Mental Health Worldwide

Culture, Globalization and Development

S. Fernando

• Publisher: Palgrave Macmillan
• Year: 2014
• Print ISBN: 9781137329592
• eBook ISBN: 9781137329608
• Topic: Social Sciences
• Subtopic: Psychiatry & Mental Health
• Index: Social Sciences

Offers a perceptive critique of the universalized model of psychiatry and its apparent exportation from the West to the developing world. Rooted in detailed analysis of the problems this causes, the book proposes new suggestions for advancing the field of mental health and wellbeing in a way that is ethical, sustainable and culturally sensitive.

Part I

Cultural History of Madness, Psychiatry and Mental Health

After a discussion of culture and globalization, this first part of the book traces the rise of psychiatry and the discourse on ‘mental health’ in the western world, associated with its post-Enlightenment approach to madness and the ‘mind’. While the illness approach to many human problems came to dominate thinking in the Global North leading to the search for medical remedies directed at curing illness, misperceptions of the ‘other’ resulted in the West being pitted against the Rest.

1

Culture and Globalization in Relation to Mental Health

People all over the world are implicated in individual problems of living, interacting with one another and the environment, trying to understand the purpose of our lives, working out in practice how we get along with one another and, finally, dealing with the end of life as individuals. We tend to address these issues not only in concert with others, as communities and societies, but also as individuals. However we think of ourselves at any particular moment, we are all biological, social and spiritual beings, essentially the same. In that sense, we are global people. But over the centuries of our existence as human beings, groups of people as communities, nations and families have developed ways of negotiating their journeys through life, relating to whatever environment they find themselves in and changing aspects of it to suit their needs, and dealing with problems (though not necessarily overcoming them). And these ways became set into traditional ways of behaviour, belief, worldviews and so on—they became ‘cultures’. And now we hear a lot about ‘globalization’ without any clear definition of the term or a consistent understanding of what it means (see below). The purpose of this chapter is to explore briefly the connection between culture—more specifically cultural diversity—across the world and the diverse meanings attached to globalization in relation to mental health and mental health services. The diverse meanings of mental health worldwide are not discussed in this chapter. Exploration of this topic runs through a good part of the rest of the book, especially in Chapters 2 and 4.

Nature of culture

Cultures were regarded at one time in the English-language literature as relatively fixed, dependent on learning and essentially territorial; localized often to one part of the world, forming the culture of a society or group of people. But ‘culture’ is now understood and written about somewhat differently. The notion of culture goes back to nineteenth-century romanticism and was elaborated in twentieth-century anthropology (Pieterse, 1995) which talked of ‘shared patterns of belief, feeling and adaptation which people carry in their minds’ (Leighton and Hughes, 1961, p. 447). But this idea of culture as ‘a unique way of life’ first took hold in anthropology during colonialism in order to separate the colonizing West from (what the West saw as) ‘uncivilized’ people that were being colonized (Eagleton, 2000, p. 26) and so it could not last. What has emerged after de-colonization, and more so in the postmodern terrain of the late twentieth century going into the twenty-first, is the notion of culture as something that is malleable and changeable; it depends not just on traditions that people inherit but also on historical and political influences in a context of power relations at various levels and at various times. Homi Bhabha’s (1994) Location of Culture emphasizes the hybridity of cultural forms and the ways in which racism, most evident during colonialism and slavery, is closely involved in the manifestation of cultural diversity, especially in many parts of the western world; and Edward Said’s (1994) Culture and Imperialism unravels the intimate connections between understandings of culture presented in Anglo-American literature and European domination of the rest of the world since about the late sixteenth century. Whether referring to that of an individual or a group, culture is now seen as something that is dynamic and far from static—a flexible system of values and worldviews that people live by, and through which they define identities and negotiate their lives (for fuller discussion, see Fernando, 2010).

While the term ‘culture’ is still applied to an individual person or group—and this is the main use of the term in the field of mental health—the term is now used for a broad range of situations associated with people and/or institutions, quite apart from its rather elitist use in some circles when some people are described as ‘cultured’ meaning more sophisticated than other uncultured or less-cultured people. In the mental health field, we talk now of family cultures, or cultures of whole communities in addition to the culture of an individual. When we say that a society is ‘multicultural’, we imply that there are broad cultural differences between groups of people within the society. We also refer to cultures of professional groups, for example, ‘medical culture’, ‘police culture’, or institutions or systems such as a particular hospital or the health service or the system of psychiatry or clinical psychology. In fact, seemingly involved in so many fields of discourse and literature, the term ‘culture’ is fast becoming an easy explanation for almost any activity associated with human beings and the ways in which institutions and systems consisting of several individuals function.

