Public Mental Health Across Cultures: The Ethics of Primary Prevention of Depression, Focusing on the Dakhla Oasis of Egypt

(Introduction to a chapter I wrote with Rachel Bingham. It will be part of the volume ‘Mental Health as Public Health: Interdisciplinary Perspectives on the Ethics of Prevention’, edited by Kelso Cratsley and Jennifer Radden.)

 

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For over a decade there has been an active and ambitious movement concerned with reducing the “global burden” of mental disorders in low- and middle-income countries.[1] Global Mental Health, as its proponents call it, aims to close the “treatment gap”, which is defined as the percentage of individuals with serious mental disorders who do not receive any mental health care. According to one estimate, this amounts to 75%, rising in sub-Saharan Africa to 90% (Patel and Prince 2010, p. 1976). In response to this, the movement recommends the “scaling up” of services in these communities in order to develop effective care and treatment for those who are most in need. This recommendation, the movement states, is founded on two things: (1) a wealth of evidence that medications and psychosocial interventions can reduce the disability accrued in virtue of mental disorder, and (2) closing the treatment gap restores the human rights of individuals, as described and recommended in the Convention on the Rights of Persons with Disabilities (Patel et al. 2011; Patel and Saxena 2014).

In addition to its concern with treatment, the movement has identified prevention among the “grand challenges” for mental and neurological disorders. It states, among its key goals, the need to identify the “root causes, risk and protective factors” for mental disorders such as “modifiable social and biological risk factors across the life course”. Using this knowledge, the goal is to “advance prevention and implementation of early interventions” by supporting “community environments that promote physical and mental well-being throughout life” and developing “an evidence-based set of primary prevention interventions” (Collins et al. 2011, p. 29). Similar objectives have been raised several years before by the World Health Organisation, who identified evidence-based prevention of mental disorders as a “public health priority” (WHO 2004, p. 15).

Soon after its inception, the movement of Global Mental Health met sustained and substantial critique.[2] Essentially, critics argue that psychiatry has significant problems in the very contexts where it originated and is not a success story that can be enthusiastically transported to the rest of the world.[3] The conceptual, scientific, and anthropological limitations of psychiatry are well known and critics appeal to them in making their case. Conceptually, psychiatry is unable to define ‘mental disorder’, with ongoing debates on the role of values versus facts in distinguishing disorder from its absence.[4] Scientifically, the lack of discrete biological causes, or biomarkers, for major psychiatric conditions has resulted in the reliance on phenomenological and symptomatic classifications. This has led to difficulties in defining with precision the boundaries between disorders, and accusations that psychiatric categories lack validity.[5] Anthropologically, while the categories themselves are associated with tangible and often severe distress and disability, they remain culturally constructed in that they reflect a ‘Western’ cultural psychology (including conceptions of the person and overall worldview).[6] Given this, critics see Global Mental Health as a top-down imposition of ‘Western’ norms of health and ideas of illness on the ‘Global South’, suppressing long-standing cultural ideas and healing practices that reflect entirely different worldviews. It obscures conditions of extreme poverty that exist throughout many non-Western countries, and which underpin the expressions of distress that Global Mental Health now wants to medicalise. On the whole, Global Mental Health, in the words of the critics, becomes a form of “medical imperialism” (Summerfield 2008, p. 992) that “reproduces (neo)colonial power relationships” (Mills and Davar 2016, p. 443).

We acknowledge the conceptual, scientific, and anthropological critiques of psychiatry and have written about them elsewhere.[7] At the same time we do not wish to speculate about and judge the intention of Global Mental Health, or whether it’s a ‘neo-colonial’ enterprise that serves the interests of pharmaceutical companies. Our concern is to proceed at face-value by examining a particular kind of interaction: on one hand, we have scientifically grounded public mental health prevention campaigns that seek to reduce the incidence of mental disorders in low- and middle-income countries; on the other hand, we have the cultural contexts in these countries where there already are entirely different frameworks for categorising, understanding, treating, and preventing various forms of distress and disability. What sort of ethical principles ought to regulate this interaction, where prevention of ‘mental disorders’ is at stake?

