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Finding a Fit: Psychiatric Pluralism in South India and its Implications for WHO Studies of Mental Disorder
Abstract
This article examines reports of improvement and decline in short-term follow-up interviews and long-term recollections among patients in three forms of therapy for mental illness in south India: ayurvedic (indigenous) psychiatry, allopathic (western) psychiatry, and religious healing. Interviews indicate that patients of all three therapeutic systems showed improvement after follow-up assessments and that several patients had radically divergent experiences with each of the three therapies; each therapy was found by some to be helpful and by others to be ineffective. These findings suggest that a greater availability of distinct forms of therapy makes it more likely that an individual will find a therapy to which he or she responds well, an insight that helps interpret World Health Organization-sponsored studies which examined mental disorders in developed and developing country sites and found a better outcome for these disorders in developing country centers. Although several studies have attempted to account for this difference in outcome, none have done so by considering that the 'developing' country sites in the World Health Organization studies are all places that have a greater availability of diverse forms of therapy when compared with the 'developed' sites.
... Studies in the Indian context have explored beliefs and explanatory models of patients, families and community regarding mental illness (e.g., Banerjee & Roy, 1998;Charles, Manoranjitham, & Jacob, 2007;Corin, Thara, & Padmavati, 2005;Raguram, Venkateswaran, Ramakrishna, & Weiss, 2002;Saravanan et al., 2008;Srinivasan & Thara, 2001;Weiss et al., 1992). Co-existence of multiple explanatory models is called healthcare pluralism, and previous studies have documented it in India in the mental illness context (Bhattacharyya, 1983;Chowdhuri, Chakraborty, & Weiss, 2001;Halliburton, 2004;Kapur, 1975Kapur, , 1979Quack, 2013). among families are homoeopathy, ayurveda and folk healing. ...
... Furthermore, Quack (2013) argued that the desire to be cured often guides the treatment choices. Halliburton's (2004) study in Kerala, (Southern India) showcased the benefits of the availability of multiple healing systems (allopathic psychiatry, ayurvedic psychiatry and religious healing) enabling the common people to find a therapy that 'fits the expectations, desires, concerns or personality of the patient' (p. 88). ...
... The advantage of the availability of multiple healing was discussed in Halliburton's (2003Halliburton's ( , 2004) study in Southern India. His findings indicate that people tend to choose those methods from the available healing methods based on their 'effectiveness'. ...
Active involvement of families in mental health care in India is well documented. This study aimed to understand the explanatory models of the family members of persons suffering from common as well as severe mental illness. Narratives were collected through interviews from family members accompanying the patients at a psychiatric clinic. Data were also obtained from professionals at the clinic as well as folk healers. The Constant Comparative Method was used for analysis. The notable findings were: healthcare pluralism at institutional, cognitive and structural levels; conflicting explanatory models about mental illness; and stigma regarding mental illness. The findings suggest that in addition to explanatory models, the accessibility and availability of healers also plays a major role in treatment choices by the families.
... Of particular importance in the healing process is the ritual of Guruthi Pooja at the temple which is attended in the evenings by those seeking recovery from mental health problems. This ritual invokes the goddess Mahakali, the form in which the deity is believed to manifest herself in the evening (Halliburton 2004). ...
... However, as we have shown, a complex array of beliefs, sources of support and practices exist with which lay people attempt to ameliorate distress or problematic behaviour. Indeed, from the point of view of lay people it way well appear that ritual healing, ayurvedic medicine and conventional allopathic psychiatry are comparable in efficacy (Halliburton 2004). Frequently, ritual, magical and Ayurvedic approaches are tried first, and a scientifically trained doctor will be consulted only if the former approaches are deemed to be showing insufficient progress. ...
The notion of ‘mental health literacy’ has been proposed as a way of improving mental health problem recognition, service utilisation and reducing stigma. Yet, the idea embodies a number of medical-model assumptions which are often at odds with diverse communities’ spiritual traditions and local belief systems. Twenty participants were recruited to this study consisting of mental health service users (N = 7), family carers (N = 8) and community members (N = 5) in a temple town in Kerala, South India participated in semi-structured interviews exploring the variety of beliefs and practices relating to mental health. Our findings indicate that the issue may be better understood in terms of multiple mental health literacies which people deploy in different circumstances. Even those sceptical of traditional and spiritual approaches are knowledgeable about them, and the traditional practices themselves often involve detailed regimes of activities aimed at effecting an improvement in the person’s mood or condition. Therefore, we argue it is appropriate to consider mental health literacy not as a unitary universal phenomenon but instead as a mosaic of different literacies which may be deployed in different settings and in line with different experiences and which may operate in synergy with each other to enable treatment but also facilitate a sense of meaning and purpose in life.
... However, these universal categories are not always a "one size fits all". In another study, Halliburton (2004) showed that the efficacies of different therapies (allopathic, Ayurveda, and religious therapy) depend upon a client's "class, religion, childhood experience, work, influence of family and community, and other personal, cultural, and historical influences that are involved in shaping a self" (p. 93). ...
... 93). These factors, unique to one's context, play critical roles in how a client may benefit from a healing system (Halliburton, 2004). ...
Where there are diverse professionals and curers dealing with possession, differences in representations exist. This study uses social representations theory as a frame to examine both the representational overlaps and differences in possession among various Filipino health professionals and the lay distinctly socialised in Western biomedical and psychological lenses and in local religious and traditional folk beliefs. Themes were extracted from 12 individual interviews. Results showed five representational themes, namely: possession as sinakluban, as a vulnerability, as a disease, as kulam, and as being chosen. Findings were discussed in relation to the interface among religion, indigenous beliefs, psychopathological frame, and the Western biomedical model.
... Efforts are ongoing to strengthen, integrate, and expand activities aimed at developing comprehensive and unified mental health services. India initiated early efforts to promote mental health through its National Mental Health Programme in the early 1980s [15] . However; mental health has historically received lower priority compared to other health and social issues, resulting in unsatisfactory progress [16] . ...
... One interesting finding of the study is how the religious healers saw the biomedical clinic's ability to manage aggressive and violent patients. This recognition is also reported in similar studies elsewhere (Halliburton, 2004;Salib & Youakim, 2001). A recent systematic review found "little evidence to suggest that [traditional healers] change the course of severe mental illnesses" (Nortje et al., 2016). ...
This exploratory qualitative study examines holy water priest healers’ explanatory models and general treatment approaches toward mental illness, and their views and reflections on a collaborative project between them and biomedical practitioners. The study took place at two holy water treatment sites in Addis Ababa, Ethiopia. Twelve semi-structured interviews with holy water priest healers found eight notable themes: they held multiple explanatory models of illness, dominated by religious and spiritual understanding; they emphasized spiritual healing and empathic understanding in treatment, and also embraced biomedicine as part of an eclectic healing model; they perceived biomedical practitioners’ humility and respect as key to their positive views on the collaboration; they valued recognition of their current role and contribution in providing mental healthcare; they recognized and appreciated the biomedical clinic's effectiveness in treating violent and aggressive patients; they endorsed the collaboration and helped to overcome patient and family reluctance to the use of biomedicine; they lamented the lack of spiritual healing in biomedical treatment; and they had a number of dissatisfactions and concerns, particularly the one-way referral from religious healers to the biomedical clinic. The study results show diversity in the religious healers’ etiological understanding, treatment approaches and generally positive attitude and views on the collaboration. We present insights and explorations of factors affecting this rare, but much needed collaboration between traditional healers and biomedical services, and potential ways to improve it are discussed.
... For some decades, the field focused more on disorders like depression and post-traumatic stress disorder, which seemed less obviously disease-like and where cultural influence could perhaps be more clearly understood (e.g., Kleinman, 1982;Young, 1995;Kitanaka, 2011). To be sure, even in those early years, there was important work on schizophrenia (for example, Estroff, 1981) and more work soon emerged (for example, Desjarlais, 1997;Good, 1997;Lovell, 1997;Hopper, 2003;Jenkins and Barrett, 2004;Wilce, 2004;Halliburton, 2004;Sousa, 2009;Myers, 2015;Pinto, 2014;Jenkins, 2015). Still, scholars mostly did not return to the old shamanism-and-schizophrenia concern. ...
This paper presents evidence that some—but not all—religious experts in a particular
faith may have a schizophrenia-like psychotic process which is managed or mitigated
by their religious practice, in that they are able to function effectively and are
not identified by their community as ill. We conducted careful phenomenological
interviews, in conjunction with a novel probe, with okomfo, priests of the traditional
religion in Ghana who speak with their gods. They shared common understandings
of how priests hear gods speak. Despite this, participants described quite varied personal
experiences of the god’s voice. Some reported voices which were auditory and
more negative; some seemed to describe trance-like states, sometimes associated
with trauma and violence; some seemed to be described sleep-related events; and
some seemed to be interpreting ordinary inner speech. These differences in description
were supported by the way participants responded to an auditory clip made to
simulate the voice-hearing experiences of psychosis and which had been translated
into the local language. We suggest that for some individuals, the apprenticeship
trained practice of talking with the gods, in conjunction with a non-stigmatizing
identity, may shape the content and emotional tone of voices associated with a psychotic process.
