Some Reflections on the Article of Vikram Patel ‘Rethinking Mental Health Care: Bridging the Credibility Gap’ in the Intervention Extra Issue: New Frontiers

Silove

Letter to the editor Some reflections on the article of Vikram Patel ‘Rethinking mental health care: bridging the credibility gap’ in the Intervention Extra Issue: New Frontiers

Derrick Silove

In his article, Patel (2014) goes a long way to expatriate experts risk perpetuating bridging the gap between the global and entrenched, post colonial power imbalances. transcultural mental health movements, a As we well know, knowledge is power. divide that has in£amed much passion in The ideal solution is to work towards recon- recent times. As a watershed moment in ciling and integrating the emic and etic the ¢eld, Patel’s article deserves to be widely perspective into a coherent framework that disseminated and carefully studied. Here, makes sense within each cultural setting. I o¡er feedback in the spirit of encouraging Nevertheless, although e¡orts have been constructive debate that may move our made to graft culture onto international ¢eld closer to a synthesis of ideas and prac- classi¢cation systems, existing models are tices. still far from satisfactory.In fact, as yet, there Like many others, Patel is critical of applying is no comprehensive nor clearly speci¢ed contemporary international diagnostic sys- set of procedures to guide researchers or clin- tems across cultures. He rightly identi¢es a icians in the process of integrating these credibility gap between the dominant world two world views.This is a critical area, where view of mental health (represented by pro- the global and transcultural mental health fessionals from high income countries) and movements should come together, to work the lived experience of the majority, i.e. towards achieving a consensus on the way people residing within diverse cultural set- forward. tings in low and middle income countries. Patel focuses particularly on the drawbacks The solution, he argues, istobase our clinical of a categorical approach to diagnosis, draw- formulations on local understandings of ing on the results of contemporary psychi- mental phenomena, what has traditionally atric epidemiological studies to support his been referred to as the emic approach, in critique. The only credible explanation for which cultural idioms of distress are the very high rates of ‘common mental disorders’ embedded in local explanatory models that yielded by these studies, is that most of the confer meaning to experiences of su¡ering people identi¢ed are experiencing situa- and healing. Few would argue with this tional forms of distress, and therefore, not position. Often, mental health concepts diseases or disorders in the sense that these imported from high income countries (the terms are used in physical medicine. There west) seem to be alien and decontextualised is much truth in Patel’s claims, but the pro- when applied across cultures. In addition, blem is that we do not yet have the tools, by claiming access to privileged knowledge, either clinical nor scienti¢c, to distinguish

