Global Mental Health

Anthropological Perspectives

Brandon A Kohrt, Emily Mendenhall

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781315428031
• Edition: 1
• Topic: Social Sciences
• Subtopic: Anthropology
• Index: Social Sciences

While there is increasing political interest in research and policy-making for global mental health, there remain major gaps in the education of students in health fields for understanding the complexities of diverse mental health conditions. Drawing on the experience of many well-known experts in this area, this book uses engaging narratives to illustrate that mental illnesses are not only problems experienced by individuals but must also be understood and treated at the social and cultural levels. The book -includes discussion of traditional versus biomedical beliefs about mental illness, the role of culture in mental illness, intersections between religion and mental health, intersections of mind and body, and access to health care; -is ideal for courses on global mental health in psychology, public health, and anthropology departments and other health-related programs.

Chapter 1

Historical Background: Medical Anthropology and Global Mental Health

Brandon A. Kohrt, Emily Mendenhall, and Peter J. Brown

There is a long history of scholarship and engagement at the intersection of anthropology and global mental health. Historically, mental health problems—in terms of diagnoses, research, and clinical practices—are inextricably linked to sociopolitical issues ranging from colonialization to migration to global markets and other issues (cf. Littlewood and Dein 2000). Prior to the 20th century, most mental health care around the world was provided by family members, and in some areas, asylums have been used for custodial purposes (Shorter 1997). Throughout most of human history, demons, spirits, sorcerers, and spiritual or religious processes have been seen as the cause of behaviors that we now consider mental illness (Clifford 1990; Hunter and Macalpine 1963; Zargaran et al. 2012). As such, religious leaders and traditional ethnomedical healers treated health problems considered mental illness in biomedical nosologies.

Within complex societies, secular understandings of mental illness marked the early development of their medical systems. For example, Galen and others in Greek medicine developed theories for severe depression and psychosis (Reiss 2003). Ayurvedic, Tibetan, and Chinese medicine also promulgated theories of constitutional and humoral balance that were used to understand, diagnose, and treat the symptoms of mental illness (Clifford 1990; Kleinman 1980; Kleinman and Lin 1980; Lad 2002; Wujastyk 1998). Asylums first came into use in ancient Persia and then spread to metropolitan areas of Europe. Such ideas and practices were then spread through colonialism, as the British, Dutch, and French instituted “lunacy laws” and asylum practices. The end of the 19th century was also a period of rapid growth and transformation in the theories and practice of biomedicine, including psychiatry and neurology. This was exemplified by German scientists, including Emil Kraepelin, Alois Alzheimer, Franz Nissl, and others, who searched for biological causes of mental and neurological conditions, which were still commonly considered spiritual afflictions at that time (Shorter 1997).

Origins of Mental Health Research in Anthropology

Anthropology has been inextricably linked with the origins of global mental health research and intervention. In 1898, anthropologists Charles Seligman and W. H. R. Rivers (also a physician) were part of the Cambridge University expedition to the Torres Strait between Papua New Guinea and Australia (Littlewood and Dein 2000). The pair studied varied native concepts ranging from kinship, to perceptions of color, to modes of healing (Rivers 1924). Later in his career, Rivers influenced mental health care by taking lessons learned from observing healing in the Torres Strait and applying them to British soldiers receiving medical and psychological treatment during World War I (Kleinman 2006). On the other hand, Seligman’s research looked for signs of mental illness and concluded that it was largely absent from the Torres Strait islanders. His conclusion, later refuted, is now known as the “Seligman error.” This error refers to the assumption that an illness category does not exist in a certain culture if the symptoms known elsewhere are not observable. For example, if a diagnostic criterion for schizophrenia were “delusions of persecution by the CIA” and this were not observed in a specific cultural group, then that cultural group would be assumed not to suffer from schizophrenia. However, if the symptoms are viewed as culturally relative, then schizophrenia may be observable in that culture but in a different form or with a different content.

The Torres Strait expedition exemplified how symptoms of mental illness may vary from one cultural context to the next. Emil Kraepelin, considered the father of current diagnostic frameworks in psychiatry and a contemporary of Rivers and Seligman, also conducted cross-cultural work in mental health (Jilek 1995). Prior to World War I, he visited a Dutch asylum in Jakarta. There he observed Javanese patients to determine if they demonstrated similar symptoms to persons with mental illness whom he studied in Germany.

During the early 20th century, anthropology grew in the same academic and clinical institutions that promoted psychology and medicine. As anthropological fieldwork became more logistically feasible in colonies around the world, anthropological research was often utilized as a tool for colonial management. Much of early anthropology in the 1920s and 1930s supported colonial concepts of cognitive “primitivism” that were used to justify political subjugation (Bock 1999). For example, both Franz Boas (1911), the father of American anthropology, and Lucien Lévy-Bruhl, the father of French anthropology, wrote important volumes on the “primitive mind.” These were group-level generalizations (Bock 1999). A remnant of the age of exploration and colonialism, “primitive mind” studies illustrated how the “other” is different, if not deficient, in mentality and pre-logical thought. Boas showed that these mental differences were culturally learned patterns of thought and not a reflection of biological differences in brain size or shape.

