappropriate therapies. Culture and mental health have close ties that are not addressed when treatment involves only the prescription of a drug. Our mental health colors how we view the world around us; how we view ourselves, our failures and our successes. It defines our identity. In the West our society is based upon science and rational thought. Such a focus has placed a large emphasis on the ‘biomedical model,’ i.e. that symptoms can be clustered together into categories, leading to a diagnosis and a form of treatment. Yet in other countries the idea of being labeled with a ‘disease’ seems bizarre. In many cultures, mental distress is explained through a spiritual lens, based upon the power of one’s ancestors or a curse placed upon one’s family. Who are we to step into this other world and banish such beliefs in the name of the ‘superior’ Western thought?
It can be argued that by placing people within a scientific category, one is filtering out a person’s lived experiences. Sure, a diagnosis may be appropriate in certain circumstances, allowing appropriate support and treatment to be offered to those who are in distress, but we must remember that the diagnoses written in the textbooks do not always correlate with the chaos that is human life.
What is it that makes someone ‘mentally unwell?’ More than anything else, it is a social judgment; it is based upon the idea that everyone over this line is unwell, while those of us who are able to follow the norms of our society are deemed ‘sane.’ Every society is different, and every society has its own ideas of what an illness is and is not. We can often be so determined to get out there and ‘save lives’, that it can be easy for us to forget that when it comes to mental health, it is they (the patients) who have the far superior knowledge of what they are going through. They are the ones who know what emotions they are feeling, what thoughts skip through their mind, what fears drench their hearts. They are the masters of their lives. What is needed is not a rush to produce pills, to prescribe, to diagnose and to medicalize – no, what is needed is humility. The appreciation of our own ignorance in a culture that is different from our own – an understanding that human beings are different. Only then can we begin to take that step to alleviate the distress of mental health problems worldwide.
If we were to take out our Diagnostic Statistical Manuals and set about drawing boxes in other countries, we would find that such a rigid classification system does not translate well to other cultures; a person who fits the criteria for Major Depressive Disorder in London, UK does not necessarily experience the same illness as someone in New Delhi, India. We need to go beyond the symptoms and think about the person’s suffering and pain; what is it that has led them to feel such despair? For some it may be the loss of a job, or status, or wealth. For others, it may be a fall within their social circle, the death of a spouse, or the belief that they are being cursed or punished. We need to be able to understand another person’s suffering if we want to help them. A setback within someone’s life needs to be seen within its context. This involves sitting with people, attempting to understand their lives, eating their food, conversing in their language and understanding what it means to be a citizen in their country. It is not a process that can be ticked through in a few minutes based on a checklist of symptoms. Such arbitrary methods do not capture the emotional and spiritual parts of mental distress, nor do they take into account the vastly different cultural contexts in which patients may live.
Remember that the labels we put on our patients are often value-laden. These criteria we use from our diagnostic manuals are often drawn from the concept of right and wrong – what each society chooses to accept and reject as the norm. When it comes to mental health, what is most important is not the structure of the neurons, nor the actions of their neurotransmitters; it is the effect on the individual, the person within, the person who breathes and feels and cries and laughs.
All of these issues can be illustrated with the worldwide response to the Tsunami in 2005. Following the disaster, many NGOs provided ‘mental health assistance’ by using the Western psychological models of distress, particularly to describe the response to trauma. Most of the workers were ignorant of the local cultural beliefs and traditions, which resulted in a set goals that were more in line with the charities than the victims.
“We are fishermen and we need space in our houses – not only to live but also to store our fishing equipment. After the tsunami we have been living in this camp, which is 12 kilometers away from the coast and in this place for reconstruction. When the international agency came and started building a housing scheme, we realized that they are building flats, which is not suitable to us. But when we try to explain this to the foreigners who are building this scheme, they looked at us as if we were aliens from another planet. What are we supposed to do?”
[..] We have lost our families, now we are having our homes stolen too.”
– Action Aid International 2006 (8)
Such interventions have raised questions as to whether this ‘external mental health aid’ is actually harmful, leading to a division between the ‘superior’ external workers with their Western knowledge, and the locals who have been left helpless and vulnerable.
I am not suggesting that we place a hold on Global Mental Health. I am not suggesting that we stop giving aid. What I am suggesting is that when it comes to mental health, we acknowledge the diversity of the human race. We accept that to be mentally unwell means more than to have an imbalance of chemicals. And by accepting that mental illness affects not just a brain but a person, an identity, a family and a society, we are able to put on our boots and trudge deep into the mud alongside those who we are hoping to help, and perhaps we may even help ourselves along the way.
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