... For some decades, the field focused more on disorders like depression and post-traumatic stress disorder, which seemed less obviously disease-like and where cultural influence could perhaps be more clearly understood (e.g., Kleinman, 1982;Young, 1995;Kitanaka, 2011). To be sure, even in those early years, there was important work on schizophrenia (for example, Estroff, 1981) and more work soon emerged (for example, Desjarlais, 1997;Good, 1997;Lovell, 1997;Hopper, 2003;Jenkins and Barrett, 2004;Wilce, 2004;Halliburton, 2004;Sousa, 2009;Myers, 2015;Pinto, 2014;Jenkins, 2015). Still, scholars mostly did not return to the old shamanism-and-schizophrenia concern. ...
This paper presents evidence that some—but not all—religious experts in a particular faith may have a schizophrenia-like psychotic process which is managed or mitigated by their religious practice, in that they are able to function effectively and are not identified by their community as ill. We conducted careful phenomenological interviews, in conjunction with a novel probe, with okomfo, priests of the traditional religion in Ghana who speak with their gods. They shared common understandings of how priests hear gods speak. Despite this, participants described quite varied personal experiences of the god’s voice. Some reported voices which were auditory and more negative; some seemed to describe trance-like states, sometimes associated with trauma and violence; some seemed to be described sleep-related events; and some seemed to be interpreting ordinary inner speech. These differences in description were supported by the way participants responded to an auditory clip made to simulate the voice-hearing experiences of psychosis and which had been translated into the local language. We suggest that for some individuals, the apprenticeship trained practice of talking with the gods, in conjunction with a non-stigmatizing identity, may shape the content and emotional tone of voices associated with a psychotic process.
... Research by Halliburton suggests that traditional interpretations of mental illness that reference spirits with names and personalities in Kerala, India, have been replaced by psychological idioms such as "tension", "stress" and "depression"-concepts that, while perhaps more standardised, lack cultural specificity or veracity (55). Halliburton advocates salutogenic approaches that incorporate traditional and biomedical modalities (56,57,58). ...
Metaphorical language is used to convey one thing as representative or symbolic of something else. Metaphor is used in figurative language but is much more than a means of delivering “poetic imagination”. A metaphor is a conceptual tool for categorising, organizing, thinking about, and ultimately shaping reality. Thus, metaphor underpins the way humans think. Our viewpoint is that metaphorical thought and communication contribute to “painogenicity”, the tendency of socio-ecological environments (settings) to promote the persistence of pain. In this perspectives article, we explore the insidious nature of metaphor used in pain language and conceptual models of pain. We explain how metaphor shapes mental organisation to govern the way humans perceive, navigate and gain insight into the nature of the world, i.e., creating experience. We explain how people use metaphors to “project” their private sensations, feelings, and thoughts onto objects and events in the external world. This helps people to understand their pain and promotes sharing of pain experience with others, including health care professionals. We explore the insidious nature of “warmongering” and damage-based metaphors in daily parlance and demonstrate how this is detrimental to health and wellbeing. We explore how metaphors shape the development and communication of complex, abstract ideas, theories, and models and how scientific understanding of pain is metaphorical in nature. We argue that overly simplistic neuro-mechanistic metaphors of pain contribute to fallacies and misnomers and an unhealthy focus on biomedical research, in the hope of developing medical interventions that “prevent pain transmission [sic]”. We advocate reconfiguring pain language towards constructive metaphors that foster a salutogenic view of pain, focusing on health and well-being. We advocate reconfiguring metaphors to align with contemporary pain science, to encourage acceptance of non-medicalised strategies to aid health and well-being. We explore the role of enactive metaphors to facilitate reconfiguration. We conclude that being cognisant of the pervasive nature of metaphors will assist progress toward a more coherent conceptual understanding of pain and the use of healthier pain language. We hope our article catalyses debate and reflection.
... More importantly, this process undermines and marginalises indigenous forms of psychological healing, even though the empirical evidence supports the need for pluralism when it comes to mental health care (Halliburton 2004). Higginbotham and Marsella (1988) pointed to the long-term deleterious 'after shocks' of efforts to replace indigenous healing practices with psychiatry's way of reasoning and systems of classification. ...
Colonial thinking runs deep in psychiatry. Recent anti-racist statements from the APA and RCPsych are to be welcomed. However, we argue that if it is to really tackle deep-seated racism and decolonise its curriculum, the discipline will need to critically interrogate the origins of some of its fundamental assumptions, values and priorities. This will not be an easy task. By its very nature, the quest to decolonise is fraught with contradictions and difficulties. However, we make the case that this moment presents an opportunity for psychiatry to engage positively with other forms of critical reflection on structures of power/knowledge in the field of mental health. We propose a number of paths along which progress might be made.
... Cultural adaption has often been assumed to be from high income to low and middle income countries but it is important to note that there are increasingly a range of counter-flows from LMIC to HIC (White et al, 2014). Health pluralism where more than one model of healing are used is being increasingly considered and evaluated (Halliburton, 2004(Halliburton, , 2009Tribe, 2007;Incayamar et al, 2009). ...
Editorial; Tribute
Moving Beyond Christianity: Islam, Judaism, Hinduism and Mental Health
Culturally Adapted Interventions in Mental Health: Global Position Statement
Position Statement on Migration Mental Health
A Magna Carta for People Living with Mental Illness
Global Position statement Stigma, Mental Illness, Diversity
... Although this finding has been observed consistently, little is known about the reason behind the relatively better outcome in certain regions. Several hypotheses, collectively and euphemistically termed as the ''sociocultural black-box'', have been proposed to explain this-these include better family support [6], lower levels of expressed emotions [7,8], availability of informal work [6], need to work for survival in the absence of formal social security benefits [9] and psychiatric pluralism [10]. Besides such sociocultural explanations, authors have noted biological and clinical distinctiveness in the nature of psychotic disorders in certain regions-these include absence of sex difference in age of onset of schizophrenia [11], possible natural selection of good-prognosis schizophrenia [12] and relatively lower prevalence of comorbid substance use [13]. ...
... LMICs have and still benefit from frameworks already laid down for CAMH research. However, investigation of any kind in the field of mental health must be cognizant of cultural nuances [56,57], more so when it comes to understanding and managing these disorders. One of the challenges experienced in the LMIC contexts, like Kenya, is the use of western designed diagnostic tools and interventions which are subject to influences from local settings and cultural differences, which may affect effectiveness in unpredictable ways. ...
Background:
Child and adolescent mental health problems account for a significant proportion of the local and global burden of disease and is recognized as a growing public health concern in need of adequate services. Studies carried out in Kenya suggest a need for a robust service for the treatment, prevention, and promotion of child and adolescent mental health. Despite a few existing services to provide treatment and management of mental health disorders, we need more knowledge about their effectiveness in the management of these disorders. This paper describes a study protocol that aims to evaluate the process and outcomes of psychotherapies offered to children and adolescents seeking mental health services at the Kenyatta National Hospital in Kenya.
Methods:
This study will use a prospective cohort approach that will follow adolescent patients (12-17 years of age) receiving mental health services in the youth clinics at the Kenyatta National Hospital for a period of 12 months. During this time a mixed methods research will be carried out, focusing on treatment outcomes, therapeutic relationship, understanding of psychotherapy, and other mental health interventions offered to the young patients. In this proposed study, we define outcome as the alleviation of symptoms, which will be assessed quantitatively using longitudinal patient data collected session-wise. Process refers to the mechanisms identified to promote change in the adolescent. For example, individual participant or clinician characteristics, therapeutic alliance will be assessed both quantitatively and qualitatively. In each session, assessments will be used to reduce problems due to attrition and to enable calculation of longitudinal change trajectories using growth curve modeling. For this study, these will be referred to as session-wise assessments. Qualitative work will include interviews with adolescent patients, their caregivers as well as feedback from the mental health care providers on existing services and their barriers to providing care.
Conclusion:
This study aims to understand the mechanisms through which change takes place beyond the context of psychotherapy. What are the moderators and through which mechanisms do they operate to improve mental health outcomes in young people?
... For instance, a study in India highlights how psychiatric professionals tend not to use diagnostic labels when discussing difficulties with patients, finding that the different meanings attached to unusual sensory experiences can enable a less pathological interpretation of their symptoms. 93 Religiosity is an important source of finding meaning in the Rohingya experiences of trauma, both from research 94 and from field experiences. Religion as a protective factor and source of resilience has been identified in other refugee populations in adolescents, 95 and in adults in conflict situations. ...
Children in armed conflict are frequently deprived of basic needs, psychologically supportive environments, educational and vocational opportunities, and other resources that promote positive psychosocial development and mental health. This article describes the mental health challenges faced by conflict-affected children and youth, the interventions designed to prevent or ameliorate the psychosocial impact of conflict-related experiences, and a case example of the challenges and opportunities related to addressing the mental health needs of Rohingya children and youth.
... Persons with psychotic disorders were found to improve in the "supportive, nonthreatening" environment provided at a temple. [1] While the earlier finding of a better outcome of psychosis in "developing countries" has been attributed to psychiatric pluralism; [2] the high rates of psychiatric morbidity and suicide in India, highlights the presence of significant barriers to access of medical care, lack of acceptance of a biological model of psychosis, and a strong belief in faith and religion as a means to overcome psychological distress. [3] It is hence conceivable that models of care that combine medical treatment with traditional practices (such as the Dava-Dua project in Mehsana, Gujarat, and the combined medical care and temple-healing at Gunasheelam, Tamil Nadu [4] ) may be better positioned to deliver culturally-sensitive, and less-stigmatized care. ...
