Transcript Culture and Context: Lessons from a Sub

Culture and Context: Lessons
from a Sub-Saharan African
Experience
Rachel Hingst, OTR, CPRP
Learning Objectives:
Attendees will be able to:
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Describe cultural values which are reflected in the
principles and practice of psychiatric rehabilitation
in the United States
Explain some of the specific challenges faced by
both individuals with mental illness and service
providers in developing countries
Recognize their responsibility as global citizens to
advocate for mental health to be prioritized on the
international health agenda
Session Outline:
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Introduction to Sub-Saharan Africa
American cultural values, norms, and
assumptions
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Small group work
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Presentations of group work
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Challenges
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Examples of practices
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Questions/discussion
“Developing countries”
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Developing/developed
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Least Developed Countries (LDC)
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Less Economically Developed Country (LEDC)
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Non-industrialized/industrialized
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Third world/first world
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Global south/global north
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Majority World
If the world was a village...
If the world's population was reduced to 100 people:
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60 Asians, 14 Africans, 12 Europeans, 8 Latin Americans, 5 from the USA
and Canada, and 1 from the South Pacific
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67 would be unable to read
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50 would be malnourished and 1 dying of starvation
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24 would not have any electricity (And of the 76 that do
have electricity, most would only use it for light at night.)
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1 would have a college education
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5 would control 32% of the entire world's wealth; all 5 would be US citizens
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33 would be receiving --and attempting to live on-- only 3% of the income of
"the village"
Global Mental Health:
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WHO estimates 450 million people
worldwide experience mental health
problems:
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154 million: depression
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25 million: schizophrenia
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91 million: alcohol use disorders
Spending in developing countries: Most
middle and low-income countries devote less than
1% of their health expenditure to mental health.
Sub-Saharan Africa:
Sub-Saharan Africa:
What words come to
mind?
Sub-saharan Africa
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Population of over 800 million
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Diversity:
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1000 different languages
Shared experiences
Resources:
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Ivory and slaves
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Copper, cotton, rubber, diamonds, tea, tin
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Oil, gold, platinum, uranium, coltan
The Scramble for Africa:
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End of 19th century
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Colonization: artificial boundaries
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Minority governments
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Apartheid
Independence:
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Decolonization
Some challenges with independence: human
resource and infrastructure...
Conflicts:
Country
Time
Estimated deaths
Nigeria
1967-1970
200,000-1 million+
Mozambique
1977-1992
900,000
Angola
1975-2002
500,000+
Sierra Leon
1991-2002
75,000-150,000
Rwanda
April 1994-July 1994
500,000-1 million
Congo
1998-2003
3 million+
Politics:
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Dictatorships
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One-party states
Economics:
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Average GDP per capital in Sub-Saharan
Africa: approximately $1,800 (compared to
about $46,000 for USA)
Almost half of people live on less than $1 a
day (extreme poverty)
HIV/AIDS:
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Accounts for 67% of HIV infections
worldwide (about 22 million people)
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Disrupted communities and families
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14 million children are orphans
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Human resources: loss of productive
citizens
Stress/grief: psychosocial burden
Psychiatric Rehab?
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Worked for 2 ½ years in Malawi
First in government psychiatric hospital then for NGO
providing mental health services
Programs included: inpatient hospital, outpatient clinic,
community outreach clinics, day rehabilitation program,
vocational training school, food security program, street
children's program, college for training psychiatric nurses
and clinical officers, and programs for children with
special needs
Where is Malawi?
Examining American norms,
values, and assumptions:
“Psychiatric rehabilitation has its origins in a
Western humanistic worldview, based
predominantly on United States and British
culture.”-from USPRA Multicultural Principles
Multicultural Principles:
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Understanding own culture:
“The essence of multiculturalism is the study of one’s own culture and
ethnicity as the basis for understanding and identifying with those
from others. Interpersonal encounters are not “objective” or “valuefree” even when these encounters occur in a therapeutic or
rehabilitation relationship.” (from Principle 2)
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Recognizing Worldview of Others:
“Psychiatric rehabilitation practitioners recognize that thought patterns
and behaviors are influenced by a person’s worldview, ethnicity and
culture of which there are many.” (from Principle 4)
Value: Individual
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American value: “Rugged individualism”
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Independence valued over interdependence
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“...appreciating cultural preferences that value
relationships and interdependence, in addition
to individuality and independence.” (Principle 7)
Value: Work and Achievement
From USPRA Vision:
“It promotes a world in which individuals with
mental illnesses can recover to achieve
successful and satisfying lives in the
working, learning and social environments
of their choice.”
