This was first published in the Spring 2015 edition (Issue 41) of the Federation of Ethnic Councils of Australia (FECCA) national magazine, Australian Mosaic. Cite as: DeSouza, R. (2015). Medical pluralism: Supporting co-existing diverse therapeutic traditions in mental health. Australian Mosaic (FECCA). 41, 34-36.
Decades afterward, I still recall the frequent waking, getting out of bed and moving around our Nairobi house in the dark. Sometimes I moved pots and pans, re-arranged furniture, but mostly I caused a disturbance. My parents decided to address my distressing behaviour by taking me to an older woman from our Goan community who chanted
prayers and anointed me with chilli and garlic. Her incantations arrested the nocturnal disturbances, which never perturbed me again. The evil eye was diagnosed, the somnambulism caused by envy, inflicted on me with a look. I later learned that the
evil eye is seen as the cause of many problems and illnesses globally with a multitude of rituals and remedies to either prevent or cure it.
My own experience of being a multiple migrant and then a clinician, led me to consider many possible antecedents to mental illness. The dominance of biomedicine to manage health and illness, assumes cross-cultural universals. Yet, mental health is a contested specialty with problematic treatments. Culturally derived norms and values from a specific location impose labels on behaviour from another context, which drive treatments, or management that flattens those contexts. Psychiatry and counseling are often viewed skeptically by people from refugee and migrant backgrounds who instead turn first to informal sources outside the health system including self-help, family, community, social networks, various forms of spirituality, religion and church. Increasingly, clinicians are appreciating the part these sources of support play.
Once mental health services are accessed, if staff focus on mental illness without understanding the cultural context or without realising that clients and their families might integrate both biomedical and more “traditional” beliefs, quality psychiatric assessment can be impaired and the potential for inaccurate diagnosis and inappropriate treatment and care can occur. Incorrectly identifying culturally appropriate behaviour or experiences as psychopathology is problematic, just as assuming that something is cultural rather than psychopathology or symptoms. However, every culture has frameworks for understanding health and illness and how these are demarcated.
In Aotearoa New Zealand, where I have spent most of my life, Maori psychiatrist Mason Durie has conceptualised Maori health as encompassing mental (hinengaro), physical (tinana), family/social (whänau), and spiritual (wairua) dimensions. In Australia, the National Aboriginal Health Strategy (1989) views wellbeing through a communal lens, broadening the concept of well-being beyond the to the social, emotional and cultural well-being of the whole community. Situating Aboriginal and Torres Strait Islander mental health within a framework of social and emotional wellbeing emphasise wellness, harmony and balance rather than illness and symptom reduction (AIHW 2012). Connection to land, culture, spirituality, ancestry, family and community, interdependence between families, communities, land, sea and spirit are also seen as necessary for health. The Ways Forward National Aboriginal and Islander Mental Health Policy Report 3 (pp19-20) adapted from Swan and Raphael also prioritises holism, self-determination, the need for cultural understanding, the impact of history in trauma and loss, human rights, acknowledges the impact of racism and stigma, kinship, cultural diversity and Aboriginal strengths.
Contemporary neoliberal health discourses have co-opted patient rights movements and positioned patients as consumers -active partners in health who are responsible for their own health. Consumer engagement and health literacy form a suite of strategies for inducing medical citizenship, so that individuals can participate and become knowledgeable consumers. Some would argue these are assimilatory processes. However, in order for medical citizenship to be a two way process, one’s own beliefs about the causes of illness and the corresponding treatments must also be considered. Health literate organisations must also be open to a multiplicity of illness explanations and to those locations from which such beliefs are derived. As Beijers and de Freitas (p.245), note:
Health care is transforming social suffering into illnesses and diagnoses, while often denying the social and moral origins and implications of the suffering
David Ingleby suggests that two perspectives are available for thinking about culture and mental illness. A technical perspective assumes mainstream frameworks and treatments can be universalised to all patients/clients and that more sensitivity and overcoming linguistic and cultural barriers will assist therapeutic efforts. With a technical approach to mental health, the goal of care is to deliver it efficiently and increase utilization (efficacy). Strategies can include access to language matched information and professional interpreting services, or improving mental health literacy and awareness, supporting community resilience and coping strategies. However, technical approaches do not ask questions about power imbalances between groups.
On the other hand when care is given through a critical lens (equity), the questions become what is going on when interventions developed for one population are applied to another? What are the underlying power relations? Whose interests are being served? Is there a covert attempt to impose the values and perspectives of the dominant group? Ingelby suggests that becoming a user of Western health care involves accepting its underlying philosophy and values and “acquiring health literacy”.
It is important that collaborations between traditional healing mechanisms and western practice are made possible, however within professional discourses traditional healing is frequently viewed as primitive and unprofessional, yet people often utilize different health beliefs simultaneously in their search for optimal treatment. Furthermore, assimilation and acculturation into the dominant culture are thought to negatively impact on migrant health status and to contribute to migrant ill health and disparities as the healthy migrant advantage that people arrive with reduces after a year. Developing collaborative models that combine traditional and Western health knowledges and combining health literacy and consumer participation with better access and quality of staff can indeed facilitate better health outcomes.
As an educator, I am interested in how I can do my part to increase the awareness and openness to pluralism, so that the next generation of nurses can be effective and therapeutic. There is guidance available from The Cultural Diversity Plan for Victoria’s Specialist Mental Health Services. There is an emphasis on being respectful and having non-judgmental curiosity about other cultures. Mental health workers are encouraged to seek cultural knowledge in an appropriate way, tolerate ambiguity and develop the ability to handle the stress of ambiguous situations. In addition, developing a family-sensitive practice, where family and community resources are viewed as partners in recovery as appropriate allow syncretism and innovation to take place. There are significant institutional barriers remaining to this in mental particularly the emphases on privacy, independence and the one-to-one relationship between consumer and professional.