... Besides allopathic (biomedical) healthcare, a variety of traditional and religious healing systems are also available, including indigenous approaches such Ayurveda, yoga, naturopathy, Unani, Siddha, homoeopathy, and local systems of medicine, as well as spiritual remedies [29]. The parallel use of multiple systems has been frequently documented [30,31]. ...
Background
There is a large “treatment gap” for depression worldwide. This study aimed to better understand the treatment gap in rural India by describing health care use and treatment-seeking for depression.
Methods
Data were analysed from a two round cross-sectional community survey conducted in rural Madhya Pradesh between May 2013 and December 2016. We examined the proportion of individuals who screened positive for depression (≥10) on the Patient Health Questionnaire (PHQ-9) who sought treatment in different sectors, for depression symptoms and for any reason, and compared the latter with health service use by screen-negative individuals. We analysed the frequency with which barriers to healthcare utilisation were reported by screen-positive adults. We also analysed the association between seeking treatment for depression and various predisposing, enabling and need factors using univariable regression.
Results
86% of screen-positive adults reported seeking no depression treatment. However, 66% had used health services for any reason in the past 3 months, compared to 46% of screen-negative individuals ( p < 0.0001). Private providers were most frequently consulted by screen-positive adults (32%), while only 19% consulted traditional providers. Structural barriers to healthcare use such as cost and distance to services were frequently reported (54 and 52%, respectively) but were not associated with treatment-seeking for depression. The following factors were found to be positively associated with treatment-seeking for depression: higher symptom severity; lack of energy, lack of interest/pleasure, low self-esteem, or slow movements/restlessness on more than 7 days in the past 2 weeks; being married; having discussed depression symptoms; and reporting problems with medication availability and supply as a barrier to healthcare. No evidence was found for an association between treatment-seeking for depression and most socio-economic, demographic or attitudinal factors.
Conclusions
These findings suggest that the majority of adults who screen positive for depression seek healthcare, although not primarily for depression symptoms, indicating the need to improve detection of depression during consultations about other complaints. Private providers may need to be considered in programmes to improve depression treatment in this setting. Further research should test the hypotheses generated in this descriptive study, such as the potential role of marriage in facilitating treatment-seeking.
... Besides allopathic (biomedical) healthcare, a variety of traditional and religious healing systems are also available, including indigenous approaches such Ayurveda, yoga, naturopathy, Unani, Siddha, homoeopathy, and local systems of medicine, as well as spiritual remedies (29). The parallel use of multiple systems has been frequently documented (30,31). ...
Background There is a large “treatment gap” for depression worldwide. This study aimed to better understand the treatment gap in rural India by describing health care use and treatment-seeking for depression. Methods Data were analysed from a two round cross-sectional community survey conducted in rural Madhya Pradesh between May 2013 and December 2016. We examined the proportion of individuals who screened positive for depression (≥10) on the Patient Health Questionnaire (PHQ-9) who sought treatment in different sectors, for depression symptoms and for any reason, and compared the latter with health service use by screen-negative individuals. We analysed the frequency with which barriers to healthcare utilisation were reported by screen-positive adults. We also analysed the association between seeking treatment for depression and various predisposing, enabling and need factors using univariable regression. Results 86% of screen-positive adults reported seeking no depression treatment. However, 66% had used health services for any reason in the past 3 months, compared to 46% of screen-negative individuals (p
... Besides allopathic (biomedical) healthcare, a variety of traditional and religious healing systems are also available, including indigenous approaches such Ayurveda, yoga, naturopathy, Unani, Siddha, homoeopathy, and local systems of medicine, as well as spiritual remedies (29). The parallel use of multiple systems has been frequently documented (30,31). ...
Background There is a large “treatment gap” for depression worldwide. This study aimed to better understand the treatment gap in rural India by describing health care use and treatment-seeking for depression.
Methods Data were analysed from a two round cross-sectional community survey carried out in rural Madhya Pradesh between May 2013 and December 2016. We examined the proportion of individuals who screened positive for depression (≥10) on the Patient Health Questionnaire (PHQ-9) who sought treatment in different sectors, for depression symptoms and for any reason, and compared the latter with health service use by screen-negative individuals. We analysed the frequency with which barriers to healthcare utilisation were reported by screen-positive adults. We also analysed the association between seeking treatment for depression and various predisposing, enabling and need factors.
Results 86% of screen-positive adults reported seeking no depression treatment. However, 66% had used health services for any reason in the past 3 months, compared to 46% of screen-negative individuals (p<0.0001). Private providers were most frequently consulted by screen-positive adults (32%), while only 19% consulted traditional providers. Structural barriers to healthcare use such as cost and distance to services were frequently reported (54% and 52%, respectively) but were not associated with treatment-seeking for depression. The following factors were found to be positively associated with treatment-seeking for depression: higher symptom severity; reporting lack of energy, lack of interest/pleasure, low self-esteem, or slow movements/restlessness on more than 7 days in the past 2 weeks; being married; having discussed depression symptoms; and reporting problems with medication availability and supply as a barrier to healthcare. No evidence was found for an association between treatment-seeking for depression and most socio-economic, demographic or attitudinal factors.
Conclusions These findings suggest that the majority of adults who screen positive for depression seek healthcare, although not primarily for depression symptoms, indicating the need to improve detection of depression during consultations about other complaints. Private providers may need to be considered in programmes to improve depression treatment in this setting. Further research should test the hypotheses generated in this descriptive study, such as the potential protective role of marriage in facilitating treatment-seeking.
... India has a great variety of healing systems, including allopathic (biomedical) services, indigenous forms of health care (including Ayurveda, yoga, naturopathy, Unani, Siddha, homoeopathy and local systems of medicine), and spiritual or religious healing (Halliburton, 2004). Patients' explanatory models of mental illness may align more closely with those of traditional or religious practitioners than biomedical models ( Wilcox et al., 2007) but the parallel use of multiple systems is common (Albert et al., 2015;Shankar, 2015). ...
Aims
Research from high-income countries has implicated travel distance to mental health services as an important factor influencing treatment-seeking for mental disorders. This study aimed to test the extent to which travel distance to the nearest depression treatment provider is associated with treatment-seeking for depression in rural India.
Methods
We used data from a population-based survey of adults with probable depression ( n = 568), and calculated travel distance from households to the nearest public depression treatment provider with network analysis using Geographic Information Systems (GIS). We tested the association between travel distance to the nearest public depression treatment provider and 12 month self-reported use of services for depression.
Results
We found no association between travel distance and the probability of seeking treatment for depression (OR 1.00, 95% CI 0.98–1.02, p = 0.78). Those living in the immediate vicinity of public depression treatment providers were just as unlikely to seek treatment as those living 20 km or more away by road. There was evidence of interaction effects by caste, employment status and perceived need for health care, but these effect sizes were generally small.
Conclusions
Geographic accessibility – as measured by travel distance – is not the primary barrier to seeking treatment for depression in rural India. Reducing travel distance to public mental health services will not of itself reduce the depression treatment gap for depression, at least in this setting, and decisions about the best platform to deliver mental health services should not be made on this basis.
... Cultural adaption has often been assumed to be from high income to low and middle income countries but it is important to note that there are increasingly a range of counter-flows from LMIC to HIC (White et al, 2014). Health pluralism where more than one model of healing are used is being increasingly considered and evaluated (Halliburton, 2004(Halliburton, , 2009Tribe, 2007;Incayamar et al, 2009). ...
The preponderance of western psychological concepts are often relied upon to conceptualise health-related phenomena. It is hardly surprising therefore that despite the availability of a number of interventions, studies have concluded that outcomes for minority cultural groups are not as good as for Caucasian people (western Europe and North America) in many high and middle income countries (HMIC). The evidence base of most psychosocial interventions is yet to be established in Low and Middle Income Countries (LMICs). There has been a propensity in some quarters to view low and middle income countries as passive beneficiaries of mental health knowledge, rather than as contributors or partners in knowledge production and development. A move towards a more equal bilateral relationship is called for, which should lead to better service provision. This Position Statement aims to highlight the current position and need for culturally adapted interventions. It is a global call for action to achieve a standardised mechanism to achieve parity of access and outcomes across all cultural groups regardless of country of residence.
... The researchers found that most suffered from psychotic illness and showed a degree of improvement (judged by reduction of symptoms and their own expressed views) that matched improvement that may be expected as a result of bio-medical therapy, although no drugs had been given to them at the temple. Halliburton (2004) reported a study of 100 people, all with problems that amounted to a diagnosis of schizophrenia, who had accessed one or more of three forms of therapy in Kerala (South India), namely Ayurvedic medicine, bio-medical psychiatry and religious healing at one or other of three locations with reputations for healing people with mental illness-a Hindu temple, Muslim mosque and Christian church-to find that similar proportions benefitted from each form of therapy. ...
This paper outlines the diversity of medical and healing systems indigenous to many regions of the world and their under-development and suppression during colonialism; describes briefly social and cultural changes that have taken place in the Global South after de-colonisation, resulting in varying degrees of a plurality (in terms of cultural style) of mental health systems currently available; summarizes important general principles of post-colonial development in the Global South; and, finally, points to ways of mental health and wellbeing development in the Global South by drawing on the example of Sri Lanka where the author was involved in a four-year research and capacity building project between 2007 and 2012. The paper takes a historical post-colonial approach to development on the principals of sustainability and cultural relevance and argues for a pragmatic approach in the short term while building up a body of knowledge about the countries concerned, their ground realities and their indigenous psychologies.
