Ethical and sustainable services for mental health and wellbeing in non-western settings.

1. Ethical and sustainable services for mental health and wellbeing in non-western settings. Suman Fernando http://www.sumanfernando.com Honorary Professor, Faculty of Social Sciences and Humanities London Metropolitan University

2. Mental Health WorldwidePalgrave Macmillan 2014

3. ‘Mental health’ and service provision for ‘mental health problems’ Worldwide 1. Terms we use come from study of madness in the context of post- Enlightenment European thinking of 17 – 18 Centuries. (i.e. Eurocentric) 2. Understanding of ‘mind’, madness, etc. developed very differently in non- western cultural traditions 3. Medicalization of human problems in the Global North has resulted in reductionist, narrow bio-medical approach to treatment dependent on drug therapy. 4. Western asylum-psychiatry was imposed during colonialism (but with little cultural impact) and since 1980s exported as ‘modernization’ / ‘globalization’ in neo-colonial movements such as the ‘Global Mental Health’ movement.

4. Support for (equivalents to) ‘mental health problems’ and ‘mental illness’ in the Majority World (Global South)(pre-colonialism and often until 1960s or even 1970s) 1. What we call ‘mental health’ (in the West) is equivalent to ‘wellbeing’ —something ‘out there’ rather than just located inside the head. 2. Western psychologies is only one of many psychologies that inform people daily lives 3. Little medicalisation of ‘m-h problems’ in many non-Western cultures—individual problems seen in spiritual, ethical etc. terms. 4. Indigenous non-Western medicalsystems deal primarily with bodily dis-ease and some ‘madness’ but are connected with religious healing and other non-medical therapies. Refs see Fernando, S. (2014) Mental Health Worldwide: Culture, Globalization and Development. Palgrave Macmillan.

5. DANGERS OF MENTAL HEALTH DEVELOPMENT ‘There is a danger that focusing attention on mental health needs only serves to divert attention from more difficult social problems that demand political and economic solutions. Psychiatry may collude with those who benefit from the status quo, neutralizing political challenges by reframing problems as aspects of individual mental health and offering treatment to individuals who are, after all, expressing the pain of a system out of joint.’ (Kirmayer, 2006: 138) Ref Kirmayer, L. J. (2006) ‘Beyond the New Cross-cultural Psychiatry’: Cultural Biology, Discursive Psychology and the Ironies of Globalisation’ Transcultural Psychiatry 43(1): 126-144.

6. PROBLEMS OF (CROSS-CULTURAL) INTERNATIONAL RESEARCH HOW TO MEASURE? ‘CATEGORY FALLACY’ (Kleinman, 1977) IS BIGGEST PROBLEM i.e. IMPOSITION OF A CONCEPT / CATEGORY DERIVED IN ONE SOCIAL AND CULTURAL SETTING INTERNATIONALLY ACROSS CULTURES This is because the meaning of ‘mental health’ and mental illness / disorder’ is culture-specific so one cannot be sure abut identifying the same ‘thing’ BUT There is overlap due to similarities in / sharing of culture Globalisation and imperialism has resulted in imposition of psychiatric system to varying extent OBSERVER BIAS COMMUNICATION PROBLEMS VARYING HELP-SEEKING PRACTICES AND ILLNESS BEHAVIOUR VARIATIONS IN SERVICE PROVISION AND WHAT IS ACCESSED

7. Lack of evidence We need much more information on: Efficacy of systems and treatments as seen by service users Local practices (religious, indigenous medicine etc.) appertaining to local understandings of ‘mental health’ Idioms of distress and ways of identifying social stress e.g. ‘collective trauma’ (e.g. Somasunderam, 2007) How individuals and communities cope with social problems, distress, disability etc. Hard data on indigenous systems in LMICs (under- developed countries / Third World) suppressed during colonial times

8. SOME POINTERS ON HOW WE SHOULD APPROACH DEVELOPMENT Some indications Outcomes of people diagnosed as ‘schizophrenic’ better in India and Nigeria compared to USA and UK (WHO’s IPSS study—see Hopper and Wanderling, 2000) in the 1960s - 1970s Healing at Hindu temple may be as good as bio-medical treatment (Raguram et al. 2002) Easy access to plurality of systems plus user-choice may give best overall outcome (Halliburton, 2004)

9. TRAUMA & GLOBAL HEALTH PROGRAM(April 2007 -2012) located in GUATEMALA, NEPAL, PERU & SRI LANKA“Teasdale Corti Program” Four year Program for Information Gathering (IG) (research) Capacity Building (CB) (training) Knowledge Transfer (KT) (dissemination) Funded by: Global Health Research Initiative (Canada) Supported by Dr Duncan Pedersen & Professor Laurence Kirmayer and team at McGill University, Montreal.

10. Our study explored…. • community perceptions of wellbeing and social stratification (defined by their own criteria) • perceived changes in wellbeing after experience of conflict / tsunami • how the state of wellbeing correlated with social stratification • factors influencing increased or reduced wellbeing • coping strategies and mechanisms adopted by communities in times of crisis • community perceptions towards services and helping agencies available Ref: Weerackody, C. and Fernando, S. (2011) Reflections on Mental Health and Wellbeing. Learning from communities affected by conflict, dislocation and natural disaster in Sri Lanka. Colombo: PRDA, 2011

11. Some conclusions for policy Culturally appropriate training of psychiatrists and psychologists Structural changes & human rights approach at man mental hospital that should be run down with development of more community-based centres De-centralise mental health care Stakeholder-led development of plurality of systems running in parallel rather than ‘integrated’ Socially focused training of social workers and community workers who should form the main system backed by psychiatrists and psychologists at arms length Close liaison with indigenous healers and religious organisations / healing centres Regulation of pharmaceutical industry Co-ordination and supervision of NGOs

12. Stakeholders for developing mental health services in the community 1. Mental heath practitioners of various disciplines – psychiatry, psychology, social work, counselling and community work. 2. Religious organisations – churches, mosques and temples 3. Community organisations and / or representatives of communities 4. People with psycho-social disabilities and those who have been patients – usually called ‘consumers’ 5. Carers of people with psycho-social disabilities 6. Indigenous healers working in the community 7. Non-governmental agencies that are working in psychosocial care or welfare 8. International organizations such as WHO Reference Weerackody, C and Fernando, S. (2011) Introduction to Mental Health for Social Workers in Sri Lanka Colombo: Peoples Rural Development Association (PRDA)

13. Ethical & Sustainable Development Ethical … for the benefit of people ‘as self-defining subjects’ rather than ‘objects of concern … entitled to choose their way of life themselves’ (Gasper, 2004) Sustainable .. for the present and future fitting into mainstream of the social and political (O’Riordian, 1998; Warburton, 1998) References Gasper, Des (2004) The Ethics of Development From Economism to Human Development. Edinburgh: Edinburgh University Press. O’Riordan (1998) ‘Civic Science and the Sustainability Transition’, in D. Warburton (ed) Community and Sustainable Development Participation in the Future. London: Earthscan Publications pp. 96-116. Warburton (1998) ‘A Passionate Dialogue: community and sustainable development’, in D. Warburton (ed) Community and Sustainable Development Participation in the Future. London: Earthscan Publications pp.1-39.

14. PROCESS OF DEVELOPMENT Bottom-up development Community based, rights based, and ethical In consultation with local communities, service users and variety of stakeholders Outcomes that are sustainable – not dependent on external (western) training and input Top-down development Address social determinants of health Regulate and run-down where necessary current systems Protect vulnerable communities from exploitation by big business (e.g. Big Pharma)