Although there is a perception that cultures of people (‘culture’ used in its limited sense) have in some way remained ‘pure’ until modern times, in actual fact, cultural interchanges and cultural mingling have always taken place—at times very extensively, resulting in mixtures seen as ‘new’ cultures or termed (sometimes pejoratively) ‘creole’ or hybrid cultures. Historian J. J. Clarke (1997) points out that ‘commercial and cultural intercourse between East and West was well established at the time when philosophical foundations of western thought were being laid down in Greece’ (p. 37), and that it continued along the silk routes between the Mediterranean and the East. The direct links between Europe and the East were curtailed by the imposition of the Islamic empire (see Chapter 2) but resumed after the thirteenth century as illustrated by European travellers to China, such as Marco Polo. This mixing of cultures has been greatly accelerated by better communication, easier travel and increased migration across the world during the past four or five decades.

The discourse on ‘culture’ that is applicable to mental health mainly concerns the culture of the individual because of the emphasis on the individual in the (western) interpretation of ‘mental health’ (see Chapter 2). But even here it is recognized that individual culture rests on a bed of traditional family culture, the culture of the community they are part of, the wider body of people they felt attached to, the region(s) they live in and even perhaps the ‘imagined communities’ (Anderson, 1991, title page) they are connected to. These ramifications of culture determine to a large extent people’s behaviour, and more generally, their social systems, religious systems and beliefs, worldviews and, most important of all (for the purposes of this book), their concept of the human condition, the meaning of life itself. In other words, ‘traditional culture’ forms an important background to a great deal of people’s lived experience, how they perceive and make sense of their lives, what they see as natural and so on. It should be pointed out here that (as discussed above) culture is not a fixed entity but subject to almost constant change and so difficult to pin down. And it could be quite complicated and problematic to work out, at any given time, what particular aspects of their traditional culture affect any one person or group (‘cultural group’). But differences are always there.

Globalization

Globalization, ‘the successor to the debates on modernity and postmodernity in the understanding of sociocultural change’ (Featherstone and Lash, 1995, p. 1), has recently become a prominent theme in many fields, even, since about 2010, in the field of mental health (see discussion of global health below). The term ‘globalization’ frequently implies an underlying message of westernization (of the non-western world) and is often tied up with modernity, a concept ‘unproblematically associated with “the West” ’ (King, 1995, p. 111), implying that the world is becoming more uniform and standardized through technological, commercial and cultural synchronization emanating from the West (Pieterse, 1995).

In the field of culture, where cultural exchanges and cultural diffusion across the world are inevitable and the fact that human beings are social beings, globalization may be seen as something inevitable when groups of people in communication with each other share ideas, technologies and so on. This could be seen as a natural process—passive globalization. A different take on globalization is put forward by Petras and Veltmeyer (2001): To them it represents a movement that imposes systemic change through a variety of institutions becoming ‘the new imperialism—the new system of “global governance” ’ (pp. 12–13). This could be called forced globalization where, in actual fact, the discourse of globalization obfuscates and hides what is really taking place. This neo-imperialism may take the form of western systems (of psychiatric diagnosis, for example) being imposed as a condition of economic aid for supposed modernization of health systems; or more subtly through pressures from evaluation of institutional systems or advice of experts from (western) centres of excellence. The thinking around globalization and culture that I have outlined is summarized in Table 1.1.

Clearly, forced and passive (or natural) globalization either may occur together reinforcing each other (in which case the outcomes are mixed) or may occur in conflict with each other; some aspects of what happens being natural and some forced, in which case there are winners and losers. In Chapter 10, I suggest that the current globalization discourse in the field of mental health tends to camouflage a process whereby western ideologies and ways of thinking are being imposed in the Third World in order to structure developing countries in such a way that perpetuates western power and profits multinational corporations.

