Understanding culture and place is paramount to effective mental health treatment
By: Sabnam Mahmuda & Alysha Ahmed (Spark Engagement Committee)
The age-old stereotype of Western psychiatry is well-known to us: we imagine a black leather chaise lounge designed for wealthy individuals to sit on while they divulge their deepest secrets and darkest fears to a physician therapist. Fast forward to the present — an evidence-based approach to mental health in high-income countries acknowledges that social supports and occupational therapy are just as important as talk-therapy and pharmaceutical approaches. However, the fact remains that Western cultural norms set the standard for the global practice of psychiatry. Approaches to treating mental illness may vary greatly between the Global North and the Global South. While behaviours characteristic of psychosis, such as hallucinations and delusions, are a clear impetus for medical intervention in Canada, they herald an entirely different set of ideas and beliefs in Haiti, for example. In many instances, mental illness in Haiti is approached first and foremost from a spiritual standpoint. Pastors, rather than physicians, are the first line of care. In Mexico, schizophrenia might be interpreted as possession by an evil spirit.
It then follows that certain cultural interpretations of mental illness will invariably butt heads with Western scientific approaches. Unfortunately, there are limits to what any one approach can provide, and it is often the most severe cases that are refractory to traditional healing approaches. The story of Rosemberg Lopez — a man living in rural Chiapas, Mexico — demonstrates this well. Mr. Lopez was treated for psychosis with herbal medications to no avail, and had been condemned to living in a locked shack for his own safety and that of his family and neighbours. Mr. Lopez was also briefly treated with psychotropic medications during an inpatient stay at the nearest psychiatric hospital, but the local health care providers in his village had been unable to provide him with the continuity of care that he required. If the resources were greater, and more importantly, if the will to collaborate between different healing approaches was stronger, Mr. Lopez might not have suffered in his makeshift jail cell for as long as he did. Sadly, stories like this are not uncommon, as more than 90% of all global mental health resources are located in high-income countries.
Cultural competence is the ability of healthcare providers and organizations to provide effective and respectful services that meet the social, cultural, religious, and linguistic needs of patients. When healthcare providers take into account the religious and cultural beliefs and practices of their patients, and make an effort to accommodate these beliefs into their treatment plans, they gain the respect of their patients and their communities. They break down the paternalistic and colonialist barriers that have historically been imposed by Western medicine, and they make treatment adherence and recovery not only far more appealing to patients, but far more possible. If health truly is state of mental and social well-being and not just physical well-being as the WHO defines it, traditional healing practices and prayer are as important as pharmacological treatment among the populations in which these beliefs have been engrained, and should be treated as such.
Partners in Health (PIH) is a non-profit global health organization that works at the nexus of healthcare and social justice. PIH acknowledges the importance and validity of culturally-competent care and provides mental health care through a community-based care model. These community-based care models are adapted to local cultures and systems of belief and are integrated within the existing primary care system. Furthermore, the model allows local clinicians and non-clinicians such as community health workers to provide mental health care services and support to patients right in their communities.
The importance and impact of such culturally-sound models of care can be seen through Regina’s story from southeast Liberia. Two of Regina’s children died during birth and her husband left her. She also witnessed her friends and relatives dying when their boat capsized nearby while they were all trying to cross the river to seek shelter in a refugee camp during the first Liberian civil war. Regina suffered from hallucinations for 20 years and her family attributed her symptoms to the misfortune which plagued Regina because she crossed the river. When a PIH nurse and mental health coordinator found Regina, they worked with her and her family to diagnose her and treat her condition with antipsychotic medication. A member of PIH’s mental health team in southeast Liberia further shared that, “In the areas you need to reach by canoe, the big challenge is that patients are not seen as patients; they’re seen as possessed by demons.” In response, the PIH mental health team worked alongside traditional healers and herbalists who are present in these communities to collaboratively diagnose and treat patients.
In Haiti, PIH is known as Zanmi Lasante and provides care to 4.5 million people through their clinics and hospitals across Central Plateau and lower Artibonite. PIH in Haiti provides mental health services and support to people through a community-based care model in which local clinicians, social workers and community health workers help diagnose mental illnesses, provide education and help manage the illness. This helps ensure that patients are receiving care in an environment that is conducive to their recovery. Stigma and discrimination against mentally ill people is highly prevalent and can act as a barrier to accessing timely and appropriate care. A culturally-sound model of care such as the one used by PIH also effectively helps address the fear, stigma and experiences of people around patients. The extent of PIH’s culturally sound model of care for treating mental illnesses also includes The Zanmi Lasante Depression Symptom Inventory (ZLDSI), a screening tool composed of universal and local descriptions of symptoms of mental illness. The ZLDSI was developed based on thorough analysis of symptoms associated with depression in rural Haiti and is now used to train clinicians to enhance their abilities to diagnose and care for mentally-ill patients in Haiti. By integrating clinical descriptors of symptoms as well as local figures of speech — such as kè sere, meaning “constricted heart” — mental health workers are more likely to capture a more accurate picture of the burden of mental illness in their communities.
With depression alone predicted to be the leading cause of disease burden by 2030, cultural competence in diagnosing and treating mental illness is more important now than ever before. Beyond providing culturally competent community-based care, Partners in Health continuously trains the next generation of care providers to treat not only individual illness but the stigma that surrounds it. You can read more about PIH’s work in mental health here: https://www.pih.org/programs/mental-health.