clearly between disorder and distress in men- indicator of a psychopathological process tal health. There is ample evidence that that canbe con¢rmed under the microscope. shows that even experienced clinicians dis- Perhaps at the root of many of our concep- agree when trying to ¢nd the dividing line tual problems is the arti¢cial distinction between a case and a non case, and current we make between mental and social worlds statistical techniques have so far failed to (the Mental^Social Gap). Patel makes the help overcome this problem. point that there is a qualitative di¡erence It is for this reason that the alternative between mental disorders and physical dis- dimensional approach has been so often pro- eases. One of the key reasons is that physical moted in recent times; instead it provides a organs such as the kidney (or liver, or heart) model in which symptoms are recognised have no direct window onto the outside as falling on a continuum, ranging from world. In contrast, thebrain is a social organ mild to severe. However, the dimensional ^ although locked physically within the approach has problems of its own. It is di⁄- skull, its frame of reference is the entire uni- cult to train newcomers in the ¢eld using verse (re£ected in its capacity for perception, complex multi-dimensional or multi-axial interpretation, thought, re£ection and initi- models. There are other formidable chal- ating action).Yet for some reason, we stub- lenges in using a dimensional approach in bornly cling to the notion of a division research, particularly when the aim is to between the mental and social worlds. identify the number of people within a com- Admittedly, biological substrates mediate munity requiring treatment. Further, within sensory inputs, but the social world is of clinical settings, the dimensional approach primary importance in assigning meaning makes it di⁄cult to specify guidelines for to experience and shaping our responses in treatment that would allow workers to use a way that, in mental health, leads either a rule of thumb to decide who should get down the path to adaptation (which we call what. From a public health perspective, try- health) or, alternatively, to dysfunction and ing to argue for funding, based on a dimen- su¡ering. sional perspective is likely to reduce the Perhaps our core problem is that we allow credibility of mental health even further, a our disciplinary backgrounds and ideo- risk we take in a world where the status of logical/epistemological allegiances to strait- our discipline cannot a¡ord to fall even jacket us and pigeon hole others, dividing lower. us into those who adhere to the medical/ In summary, there are good reasons why biological or social models. mental health professionals cling to the Many of the controversies, questions and categorical/diagnostic approach. However philosophical di¡erences that are evident imperfect, the common language o¡ered in the ¢eld can be traced back to this false by universal diagnostic terms helps to facili- dichotomy: debates about whether trauma tate transnational communication, sharing (as a medical/psychological form of ‘injury’) and comparing of knowledge, estimation of or adverse social conditions in a post con£ict community needs, and standardisation and environment, are ‘‘more important’’ in deter- benchmarking of practices. The error we mining the mental health of refugees; commonly make, however, is to treat diag- whether we should build resilience, or treat nostic categories as if they are concrete or real people for their intrinsic vulnerabilities entities (the fallacy of rei¢cation), rather and psychopathology; whether we should than representing the best approximations focus on the individual or the collective; we can make of common patterns of mental whether the PTSD reaction is a bio- distress at any point in time. In that sense, medically de¢ned mental disorder, ¢xed in diagnosis is a useful abstraction, not an the circuitry of the brain, or represents a

barometer of the overall level of eco-social Highlighting that reality brings us to the threats experienced by the community; ¢nal gap, the one that divides the ideal from and, whether we should focus on o¡ering the pragmatic.Weall know that the majority clinical services or psychosocial pro- of the world’s population has no, or very grammes. The list goes one. limited, access to mental health services. If considered from this vantage point, the The standard practice model, at present, is real value of epidemiological data accrued a long line of patients waiting outside health in our ¢eld is the close nexus that this body posts in the hope of receiving some relief of work has demonstrated between the social from their su¡ering. The mental health and the mental worlds. Populations exposed worker (if there is one), faces the daily chal- to human rights abuses, mass disruptions and lenge of attending to an overwhelming list gross deprivations, regularly and predict- of patients, within a context of isolation, ably manifest high levels of mental distress. limited resources, little or no access to super- Mental distress, in turn, impacts adversely vision and/or training, and few opportu- on individual and collective functioning. nities for career advancement. Even if the This is a re£exive process which, if not pace of change is slow, incremental improve- addressed, can lead to vicious cycles of ments to this dire situation are better than su¡ering, disability and even recurrent none. At times, therefore, our debates may violence. Restoration of the psychosocial seem somewhat rare¢ed given the extent of structures that promote functioning, there- unmet needs.Yet, at the same time, we need fore, is key to mental health recovery at a to be clear about our premises and the population level, a lesson that has implica- models we draw on when o¡ering assistance, tions that go beyond the limits of our ¢eld. so as to avoid the worst transgression of all, Nevertheless, it is also vital to recognise that, which is to do more harm than good. in any society, there is a core group of people with disabling mental states (whether diag- Reference nosed according to western or indigenous Patel, V. (2014). Rethinking mental health care: categories) who are in urgent need of special- bridging the credibility gap. Intervention, Extra ist assistance. The treatments we can o¡er Issue, 12(4), 15-20. are moderately e¡ective, and in most cases, the bene¢ts outweigh the risks (the risk/ Derrick Silove is a Professor and Director of the bene¢t ratio becoming more favourable Psychiatry Research and Teaching Unit at the where skills, knowledge and resources are School of Psychiatry and Ingham Institute,Uni- higher).Failure to provide treatment to those versity of New South Wales, Sydney, Australia. in need is a violation of the rights of the email: [email protected] mentally ill.