... The wide treatment gap attributed to the global South is seen by some to be ''structurally blind'' (Sax 2014) to ritual healing, with the result that the latter is sometimes criminalized (Sood 2016) and the mental health care provided by already existing alternatives to psychiatry are ignored, destroyed ( Davar 2017) or not counted as ''treatment'' within the confines of 'evidence-based' definitions (Bartlett, Garriott, and Raikhel 2014;Davis 2018). Scholars like Murphy Halliburton attribute the well-known reports of better recovery rates for schizophrenia and other mental illnesses in low-income countries (Hopper et al. 2007) to this pluralism (Halliburton 2004). ...
Within the proliferation of studies identified with global mental health, anthropologists rarely take global mental health itself as their object of inquiry. The papers in this special issue were selected specifically to problematize global mental health. To contextualize them, this introduction critically weighs three possible genealogies through which the emergence of global health can be explored: (1) as a divergent thread in the qualitative turn of global health away from earlier international health and development; (2) as the product of networks and social movements; and (3) as a diagnostically- and metrics-driven psychiatric imperialism, reinforced by pharmaceutical markets. Each paper tackles a different component of the assemblage of global mental health: knowledge production and circulation, global mental health principles enacted in situ, and subaltern modalities of healing through which global mental health can be questioned. Pluralizing anthropology, the articles include research sites in meeting rooms, universities, research laboratories, clinics, healers and health screening camps, households, and the public spaces of everyday life, in India, Ghana, Brazil, Senegal, South Africa, Kosovo and Palestine, as well as in US and European institutions that constitute nodes in the global network through which scientific knowledge and certain models of mental health circulate.
... This health care pluralism need not necessarily be viewed as a problem or barrier, but may reflect 'the people's strong desire to get well, in any way possible' (Quack, 2013). In a study of multiple healing systems (psychiatry, Ayurveda, religious healing) in Kerala (Southern India), Halliburton (2004) discussed how this allows people to access interventions that align with their expectations, desires, concerns and personalities. In fact, this pluralistic framework may work to reduce the treatment gap and help patients and family members initiate the process of helpseeking. ...
Background: Understanding the explanatory models of family caregivers is particularly important in interdependent contexts like India, where they often play a significant role in the help seeking behaviours, treatment decision-making and long term care of those diagnosed with mental illness.
Aims: This study was planned to explore the diversity of explanatory models among family caregivers at a centre for recovery-oriented rehabilitation services in South India.
Methods: The sample for this study included 60 family caregivers of patients referred to Psychiatric Rehabilitation Services within a tertiary care hospital for mental health and neuro sciences. Bart’s Explanatory Model Inventory, including a semi-structured interview and a checklist, assessed the family caregivers’ explanatory model of distress on five domains: identity, cause, timeline, consequences and control/cure/ treatment.
Results: The results indicated the co-existence of multiple causal explanatory models including psychosocial, supernatural, situational and behavioural contributors. While 36.7% of the caregivers displayed two explanatory models, 33.3% of the caregivers held three explanatory models and 16.6% of the caregivers endorsed four explanatory models. Caregivers shared their concerns about varied consequences of mental illness but less than half of them were aware of the name of the psychiatric disorder. While they accessed various forms of treatments and adjunctive supports such as prayer, medication was the most frequently used treatment method.
Conclusions: The findings have implications for collaborative goal setting in recovery oriented services for persons with mental illness and their families.
... Research about mental health has been conducted in various parts of India, mostly focusing on the stigmatisation of the people affected by psychiatric disorders [2]. Other studies have considered the topic of psychiatric pluralism, focusing on how to improve the patients' condition by means of different types of therapies [3]. However, most of them have investigated Hindu or Muslim populations, and we notice a lack of research and literature concerning tribal communities, especially when it comes to the cultural perceptions of mental health and illness and their social implications for the individuals concerned. ...
... Research about mental health has been conducted in various parts of India, mostly focusing on the stigmatisation of the people affected by psychiatric disorders [2]. Other studies have considered the topic of psychiatric pluralism, focusing on how to improve the patients' condition by means of different types of therapies [3]. However, most of them have investigated Hindu or Muslim populations, and we notice a lack of research and literature concerning tribal communities, especially when it comes to the cultural perceptions of mental health and illness and their social implications for the individuals concerned. ...
... Addressing these issues would be a first step towards understanding the solid foundation of traditional medicine that is necessary before collaboration can be successfully attempted. Engel and other scholars [44], as well as Kleinman and Cohen [45], argue that THPs may rather possess the much-needed sensitivity to cultural variation that is shown to be vital in mental health, and the availability of diverse forms of treatment may actually increase the chances that a patient finds one that will suit their needs [46]. Additionally, further research is recommended to assess patient needs and explore potential forms of collaboration, in order to achieve sustainable improvement in the mental health care pathways for patients throughout Kenya. ...
Background
Involvement of traditional health practitioners (THPs) in the form of collaboration with the formal health care system is suggested to improve the pathways to mental health care in Kenya, yet understanding of the current traditional practice and THPs’ perspectives is lacking. The aim of this study was to explore the views of THPs with respect to their mental health practice.
Methods
This study qualitatively explored the views of THPs, using four focus group discussions (FDGs) each consisting of 8–10 traditional and faith healers, resulting in a total of 36 participants. Thematic content analysis using a grounded theory approach was performed using QSR NVivo 10. Emerging topics were identified and examined by re-reading the transcripts several times and constantly re-sorting the material.
Results
Four themes that reflect THPs’ mental health practice perspectives emerged as follows: 1) Categorization of mental illness; 2) Diagnostics in traditional mental health practice; 3) Treatments and challenges in current traditional mental health practice; and 4) Solutions to improve traditional mental health practice.
Conclusions
These themes provide insight into the perspectives of Kenyan traditional and faith healers on their mental health practice, in an attempt to offer a meaningful contribution to the debate on collaboration between informal and formal health care providers in improving mental health services in Kenya. Furthermore, the presented challenges and solutions can inform policy makers in their task to improve and scale up mental health services in resource-poor areas in Kenya. Addressing these issues would be a first step towards understanding the solid foundation of traditional medicine that is necessary before collaboration can be successfully attempted. Further research is also recommended to assess patients’ needs and explore potential forms of collaboration, in order to achieve sustainable improvement in the mental health care pathways for patients.
Electronic supplementary material
The online version of this article (10.1186/s12906-018-2393-4) contains supplementary material, which is available to authorized users.
... Over the years, several methods have evolved for managing challenges to mental health. They are generally grouped into three: western psychiatry, traditional psychiatry and religious healing [6] . In his study, Messman (2005) came to the conclusion that western medications are expensive and difficult to afford by low income earners. ...
The use of plants in medicine continues to gain applaud World over. This is in part due to the cost of western medication which is not easily affordable by the low income earners, especially in Africa; and also due to myths and beliefs held about the cause of diseases. Carpolobia lutea is one of the topical shrubs with a lot of proven medicinal properties. However, its effect on anxiety, a major risk factor for mental health disease has not been investigated. The present study therefore seeks to investigate the effect of acute administration of ethanolic root extract of Carpolobia lutea on anxiety and fear. 30 adult male Swiss white mice assigned into 3 groups of 10 each were used for the study. Mice in group I (control) were given 0.9% normal saline while mice in Groups II and III were given 1500mg/kg (low dose) and 2500mg/kg (high dose) of ethanolic root extract of Carpolobia lutea respectively. Administration was done orally two minutes before testing. All the animals were allowed food and water ad libitum. The light/dark transition box and the elevated plus maze were used to assess anxiety and fear related behaviour. The result of the study showed a significant decrease in the frequency of light/dark transitions in the test groups (p<0.05). Stretch-attend postures was significantly increased (p<0.001 and p<0.05) in the high dose and low dose groups respectively. This was followed by a corresponding trend of increased frequency of grooming and grooming duration (p<0.001 and 0.01) in the high and low dose groups respectively. The closed arm entries and duration in the extract treated groups was significantly increased with a corresponding decrease in open arm entries (P<0.001). The frequency of rearing was also significantly decreased in the extract treated groups. These results show a decrease in open arms activity and a general increase in anxiety-like behavior in the treated groups of mice. Therefore, the crude root extract of C. lutea increased anxiety and fear in mice
... By moving through the mental health pluralism of Kerala, patients find multiple options of treatment and care for their suffering. They are thus able to experiment in order to find a therapy that works for them (Halliburton 2004) and this also prevents sufferers from becoming locked into a single diagnosis (Rhodes 1980). Through mental health pluralism, meanings, worlds and experiences multiply. ...
... However, there are abuses of people with mental illness within every system and each has something to learn from the others. Recently some evidence has been published that it is the presence of psychiatric pluralism (the easy availability of religious, indigenous and allopathic practice) that may be the beneficial factor in the superior prognosis in the subcontinent ( Halliburton, 2004). Within Western mental health services, groundbreaking findings in Australia started to document that better outcomes can be achieved in applying a 'recovery' model ( Tooth et al, 1997). ...
