Conquering Culture: The Quest for Change in the Mental Health System

akerle's picture

‘Not only are cultures occasions for disabilities, they actively organize ways for persons to be disabled.’

Ray McDermott and Herve Varenne Culture as Disability  

 

During our time together this year, we have broadened the definition of mental health. Thanks to meaningful considerations of what it means to be mentally ill, mentally healthy or anything above and beyond those labels[1] we wrote a new and holistic story on the human experience. In our last class we chose to define mental health as a series of revisions to the ‘personal’ story, a desire for acceptance, change and a transformation of our perceptions of the self. Abstract? Yes. Noble and grandiose? Definitely. Logistically feasible? We will have to see about that. You see, the ultimate barrier we encounter in trying to revolutionise the mental health industry is culture. Culture defines what is normal and therefore what is abnormal. Cultural trends change over time and space. It has taken us all an entire semester to re-evaluate what our cultural norms have told us about mental health and still after this, all those from our class who plan to enter the medical profession intend to do so conforming to the social norms of medical health. In asking to change perceptions of mental health we are really asking to overturn mainstream social norms. If this does not happen, if there is not fundamental and pervasive cultural change, then all the work done in this classroom will be of little use.

            So what does culture really mean in the context of the human experience? People are naturally ‘group oriented’ creatures. There is no place on earth that is cultureless because wherever there exists more than one person, there exists some form of a group dynamic. This ‘groupishness’ reflects a necessity for protection and survival. Isolation did not help you in the evolutionary struggle for survival, but your odds were certainly greater if you belonged to a group.

Part of living and working in a group means that certain behaviours become acceptable, whereas others do not. In the earlier stages of our evolution, those unaccepted behaviours threatened the overall existence of the group in the struggle for survival. This ‘fear’ of abnormality has been inherited by modern humans and is reflected in our treatment of those who do not conform to what is culturally accepted. McDermott and Varenne, in this sense, describe culture as ‘disabling’. By creating a certain set of cultural norms, you automatically create a set of disabilities. Those that do not conform to mainstream culture are viewed as deviant, and inherently less worthy. 

            So what does this have to do with mental health you may ask? Well, those who do not reflect the mainstream American cultural norms, no matter if they are happy with who they are and their life experiences, they are viewed by society as deviant. This ancient and inherited fear of the abnormal reflects our cultural position on mental health.  Within every group, there exists a certain sense of ‘normality’ that those who are ‘mentally ill’, do not conform to. As McDermott and Varenne note,

‘People also use established cultural forms to define those who do not work on the "right" things, for the "right" reason, or in the "right" way. Being in a culture is a great occasion for developing disabilities, or at least for having many people think they have disabilities. Being in a culture may be the only road to enhancement; it is also very dangerous.’[2]

Culture makes it impossible for us to interact as mere individuals. We are products of collective thought. Unfortunately, in our particular culture, western culture, collective thought has inherited a fear of mental illness, disabling those who experience varied forms of mental health.

            The strange irony of this disabling culture is that almost one in four Americans will experience some form of a mental illness in their lifetime[3]. I suspect the number is far higher in terms of people who may be unhappy with their mental state but feel they cannot seek help. Thankfully, the mentally ill are no longer treated as they were 100 years ago, beaten, chained and tortured. Yet in many ways, the stigma and the fear associated with mental illness still remains. So what is it about this stigma that is so particular to western culture? In other cultures, and even in earlier western history, many people we would classify today as mentally unhealthy were actually revered as gods, shamans or particularly spiritually enlightened. I believe that American society in particular has a set of cultural norms that are particularly difficult to live up to and in many ways, foster a sense of isolation and competitiveness.

