Rethinking mental illness
The diagnostic parameters need to be completely overhauled as they embody a Western mode of understanding which itself is culturally bound.
All cultures, past and present, have identified abnormal human behaviors – anomalous thoughts and actions – that once sustained tend to be judged negatively. Unable to participate or function within social life, psych behaviors are regarded disruptive to the person and the organization of society. The boundaries drawn to distinguish between normality and madness are born and influenced by consensuses in culture moulded by beliefs, expectations, norms, the meanings assigned to thoughts and the expression of emotions. These agreements are central to registering unusual behavior. For the West the dominant method for determining mental health relies upon the taxonomy of mental illness outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This, a revisable bible, categorizes, defines and names madness from which the entire mental health industry has grown from, and upon which Western clinicians are reliant upon.
In November 2011, Rethink Mental Illness launched an independent commission, ‘The Schizophrenia Commission’ to review England’s capacity to provide the necessary care for people living with a diagnosis of schizophrenia and psychosis. The collated evidence and research in ‘The Abandoned Illness’ presents a stark and dismal picture of mental health provision and detailed its broad failings. No group of people read as chillingly than the section dedicated to ‘Mental Health and Minority Ethnic Groups (BME)’. The section illuminates decades of mounting evidence into the disparity of care within BME groups in England. The report reiterates that people from ‘African-Caribbean and African backgrounds are more likely to be given a diagnosis of schizophrenia or psychosis’, between 4-10 times greater compared to the white population. In addition to elevated diagnosis rates, the BME groups are overrepresented in hospitals, with higher rates of admission under section and for higher rates of ‘police involvement in their admission’. ‘Black people’ are ‘less likely to receive psychological therapy’ yet more likely to be forcibly restrained and prescribed higher doses of medication.
The commission heard evidence from research that the higher incidence rates of psychosis for people from African-Caribbean and African backgrounds living in the UK is not equivocal to that of their origin countries, claiming in the report that the ‘high rates aren’t found in the Caribbean’. This was an assertion propagated and extended in the press to include that ‘high rates aren’t found in Africa’ either. Such comparisons are founded upon studies carried out in these countries rather than the research deriving from the countries themselves. Three major incidence studies – often referenced in comparisons – conducted during the 1990’s in Jamaica, Trinidad and Barbados were undertaken by Western psychiatrists who entered these cultures searching for phenomena that conformed to the predetermined Western diagnostic categories laid out by the DSM. By applying these ‘standard’ diagnostic criteria they found the cited lower rates of psychosis than that of migrants in the UK. These studies defined culture, only in terms of geography, and almost completely neglected to include cultural factors in their measurements that might account for the observed differences thereby neglecting to establish whether these categories were meaningful or even relevant to the people in those countries. The research assumed Western psychiatry knows best and the robust definitions of mental illness in the DSM can be applied to any culture, without loss or distortion of meaning. The comparisons made undermine the serious concerns voiced by the BME groups that ‘mental health services are based upon a western understanding of mental illness which they do not share’ and specifically concerning the ‘reliability and validity of the diagnosis of schizophrenia’ itself.
The prevalence of mental illness on the African continent remains largely veiled due to the lack of reliable records in facility-based information systems. The data available can only be surmised in ‘estimates’ and in 2010 the World Health Organisation (WHO) said is was ‘difficult to get a clear picture as data collection was patchy’. But the essential message delivered by Professor Ndetei, founder and director of the African Mental Health Foundation, on October 18th 2012 at the University of Berkeley was: ‘All indicators from the available epidemiological data suggest that the patterns and prevalence of mental disorders in Africa are similar to those found in High Income Countries, but that is as far as the similarities go’. According to the WHO report of 2005, 50% of African countries have a mental health policy but many laws are outdated, with 70% of countries spending less than 1% of their total health budget on mental health. The lack of reliable data keeps the burden of mental ill health unknown keeping it out of the priorities of policy makers despite the economic and social costs.
Kenya is among the 70% of African countries that allocates less than 1% of their health budget to mental healthcare provision. Despite its own figures suggesting that one-quarter of all patients going the hospitals or clinics express experiencing mental health symptoms. However the people receiving care in Kenya are being met with a holistic approach to treatment that is discovering evolving benefits. By developing partnerships with traditional solutions Dr Frank Njenga, a Consultant Psychiatrist practising in Nairobi, and founding president of the African Association of Psychiatrists and Allied Professionals (AAPAP) says:
Psychiatrists who have Western-style training are only able to handle a small number of these conditions. So what we have deliberately and consciously done is to develop partnerships – firstly with traditional healers. They are the ones who come face to face with the huge majority of people who suffer from mental disorder. And we try to get them to understand that there are some conditions they treat better than we do, and some conditions we treat better than they do.
With no one approach competing in the belief that they offer the only, or most effective, treatment they are able to focus on adapting methods of care specifically for the service user. A malleability that does not strip patients of their culture in order to care for them, which the Schizophrenia Commission’s report underlines as woefully absent in the treatment of people from BME groups in England.
Dangerously, the various findings found by the WHO’s research in non-Western countries is still often cited as demonstrating the universality of mental illness, in the western classification model, thereby legitimising its application across cultures. But as the report clearly presents in the case of BME groups, neglecting to integrate – or better meld – cultural contexts into the DSM, the diagnosis and treatment of mental illness will continue to welcome: marginalisation, stigma, mistrust of Western services, appalling care and discrimination.
The diagnostic parameters need to be completely overhauled as they embody a Western mode of understanding which itself is culturally bound. The DSM blindly casts the same net over everyone regardless of origin, colour or background. It’s a frighteningly failed philosophy.