The mission to find ‘the secret of the village’ is one attraction of engaging in mental health services in Bangladesh. Over the last 15 years much attention in world psychiatry has been given to the fairly robust finding that the prognosis of people with established and severe mental illness is better in ‘developing countries’ than in ‘developed’ ones (e.g. World Health Organization, 1979; Leff et al , 1990; Jablensky et al , 1992). Earlier assumptions that ‘developing’ is a simple variable were almost certainly a result of racist ignorance (Kulhara, 1994). Developing countries are not homogeneous. The variation in mental health outcomes seems to be clearer in more remote villages and tribal areas (Chatterjee et al , 2003), especially those that have less contact with Western (colonial) models of psychiatry and ways of life. More studies on this topic across a wider range of rural and urban settings would have much to offer. Is there something poisonous that comes with lots of expensive services? Or is there something missing?
... What impact, if any, is traditional mental healthcare having even now on the members of society in low-and middleincome countries, where it is most prevalent? Haliburton (2004) analysed the follow-up data of patients in India who patronised the three recognised systems of mental healthcare in the country: Ayurvedic (indigenous), 'allopathic' (Western psychiatry) and 'religious healing'. He found that patrons of all three showed improvement on follow-up. ...
Many patients in Nigeria consult traditional healers before, or in parallel with, modern psychiatric services. Part of the attraction of traditional medicine for the populace, apart from its lower cost and easier accessibility, may lie in its ‘cultural’ explanatory concepts of the nature and course of mental disorder.
... Meanwhile, different meanings attached to unusual sensory experience may enable people to hold a less pathological interpretation of their symptoms. 15 The presence of an extended family. Is there another breadwinner? ...
For decades, social scientists have critiqued the construction of knowledge in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). However, they have not conducted research with an alternate classification from psychoanalytic and psychodynamic practitioners known as the Psychodynamic Diagnostic Manual (PDM), which is beginning to disseminate globally. This article analyzes cultural assumptions underpinning the classification rationale, concept of the self, and relationship between culture and mental disorders through close readings of DSM‐5‐TR (2022) and PDM‐2 (2017). It shows that DSM‐5‐TR's notion of scientific evidence is informed by an emphasis on biological research in psychiatry, which PDM‐2 views as mostly irrelevant to clinical work. Instead, PDM‐2 claims to speak authoritatively for the inner experiences of patients and clinicians in the therapeutic relationship. Both classifications share a concept of an ideal self that is individualistic, consistent across time, able to narrate rather than just feel emotions, and in control of cognition, emotion, and relationships. Whereas DSM‐5‐TR views the culture concept as a lens to interpret the patient–clinician encounter, PDM‐2 uses the culture concept inconsistently. I situate these findings within extant anthropological research and propose new directions to examine how both classifications are used in local contexts.
As the world experiences rapid industrialization and we stray away from deeper aspects of being, there is an alarming increase in problems related to mental health. A paucity of mental health professionals burdens health‐care systems worldwide, and this problem has become more evident postpandemic. Such a situation indicates a gap that indigenous healing systems can bridge. This article aims to recognize the role of indigenous healing systems in mental health promotion. We also focus on how alternative medicine addresses cultural differences in mental health. After a brief comparison between conventional and alternative medicine, we explore possibilities for collaboration between the two. Findings suggest that individuals in emerging and low‐income countries widely resorted to alternative medicine. It has a comprehensive set of benefits but also has its limitations as it is a loosely regulated field. Alternative practices remain a popular healthcare choice in emerging countries, and combining them with conventional medicine opens up new possibilities for holistic healing and decolonizing narratives in mental health.
Background
According to the WHO, people diagnosed with schizophrenia in developing countries recover more fully than people with the same diagnosis in developed countries. At a time when international organizations are attempting to scale up biomedical psychiatric interventions in India and other low-income countries, it is important to understand why a place like India is doing better in recovery from serious psychosis.
Method
Interviews of 20 people diagnosed with schizophrenia in Kerala, India were conducted to determine level of functioning and quality of worklife. Quantitative assessments of the relations between these factors were undertaken along with qualitative, ethnographic analysis of narratives of interviewees.
Results
Analysis of interviews shows that quality of worklife is correlated with higher functioning among this group, and service user narratives claim that work enabled their recovery. Comparisons to other research further indicates that people in India with this diagnosis are more often employed than people with the same diagnosis in the United States and Europe.
Discussion
Employment and the quality of worklife appear to be positively related to recovery in terms of increasing functionality among people diagnosed with schizophrenia in this part of India. Certain employment programs and sociocultural factors likely contribute to differences in outcome.
https://www.routledge.com/Barriers-to-Recovery-from-Psychosis-A-Peer-Investigation-of-Psychiatric/Sharma/p/book/9781032158327.
Preview available on the link above.
Chapter abstracts available via the following link: https://www.taylorfrancis.com/books/mono/10.4324/9781003248804/barriers-recovery-psychosis-prateeksha-sharma
Under the aegis of the World Health Organization, the Movement for Global Mental Health and an Indian Supreme Court ruling, biomedical psychiatric interventions have expanded in India augmenting biomedical hegemony in a place that is known for its variety of healing modalities. This occurs despite the fact that studies by the WHO show better outcomes in India for people suffering from schizophrenia and related diagnoses when compared to people in developed countries with greater access to biomedical psychiatry. Practitioners of ayurvedic medicine in Kerala have been mounting a claim for a significant role in public mental health in the face of this growing hegemony.
This study examines efforts by ayurvedic practitioners to expand access to ayurvedic mental health services in Kerala, and profiles a rehabilitation center which combines biomedical and ayurvedic therapies and has been a key player in efforts to expand the use of Ayurveda for mental health. The paper argues for maintaining a pluralistic healing environment for treating mental illness rather than displacing other healing modalities in favor of a biomedical psychiatric approach.
Approaching mental health on a global scale with particular reference to low- and mid-income countries raises issues concerning the disregard of the local context and values and the imposition of values characteristic of the Global North. Seeking a philosophical viewpoint to surmount these problems, the present paper argues for a value-laden framework for psychiatry with the specific incorporation of value pluralism, particularly in relation to the Global South context, while also emphasizing personal values such as the choice of treatment. In sketching out this framework, the paper aims to overcome the clash between universalism and relativism about psychiatric categories by focusing on how overlaps between cultures can contribute to ontology-building. A case study analyzing ethnopsychiatric research in the context of South India will illustrate the proposed view, while also pointing out avenues for further research on the causal efficacy of local shared beliefs about mental disorder. If approaches across different traditions and theoretical frames are shown to work in treating similar ailments, causal connections appear to cut across the different ontologies. Ethnopsychiatry would play a central role in such research, namely in disclosing the variables and mechanisms at work within the local approaches.
Psychosomatic Medicine has been an integral part of medicine in India since ancient times. India here refers to Indian sub-continent or South Asia, and includes modern countries of India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan, and Maldives.
Within public health, investigations into the rise of metabolic syndrome disorders, such as obesity and type II diabetes, following on the heels of globalisation have tended to focus on the twin axes of diet and physical exercise. However, such a limited focus obscures wider transformations in bodily and health-related practices that emerge in response to globalisation. This paper is an exploration of public discourses about PCOS—a hormonal disorder that affects menstruation, is associated with obesity, heart disease, and type II diabetes, and has been on the rise in India since the liberalisation of its economy in 1991— and it examines the concerns regarding sociocultural, environmental, and political–economic changes brought by liberalisation that these discourses index. Attention to medical semantics, as revealed through public discourses about PCOS, can help counter the limited focus of diet and physical activity-centred models through an emphasis on the political ecology of health. Such engagement can reveal how an emerging relationship between the body and its environment, which is seen as characteristically modern, is implicated in the rise of metabolic disorders. It can also offer critical insights for biomedical and public health research into such disorders.
The thesis is about plurality of alternative healing practices for mental illness in Kerala. It's a qualitative study with typology of six different healing centers in different parts of Kerala.
In this opening chapter we describe and situate our findings of culturally patterned remitting-relapsing, predominantly brief-psychosis, within both the colonial-occupied history of Timor-Leste, historical psychiatric literature pertaining to reactive/psychogenic psychosis, and the wider transcultural psychiatric research literature. Methodology and results, including characteristic symptoms profiles, alongside two principle case histories are described, and we outline the relevance of historical and contemporary ethnography in Timor-Leste, in particular noting points of similarity across the differing Austronesian ethnolinguistic groups, characterising the research cohort. We explore and critique conventional diagnostic classifications of the psychotic phenomena encountered and endorse the possibility of a bio-psycho-social(cultural) formulation that cuts across diagnostic categories. In the context of mass trauma and human rights violations we also set out the basis for understanding our findings through the lens of culturally informed models of dissociation, potentially elucidating relationships between PTSD, brief- and chronic- psychosis. Finally we locate our arguments within wider epistemological dilemmas concerning the nature of mental disorder, in particular the tension between agentic and deterministic accounts. We further relate this to corresponding tensions within the Global Mental Health movement, and address possible resolutions in relation to our work.
Recovery is an individual process that involves living a satisfying life even with limitations caused by mental illness (Anthony 1993). In this chapter, the authors discuss the conceptualization and implementation of recovery in three case studies from the USA, New Zealand, and Nigeria. In all three cases, recovery is facilitated by (1) ensuring that people with mental illness can fully participate and thrive within their respective societies; (2) diminishing barriers to social inclusion and full citizenship at individual, familial and community levels; and (3) reforming mental health services to be humane, empowering and holistic. This chapter demonstrates that the recovery model provides scaffolding to give shape to reform of mental health services, while allowing flexibility for adaptation to local circumstances and values.