The meaning of prevention with which we are concerned in this chapter is primary, universal prevention, to be distinguished from mental health promotion, from secondary prevention, and from primary prevention that is of a selective or indicated nature. Primary prevention “aims to avert or avoid the incidence of new cases” and is therefore concerned with reducing risk factors for mental disorders (Radden 2018, p. 127, see also WHO 2004, p. 16). Secondary prevention, on the other hand, “occurs once diagnosable disease is present [and] might thus be seen as a form of treatment” (Radden 2018, p. 127). In contrast to prevention, mental health promotion “employs strategies for strengthening protective factors to enhance the social and emotional well-being and quality of life of the general population” (Peterson et al. 2014, p. 3). It is not directly concerned with risk factors for disorders but with positive mental health. With universal prevention the entire population is within view of the interventions, whereas with selective and indicated prevention, the target groups are, respectively, those “whose risk for developing the mental health disorder is significantly higher than average” and those who have “minimal but detectable signs or symptoms” (Evans et al. 2012, p .5). While there is overlap among these various efforts, we focus on primary, universal prevention. Our decision to do so stems from the fact that such interventions, in being wholly anticipatory and population wide put marked, and perhaps even unique, ethical pressure on the encounter between the cultural context (and existing ideas on risk and prevention of distress and disability) and the biomedical public mental health approach.

It is helpful for ethical analysis to begin with a sufficiently detailed understanding of the contexts and interactions that are the subject of analysis. With these details at hand, what matters in a particular interaction is brought to light and the ethical issues become easier to grasp. Accordingly, we begin in section 2 with an ethnographic account of the primary prevention of ‘depression’ in the Dakhla Oasis of Egypt from the perspective of the community. The Dakhla Oasis is a rural community where there is no psychiatric presence or modern biomedical concepts yet – like most communities around the world – there is no shortage of mental-health related distress and disability. It is a paradigmatic example of the kind of community where Global Mental Health would want to action its campaigns. In section 3 we move on to the perspective of a Public Health Team concerned with preventing depression in light of scientific and evidence-based risk factors and preventive strategies. Section 4 outlines the conflict between the perspective of the Team and that of the community. Given this conflict, sections 5 and 6 discuss the ethical issues that arise in the case of two levels of intervention: family and social relationships, and individual interventions.

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Notes:

[1] See Horton (2007), Prince et al. (2007), and Saxena et al. (2007).

[2] Most recently there was vocal opposition to a ‘Global Ministerial Mental Health Summit’ that was held on the 9th and 10th of October 2018 in London. The National Survivor and User Network (U.K.) sent an open letter to the organisers of the summit, objecting to the premise, approach, and intention of Global Mental Health.

[3] See Summerfield (2008, 2012, 2013), Mills and Davar (2016), Fernando (2011), and Whitley (2015).

[4] For debates on the definition of the concept of mental disorder consult Boorse (2011), Bolton (2008, 2013), Varga (2015), and Kingma (2013).

[5] For discussions of the (in)validity of psychiatric categories see Kinderman et al. (2013), Horwitz and Wakefield (2007), and Timimi (2014). Often, the problem is framed by asking whether mental disorders are natural kinds (see Jablensky 2016, Kendell and Jablensky 2003, Zachar 2015, and Simon 2011).

[6] See, for example, Fabrega (1989), Littlewood (1990), and Rashed (2013a).

[7] For example: Rashed and Bingham (2014), Rashed (2013b), and Bingham and Banner (2014).

