Public Mental Health Across Cultural Contexts: An Essay on the Ethics of Primary Prevention of Depression, With a Focus 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.

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).

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More Things in Heaven and Earth

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For a few months in 2009 and 2010 I was a resident of Mut, a small town in the Dakhla Oasis in the Western desert of Egypt. My aim was to become acquainted with the social institution of spirit possession, and with sorcery and Qur’anic healing (while keeping an eye on how all of this intersects with ‘mental disorder’ and ‘madness’). I learnt many things, among which was the normalness with which spirit possession was apprehended in the community: people invoked spirits to explain a slight misfortune as much as a life- changing event; to make sense of what we would refer to as ‘schizophrenia’, and to make sense of a passing dysphoria. It was part of everyday life. The way in which spirit possession cut across these diverse areas of life got me thinking about the broader role it plays in preserving meaning when things go wrong. To help me think these issues through I brought in the concepts of ‘intentionality’ and ‘personhood’. The result is my essay More Things in Heaven and Earth: Spirit Possession, Mental Disorder, and Intentionality (2018, open access at the Journal of Medical Humanities).

The essay is a philosophical exploration of a range of concepts and how they relate to each other. It appeals sparingly, though decisively, to the ethnography that I had conducted at Dakhla. If you want to know more about the place and the community you can check these blog-posts:

The Dakhla Diaries (1) : Fast to Charing-X, Slow to Hell

The Dakhla Oasis: Stories from the ‘field’ (0)

The Dakhla Diaries (3): Wedding Invitation

Old Mut, Dakhla

The Dakhla Oasis: Stories from the ‘field’ (I)

And this is a piece I published in the newspaper Al-Ahram Weekly (2009) voicing my view on some of the practices that I had observed: To Untie or Knot

 

Islamic Perspectives on Psychiatric Ethics

My chapter published online at Oxford Handbooks.

Will appear in print in the Oxford Handbook for Psychiatric Ethics Volume 1 next year.

Abstract

Islamic Perspectives on Psychiatric Ethics explores the implications for psychiatric practice of key metaphysical, psychological, and ethical facets of the Islamic tradition. It examines: (1) the nature of suffering and the ways in which psychological maladies and mental disorder are bound up with the individual’s moral and spiritual trajectory. (2) The emphasis placed on social harmony and the formation of a moral community over personal autonomy. (3) The sources of normative judgements in Islam and the principles whereby ethical/legal rulings are derived from the Qur’an and the Prophetic Traditions. Finally, the perspective of the chapter as a whole is employed to present an Islamic view on a number of conditions, practices, and interventions of interest to psychiatric ethics.

Click HERE for Pre-Production version

Spirit Possession, Personhood, & Intentionality: Perspectives for the Philosophy of Mental Health

Summary of an essay I completed recently.

Spirit possession is a common phenomenon around the world in which a non-corporeal agent is involved with a human host. This manifests in a range of maladies or in displacement of the host’s agency and identity. Prompted by engagement with the phenomenon in Africa, this paper draws some connections between spirit possession, and the concepts of personhood and intentionality. It employs these concepts to articulate spirit possession, while also developing the intentional stance as formulated by Daniel Dennett. It argues for an understanding of spirit possession as the spirit stance: an intentional strategy that aims at predicting and explaining behaviour by ascribing to an agent (the spirit) beliefs and desires, but is only deployed once the mental states and activity of the subject (the person) fail specific normative distinctions. Applied to behaviours which are generally taken to signal ‘madness’ or ‘mental illness’, the spirit stance preserves a peculiar form of intentionality where otherwise behaviour would be explained as consequence of a broken physical mechanism. Centuries before the modern disciplines of psychoanalysis and phenomenological-psychopathology endeavoured to restore meaning to ‘madness’, the social institution of spirit possession had been preserving the intentionality of socially deviant behaviour.

Political Protest, Social Change and Bare Breasts

(Inspired by a recent conversation with Nina Mankin and Tatiane Feres)

 

In the midst of the Femen-inspired current where women and girls in North Africa (Egypt and now Tunisia) pose naked in the name of freedom from societal oppression and patriarchy, I feel compelled to make a few remarks. I am aware that this is an extremely sensitive and emotional topic for everyone and I am keen not to be misunderstood. Therefore I will very carefully specify what I think the issues are.