Scaling up access to mental health services globally, and particularly in low and middle income countries (LMIC), is a central priority within current global mental health advocacy. This chapter asks a number of pertinent questions aimed at facilitating critical reflection and exploration of the complexities of efforts to scale-up mental health services in LMIC. The questions to be considered include: Is the validity of psychiatric diagnosis being over-emphasised? Is a preoccupation with eliminating symptoms of illness obscuring understanding about what constitutes ‘positive outcomes’ for individuals experiencing mental health difficulties? Is the ‘treatment gap’ in LMICs as large as it is reported to be? Are alternative forms of support being neglected? Are social determinants of mental health being sufficiently considered? Is the evidence base for GMH sufficiently broad, and has the efficacy of ‘task-shifting’ been sufficiently demonstrated?
Using these questions as a lens through which to explore scaling up, the chapter contends that while laudably drawing attention to the much neglected arena of mental health, efforts to scale up may also serve to divert attention away from the need to reform the underlying assumptions of mental health services in HIC, and the need to rethink the role of psychiatry in promoting wellbeing worldwide. The chapter concludes with a call for reciprocity between high-income countries and LMIC in how mental health services are designed and delivered, and greater recognition of the differing worldviews that inform knowledge about mental distress.
Global Mental Health (GMH) initiatives unfold within contexts of medical pluralism, where people experiencing mental health difficulties may be faced with diverse therapeutic options. In this chapter, David Orr and Serena Bindi discuss how GMH interacts with other forms of healing with which it comes into contact. Focusing primarily on ‘traditional healing,’ a problematic but influential concept within GMH literature and World Health Organisation policies, Orr and Bindi go on to explore three factors that shape its relationship with GMH. These are the contrasts in epistemological frameworks, notions of effectiveness, and political power and social prestige that characterise these different approaches to mental health. The chapter reviews the debates to which these factors give rise and the importance for GMH planners of engaging closely with them.
In a context of a WHO collaborative study, 12 research centres in 10 countries monitored geographically defined populations over 2 years to identify individuals making a first-in-lifetime contact with any type of 'helping agency' because of symptoms of psychotic illness. A total of 1379 persons who met specified inclusion criteria for schizophrenia and other related non-affective disorders were examined extensively, using standardized instruments, on entry into the study and on two consecutive follow-ups at annual intervals. Patients in different cultures, meeting the ICD and CATEGO criteria for schizophrenia, were remarkably similar in their symptom profiles and 49% of them presented the central schizophrenic conditions as defined by CATEGO class S+. However, the 2-year pattern of course was considerably more favourable in patients in developing countries compared with patients in developed countries, and the difference could not be fully explained by the higher frequency of acute onsets among the former. Age- and sex-specific incidence rates and estimates of disease expectancy were determined for a 'broad' diagnostic group of schizophrenic illness and for CATEGO S+ cases. While the former showed significant differences among the centres, the differences in the rates for S+ cases were non-significant or marginal. The results provide strong support for the notion that schizophrenic illness occur with comparable frequency in different populations and support earlier findings that the prognosis is better in less industrialized societies.
The preponderance of women in spirit possession cults is linked with the likelihood of deficiencies in thiamine, tryptophan-niacin, calcium, and vitamin D in women in Old World traditional societies in which poverty and/or sumptuary rules restrict women's nutrient intakes more than those of men. The higher nutrient needs of pregnant and lactating women may exacerbate the inadequacy of their diets. It is postulated that involuntary symptoms of deficiencies affecting the central nervous system and muscles have been recognized in these societies as manifestations of spirit possession and institutionalized as a means of reducing victims' anxieties and restoring their ability to function normally
This monograph presents the findings of a WHO Collaborative Study on the Determinants of Outcome of Severe Mental Disorders (DOS). The study was designed to investigate further some of the findings of the WHO International Pilot Study of Schizophrenia (IPSS) which produced the unexpected finding that patients suffering from schizophrenia in the centres in developing countries appear to have a more favourable outcome at both two and five years follow-up than initially similar patients in centres in developed countries. The DOS was carried out in field centres in Aarthus (Denmark), Agra and Chandigarh (India), Cali (Columbia), Dublin (Ireland), Honolulu and Rochester (United States of America), Ibadan (Nigeria), Moscow (USSR), Nagasaki (Japan), Nottingham (United Kingdom), and Prague (Czechoslovakia). Six of these centres had also taken part in the IPSS. One of the major achievements of the IPSS had been the demonstration that large-scale cross-cultural studies using standardized methods of interviewing, symptom rating and diagnosis are possible. The study reported here rested upon the same methodological foundations but used an epidemiological approach. In each of the twelve centres of the DOS, all individuals from a defined catchment area making a lifetime first contact with specified psychiatric, medical or other agencies because of symptoms of a possibly schizophrenic illness were identified, assessed, and followed up for two years. The finding of a better outcome of patients in developing countries was confirmed, as was the existence of a substantial proportion of patients (often more than half) with undoubted initial schizophrenic symptoms but a good outcome at two years. About one-third of all patients in the study were never admitted to a psychiatric hospital, and of those that were admitted the majority were in hospital for only short periods. The Study also produced evidence about the incidence rates of schizophrenia. Significant differences were found between centres in the incidence of schizophrenia using a broad definition, although the rates ranged only from 1.5 to 4.2 per 100,000 population aged 15-54. In contrast, the incidence of schizophrenia using a narrow definition based on the presence of a limited number of 'classical' symptoms in the present mental state (category S+ of the CATEGO program derived from the PSE-9 interview) was not significantly different between centres. This study confirms that schizophrenic illnesses are ubiquitous, appear with similar incidence in different cultures and have clinical features that are more remarkable by their similarity across cultures than by their difference. They are illnesses with variable outcomes which are more favourable in the developing countries and depend on genetic, developmental and environmental influences whose exact nature, interaction and relative importance have yet to be identified.
The Explanatory Model Interview Catalogue (EMIC) has been developed to elicit illness-related perceptions, beliefs, and practices in a cultural study of leprosy and mental health in Bombay. Leprosy is an especially appropriate disorder for studying the inter-relationship of culture, mental health and medical illness because of deeply rooted cultural meanings, the emotional burden, and underuse of effective therapy. Fifty per cent of 56 recently diagnosed leprosy out-patients, 37% of 19 controls with another stigmatised dermatological condition (vitiligo), but only 8% of 12 controls with a comparable non-stigmatised condition (tinea versicolor) met DSM-III-R criteria for an axis I depressive, anxiety or somatoform disorder. Belief in a humoral (traditional) cause of illness predicted better attendance at clinic.
A two-year follow-up was conducted of a subsample of the Chandigarh cohort of first-contact schizophrenic patients from the WHO Determinants of Outcome project. The patients were those living with family members who had been interviewed initially to determine their levels of expressed emotion (EE). The interview was repeated for 74% of the relatives at one-year follow-up. A dramatic reduction had occurred in each of the EE components and in the global index. No rural relative was rated as high EE at follow-up. Of the patients included in the one-year follow-up, 86% were followed for two years. In contrast to the one-year findings, the global EE index at initial interview did not predict relapse of schizophrenia over the subsequent two years. However, there was a significant association between initial hostility and subsequent relapse. The better outcome of this cohort of schizophrenic patients compared with samples from the West is partly attributable to tolerance and acceptance by family members.
Synopsis
In a context of a WHO collaborative study, 12 research centres in 10 countries monitored geographically defined populations over 2 years to identify individuals making a first-in-lifetime contact with any type of ‘helping agency’ because of symptoms of psychotic illness. A total of 1379 persons who met specified inclusion criteria for schizophrenia and other related non-affective disorders were examined extensively, using standardized instruments, on entry into the study and on two consecutive follow-ups at annual intervals. Patients in different cultures, meeting the ICD and CATEGO criteria for schizophrenia, were remarkably similar in their symptom profiles and 49% of them presented the central schizophrenic conditions as defined by CATEGO class S+. However, the 2-year pattern of course was considerably more favourable in patients in developing countries compared with patients in developed countries, and the difference could not be fully explained by the higher frequency of acute onsets among the former. Age- and sex-specific incidence rates and estimates of disease expectancy were determined for a ‘broad’ diagnostic group of schizophrenic illness and for CATEGO S+ cases. While the former showed significant differences among the centres, the differences in the rates for S+ cases were non-significant or marginal. The results provide strong support for the notion that schizophrenic illnesses occur with comparable frequency in different populations and support earlier findings that the prognosis is better in less industrialized societies.
We conducted a one-year follow-up of patients who had made a first contact with psychiatric services in Chandigarh, North India, and had been assigned a diagnosis of schizophrenia. The expressed emotion (EE) of the patients' relatives was assessed early on. We found the same associations between the individual components of EE and relapse of schizophrenia as in previous Anglo-American studies, but only the association between hostility and relapse was statistically significant. Applying the same criteria as in the Anglo-American studies for 'high EE', we found a significant relationship between high EE and relapse rates. We conclude that the significantly better outcome of Chandigarh first-contact patients compared with a London sample is largely due to the significantly lower proportion of high-EE relatives in the North Indian sample.
