Developing, delivering and Sustaining Culturally Appropriate Mental Health Care Globally

By Lic. Analia Henriquez Cross, MSc Global Mental Health

The best way of developing, delivering and sustaining effective care in global mental health is developing and delivering from within the culture, and sustaining along with it. The path must be to identify cultural determinants, explanatory models and Idioms of Distress (IDs), as a result of producing local ethnographic research for the developing phase. To work with the tools that the culture gives us and not impose counteracting western instruments on it, as well as training culturally competent mental health practitioners in the delivering phase. To promote research among national professionals, focusing on local evidence-based practice in national settings, including training traditional healers and blending tested clinical interventions with local methods in the sustaining phase. All of this, considering, organizing and using the multiple conceptualizations of well-being currently existing globally.

Transcultural Psychiatry is essential in a globalized world.

One country can have multiple nationalities and cultures co-existing, which urges mental health professionals to broaden their local tools. Acknowledging that the western clinical approach, especially the biopsychosocial model, is just one type of approach, and should not be predominant worldwide, is the first step. Babalola and co-authors (2017) understand this model as limited and lacking cultural and spiritual aspects. It may seem holistic, but it does not reflect the priorities of most societies and simplifies health understanding. Kirmayer (2001) recognizes that separating ‘western’ and ‘non-western’ can be colonialist and unsustainable. Explaining the world as 'western' and 'non-western' makes the ‘rest of the world’ invisible and allocates it in a single category, considering western countries as central and the rest as secondary.

Developing strategies from within the culture mean using local data produced from ethnographic research. Avoiding the argument that using culturally developed strategies can be dangerous because of its lack of scientific validity, culturally competent strategies are not meant to be used without guidance, and as Kirmayer (2012) states, these should have research backing them up to ensure validity. This author affirms that both Evidence-Based Practice (EBP) and cultural competency have limitations when used independently, and that one needs the other. Helms (2015) cites the American Psychological Association (APA) (2006, p. 284) on the definition of EBP: ‘the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences, this means that the best available research is the one done in context, and EBP based on the western model may not be, because it forgets the personal context. Interventions must be evidence-based, but locally evidence-based.

Following these ideas, local data can be produced using qualitative research, providing useful information, and avoiding using non-adapted quantitative instruments. Summerfield (2008) encourage researchers to focus on this methodology due to its capacity to provide a framework to work with, and Waldram (2006) expresses, is critical to understand IDs, culture and experiences Whitley (2007) cite Mueser (2005), recognizing that researchers are adopting qualitative research because it helps to develop EBP. Ethnography and psychiatry should be used together in Global Mental Health Practice in the developing phase. All of this should be done through collaborative research, integrating local professionals. Abas and colleagues (1994) coincide by asserting that the job is complete when suggestions are made, research is done, and priorities are established by those who work locally.

IDs diverge between cultures; consequently, we must learn to identify them to make the right diagnosis in every setting. On the other hand, Keys and colleagues (2012) found that in Haiti people communicated their suffering in a very specific way, so they suggest learning to identify these ways, and paying attention to the ineffectiveness of exporting foreign screening tools and interventions to diverse settings. They encourage practitioners to understand the differences in IDs among areas of the same country as well, and not to assume that one explanation may fit in the whole country. Following this, Jayawickreme, and colleagues (2012) trying to adapt mental health measures in Sri Lanka, found many limitations in these to the point of not being able to use one at all for screening. Considering these findings, more cultural research almost from scratch on IDs should be done in every possible setting to develop screening tools that ensure the best diagnosis, therefore, the right treatment.

Based on this new local data, the necessary screening tools will be developed. These should include IDs and explanatory models to be culturally relevant. As Kaiser and colleagues (2012) stated, one cannot make valid interpretations only by translating instruments, and, in fact, they have found, for example, that certain items of Beck's measures of depression and anxiety could not fit in Haitian participants experiences. Other researchers (Kohrt et al., 2011; Watson et al., 2019; Kaiser et al., 2019;) have stated the importance of adapting instruments to different cultures. In this tone, Global Mental Health Practitioners either translate and adapt instruments correctly, or develop new ones using local data, to help identify better how people represent their suffering through IDs.