Jennifer Radden: “Rethinking disease in psychiatry: Disease models and the medical imaginary”

Abstract

The first decades of the 21st century have seen increasing dissatisfaction with the diagnostic psychiatry of the American Psychiatric Association’s Diagnostic and Statistical Manuals (DSMs). The aim of the present discussion is to identify one source of these problems within the history of medicine, using melancholy and syphilis as examples. Coinciding with the 19th‐century beginnings of scientific psychiatry, advances that proved transformative and valuable for much of the rest of medicine arguably engendered, and served to entrench, mistaken, and misleading conceptions of psychiatric disorder. Powerful analogical reasoning based on what is assumed, projected, and expected (and thus occupying the realm of the medical imaginary), fostered inappropriate models for psychiatry. Dissatisfaction with DSM systems have given rise to alternative models, exemplified here in (i) network models of disorder calling for revision of ideas about causal explanation, and (ii) the critiques of categorical analyses associated with recently revised domain criteria for research. Such alternatives reflect welcome, if belated, revisions.

Click here for paper

 

 

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In Defense of Madness: The Problem of Disability

By developing a perspective on the social model of disability and by appealing to the concept of intelligiblity, I respond to arguments against Mad Pride activism. You can access the articlm_covere HERE.

The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, Volume 44, Issue 2, April 2019, Pages 150–174, https://doi.org/10.1093/jmp/jhy016

 

Abstract: At a time when different groups in society are achieving notable gains in respect and rights, activists in mental health and proponents of mad positive approaches, such as Mad Pride, are coming up against considerable challenges. A particular issue is the commonly held view that madness is inherently disabling and cannot form the grounds for identity or culture. This paper responds to the challenge by developing two bulwarks against the tendency to assume too readily the view that madness is inherently disabling: the first arises from the normative nature of disability judgments, and the second arises from the implications of political activism in terms of being a social subject. In the process of arguing for these two bulwarks, the paper explores the basic structure of the social model of disability in the context of debates on naturalism and normativism, the applicability of the social model to madness, and the difference between physical and mental disabilities in terms of the unintelligibility often attributed to the latter.

 

Mohammed Abouelleil Rashed, In Defense of Madness: The Problem of Disability, The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, Volume 44, Issue 2, April 2019, Pages 150–174, https://doi.org/10.1093/jmp/jhy016

Mad Activism and Mental Health Practice

On the 6th of August 2018 I delivered a live webinar that was part of a Mad Studies series organised by Mad in America. The aim of the webinar was to explore ways of incroporating ideas from Mad activism into clinical practice. The full recording of the webinar and the accompanying slides can be found below.

 

The Identity of Psychiatry in the Aftermath of Mad Activism

[Introduction to an essay I am working on for a special issue of the Journal of Medicine & Philosophy with the title ‘The Crisis in Psychiatric Science’]

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THE IDENTITY OF PSYCHIATRY IN THE AFTERMATH OF MAD ACTIVISM

  1. INTRODUCTION

 Psychiatry has an identity in the sense that it is constituted by certain understandings of what it is and what it is for. The key element in this identity, and the element from where other features arise, is that psychiatry is a medical speciality. Upon completion of their medical education and during the early years of their training, medical students – now budding doctors – make a choice about the speciality they want to pursue. Psychiatry is one of them, and so is ophthalmology, cardiology, gynaecology, and paediatrics. Modern medical specialities share some fundamental features: they treat conditions, disorders, or diseases; they aspire to be evidence-based in the care and treatments they offer; they are grounded in basic sciences such as physiology, anatomy, histology, and biochemistry; and they employ technology in investigations, research, and development of treatments. All of this ought to occur (and in the best of cases does occur) in a holistic manner, taking account of the whole person and not just of an isolated organ or a system; i.e. person-centred medicine (e.g. Cox, Campbell, and Fulford 2007). In addition, it is increasingly recognised that the arts and humanities have a role to play in medical education, training, and practice. Literature, theatre, film, history, and the various arts, it is argued, can help develop the capacity for good judgement, and can broaden the ability of clinicians to understand and empathise with patients (e.g. Cook 2010, McManus 1995). None of the above, I will assume in this essay, is particularly controversial.