This paper focuses attention on alternative modes of expressing distress and the need to analyze particular manifestations of distress in relation to personal and cultural meaning complexes as well as the availability and social implications of coexisting idioms of expression. To illustrate this point the case of South Kanarese Havik Brahmin women is presented. These women are described as having a weak social support network and limited opportunities to ventilate feelings and seek counsel outside the household. Alternative means of expressing psychosocial distress resorted to by Havik women are discussed in relation to associated Brahminic values, norms and stereotypes. Somatization is focused upon as an important idiom through which distress is communicated. Idioms of distress more peripheral to the personal or cultural behavioral repertoire of Havik women are considered as adaptive responses in circumstances where other modes of expression fail to communicate distress adequately or provide appropriate coping strategies. The importance of an 'idioms of distress' approach to psychiatric evaluation is noted.
Data on the two-year pattern of course of illness have been collected in the WHO study of the Determinants of Outcomes of Severe Mental Disorder (DOSMD). These data are reanalysed using recursive partitioning, a method not yet applied to psychiatric data to test the hypothesis that subjects from participating centres in developing countries had better outcomes than those in developed countries.
Subjects were those from the DOSMD study for whom two-year follow-up data were available (n = 1056). The classification and regression trees recursive partitioning technique was used to examine the predictor variables associated with the outcome variable two year pattern of course.
Pattern of course was best predicted by centre, but two developed centres (Prague and Nottingham) grouped with the developing country centres excluding Cali, having better outcomes than in the remaining developed country centres and Cali. Type of onset (insidious v. non-insidious) was the next strongest predictor, but its effect differed across these two centre groupings. Effects for some groups were modified by other predictor variables, including age, child and/or adolescent problems, and gender.
The predominant predictor effects on two-year pattern of course continued to be centre and type of onset, but complex interactions between these variables and other predictor variables are seen in specific centre groupings not strictly defined by 'developing' and 'developed'.
This article examines the long-standing and provocative finding of a differential advantage in course and outcome for persons with schizophrenia living in "developing" countries, using results from the newly completed World Health Organization (WHO) collaborative project, the International Study of Schizophrenia (ISoS). The article addresses two questions: Has the differential survived the 13 years since it was last reported? If so, are the results demonstrably not attributable to artifactual confounding? The analysis focuses on the 809 subjects who make up the combined incidence cohort of ISoS. These include members of the original treated incidence cohorts of two earlier WHO studies (the Determinants of Outcome of Severe Mental Disorders and the Reduction of Disability Studies) as well as subjects drawn from two additional samples (Hong Kong and Madras/Chennai). We first review the consistency of the finding of a "developed versus developing" differential in course and outcome and then examine a variety of course and outcome measures for the ISoS incidence cohorts. Evidence of differences in illness trajectory in favor of the developing centers was consistently found. Six potential sources of bias are then examined: differences in followup, arbitrary grouping of centers, diagnostic ambiguities, selective outcome measures, gender, and age. None of these potential confounds explains away the differential in course and outcome. We conclude with suggestions for further research, with particular attention to the need for close documentation of everyday practices in the local moral worlds that "culture" refers to.
The use of complementary medicine and the traditional medicine of other cultures has been increasing in Europe and North America.(3) Although less well documented, the use of complementary medicines and consultations with traditional healers is widely acknowledged in low income countries, such as India. Here too the limited availability of health services motivates the use of a wide range of alternative systems of care for various ailments, including mental illnesses(4).
This volume brings together a number of the foremost scholars - anthropologists, psychiatrists, psychologists, and historians - studying schizophrenia, its subjective dimensions, and the cultural processes through which these are experienced. Based on research undertaken in Australia, Bangladesh, Borneo, Canada, Colombia, India, Indonesia, Nigeria, the United States and Zanzibar, it also incorporates a critical analysis of World Health Organization cross-cultural findings. Contributors share an interest in subjective and interpretive aspects of illness, but all work with a concept of schizophrenia that addresses its biological dimensions. The volume is of interest to scholars in the social and human sciences for the theoretical attention given to the relationship between culture and subjectivity. Multidisciplinary in design, it is written in a style accessible to a diverse readership, including undergraduate students. It is of practical relevance not only to psychiatrists, but also to all mental health professionals.
Ayurveda possesses a highly abstract metatheoretical framework for explaining diseases, similar in form to theories in the social sciences and psychoanalysis. The highly abstract metatheoretical framework, unlike philosophical and religious speculations, does not exist without empirical verification, but is grounded in well-recognized procedures of validation and experimentation. Although Ayurveda is a science in its sense of the term, there are no professional scientists of Ayurveda, that is, those whose main role is the generation of scientific knowledge through research. Ayurveda practitioners are physicians and their science emerges out of their medical practice. But it is also obvious that some are more interested than others in the practice of science in the course of their practice of medicine. This chapter presents interviews of such out-of-the-ordinary individuals. It selects a small number of physicians from a variety of backgrounds, including Dr. W. A. Fernando.
Recent theorists have noted that the discovery of differences in self concepts has led to an overly dichotomized view of Eastern sociocentric selves "versus" Western individualistic selves.1 While most anthropologists agree on the need for a richer theoretical understanding of the self beyond the bipolar ego/sociocentric model, few theorists have suggested ways in which this model could be improved upon, especially on the Western side of the dichotomy. Although many anthropologists are beginning to break down the homogenous constructs of the sociocentric self in Eastern societies they study,2 this has not yet been rigorously attempted in the West. In this article, I focus on some of the problems with the dichotomy, with particular emphasis on problems on the Western "side" - namely, the assumption that individualism precludes sociocentrism, the tendency to equate the West with America, the misrepresentation of the Western philosophical tradition, the homogenization of Western individualism, and the re-creation of the ego/sociocentric dichotomy within the West along gender and class lines. Finally, questions posed by social psychologists engaged in the individualism/collectivism debate, as well as examples from my own research on child rearing in Manhattan and Queens (Kusserow 1999), suggest ways in which conceptions of the Western self must be complexified.
This paper presents a brief account of the theory of psychological medicine in the ancient Indian medical tradition of Ayurveda. In doing so, attention is drawn to the integration of medical belief and theory with cultural propositions about mind, bodily functioning and the environment. The application of Ayurvedic theory by medical practitioners is illustrated with case material derived from fieldwork carried out in Sri Lanka. In discussing the uses of theory in psychological and physical treatments, I suggest that experimentation and the generation of new ideas have had a continuing impact on the paradigm of Ayurvedic medicine.
This article presents a model for research that aims to address challenges in transcultural psychiatric epidemiology. The model involves eclectic application of quantitative and qualitative techniques, namely: focus groups, in-depth interviews, snowball sampling and population surveys. The qualitative methods help provide information on the context of symptoms, illness experience and disease. These methods provide the background information needed to shape research questions, to modify instruments for local situations, and to interpret collected epidemiological data. Examples are provided.
and discriminating research assistance. My warmest thanks to them and to “Dr. Zhao, ” Hospital Director Li Mingzhong, Dr. Niu Wenquan, and Foreign Affairs Director Shi Changxiang, all of whom were of invaluable assistance during the field research on which this article is based. Gratitude also to Margie Hattori, Jim Hevia, Ann Stewart and Jing Wang, who critically read the manuscript and provided useful advice, and to Faith Wallis who advised on medieval European
Relying on experience with a traditional healer, focus group discussions, and interviews with traditional healers, the author analyzes the functions and importance of traditional healers in the health care delivery system of Nigeria. It is concluded that in a society where healing involves not just the curing of disease but also the protection and promotion of human physical, spiritual, and material well-being, traditional healers remain the very embodiment of conscience and hope in their respective communities. The holistic and cathartic nature of their treatment and the fact that in certain places in the country they are the major or only source of health care, make them very important. The author also examines the debate over the possible integration of traditional and scientific medicine. It is concluded that outright integration would be too ambitious and practically impossible but that some form of cooperation is possible, given political will. Regardless of the official government policy on the issue, the two traditions are complementary and Nigerians patronize both of them.
Reviews the book,
Rethinking psychiatry: From cultural category to personal experience by Arthur Kleinman (see record
1988-97773-000). The reviewer congratulates Dr. Kleinman for writing a brilliant, transformative, and scholarly book. In her review, Dr. Victoria Gorski notes that to fully appreciate his writing requires some facility in each the following areas: clinical practice, anthropology, biopsychosocial research, and reflective pedagogy. The book is laid out in seven chapters, each of which poses an important question to be examined in the formulation of the biopsychosocial model. "Why anthropology?" is presented as a prologue and sets the stage for expanding psychiatry beyond its biomedical focus. Kleinman then proceeds to the question "What is a psychiatric diagnosis?" His brief critique of the limits of classification serves to remind readers of the power of medicalization as a form of social control. The second question follows naturally and frames the next two chapters: "Do psychiatric disorders differ in different cultures?" Other chapter titles include: "How do professional values influence the work of psychiatrists?"; "How do psychiatrists heal?"; and "What relationship should psychiatry have to social science?" Dr. Gorski's only criticisms of Dr. Kleinman's book include Kleinman's failure to refer to the interviewing techniques used by some family therapists that so well complement ethnographic strategies; and Kleinman's omission of gender-related perspectives. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
While the growing volume of new long distance oceanic trade which developed during the fifteenth century helped to stimulate an awareness of the wider world in Western Europe, it also had a much more specific enabling effect on the development of natural history and the status of science in the eyes of government. A rising interest in empirical fact-gathering and experimentation led to a growing enthusiasm for experimentation with new types of medical practice and new drugs. Apothecaries' gardens became established at the universities and were increasingly stocked with plants imported from distant lands. These gardens became the sites of the first attempts to classify plants on a global basis. The voyages of the first century and a half after the journeys of Henry the Navigator from 1415 onwards had already begun to transform the science of botany and to enlarge medical ambitions for the scope of pharmacology and natural history. The foundation of the new botanic gardens was, therefore, clearly connected with the early expansion of the European economic system and remained an accurate indicator, in a microcosm, of the expansion in European knowledge of the global environment. The origins of the gardens in medical practice meant that, as a knowledge of global nature was acquired, the Hippocratic agendas of medicine and medical practitioners continued to form the dominant basis of European constructions of the extra-European natural world.