 

  1. There is no doubt that there is societal prejudice against and relatively excessive control of the behaviour of women in Egypt and, I assume, in Tunisia.
  2. This is consciously problematic for some (and not all) women. This is an important point because many women will vehemently deny that they are under any oppression – which brings us to point 3.
  3. This control is society-wide in the sense that it is not just the prerogative of men, but also of women who believe that their place is defined by the space men have created for them.
  4. Some women and some men strongly believe that something should be done about this.
  5. Aliaa el-Mahdy and (more recently) Amina believed they were doing something about this by posing naked (Amina had the slogan ‘my body is mine and not the source of anyone’s honour’ written on her chest- see the photo attached). They believe they are challenging patriarchy and social/moral norms.
  6. There is no doubt that such actions, by definition, constitute a challenge to patriarchy and norms, but are they addressing women’s broader problems of achieving equal rights and recognition in these societies?
  7. One answer is yes: through being subversive you launch debate and discussion on those issues, issues which otherwise remain dormant.
  8. An alternative answer would be that such actions are counter-productive since in being so radical they will cause serious offence in those communities, and people will not see beyond the offence and grasp the message conveyed by this subversive act.
  9. There is truth in both answers. In the case of Egypt some felt that what Aliaa el-Mahdy did will be pivotal for women’s liberation movements, while some women activists felt it was counterproductive as it tainted women civil rights movement in the eyes of a conservative society waiting for any chance to accuse such movements of immorality.
  10. Again there might be some truth in both claims.
  11. So I don’t particularly feel I can confidently say such actions are productive or not, as this really will depend on the nature of the goal you want such actions to achieve. If you want to shock, and you perceive some long-term value in shock – through introducing new elements into collective consciousness for example – then they are productive. If you are concerned with slow, gradual, social change then you will perceive such actions as counterproductive, if not downright harmful to the cause.
  12. Both points of view have something going for them. I am left, then, with the message conveyed by women who bare nude in protest. This message at the core of it is quite simple: My body belongs to me.
  13. The simplicity of this message is what makes it so powerful and divisive.
  14. Basically you can either agree with this message or reject it. This is the source of the perennial misunderstanding between those with a religious outlook and those without, or between the majority of Egyptians, say, and the majority of North Europeans in relation to the question of the meaning of acts of nudity (excuse my generalisation but the point is to identify two positions rather than groups).
  15. The first position (P1) rejects this statement as false: your body does not belong to you, there are so many other caretakers such as God and Society.
  16. The second position (P2) finds this hugely insulting and demeaning. My body is mine, it’s the most ‘mine’ of all things, like my private thoughts. No one has any claim on my body.
  17. And so for P2, those who adhere to P1 appear to disrespect individuality at its most basic – the notion that you have sole autonomy over your body. This disrespect is further explained in line with common prejudice by saying, for instance, that those people (Arabs/Muslims/etc) are backward and belong to the dark-ages.
  18. Alternatively, for P1, those who adhere to P2 represent the worst excesses of individualism: unhinging the body from the sphere of morality as a meaningless physical substance. This may be further explained in line with common prejudice by saying, for instance, that those people (Europeans/Westerners/etc) are mired in immorality and disgusting in the way they have forsaken God.
  19. And so there is a stalemate and we can all part without an ounce of shared understanding and with both sets of prejudices confirmed. Great. Just another day of life as we know it.
  20. But there is a solution. And as with all good solutions it involves some kind of synthesis of P1 and P2, as both contain some truths, and the challenge is to articulate this synthesis .. to be continued ..

 

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THE DOGMA IS DEAD! LONG LIVE THE DOGMA!