Even though psychiatry is a medical speciality, it is a special medical speciality. This arises from its subject matter, ordinarily conceived of as mental health conditions or disorders, to be contrasted with physical health conditions or disorders. Psychiatry deals with the mind not working as it should while ophthalmology, for example, deals with the ophthalmic system not working as it should. The nature of its subject matter raises certain complexities for psychiatry that, in extreme, are sometimes taken to suggest that psychiatry’s positioning as a medical speciality is suspect; these include the normative nature of psychiatric judgements, the explanatory limitations of psychiatric theories, and the classificatory inaccuracies that beset the discipline.[1] Another challenge to psychiatry’s identity as a medical speciality comes from particular approaches in mental health activism. Mad Pride and mad-positive activism (henceforth Mad activism) rejects the language of ‘mental illness’ and ‘mental disorder’, and rejects the assumption that people have a ‘condition’ that is the subject of treatment. The idea that medicine treats ‘things’ that people ‘have’ is fundamental to medical practice and theory and hence is fundamental to psychiatry in so far as it wishes to continue understanding itself as a branch of medicine. Mad activism, therefore, challenges psychiatry’s identity as a medical speciality.

In this essay, I argue that among these four challenges, only the fourth requires of psychiatry to rethink its identity. By contrast, as I demonstrate in section 2, neither the normative, nor the explanatory, or the classificatory complexities undermine psychiatry’s identity as a medical speciality. This is primarily for the reason that the aforementioned complexities obtain in medicine as a whole, and are not unique to psychiatry even if they are more common and intractable. On the other hand, the challenge of Mad activism is a serious problem. In order to understand what the challenge amounts to, I develop in section 3 the notion of the hypostatic abstraction, a logical and semantic operation which I consider to lie at the heart of medical practice and theory. It distinguishes medicine from other social institutions concerned with human suffering such as religious and some therapeutic institutions. In section 4 I demonstrate how Mad activism challenges the hypostatic abstraction. And in section 5 I discuss a range of ways in which psychiatry can respond to this challenge, and the modifications to its identity that may be necessary.

[1] These are not the only complexities; there are, for example, well-known difficulties and controversies surrounding the efficacy and risks of anti-depressant and anti-psychotic medication. In addition, psychiatry faces distinctive ethical complexities arising from the fact that mental health patients can be particularly vulnerable which raises questions of capacity not ordinarily raised in other medical specialities (see Radden and Sadler 2010).

 

The Meaning of Madness

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Excerpt from Chapter 1 of my book “Madness and the Demand for Recognition”. Forthcoming with Oxford University Press, 2018

Mad with a capital m refers to one way in which an individual can identify, and in this respect it stands similar to other social identities such as Maori, African-Caribbean, or Deaf. If someone asks why a person identifies as Mad or as Maori, the simplest answer that can be offered is to state that he identifies so because he is mad or Maori. And if this answer is to be anything more than a tautology – he identifies as Mad because he identifies as Mad – the is must refer to something over and above that person’s identification; i.e. to that person’s ‘madness’ or ‘Maoriness’. Such an answer has the implication that if one is considered to be Maori yet identifies as Anglo-Saxon – or white and identifies as Black – they would be wrong in a fundamental way about their own nature. And this final word – nature – is precisely the difficulty with this way of talking, and underpins the criticism that such a take on identity is ‘essentialist’.

Essentialism, in philosophy, is the idea that some objects may have essential properties, which are properties without which the object would not be what it is; for example, it is an essential property of a planet that it orbits around a star. In social and political discussions, essentialism means something somewhat wider: it is invoked as a criticism of the claim that one’s identity falls back on immutable, given, ‘natural’ features that incline one – and the group with which one shares those features – to behave in certain ways, and to have certain predispositions. The critique of certain discourses as essentialist has been made in several domains including race and queer studies, and in feminist theory; as Heyes (2000, p. 21) points out, contemporary North American feminist theory now takes it as a given that to refer to “women’s experience” is merely to engage in an essentialist generalisation from what is actually the experience of “middle-class white feminists”. The problem seems to be the construction of a category – ‘women’ or ‘black’ or ‘mad’ – all members of which supposedly share something deep that is part of their nature: being female, being a certain race, being mad. In terms of the categories, there appears to be no basis for supposing either gender essentialism (the claim that women, in virtue of being women, have a shared and distinctive experience of the world: see Stone (2004) for an overview), or the existence of discrete races (e.g. Appiah 1994a, pp. 98-101), or a discrete category of experience and behaviour that we can refer to as ‘madness’ (or ‘schizophrenia’ or any other psychiatric condition for this purpose). Evidence for the latter claim is growing rapidly as the following overview indicates.