Anthropologists also were influenced by the work of Sigmund Freud and the psychoanalysis movement. A school of research that combined psychoanalysis and anthropology, referred to as “Culture and Personality,” arose in the United States between the First and Second World Wars (Bock 2000; LeVine 2001). Pioneers such as Irving Hollowell, Ruth Benedict, Margaret Mead, and Gregory Bateson focused on group-level variation in psychology, emotions, sexuality, and child- rearing practices using a psychoanalytic frame of reference (Bock 1999). In a famous volume, Patterns of Culture, Benedict (1934) classified the modal personalities of different cultural groups as paranoid, megalomaniacal, Apollonian, and Dio- nysian. Benedict’s discussion of “tradition” resembled Freud’s discussion of culture as group neurosis. The “Culture and Personality” approach also spawned “national character studies,” in which enemies of the United States in World War II were described and analyzed according to stereotyped group identity. Hallowell (1941) employed Freudian anxiety theories to describe how anxiety motivates behaviors differently across cultures, and his work contributed to the beginning of ethnopsy-chology, advancing the study of self, human nature, and motivation within particular cultural contexts.

After the Second World War, Anthony F. C. Wallace and other psychological anthropologists criticized the Culture and Personality school because of its reliance on descriptions of homogeneous and stereotypical “character” for an entire social group while failing to account for obvious individual variations within that group (Bock 1999; Wallace 1968). The tension between individual and group is important, especially in child development and adolescence. Mead’s work on gender and culture (1949) examined how males and females were shaped by their societies and cultural ideals. She showed that incongruence between individual and cultural ideals of masculinity, femininity, and sexuality could be a source of distress and deviance. The fundamental principle of these findings is that culture creates a model of an appropriate “modal” personality and that social institutions (such as coming-of-age rituals or schools) shape how individuals think they should behave. The creation of gendered identities is a case in point, and Mead’s book Sex and Temperament in Three Primitive Societies (1935) clearly illustrated gender variations. In later iterations of this approach, Beatrice and John Whiting (1974) demonstrated how such institutions became both the progenitors and resolving bodies of cultural conflict for individual development. The Whitings were Harvard anthropologists who developed new approaches to studying and conceptualizing childhood cross-culturally. They demonstrated that culture shapes the parameters for conflict during child development, and culture also provides the mechanisms children learn to resolve these conflicts. The nature and pathways of conflict resolution vary among cultures. In 1972, Francis Hsu suggested that the “Culture and Personality” approach be renamed “psychological anthropology.”

Differentiation of Psychological Anthropology, Medical Anthropology, and Cultural Psychiatry

There are some divergences among psychological anthropology, medical anthropology, and cultural psychiatry, which became relevant in the late 20th century. Psychological anthropology followed the ideas of culture, personality, and child development to focus on so-called “normal”—or culturally appropriate—patterns of thought and behavior (Bock 1980; Levine 1999; Lutz, White, and Schwartz 1992). This included the exploration of the cognitive categorization of the world as experience—that is, how people think about and interpret their worlds (Shore 1995). This approach was also linked to the structural anthropological analysis of such cultural materials as mythology, pioneered by Claude Lévi-Strauss (1949), which argued that universal human thought processes were based on binary oppositions (e.g., good/evil) and their transformations.

Medical anthropology and cultural psychiatry have focused on how social phenomena, such as suffering and social-psychological distress, influence the so-called “abnormal” phenomena in thought, emotions, and behavior, as well as the role of social, political, economic, and health institutions in shaping definitions of normality and sickness (Littlewood 1990, 2002). These fields focus more on cultural theories of illness causation and on the techniques of diagnosis and healing that practitioners utilize (Desjarlais 1992; Kleinman 1980; Weiss et al. 1986; Wikan 1990). For example, the ethnologist George Devereux and the Haitian psychiatrist Louis Mars defined the field of ethnopsychiatry as the study of local healing systems for mental illness and cultural contributions to psychopathology (Devereux 1980; Gaines 1992). As such, ethnopsychiatry could be considered one component of the medical anthropological field of ethnomedicine, which is the study of local medical systems whose medical and religious belief systems can be difficult to differentiate. Devereux’s (1980) definition of culture was rooted in psychoanalytic theory in which universal unconscious conflicts were socially resolved. He considered shamans as neurotics and...

Table of contents

• Cover Page
• Half Title Page
• Series Page
• Title Page
• Copyright Page
• Contents
• Foreword
• Acknowledgments
• Introduction Anthropological Perspectives on Global Mental Health
• 1 Historical Background: Medical Anthropology and Global Mental Health
• 2 Anthropological Methods in Global Mental Health Research
• Part I: Social and Structural Origins of Mental Illness in Global Context
• Part II: Treatment Approaches and Access to Care in Low- and High-Resource Settings
• Part III: Task-Sharing and Alternative Care Models
• Index
• Contributors