CULTURAL ISSUES IN MENTAL HEALTH CARE

THE PLACE OF CULTURE IN MENTAL HEALTH CARE : A CROSS-NATIONAL COMPARATIVE PERSPECTIVE

L.J. Kirmayer

Division of Social and Transcultural Psychiatry, McGill University, Montreal, Canada

Cultural psychiatry has moved from exoticizing the other through attention to ‘culture-bound syndromes’ to the recognition that psychiatric theory itself is a cultural product. This shift reflects fundamental changes in our understanding of the nature of culture in a globalizing world. Culture is now understood as a biological construct, both cause and consequence of the social brain. Local cultural worlds emerge from interactions between individual agency and global systems. This presentation will consider the implications of these new notions of culture for mental health care. The cross-national comparative study of models of mental health care reveals some of the cultural assumptions of psychiatric practice. Models of service delivery developed in different countries reflect the demographics of the population and the history of dominant approaches in psychiatry and medicine. However, models of service are also strongly influenced by health policy, which in turn reflects ideologies of citizenship, response to migration, and the politics of national and ethnocultural identity. These social factors in turn influence psychiatric modes of interpreting individual suffering. International psychiatry presents itself as a « value-free » system of rational medical science and evidence-based « best practices ». However, there is ample evidence for the social, political and economic shaping of psychiatric theory and practice. The call for evidence-based psychiatry makes attention to culture essential to clarify the context and generalizability of psychiatric theory and practice.

CULTURAL INFLUENCES ON HELP SEEKING AND MODES OF ADMISSION : IMPLICATIONS FOR THE ORGANIZATION OF MENTAL HEALTH SERVICES

J. Leff

TAPS Research Unit, London, UK

Cultural factors exert an influence on many aspects of mental health care, from the initial seeking of professional help, through the procedures of diagnosis and treatment, to aftercare and social reintegration, including the organisation of mental health services. The first resource that individuals and their families utilise in the case of psychiatric disorders is often the informal network of relatives and friends. If that fails, then the next stage on the pathway to care depends on cultural factors, particularly beliefs about the causes and treatments of mental disorders. In developing countries, traditional beliefs usually lead to consultation with a healer before biomedical services are sought. The scarcity of such services also dictates this course of action. Ethnic minority groups in a developed country also consult healers in their own community first, at least until some degree of acculturation is achieved. It has been claimed that psychiatric professionals faced with a person from an unfamiliar culture are prone to make incorrect diagnoses, mistaking culturally acceptable ideas and behaviour as indicative of psychopathology. While there is little evidence for these claims, they create an atmosphere of suspicion in ethnic minority communities which inhibits contacting the services. Racial prejudice has also been claimed as the cause of differential treatment experiences of majority and minority ethnic patients. The engagement of patients in follow-up care after treatment of an acute episode is often fraught with difficulties. Beliefs concerning cure as opposed to maintenance are culturally influenced. Furthermore, patients from ethnic minority groups who feel they have been discriminated against during their acute care are less likely to comply with aftercare. Full reintegration into the community depends crucially on the attitudes of the public towards psychiatric illness, and these vary markedly between cultures. A contentious issue in a multicultural society is whether dedicated services should be provided for patients from minority ethnic groups. There are strong arguments for segregated services, including culturally sensitive staff and case of communication with patients and relatives. However, there is the contrary argument that such services perpetuate difference and foster discrimination. All the above issues are difficult to resolve but open discussion between professionals, clients and family members holds out hope of developing acceptable solutions.

CULTURAL ISSUES IN MENTAL HEALTH CARE : INTERACTION BETWEEN LEGISLATION AND MENTAL HEALTH

M. Kastrup

Centre for Transcultural Psychiatry, Rigshospitalet, Copenhagen, Denmark

Refugees seeking asylum have a high frequency of traumatic experiences. Such events include pre-flight experiences such as persecution, internment or torture as well as post-flight experiences such as language barriers, discrimination, alienation, or social problems. Mental health professionals meeting refugees should be aware of this and the possible negative consequences on their mental health. There is increasing recognition on how important the conditions in country of exile are for the mental health and quality of life of the refugee population and its integration in the new environment. In many Western countries we are presently experiencing changes in the legislation involving immigrants. Such alterations may relate to family reunions among refugees, social benefits in the host country, conditions for granting asylum, length of permission to stay in the country These changes and the implied uncertainties for the refugee population may result in an exacerbation of an already fragile mental health situation. The paper will provide an overview of issues of concern regarding refugee mental health and the relationship between altered immigration policy and the mental health status of those involved.

CULTURAL ISSUES IN MENTAL HEALTH CARE : A VIEW FROM DEVELOPING COUNTRIES

R. Srinivasa Murthy

Eastern Mediterranean Regional Office, World Health Organization, Cairo, Egypt

All over the world there is a major shift in the organisation of mental health care. In developed countries, the shift is from institutional care to community care. In developed countries, the organisation of mental health care in a systematic manner is less than three decades old. Most of the countries have only in the recent times initiated measures to develop mental health programmes to cover the total populations. The challenges in developing countries are the lack of mental health infrastructures and trained professionals, public ignorance and lack of supportive policies, funding and legislation. There are a number of areas where cultural issues play an important role in the organisation of mental health care. There are both positive and negative aspects of culture that influence mental health care. On the negative side, the existing beliefs about the supernatural causation lead to seeking initially help from traditional healers or not considering the illness as requiring medical care. The differential roles of men and women gets reflected in the differing ways ill men and women are brought to care. The trend of the population to express their psychological distress in somatic terms leads to people seeking help mainly from primary health care and being treated for physical problems rather than the psychological problems. The strong belief of heredity as a cause of mental disorders presents problems in marriage and breakdown of marriage among the ill persons. On the positive side, the high tolerance in the community to deviant behaviour in general and mental illnesses in particular limits « exclusion » of the mentally ill from community life. Ill persons continue to live in families and communities, especially in the rural areas. There is also less resistance to setting up of community care facilities like half-way homes, day care centres and hostels in the residential areas. The family as a readily available and abiding source of support is an advantage in planning of care programmes. Studies in Sri Lanka in the 1970s, Nigeria, Colombia and India as part of the World Health Organization’s International Pilot Study on Schizophrenia and from a number of countries in the last decade have pointed to the value of this type of support towards recovery. Some countries in Africa and Pakistan have developed linkages with traditional healers to reach ill persons to the advantage of the patients and to develop services in a culturally acceptable manner. The « externaF’ orientation to understanding the causation in some ways decreases the stigma and blaming of the ill persons. The availability of cultural practices relating to grief and child rearing, and therapeutic measures like yoga and meditation are valuable for prevention of mental health and promotion of mental health. The mental health professionals in developing countries have to recognise that culture can function as a friend and foe. The challenge is to harness the positive aspects and minimise/eliminate the negative aspects of cultural practices, to meet the modern needs of mental health care.