            Western culture, but American culture in particular, favours the concept of a hardworking, independent, successful individual. One website succinctly listed all these characteristics with a particular emphasis on, ‘Autonomy: being capable of independent action and environmental mastery: meeting the requirements of the many different situations encountered in everyday life.’[4] In reading this I am amazed by the narrow definition of what it means to be healthy, but in some ways not surprised. The fact that so many Americans fail to live up to this concept of ‘normal’ reflects an inherent competitiveness in this society. We value ambition and single-mindedness, control and success. Those who are mentally ill profoundly deviate from these ingrained cultural norms. The culture fears them, and therefore stigmatises them. Yet if these cultural norms are different or even non-existent, then the fear of deviance vanishes. As McDermott and Varenne say, ‘No ability, no disability. No disability, no ability.’[5]

            Not only does culture as a whole have disabling functions when it comes to mental health, but the ignorance of another’s culture can also affect the success of treatment. Sadly, the mental health system places an emphasis on the well being (so to speak) of the dominant group. There have been many instances of minorities being ignored by nurses or doctors, or misdiagnosed thanks to a cultural misunderstanding. Take the instance where a 49-year-old Puerto Rican woman was diagnosed as depressed and psychotic when what she really wanted was help reconciling with her son. It turns out that the ‘psychosis’, hearing voices and seeing visions, was a regular part of her culture and she in no way viewed it as negative.[6] Indeed cultural understanding is vitally important to successful diagnosis and treatment. Often when the dominant group misunderstands the motivations of the other, or indeed takes no concrete interest in these motivations, the results can be at best alienating and at worst highly dangerous. 

            Up to this point we have been able to discuss the aspects of culture in general and American culture in particular that alienate certain members of society. Now I wish to focus on the fact that culture is not static, and that social change is not only possible but also reflective of how much mental health/illness is a product of cultural norms. Let us take, for example, homosexuality.

During the 1950’s homosexuality was defined by mainstream society and the DSM IV (The Diagnostic and Statistical Manual of Mental Disorders) as a mental illness. It defied the cultural values of the time and was viewed as a real deviance, a sickness. Now, however, the DSM IV no longer classifies homosexuality as a psychiatric illness. Some may not agree with this reclassification, but large groups in the United States accept homosexuality as another facet of the human experience.

There are several important conclusions to draw from this. The first being that cultural norms dictate the classification of mental illness. Clearly the behaviour has existed since humans have been on the earth, but the cultural attitude towards it has changed. In some parts of the world this is still not the case, and many people may view homosexuality as an unnatural deviance. This brings me to the second important conclusion: change in social attitude is possible. As we can see, something that has for centuries (especially in the United States) been viewed as a deviant behaviour is now viewed in certain parts of the country as nothing short of normal. If we can learn to embrace homosexuality as a part of mainstream culture, then perhaps there is hope for change in other aspects of mental health.

I have been grappling with the idea of a ‘disabling’ American culture that makes it difficult for certain individuals with mental health problems to feel they are a part of society, but what about aspects of different cultures that are ‘enabling’? No culture is perfect, but some are capable of handling certain aspects of mental health better than others.

A World Health Organisation study discovered that individuals suffering from schizophrenia had higher rates of recovery and more stable, functioning lives if they lived in the third world. This highlights an interesting aspect of the treatment of mental health in developing countries. As developing nations they often do not have the resources to spend on any kind of public service, and most citizens cannot afford to use the medication we enjoy here. Yet schizophrenia exists internationally, so the fact that individuals in the third world are receiving more effective mental health care raises this question: What are they doing that we are not?

Shankar Verdam tries to answer this question, and in doing so focuses on India and the innate cultural difference between Indian cultural norms and American ones. He writes,

‘ Most people with schizophrenia in India live with their families or other social networks -- in sharp contrast to the United States, where most patients are homeless, in group homes or on their own, in psychiatric facilities or in jail. Many Indian patients are given low-stress jobs by a culture that values social connectedness over productivity; patients in the United States are usually excluded from regular workplaces.’ [7]

 

Culture in the developing world tends to be a lot more inclusive than that in the west. Indeed, the tenets of western culture are based in the ideas of competition and success above all others. This concept does not exist in many parts of the developing world, although you would be more likely to see it in the cities rather than in rural areas.  In the west we isolate the mentally ill, excluding them from ‘functioning’ society. In the developing world, the notion of a functioning society takes on a different form so the need to isolate those who do not conform does not exist as strongly.