Table 1.1 Globalization and culture

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Passive globalization

Natural process through diffusion of ideas and cultural forms in voluntary interchange

Forced globalization

Process imposed overtly—for example, as part of economic aid for ‘modernization’—or subtly, for example, via institutional pressures

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In considering mental health development as a social process, the loose use of the word ‘globalization’ means that it can mean different things to different people and in different circumstances. Jonathan Friedman (1995) suggests that we could see globalization as something that is limited to the formation of global institutional structures ‘that organize the already existing global field and global cultural forms’ (p. 75) that may, at most, have an indirect effect on the diverse cultural forms (such as medical and religious systems meant to help people with personal problems, including mental health problems) but, on the whole, allow different systems to flourish. This could be seen as an ‘organizational globalization’. Alternatively, we could see globalization as a global force that compresses ‘civilizational cultures, national societies, intra- and cross-national movements and organizations, subsocieties and ethnic groups, intra-societal quasi groups, individuals, and so on … [yielding] “third cultures”—such as transnational movements and international organizations’ (Robertson, 1992, p. 61). Initially discussed in political and economic terms (of trade treaties and political action) at an international level, globalization would then imply a ‘global culture’. In this case, globalization is intrusive and comes up against (that is, in conflict with) existing cultural forms and indeed the pluralism of cultural forms, including healing systems and medical systems that exist in the world. Such an intrusive globalization, inducing, or trying to induce, a global culture, opposes the right to be ‘different’ and, in doing so, impinges on the rights of national or ethnic communities. Given the geopolitical power structures in the world today, this sort of globalization is no different to imperialism and akin to what was described as forced globalization (above). The thinking around globalization and mental health development is shown in Table 1.2.

A point about the popular use of the terms ‘global health’ and the more recent appearance in the public arena of the term ‘global mental health’ should be noted here although discussed in more detail in Chapter 8. In short, what was thought of as ‘international health’ (IH), to refer to the health status of countries outside the West, became, in the mid-1990s, ‘global health’ mainly to emphasize how human health is interconnected across the globe (McInnes and Lee, 2012). It appears that the term ‘global mental health’ came into use after joint directors of a newly formed Centre for Global Mental Health announced it as a ‘new global health field [that] comes of age’ (Patel and Prince, 2010, p. 1976). The term itself has been described as an ‘oxymoron’ (Summerfield, 2012, p. 3) because mental health (unlike general health whose parameters can be measured) is understood very differently across the world, the meaning given to it being determined largely by cultural background and social context (see Chapter 2). Global perspectives on, or perceptions of, mental health that this book is concerned with are as much about difference as similarity; as much about diversity as concordance; as much about individuals, their societies and their cultures as about the unity of the human race as well as the need for people around the world to recognize their common humanity.

Table 1.2 Globalization and mental health development

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Organizational globalization

Formation of institutional structures to ease cooperation worldwide

Intrusive globalization

Pressures to compress local diversity into global uniformity

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Conclusions

Issues around culture and globalization are implicit throughout this book. The former has a long history in the field of mental health while the latter only recently emerged as a theme in the field of mental health. The use of the term ‘culture’ in mental health discourse is usually limited to matters to do with individuals (so referring to culture of individuals) and the connections they have to people and events around them as well as their heritage and background—in effect, the total reality within which people live their lives. Globalization of concepts around mental health may either mean that ideas and ways of thinking are being spread across the world more easily than they were in the past through passive globalization, which has always taken place but has been greatly accelerated recently because of ease of travel and communication across the world; or else means that particular ways of thinking are being imposed so that cultural changes are coming about as a result of economic and political forces—in other words, there is forced globalization. When it comes to developing mental health services, the discourse of ‘globalization’ confuses issues. In this instance, if globalization merely implies improving understanding, and hence cooperation, between local systems and systems in other places, all well and good. But if globalization means that global remedies and global ideas about mental health and illness are to be imposed, the current power structures would predicate pressures to abolish diversity and enforce western ways of thinking and western therapies worldwide—something that is contrary to the human rights of individuals and communities.

The interplay between culture and globalization in the mental health field is complicated by the fact that (a) culture (of an individual or group) is not something that is static but both changeable according to context and malleable i...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Tables
• Acknowledgements
• Introduction
• Part I: Cultural History of Madness, Psychiatry and Mental Health
• Part II: What Happened in the Majority World
• Part III: Psychiatry and Mental Health after the Second World War: Exporting Psychiatry to the Global South
• Part IV: Developing Mental Health Services
• Bibliography
• Author Index
• Subject Index