Ideas, like their bearers, pass through several stages unto death. They start life as solutions to practical problems and, if they endure, sediment as inviolable truths about the world. These truths may take on an ethical significance and the ideas become binding moral imperatives. Ideas are born pragmatic, their coming-of-age is positivist, and their maturity lies in a mysteriously compelling normativity. Perpetually and surely, ideas progress towards death, a death that we call ‘reality’. We do not allow ideas to die, we resurrect them by keeping them part of that most concrete of things: reality, the archaeological sediment of centuries of ideas; what our great relatives and their ancestors have thought up to control the world and each other. An idea is most relevant and immediate when it is born, when it still has an intimate relationship to the practical circumstances it arose to address. In time, the material and social conditions change and ideas must change with them. But many ideas persist and we, seemingly oblivious to their death, allow them to remain in our cognition much like mummified relics or, in a word, dogma.

*

To be free of dogma is to realise when an idea has died. Dogma is death, the death of ideas. For an idea only rises to the status of dogma when it presents itself as that which it is not: as ‘truth’ or ‘reality’ or the ‘good’ as opposed to that which it was: a solution to a problem somewhere in the past, a problem that no longer exists but for which the idea continues to present a ‘solution’. Dogma recreates the original problem, in order to present itself as the only solution.

*

Religion in the 21st century is pure dogma. The ideas that constitute organised, prescriptive, a-spiritual religion have served their purpose. Religion has nothing to offer but a limitation on thought and a constraint on morality. It tells us what we cannot think; it delineates the limits of thought. Religion tells us what we should do in a world that is different to the one where its precepts were first formulated. A sceptic questions a grand ideology that purports to explain everything without ever doubting itself. Religious dogma tells us that a woman’s body is sinful, it needs to be hidden and covered, and this is presented to us as an entirely natural and self-evident truth; a real and genuine problem. Religious dogma recreates a problem – the woman’s body – in order to offer a solution: a host of limitations on women’s freedom. And it doesn’t matter if women endorse the dogma willingly or if they believe that by covering themselves they will go to heaven. It doesn’t matter because they too are allowing the dead ideas of religion to persist among us: they too are guilty of this perpetual resurrection.

*

Scepticism is the mirror that confronts the idea with the image of its own death. Scepticism frees us of dogma, and allows us to align ideas with the social and material world surrounding us.  A sceptic questions the basis of an idea, its raison d’être. A sceptic is not scared by an idea’s claim to truth or goodness; he can see beyond this, he can see that it is dead: a sediment.

*

For many decades now and we have had the foundations to live without an eternal guarantor. Unlike Descartes for whom the world was unimaginable, unthinkable without a mighty Agent overseeing its Truth. We no longer need God. It is not that we have, necessarily, ceased to believe in Him (even if some of us think admitting this is crucial), nor that we feel compelled to prove His non-existence – as atheists are inclined to do, no: we just no longer need him; much like a toddler no longer needs a walking-brace once his legs can carry him. We can tolerate a sense of ‘fundamental insecurity’, we can tolerate ‘existential angst’ – in short, we can tolerate life without God. And none of this is new: this is the legacy of the enlightenment, and has been with us, with a particular laity that is, for centuries. It is no longer unusual – let alone heroic – to forsake God.

*

Throughout the enlightenment, the idea that religion is a necessary condition of meaning-fullness gradually declined, and a slowly emerging humanism began to fill its place. This was not easy. Descartes, the first of the modern, radical sceptics, went as far as the cogito. But he ended up preserving God, the guarantor against falsehood and the protector from nihilism. Nietzsche’s madman roamed the streets declaring the death of God, only for the philosopher himself to die, in the most ironic of predicaments, in the midst of syphilitic insanity. In time, the conditions for a genuine secularity were laid down and human beings were able to seek fullness and meaning without the need for God.

*

Religious political parties are agents of death; they traffic in the dead ideas of religion. And they are only able to do so because we, the People, have allowed these ideas to persist among us; we have continually resurrected them. By capitulating on our failure to eradicate dogma, Religious parties secure power and wield it upon us the willing and thankful people.

*

Have we, Heirs of the Enlightenment, rid ourselves of dogma? Have we trained ourselves to see ideas through the lens of pragmatism? Liberty, Equal Opportunities, Human Rights, Individualism, Freedom of Speech. These are just a few of the ideas that have become our lingua-franca. They are, or have become, self-evident truths. While John Stuart Mill might have had to argue for Liberty, we no longer need to. Evidently, it seems, these ideas represent a massive leap over religious dogma: they reflect a more inclusive society and broader possibilities for human flourishing. But are these ideas beginning to exert a hold on us that exceeds the hold of expediency? Are they, that is, progressing slowly towards death?