            I have tried, to the best of my ability, to outline some of the ways in which culture has both negatively and positively affected how we view mental health. As I mentioned earlier, it would appear that in order to really transform the mental health industry, we need to change our culture. We need to change how we relate to each other and in particular we need to re evaluate where our priorities lie. I have found myself agreeing with our new evolved vision of mental health because to me it seems like the best option. However, our current culture still seems to make any real progress in the way of re evaluating mental health an impossibility. In trying not to appear entirely fatalistic, I want to tentatively ask what can actually, really happen in order to make the changes to the mental health system that we so desperately need.

            The first relates to previous social changes we have seen happen in recent history. If we look at the civil rights movement, the women’s movement and even the gay rights movement, we can see a real possibility in mobilising people in order to transform social norms. These movements have by no means been perfect, nor have we seen a perfect outcome, but they have radically changed accepted social norms and perceptions. They have forced the hand of the government into passing laws and changing public policy and in that sense they have been highly successful. Yes, there are still aspects of the culture that have not been changed, but for many people these movements have transformed their lives.

Could we have a mental health movement? Would it be possible for enough people to come together to really change the way mental health is viewed in our society? Remember, with other social movements, the initial goal was to change government policy towards institutionalised sexism, racism and homophobia. Along with that, however, came a transformation in cultural awareness. The mental health movement might aim for the same goals and the same final outcome. If our aim with mental health is to change the system to benefit each individual patient, to help them change and grow in the most holistic way possible, then perhaps we need laws to reflect that aim. Perhaps at the very least, making it illegal for insurance companies to treat mental health as secondary to physical health. The recent bill in mental health parity reflects some movement in this direction, but something needs to happen on a larger scale with the force of a social movement behind it.

The second concrete possibility can be found in education, education, education. This may seem obvious, but the power of education is often underestimated. At all levels of society education about the nuances and subtleties of the human experience can really transform how we as a culture view our position on mental health. As someone who has grown to understand the importance of mental health thanks to education, I strongly believe that this kind of information can benefit people in how they perceive themselves, especially in relation to the wider world. As groups of individuals grow more learned, you must surely see a transformation in the overall attitudes of society. Mental health awareness has not ever really, on a grand scale, been introduced into school and university curriculum’s nationwide, but perhaps if that were to happen we would experience the kind of change for mental health that we so desperately need.

            I have tried, in as comprehensive a way possible, to outline the difficulties associated with culture. The ‘social’ mountain is always the hardest to climb and the most brutal to overcome. Culture, by simply existing, creates a dichotomy between those who are able to maintain mainstream norms, and those who cannot. For as much as culture enables individuals, it disables others as well. This of course applies to the way mental health is experienced in modern America. The American cultural values, placing an emphasis on hard work and autonomy, make it difficult for those who have mental health problems to feel as though they are members in this society. They are feared and isolated in the severest cases, but in less severe mental health cases many people find themselves facing a stigma, or a kind of disdain for not being ‘in control.’ The problems with American culture and mental health become all the more apparent when compared to the experiences of mentally ill people in the third world. The strong social networks make recovery from mental health illnesses not only possible but probably. Yet all is not hopeless. Cultures change. Cultures grow and mature as people do. Something can be done to change the prevailing attitude in order to ultimately change the mental health system. Through social movements, education or anything else that we can come up with, there is always the possibility of change.


[1] For the sake of simplicity I shall use these terms as people in the mainstream, who have NOT taken this class, would define them. Their validity as labels is obviously circumspect, but that question can be answered in another essay. 

[2] McDermott, Ray, and Herve Varenne. "Culture as Disability." Anthropology and Education Quarterly 26 (1995): 323-48.