The WHO cross-cultural studies of schizophrenia exemplify both the achievements and the pitfalls of large-scale psychiatric epidemiology. Their logistical and technical advances have been justly celebrated; the consistent—and unexpected—finding of better outcome in the developing than in the developed world continues to vex analysts. At the same time, anthropological critics have not been shy about pointing up the limitations and blind spots of such research. Criticisms range from charges of ethnocentrism and category errors in the psychiatric research enterprise itself especially the inapplicability of its disease taxonomy to some non-Western cultures, to translation difficulties, the suspect and “thin” quality of questionnaire-generated accounts of illness, disregard for variant understandings of the “self,” and the naïveté of treating culture as a set of variables. Not all of these objections, I argue, are well-founded; some more properly reflect persisting instabilities in anthropological theory. This critical commentary all but ignores the striking epidemiological findings in the West that dispute the received wisdom of chronicity as the natural trajectory of schizophrenia. A natural alliance awaits realization between clinicians—newly alerted to ill-understood factors affecting course and outcome—and fieldworkers—bent on close ethnographic analysis of the configurations and roles of beliefs, work, kin-based support, the uses of public space, and “the natives”‘ own understanding of what ails them.
An unexpected finding of the International Pilot Study of Schizophrenia, launched by the World Health Organization (WHO) in 1967, was that patients in countries outside Europe and the United States have a more favourable short- and medium-term course of the disease than those seen in developed countries. Since then, WHO has intensified its schizophrenia research programme and has initiated a set of international studies that have confirmed these initial findings and explored possible reasons for such differences in the course and outcome of schizophrenia. While such work has provided important findings and has generated additional pertinent hypotheses, it did not explain the differences in outcome. The present paper describes a new initiative in which approximately 2500 subjects involved in previous WHO multicentre schizophrenia studies are being followed up for between 15 and 25 years after initial examination. Nineteen research centres in 16 countries are taking part in this work. The research methodology is described.
Working with the image of the Indian shaman as Wild Man, Taussig reveals not the magic of the shaman but that of the politicizing fictions creating the effect of the real. "This extraordinary book . . . will encourage ever more critical and creative explorations."âFernando Coronil, [I]American Journal of Sociology[/I] "Taussig has brought a formidable collection of data from arcane literary, journalistic, and biographical sources to bear on . . . questions of evil, torture, and politically institutionalized hatred and terror. His intent is laudable, and much of the book is brilliant, both in its discovery of how particular people perpetrated evil and others interpreted it."âStehen G. Bunker, Social Science Quarterly
Sudhir Kakar, a psychoanalyst and scholar, brilliantly illuminates the ancient healing traditions of India embodied in the rituals of shamans, the teachings of gurus, and the precepts of the school of medicine known as Ayurveda. "With extraordinary sympathy, open-mindedness, and insight Sudhir Kakar has drawn from both his Eastern and Western backgrounds to show how the gulf that divides native healer from Western psychiatrist can be spanned."âRosemary Dinnage, New York Review of Books "Each chapter describes the geographical and cultural context within which the healers work, their unique approach to healing mental illness, and . . . the philosophical and religious underpinnings of their theories compared with psychoanalytical theory."âChoice
Thesis (Ph. D.)--University of Washington, 1998 The central theme of the dissertation is the development of indigenous modernities in contemporary Ayurvedic medicine in India. I trace the genealogy of Ayurveda through late-colonial and postcolonial contexts, as not simply a set of healing practices but a sign of Indian national culture. Along the way I discover the various ways that practitioners engage, transform, or circumvent the styles of medical knowledge introduced through modern institutional structures. Such structures which typically enforce a particular corporeal discipline, separating disease from social and natural contexts and locating it in bodies which are construed as discrete, docile and enclosed, are reworked in Ayurvedic settings to sustain other discourses of illness, body and personhood. I also consider the interaction between modern institutions and the epistemological bases of Ayurvedic knowledge. Modern technologies of knowledge developed in colonial contexts involve a particular relationship between sign and referent, representation and reality, form and content, language and world. The dissertation describes how contemporary Ayurvedic discourses and practices complicate this binarism at nearly every level. The dissertation suggests that the above binary relationships, when transposed into the Ayurvedic context, operate paradoxically as both signs and parodies of modernity. Finally, I address Ayurvedic trajectories in a transnational era, when Ayurveda becomes a healing force not only for postcolonial scars but for an imagined cultural emptiness at the heart of global modernity.
Surveys indicate that between thirty and forty million Indians suffer psychiatric problems serious enough to require urgent attention. However, there are only 500 psychiatrists, 400 clinical psychologists, and 100 psychiatric social workers to provide them cosmopolitan health care. Most of the mentally ill are cared for by indigenous healers.A one-year study of the concepts and practices of indigenous healers was carried out in a town of western India. With a population of 10,000, the town boasts 26 healers of which 3 are MDs. 2 Vaids, 3 Mantarwadis. 4 Patris, and 14 of mixed tradition called Patrimantrik.Results show that healers and patients are in agreement with psychiatrists in the diagnosis and identification of “serious” symptoms of mental illness. With the exception of one condition, “possession”, the MDs were the healers initially preferred by patients, in spite of the former's poor psychiatric training. However, the majority of the patients had consulted more than one kind of healer for their problem. There was no association between a patient's choice of healer and his age, wealth, or formal level of education.
Two cases of kitsune-tsuki (fox possession) in a mountain village are examined from psychiatric and ethnographic viewpoints. Kitsune-tsuki, one of the most familiar expressions of "madness" in Japan, represents, as an interactive performance, religious and mythopoetic contexts metaphorically in time of crises. The atypical symptoms and the complicated clinical process of these cases reflect a multistratified cultural background and its transformation; communal religion, folk tales, kyôgen play, shared concepts of illness, and the post-war rise of one religious cult. The psychiatric diagnosis, trying to arrive at a single correct understanding, partially translates the entangled indigenous illness. Focusing on these issues; the dichotomy between form and content of mental illness, the atypicality of the symptoms and the restructive process of illness experiences, the author reconsiders the possibility of interpretation, diagnosis and treatment which respect the multiple realities.
The authors critically review the existing literature on the outcome of schizophrenia in non-Western countries. Compared to studies conducted in Europe and North America, the majority of these non-Western longitudinal followup studies indicated significantly better outcome. Such cross-national variations in the outcome of schizophrenia have been substantiated by two large-scale multicentered studies sponsored by the World Health Organization. Along with this literature review, the authors also discuss potential methodological problems of these studies and examine in detail several key hypotheses concerning mediating factors that could differentially influence the fate of schizophrenic patients in divergent cultural settings. Finally, specific suggestions are made for future research directions.
This paper considers the involvement and performance in the health sector of the Hong Kong government prior to and beyond the transfer of sovereignty from Britain to China in July 1997. The paper commences with a historical survey of health services development, which provides insights into why the health system functions in its present haphazard manner. This section culminates by discussing the 1991 establishment of the statutory Hospital Authority which was an attempt to alleviate escalating problems in the administration of hospitals and public health services. Next, the paper surveys the present, discussing, respectively, the roles of government and private service providers, health care outcomes and the contribution of traditional Chinese medicine. Finally, the paper outlines a range of pressing issues which Hong Kong's future policy-makers will need to confront: the organization of the health sector, health financing and the health policy deficit. In the conclusion, it is posited that there is a need for government to formulate a health policy and to clarify its role in the provision of services.
Ethnographic observations and interviews with psychiatrists at two general hospital psychiatric units in northern India reveal the extent of family involvement in the localized adaptation of biomedical psychiatry that occurs in these settings. By assuming many of the roles filled by auxiliary personnel in the USA, families maintain considerable control over many aspects of the psychiatric process: defining disorder, outpatient consultation, record keeping, admissions, inpatient care, discharge, and continuing care. The implications of these observations are considered in relation to theoretical concerns about biomedical hegemony, advantages and disadvantages of family involvement from an applied perspective, and the methodological adequacy of cross-cultural psychiatric epidemiology with respect to studies of "expressed emotion."
This paper reports on the results of a literature survey involving 166 different species of plants used in the Ayurvedic pharmacopoeia, based on a sampling of the literature available to us. We found a wide range of clinical and other in vivo studies for many of the plant-based therapies utilized in the Ayurvedic system. Of the 166 plants investigated, 72 (43%) had at least one or more human studies and 103 (62%) had one or more animal studies. These results appear to contradict the generally held notion that herbal remedies used in non-Western systems of botanical medicine have not been evaluated in human or in vivo trials. Some of these studies are not always as large or methodologically rigorous as clinical studies reported in major medical journals. Indeed, a critical assessment of the research according to the standards of evidence-based medicine would eliminate many of these studies for lack of rigor according to criteria of randomization, sample size, adequacy of controls, etc. However, the studies do suggest which species might be appropriate for larger and better-controlled trials in the future. Accordingly, a synopsis of the plants, their therapeutic applications, and their clinical or experimental evaluations is presented.