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It is no more radical or controversial to say today that, mental health is a cultural practice. Social scientists, who have engaged themselves critically with psychiatry, psychology and related disciplines in the last two decades, have convincingly argued that mental health is not a neutral, independent area and much of its claimed ‘scientific’ status can be questioned. Even psychiatrists have been raising these questions for long. Whether one reads the anti-psychiatry movement of 1970s or Fanon’s work, or just browse through reputed journals like Culture, Medicine, Psychiatr; Journal of Human Sciences or Journal of Medical Humanitie; one will find enough evidence for this. In this small essay I am not going to elaborate on this debate which is well documented and mostly (and enrichingly) theoretical. Rather I would like to tell you the significance of culture in our practices of mental health. And for me, culture is not a secondary issue to the foundation of biology. It is an integral part of our mental health discourse constantly challenging the universal hegemony of a modern, western science. Let me start with an obvious example: 5-Year Outcome of WHO Study of Schizophrenic Patients: Cities in “Developed” versus “Developing” Countries [R. Desjarlais, L. Eisenberg, Byron Good & A. Kleinman eds., World Mental Health: Problems and Priorities in Low-Income Countries, New York & Oxford: Oxford University Press, 1995, table 2.2, p. 42.] Location Percentage with Percentage with Best Outcome Worst Outcome Developed Countries: 1. Aarhus, Denmark 6 40 2. London, UK 5 14 3. Moscow, Russia 6 21 4. Prague, Czechoslovakia 9 23 5. Washington DC, USA 17 23 Developing Countries: 1. Agra, India 42 10 2. Cali, Colombia 11 21 3. Ibadan, Nigeria 33 10 I am sure, you did not fail to notice that we have much higher percentages of best outcome compared to ‘developed’ countries. Now how do you explain this? The researchers initially thought it to be due to faulty methodology, but repeat studies only confirmed this! I would argue here that, this outcome is possible because of our culture and (thankfully) a poor understanding of the concept of ‘schizophrenia’ among the population. Not only there are many positive aspects of our cultural practices but also our understanding of the concept of mental disorder is different. Our selves are still not an individual, atomised, autonomous self that emerged from the rationalistic discourses of Enlightenment. We have the capacity to see ourselves as communitarian selves inspite of three hundred years of modernity. This is indeed an important fact. The mental health concept we have today is developed in Europe and North America over a past century or so, and there is evidence of biased, value-based and often racist undercurrents in psychiatry (Chakraborty, 1991). The ethnographic database strongly suggests that, apart from brain tumors and infections, Alzheimer’s disease, metabolic encephalopathy, substance abuse and other well documented brain-based disorders such as certain sleep disorders, only five psychiatric syndromes of the adults can be found cross-culturally. The conditions are schizophrenia, brief reactive psychoses, major depression, bipolar disorder, and a range of anxiety disorders from panic states through phobias to obsessive-compulsive disorder. Most of the other hundreds of conditions described in DSM IV (Diagnostic and Statistical Manual, Revision IV), for example, are culture bound to Euro-America (Ameen 2005). Think about the situation, when everyday hundreds of mental health professionals in our country converse with patients in their local languages and try to translate it to fit the given universal categories. Isn’t it that each time a possibility is created where the western category may undergo transformation? Have we been able to create a vocabulary in all the languages that we use here, which perfectly represents the universal mental health? And when you take up interpreting non-verbal signs things get much complicated. Even imagining a phenomenal increase in the number of mental professionals to cover each Indian, the problem will not get erased just because our view of the ‘self’ is different and again it is different in each culture. And you will agree with me that treating with pharmaceutical drugs of patients with impaired insight and thought is not providing the final solution as their question of drug-maintenance and rehabilitation has to be worked out with solid cultural understanding. Now consider those innumerable non-psychotic states that we need to encounter for whom medicine is only a part of the solution. What I am trying to implicate through these examples is to make you sensitive to the strategic issue that, our mental health programmes needs to be culture and community based. The modern western knowledge of medicine (mostly controlled by the big multinational corporations) serves an important but a small fraction of our mental health needs at large. Considering the present prevalence of mental health problems in a country like India can we think of building enough mental hospitals for us in a foreseeable future? Is it possible to comply everybody to modern treatment? I don’t think so, because there are hundreds of non-modern therapeutic systems which will never become extinct. And why should they be forced to extinction when it is providing effective healing for millions? The only important need is to fight the coercive and violent practices in some of the systems. To have more community based mental health programmes is a potential possibility to address the issue where cultural and the universal model have to come to an effective compromise. There are already such programmes giving good results (Chatterjee et.al. 2003). In UK, the question of having separate psychiatric services for ethnic minority has also been argued (Bhui & Sashidharan 2003). If we have to deliver effective mental health services then culturally designed community based services, according to me, is the best option. Where we would radically revise the western knowledge with our practices and knowledge systems. This kind of services has to be pluralistic, and omnipotence of a particular system has to be brought down. It has to be more democratic by acknowledging the cultural differences brought by different religion, caste, age, gender and class. It is through the specificity of culture one expresses his/her difficulty and also seeks relief. It is the vast resource of this cultural knowledge that would facilitate the development of our own mental health concepts. And why should we feel ashamed if it is not fully ‘modern’? Rather much of our strength lies here if we consider the WHO study I have referred before. In other words, it is the cultural understanding that would help us to construct an effective mental health policy for us. How can a medical student, a nurse, a social worker and a health worker understand the person and his/her community without having a respectful learning from his/her culture? If as professional healers our duty is to provide our best to the community, then it is imperative that we negotiate with other knowledge systems and cultures that is sustaining positive mental health despite the destruction brought by modernity and its controlling mechanism (Nandy 2002). For mental health we would like to help people from their trauma, helplessness, alienation, violence and numerous other problems of mind so that we gain strength to fight those and live life as harmoniously as possible. Do you think western medicine and our culture-free training in mental health has really passed the test in our grounds to be the ‘only’ and the ‘best’? References: Ameen, Shahul (2005) ‘Transcutural Psychiatry: A Critical Review’, http://www.psyplexus.com/excl/transcultural_psych.html Bhui, K. A. M. & Sashidharan, S. P (2003) ‘Should there be Separate Psychiatric Services for Ethnic Minority Groups’, British Journal of Psychiatry, 182, pp. 10-12. Chakraborty, A. (1991) ‘Culture, Colonialism and Psychiatry’, Lancet, 337, pp. 1204-7. Chatterjee, Sudipto, Patel, Vikram, Chatterjee, Achira & Weiss, Helen A (2003) ‘Evaluation of a Community-Based Rehabilitation Model for Chronic Schizophrenia in Rural India’, British Journal of Psychiatry, 182, 57-62. Nandy, Ashis (2002) ‘A Report on the Present State of Health of the Gods and Goddesses in South Asia’, in his Time Warps: The Incessant Politics of Silent and Evasive Pasts. Delhi: Permanent Black, pp. 129-156. Correspondence: Dr. Amit Ranjan Basu BE 318, Salt Lake, Kolkata700064, India. amitrbasu53@gmail.com
Article Source: http://www.articledestination.com
Health Action, November 2005, pp. 7-8 (references added in this article)
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