There is a body of literature in philosophy and psychiatry that critiques essentialist thinking about ‘mental disorder’, usually by rebutting the claim that psychiatric categories can be natural kinds (see Zachar 2015, 2000; Haslam 2002; Cooper 2013 is more optimistic). A ‘natural kind’ is a philosophical concept which refers to entities that exist in nature and are categorically distinct from each other. The observable features of a natural kind arise from its internal structure which also is the condition for membership of the kind. For example, any compound that has two molecules of hydrogen and one molecule of oxygen is water, irrespective of its observable features (which in the case of H2O can be ice, liquid, or gas). Natural kind thinking informs typical scientific and medical approaches to mental disorder, evident in the following assumptions (see Haslam 2000, pp. 1033-1034): (1) different disorders are categorically distinct from each other (schizophrenia is one thing, bipolar disorder another); (2) you either have a disorder or not – a disorder is a discrete category; (3) the observable features of a disorder (symptoms and signs) are causally produced by its internal structure (underlying abnormalities); (4) diagnosis is a determination of the kind (the disorder) which the individual instantiates.

If this picture of strong essentialism appears as a straw-man it is because thinking about mental disorder has moved on or is in the process of doing so. All of the assumptions listed here have been challenged (see Zachar 2015): in many cases it’s not possible to draw categorical distinctions between one disorder and another, and between disorder and its absence; fuzzy boundaries predominate. Symptoms of schizophrenia and of bipolar disorder overlap, necessitating awkward constructions such as schizoaffective disorder or mania with psychotic symptoms. Similarly, the boundary between clinical depression and intense grief has been critiqued as indeterminate. In addition, the reductive causal picture implied by the natural kind view seems naive in the case of mental disorder: it is now a truism that what we call psychiatric symptoms are the product of multiple interacting factors (biological, social, cultural, psychological). And diagnosis is not a process of matching the patient’s report with an existing category, but a complicated interaction between two parties in which one side – the clinician – constantly reinterprets what the patient is saying in the language of psychiatry, a process which the activist literature has repeatedly pointed out permits the exercise of power over the patient.

The difficulties in demarcating health from disorder and disorders from each other have been debated recently under the concept of ‘vagueness’; the idea that psychiatric concepts and classifications are imprecise with no sharp distinctions possible between those phenomena to which they apply and those to which they do not (Keil, Keuck, and Hauswald 2017). Vagueness in psychiatry does not automatically eliminate the quest for more precision – it may be the case, for example, that we need to improve our science – but it does strongly suggest a formulation of states of health and forms of experience in terms of degrees rather than categorically, i.e. a gradualist approach to mental health. Gradualism is one possible implication of vagueness, and there is good evidence to support it as a thesis. For example, Sullivan-Bissett and colleagues (2017) have convincingly argued that delusional and non-delusional beliefs differ in degree, not kind: non-delusional beliefs exhibit the same epistemic short-comings attributed to delusions: resistance to counterevidence, resistance to abandoning the belief, and the influence of biases and motivational factors on belief formation. Similarly, as pointed out earlier, the distinction between normal sadness and clinical depression is difficult to make on principled grounds, and relies on an arbitrary specification of the number of weeks during which a person can feel low in mood before a diagnosis can be given (see Horwitz and Wakefield 2007). Another related problem is the non-specificity of symptoms: auditory hallucinations, thought insertion, and other passivity phenomena which are considered pathognomonic of schizophrenia, can be found in the non-patient population as well as other conditions (e.g. Jackson 2007).

