When health care is inadequate to nonexistent in a country, mental health care is generally much worse. In places like sub-Saharan Africa, where treating AIDS and malaria burden an already overrun health care system, mental illness is largely ignored. Families in the poorest countries around the world sometimes resort to tying mentally ill family members to posts or keeping them in cages lest they wander off and find themselves in even worse circumstances. Drug and alcohol abuse is also a worldwide problem, and attests to the need for people to ‘treat’ their own emotional suffering. Even in the Unites States, one of the richest countries in the world, a recent National Institute of Mental Health (NIMH) survey revealed only 18 percent of those who sought care for mental problems received “minimally” adequate services.
The NIMH claims that mental illness ranks among the top ten illnesses causing disability worldwide, affecting about 400 million people. An editorial in the August 2006 issue of the American Journal of Psychiatry framed the problem in ethical terms, stating “moral arguments are just as important as evidence to make the case for mental health intervention.”
It’s not difficult to agree that unaddressed mental illness has a moral component when the majority of people aren’t receiving adequate treatment and families must resort to treating mentally ill relatives like livestock just to keep them ‘safe’. Further, we can clearly identify when the inhumane treatment and neglect of mental illness has occurred. But does this mean we know what counts as humane treatment?
Take for example the treatment of post-traumatic stress disorder (PTSD). While depression is considered the leading cause of disability around the world, PTSD may be the most commonly diagnosed disorder. In refugee camps and post-war/conflict areas, PTSD is the de rigueur diagnosis of the victimized. PTSD symptoms such as nightmares, flashbacks, and intrusive memories are viewed as universal response to trauma, and perhaps they are. Yet the symptoms of a mental disorder do not necessarily dictate what is the right treatment. When well-meaning Western mental health workers descend on a foreign social group, they can risk replacing local customs for addressing trauma by the introduction of the Western model for healing PTSD.
Trauma and its aftereffects have been with humans throughout our history. Yet Western notions of PTSD, like all biomedical conceptions of mental disorders, were developed in response to particular social needs and conditions. In the case of PTSD, the diagnosis was developed in response to the experiences of war veterans who were extricated from the location of their trauma—war on foreign soil—and then returned to their own social groups in America. For many soldiers, the people they returned to were unable to comprehend (and sometimes unwilling to hear) their personal tragedies. In this context, and for other social contexts where trauma is silenced, individual counseling has made great strides in regaining mental well-being.
But consider a country like Cambodia where mind is indivisible from both spirit and body, and the person is inseparable from the group—a social context wholly different from American society with its emphasis on autonomous individualism and the centuries-old habit of distinguishing mind and body. In Cambodia, it takes the entire village to heal one person’s trauma. How valuable, then, is individual counseling for Cambodians who suffered through Pol Pot? In the aftermath of Pol Pot, Cambodia has been inundated with Western mental health workers who often point out that the memories of the horrendous killings have not been worked through, which according to the Western model of PTSD is integral to healing. Rather than seeking Western methods of treatment, Cambodians have preferred our help for solving problems associated with daily living that impede the reemergence of the social collective.
How different is the globalization of Western notions of mental illness from other colonizing practices in which Western customs replace local traditions? At risk is the loss of age-old traditions for dealing with personal suffering. As anthropologist Allan Young of McGill University observed, PTSD “may turn out to be the greatest story of globalization.”
Even in America, many argue the current concept of PTSD has limited applicability. For example, trauma specialists devoted to the treatment of the effects of childhood abuse recommend adding “complex PTSD” to the ever-expanding Diagnostic and Statistical Manual of Mental Disorders, thereby witnessing the specific effects of this form of trauma. America also needs to adapt to increasing numbers of minorities whose needs in the aftermath of trauma may be different from current treatment methods developed for a predominantly white, middle-class population. By 2020 it has been estimated that the majority of the American population will be made up of minority groups. The patients in current evidence-based practice studies that will serve as the basis for future treatment paradigms often do not show the cultural diversity that is emerging in America.
When so few people receive adequate mental health care, it is a moral issue. However, it is also immoral to exert pressure on people to adopt belief systems not inherently their own. It is necessary to respond to the present mental health crisis, but cultural sensitivity needs to frame the urge to help others.
© 2009 Laura K Kerr, PhD. All rights reserved (applies to writing and photography).