*

It’s a story we are all familiar with now: we live in the midst of an aggressive Individualism. Our value system is struggling to define itself independently of the ethos of consumption. We struggle against this but are always driven back by sheer momentum but also by bottomless greed. And then we are faced with fundamental inequalities, and many tell us that that is fine; that is the way it should be. We all have Equal Opportunities, the dogma goes, so you have only yourself to blame when your share of the material world doesn’t match your expectation or your needs: each to his own. And not only do we no longer need to justify the primacy of Liberty, no, some of us are prepared to kill others to bequeath upon them that most precious of our discoveries: Freedom. And you can talk, you can denigrate others, you can burn books like they did in the Middle-Ages and we will call it Free Speech. The rot at the core of enlightenment ideology is rapidly spreading and the stench is becoming unbearable.

*

Freedom of Speech, Individualism, Liberty, Equal Opportunities: dogmas rapidly approaching death. To free itself of thousands of years of Pharaohs, Sultans, Kings and Lords humanity had to discover the individual. It had to enshrine the rights of each and every person, not in order to worship them, but by way of expediency: a solution to the problem of absolute power. Now, these ideas have lost their pragmatic value: they are no longer responding to a practical need. Absolute power is no longer in the hands of the Monarchs; power is in our hands. But we squander it willingly to those gigantic entities that manufacture our desires while also selling us their satisfaction. Individual rights and Liberty have become the justification for the status quo: they have become ideals that no longer limit absolute power but create it.

*

Some of us can see that the dogma of the enlightenment and the status quo which it now creates are not sustainable. We are told that we are using up the planet’s resources; melting the poles; raising the temperatures. And if we do not do something about it, many of us will die not so far from now. And this indeed might appear as a highly pragmatic set of ideas. There is a problem, we need to address it, and this is how we do so. But… already, we can hear those who want to raise those ideas to the status of ethical imperatives. They are not content with the issue being a pragmatic issue which should be addressed, they want to transform the ideas into dogma, and thereby move them faster along the path of their inevitable destruction; towards their death. And we must resist this; we must insist that the connection between an idea and the practical need it arose to address is not lost. Because if we do not do so we will join the chorus of humanity in that famous call that echoes from the dark ages and has not yet left us: The dogma is dead! Long live the dogma!

Mohammed Abouelleil Rashed   2012

Abstract for the 15th International Philosophy & Psychiatry Conference: July 2012: Autonomy and Agency in Islamic Culture & Theology: Implications for Psychiatric Ethics

 

Ethical practice in psychiatry is underpinned by a secular, anthropocentric concept of autonomy. While this reflects the cultural heritage of the communities where modern psychiatry was developed, it might not be suitable for populations with different understandings of autonomy. This presentation outlines some Islamic cultural/ethical issues of particular relevance to decision-making in psychiatry.

 

First, the scope of autonomy is considered. Outside one’s personal relation with God, autonomy is secondary to community. A collectivity can only achieve salvation when the conduct of each member is aligned with the norms of the faith. Moral/social violations are not individual choices but a threat to this order, and therefore of concern for others. Shared responsibility for the actions of others renders decision-making a collective enterprise guided by figures of authority. This has implications for informed consent, confidentiality, privacy, and the duty of clinicians towards patients.

 

Second, the paradox of agency is considered. Action in Islamic theology is both predetermined and the full responsibility of the agent. Suffering, in a determinist theodicy, is foreknown to God and is a trial and expiation for sins. This may promote fatalism towards treatment. With a free-will theodicy, humans bring suffering upon themselves through their actions, and must take an active attitude towards relieving it. Deterministic attitudes complicate the clinician’s duty to relieve suffering within the available means, and render sharing information (e.g. about prognosis) irrelevant. The presentation concludes by asking whether and to what extent a clinician should abandon her secular ethical principles in favour of other religious or cultural ones.

 

Intereseting blog on bioethics

Conference webpage