[3] "Statistics." Health and Outreach. 28 Feb. 2008. The National Institute of Mental Health (NIMH). 17 Dec. 2008 <http://www.nimh.nih.gov/health/topics/statistics/index.shtml>.

[4] "Defining Mental Illness." Measuring the Unmeasurable: An Introduction to Psychology. 2004.Making the Modern World: Stories About the Lives We've Made. 17 Dec. 2008<http://www.makingthemodernworld.org.uk/learning_modules/psychology/02.tu.04/?section=3>.

[5] McDermott, Varenne. Opcit.

[6] Vedantam, Shankar. "Patient's Diversity is Often Discounted." Mind and Culture: Psychiatry's Missing Diagnosis. 26 June 2005. The Washington Post. 17 Dec. 2008 <http://www.washingtonpost.com/wp-dyn/content/article/2005/06/25/ar2005062500982.html>.

[7] Vedantam, Shankar. "Social Network's Healing Power Is Borne Out in Poorer Nations." Mind and Culture: Psychiatry's Missing Diagnosis. 27 June 2005. The Washington Post. 17 Dec. 2008 <http://www.washingtonpost.com/wp-dyn/content/article/2005/06/26/ar2005062601091.html>.

Comments

Nicki Glasser's picture

language and culture change

It is hard for me to read your article about changing mental health culture to something more inclusive and less judgment-laden (if you are labeled/diagnosed you are not "other" but "us", human behavior can be seen on a continuum) when you are using words that impart otherness, in particular labeling people as "the mentally ill" or "being mentally ill". Rather, we are people-first and have a condition or have been labeled as having one. Please keep in mind how culture is passed on through just these types of assumptions and in our language. I suggest reading the following articles which have some important ideas about language/words and the impact on culture. The first 2 are available free online.
- Language: The Importance of Language in Promoting Community Integration. UPENN Collaborative on Community Integration. http://www.upennrrtc.org/issues/view.php?id=8
- IAPSRS Language Guidelines https://www.bu.edu/cpr/prj/langguidelines.pdf
- Spaniol, S., & Cattaneo, M. (1997). The power of language in the helping relationship. In L. Spaniol, C. Gagne, & M. Koehler (Eds.), Psychological and social aspects of psychiatric disability. Boston, MA: Center for Psychiatric Rehabilitation.

A key component of culture change in mental health services will require a system that is driven by the people who use it. Recent policy reports including the Surgeon General's on Mental Health, the President's New Freedom Commission and the Institute of Medicine's Quality Chasm Series on Mental Health and Substance Abuse all state the importance of service users and family members playing key roles in system change. I'd suggest every individual working in the system think of ways to create meaningful partnerships in their day to day work, from writers, trainers, and educators to adminstrators and service providers. When that happens language and so many other key components of change will become daily realities.

Paul Grobstein's picture

Mental health and cultural change

"Western culture, but American culture in particular, favours the concept of a hardworking, independent, successful individual"

Compelling argument about the need for a cultural change, indeed inspirational in the assertion of the possibility of such change.

If I'm hearing you correctly, the particular feature that needs to change is the high value placed on "independent"? Schizophrenics, our elephant in the room touchstone, do better in India because they "live with their families or other social networks."

But perhaps there is a conflict between a vision of mental health that respects and encourages individual distinctiveness ("to benefit each individual patient") and one that places renewed emphasis on interdependence? Families aren't notorious for the former, in India or other places. Can families change, or are there other forms of social organization that might do better in that regard? Could education promote a recognition of the importance of both interdependence and individuation? How?

jrlewis's picture

I strongly agree with your

I strongly agree with your point about the need for education in a project of social change.  Schools are there own communities with special cultures not entirely identical to the their surroundings.   Seesms like a good location to creat change. 

Coming from a conservative high school where the gay-straight student alliance is trying to encourage the faculty to discuss something anything about gay rights or lifestlye.  For example, in health class, conversations about safe sex are currently limited to heterosexual sex.  Even acknowledging mental health alternatives is an important step in some contexts. 

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