Vagueness in mental health concepts and gradualism with regards to psychological phenomena undermine the idea that there are discrete categories underpinned by an underlying essence and that go with labels such as schizophrenia, bipolar disorder, or madness. But people continue to identify as Women, African-American, Maori, Gay, and Mad. Are they wrong to do so? To say they are wrong is to mistake the nature of social identities. To prefigure a discussion that will occupy a major part of Chapters 4 and 5, identity is a person’s understanding of who he or she is, and that understanding always appeals to existing collective categories: to identify is to place oneself in some sort of relation to those categories. To identify as Mad is to place oneself in some sort of relation to madness; to identify as Maori is to place oneself in some sort of relation to Maori culture. Now those categories may not be essential in the sense of falling back on some immutable principle, but they are nevertheless out there in the social world and their meaning and continued existence does not depend on one person rejecting them (nor can one person alone maintain a social category even if he or she can play a major role in conceiving it). Being social in nature they are open to redefinition, hence collective activism to reclaim certain categories and redefine them in positive ways. In fact, the argument that a particular category has fuzzy boundaries and is not underpinned by an essence may enter into its redefinition. But demonstrating this cannot be expected to eliminate people’s identification with that category: the inessentiality of race, to give an example, is not going to be sufficient by itself to end people’s identification as White or Black.

In the context of activism, to identify as Mad is to have a stake in how madness is defined, and the key issue becomes the meaning of madness. To illustrate the range of ways in which madness has been defined, I appeal to some key views that have been voiced in a recent, important anthology: Mad Matters: A Critical Reader in Canadian Mad Studies (2013). A key point to begin with is that Mad identity tends to be anchored in experiences of mistreatment and labelling by others. By Mad, Poole and Ward (2013, p. 96) write, “we are referring to a term reclaimed by those who have been pathologised/ psychiatrised as ‘mentally ill,'”. Similarly, Fabris (2013, p. 139) proposes Mad “to mean the group of us considered crazy or deemed ill by sanists … and are politically conscious of this”. These definitions remind us that a group frequently comes into being when certain individuals experience discrimination or oppression that is then attributed by them as arising from some features that they share, no matter how loosely. Those features have come to define the social category of madness. Menzies, LeFrancois, and Reaume (2013, p. 10) write:

Once a reviled term that signalled the worst kinds of bigotry and abuse, madness has come to represent a critical alternative to ‘mental illness’ or ‘disorder’ as a way of naming and responding to emotional, spiritual, and neuro-diversity. … Following other social movements including queer, black, and fat activism, madness talk and text invert the language of oppression, reclaiming disparaged identities and restoring dignity and pride to difference.

In a similar fashion, Liegghio (2013, p. 122) writes:

madness refers to a range of experiences – thoughts, moods, behaviours – that are different from and challenge, resist, or do not conform to dominant, psychiatric constructions of ‘normal’ versus ‘disordered’ or ‘ill’ mental health. Rather than adopting dominant psy constructions of mental health as a negative condition to alter, control, or repair, I view madness as a social category among other categories like race, class, gender, sexuality, age, or ability that define our identities and experiences.

Mad activism may start with shared experiences of oppression, stigma and mistreatment, it continues with the rejection of biomedical language and reclamation of the term mad, and then proceeds by developing positive content to madness and hence to Mad identity. As Burstow (2013, p. 84) comments:

 What the community is doing is essentially turning these words around, using them to connote, alternately, cultural difference, alternate ways of thinking and processing, wisdom that speaks a truth not recognised …, the creative subterranean that figures in all of our minds. In reclaiming them, the community is affirming psychic diversity and repositioning ‘madness’ as a quality to embrace; hence the frequency with which the word ‘Mad’ and ‘pride’ are associated.