Value: Work and Achievement
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Do all cultures highly value work and achievement?
“Psychiatric rehabilitation practitioners show respect towards
others by accepting cultural values and beliefs that emphasize
process or product, as well as harmony or achievement.”
(Principle 7)
“Most mental health service systems in the U.S. place a great
deal of emphasis on outcomes, especially achievement of
independence and success in role functioning, such as
competitive employment. Psychiatric rehabilitation practitioners
recognize that people who use psychiatric rehabilitation
services will have a variety of definitions of what constitutes
success, satisfaction, and recovery.”
Value: Future Orientation
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Emphasis on planning and progress: Life goals,
short-term and long-term goals, strategic
planning, etc.
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Is this something all cultures can relate to?
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Importance of the past
Value: Control
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American dream: we control our own destinies;
have the ability to bring prosperity to ourselves
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Tradition of democracy
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Automony
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Not everyone has choices: influenced by
political, social, and economic factors
Role of fate and the supernatural
Assumption: Infrastructure
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Roads/transportation
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Communication: phone, mail, internet
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Water/sanitation
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Electricity
Assumption: Healthcare/social
service system:
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Functional structure
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Human resource
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Other basic resources: medication, soap, lab
tests, etc.
Social security/welfare system: housing options,
disability benefits, etc.
Assumption: Economic
opportunities
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Employment: diverse economy with various
sectors
Loans accessible: business, education,
housing, etc.
Small Group Work:
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Each group will be given one principle or practice
of psychiatric rehabilitation or a characteristic of
recovery-focused services
Discuss the challenges and opportunities you
anticipate in applying this principle/practice in the
context of a developing country
Consider the cultural differences, social and
political factors, and economic disparities
Challenges in implementing
psychiatric rehab services:
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Based on personal experiences in Malawi
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In addition to day to day challenges
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Economic
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Available support
Traditional Beliefs:
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Causes of mental illness
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Witchcraft
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Traditional healers
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Locus of control
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Challenges: adherence to medication/treatment
poor; active role in illness management difficult
Stigma
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Disability in general seen as burden
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Enormous public stigma
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Open discrimination by leaders, public figures, and health
workers
Staff working in mental health also stigmatized
Challenges: mental health is relegated to background; no
resources allocated; even with good skills clients struggle to
have satisfying lives due to public stigma
Donor culture
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International development sector: controversy
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Allowances for workshops: “allowance culture”: created by donors
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Volunteering as a job
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Donors have the power
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Challenges: difficult to find committed employees and volunteers;
resources spent on trainings with questionable outcomes; Western
standards/expectations imposed which may not be
needed/realistic/sensible in the context
Evidence
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Digital divide: how many people in this world have internet
access?
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Imported evidence
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Validity of tools: cultural bias
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Capacity for research
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Outside researchers
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Challenges: Difficulty measuring outcomes—building an
evidence base; relying on imported evidence; alienation of our
colleagues across the digital divide
What works?
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Examples of practices...
Sensitization
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Employers
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Police and prison workers
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Churches
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Traditional/community leaders
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Community-level
Relationships with Traditional
Healers
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Early identification of problems
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Using as part of the team
Skills training
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Adapting to language and culture
Examples: conflict management, problem
solving, stress management
Food Security Program
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“Supported farming”
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Involves family and community
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Gives client status/fights stigma
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Links with housing
Vocational training
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Various trades for self-employment or
community employment
Educational support
Business/supported employment
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“supported employment”--not same as US
model
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Business raises money for service
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Gives clients work experience
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Fights stigma
Community-Based Rehabilitation
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CBR
Model for rehabilitation and social integration for
people with disabilities
See WHO references in handout
Plea for Advocacy:
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Remember the Majority World
Be an advocate for making mental health a
global priority
“No health without mental health.”
Celebrate World Mental Health Day on October
10.