Strategies should be created based on each culture's conceptualization of well-being. Nettleton and co-authors (2007) gathered information about indigenous people, and one participant in Guatemala associated well-being with family, nutrition, and peace of mind. While for a young participant in the UK in a study conducted by Vujčić (2019), well-being is associated with learning and helping others. The implications of cultural conceptualizations of well-being in Global Mental Health practice are critical because they should be present when developing interventions in each setting. In this sense, after finding 196 dimensions of well-being, Linton, Dieppe, and Medina-Lara (2016) suggest it should be viewed as an umbrella concept. These findings represent that well-being cannot be understood as the same thing worldwide. Also, Lomas (2016) found 216 terms, and the list goes on, of positive psychological states that people can not translate to the English language. This finding reflects values that the western cultures do not have and consequently, its clinical diagnostic and intervention framework neither, and is yet another spark that lights the path away from the western approach to centralization. Western clinical conceptualization of well-being may not find their correspondence in other parts of the world. This brings evidence to understand the western approach as just one in many, making it culturally limited outside its boundaries, and therefore, inefficacious.

Mental health delivery should be working with the tools the culture provides, rather than imposing what is done in another context, also, training clinical practitioners in cultural competence, and using local-based research for their practice. Solomon (2010) exposed a Rwandan man's thought on this, who expressed disappointment in the way western mental health workers delivered care. They prioritize integrating the community and spiritual aspect and getting sunshine and music for their improvement, and the traditional psychotherapy model did not fit. As previously stated, strategies should be developed considering each culture's values taking this information from local practitioners and ethnographic research. This information from Rwanda can provide the cultural tools needed for the treatment and recovery of patients. We should prioritize what the culture gives us, values, traditions, religion, collective ideas, ways of relating to each other, and explanatory models to drive the interventions. These can complement or displace the interventions used in the western world, as stated by Kirmayer (2001).

Pierre (2010) wrote about Haitian spiritual practices and their clash with the western model, redirecting the discourse from mutual exclusion, to connecting both as success. He also saw Vodou as a source of information for prevention and as a tool to be used in interventions. Kirmayer (2001) points to negotiating with the patient as key to delivering care in a way that matches their expectations and is justifiable for them in their social context. In this part, the Cultural Formulation Interview in the DSM can be used as support because it evaluates their priorities and coping strategies.

Finally, to sustain culturally sensitive mental health care, efforts should be made along with the culture. Local practitioners and researchers should be the principal empowered leading actors of the strategies, switching the focus from ‘helping’ from a foreign culture, to ‘collaborating’. In religious cultures, the spiritual healer should link mental health clinicians to patients in their practice as useful people in their process. In each part, mental health clinicians and traditional healers need to understand where their knowledge ends and the others begin. In India, people go to the temple for help, and Raguram and co-authors (2002) found 20% of improvement due to the treatment they received there. Also, in Zimbabwe, they involved these leaders in the planning phase, which undoubtedly improved and contextualized the strategy nationally (Abas, Broadhead, Mbape, & Khumalo-Sakatukwa, 1994). Moreover, Raguram (2002) noted that in India, few people visited their primary care centre, although this was near the temple. And in fact, local mental health professionals are not using western tools alone; they blend them with traditional ones (Taitimu & Read, 2018. Lastly, Global Mental Health commissions should include enough representation of every country and culture to ensure significant decisions are taken with greater perspectives to assure sustainability through official statements and protocols.

Approaches in which culturally adequate mental health care strategies can be developed, delivered and sustained are diverse, and their use is urgent in the global context. To better develop Mental Health Strategies, one should consider idioms of distress and well-being conceptualizations to screening tools, all based on local research. To improve mental health care delivery, practitioners must be culturally competent and integrate cultural tools, and finally, to sustain these, local practitioners should be authorities and partners through the whole clinical process, using an eclectic intervention, and should be representing their society at an international level in decision making to ensure global mental health operations start-up with cultural diversity in its roots.