Culture and Context: Lessons from a Sub-Saharan African

Experience

Rachel Hingst, OTR, CPRP

Learning Objectives:

Attendees will be able to: Describe cultural values which are reflected in the

principles and practice of psychiatric rehabilitation in the United States

Explain some of the specific challenges faced by both individuals with mental illness and service providers in developing countries

Recognize their responsibility as global citizens to advocate for mental health to be prioritized on the international health agenda

Session Outline:

Introduction to Sub-Saharan Africa American cultural values, norms, and

assumptions Small group work Presentations of group work Challenges Examples of practices Questions/discussion

“Developing countries”

Developing/developed Least Developed Countries (LDC) Less Economically Developed Country (LEDC) Non-industrialized/industrialized Third world/first world Global south/global north Majority World

If the world was a village...

If the world's population was reduced to 100 people: 60 Asians, 14 Africans, 12 Europeans, 8 Latin Americans, 5 from the USA

and Canada, and 1 from the South Pacific

67 would be unable to read

50 would be malnourished and 1 dying of starvation

24 would not have any electricity (And of the 76 that do have electricity, most would only use it for light at night.)

1 would have a college education

5 would control 32% of the entire world's wealth; all 5 would be US citizens

33 would be receiving --and attempting to live on-- only 3% of the income of "the village"

Global Mental Health:

WHO estimates 450 million people worldwide experience mental health problems: 154 million: depression 25 million: schizophrenia 91 million: alcohol use disorders

Spending in developing countries: Most middle and low-income countries devote less than 1% of their health expenditure to mental health.

Sub-Saharan Africa:

Sub-Saharan Africa:

What words come to mind?

Sub-saharan Africa

Population of over 800 million Diversity:

1000 different languages Shared experiences

Resources: Ivory and slaves Copper, cotton, rubber, diamonds, tea, tin Oil, gold, platinum, uranium, coltan

The Scramble for Africa:

End of 19th century Colonization: artificial boundaries Minority governments Apartheid

Independence: Decolonization Some challenges with independence: human

resource and infrastructure...

Conflicts:

Country Time Estimated deaths

Nigeria 1967-1970 200,000-1 million+

Mozambique 1977-1992 900,000

Angola 1975-2002 500,000+

Sierra Leon 1991-2002 75,000-150,000

Rwanda April 1994-July 1994 500,000-1 million

Congo 1998-2003 3 million+

Politics:

Dictatorships One-party states

Economics:

Average GDP per capital in Sub-Saharan Africa: approximately $1,800 (compared to about $46,000 for USA)

Almost half of people live on less than $1 a day (extreme poverty)

HIV/AIDS:

Accounts for 67% of HIV infections worldwide (about 22 million people)

Disrupted communities and families 14 million children are orphans Human resources: loss of productive

citizens Stress/grief: psychosocial burden

Psychiatric Rehab?

Worked for 2 ½ years in Malawi

First in government psychiatric hospital then for NGO providing mental health services

Programs included: inpatient hospital, outpatient clinic, community outreach clinics, day rehabilitation program, vocational training school, food security program, street children's program, college for training psychiatric nurses and clinical officers, and programs for children with special needs

Where is Malawi?

Examining American norms, values, and assumptions:

“Psychiatric rehabilitation has its origins in a Western humanistic worldview, based predominantly on United States and British culture.”-from USPRA Multicultural Principles

Multicultural Principles:

Understanding own culture:

“The essence of multiculturalism is the study of one’s own culture and ethnicity as the basis for understanding and identifying with those from others. Interpersonal encounters are not “objective” or “value-free” even when these encounters occur in a therapeutic or rehabilitation relationship.” (from Principle 2)

Recognizing Worldview of Others:

“Psychiatric rehabilitation practitioners recognize that thought patterns and behaviors are influenced by a person’s worldview, ethnicity and culture of which there are many.” (from Principle 4)

Value: Individual

American value: “Rugged individualism” Independence valued over interdependence

“...appreciating cultural preferences that value relationships and interdependence, in addition to individuality and independence.” (Principle 7)

Value: Work and Achievement

From USPRA Vision:

“It promotes a world in which individuals with mental illnesses can recover to achieve successful and satisfying lives in the working, learning and social environments of their choice.”

Value: Work and Achievement

Do all cultures highly value work and achievement? “Psychiatric rehabilitation practitioners show respect towards

others by accepting cultural values and beliefs that emphasize process or product, as well as harmony or achievement.” (Principle 7)

“Most mental health service systems in the U.S. place a great deal of emphasis on outcomes, especially achievement of independence and success in role functioning, such as competitive employment. Psychiatric rehabilitation practitioners recognize that people who use psychiatric rehabilitation services will have a variety of definitions of what constitutes success, satisfaction, and recovery.”

Value: Future Orientation

Emphasis on planning and progress: Life goals, short-term and long-term goals, strategic planning, etc.

Is this something all cultures can relate to? Importance of the past

Value: Control

American dream: we control our own destinies; have the ability to bring prosperity to ourselves

Tradition of democracy Automony Not everyone has choices: influenced by

political, social, and economic factors Role of fate and the supernatural

Assumption: Infrastructure

Roads/transportation Communication: phone, mail, internet Water/sanitation Electricity

Assumption: Healthcare/social service system:

Functional structure Human resource Other basic resources: medication, soap, lab

tests, etc. Social security/welfare system: housing options,

disability benefits, etc.

Assumption: Economic opportunities

Employment: diverse economy with various sectors

Loans accessible: business, education, housing, etc.

Small Group Work:

Each group will be given one principle or practice of psychiatric rehabilitation or a characteristic of recovery-focused services

Discuss the challenges and opportunities you anticipate in applying this principle/practice in the context of a developing country

Consider the cultural differences, social and political factors, and economic disparities

Challenges in implementing psychiatric rehab services:

Based on personal experiences in Malawi In addition to day to day challenges Economic Available support

Traditional Beliefs:

Causes of mental illness Witchcraft Traditional healers Locus of control Challenges: adherence to medication/treatment

poor; active role in illness management difficult

Stigma

Disability in general seen as burden

Enormous public stigma

Open discrimination by leaders, public figures, and health workers

Staff working in mental health also stigmatized

Challenges: mental health is relegated to background; no resources allocated; even with good skills clients struggle to have satisfying lives due to public stigma

Donor culture

International development sector: controversy

Allowances for workshops: “allowance culture”: created by donors

Volunteering as a job

Donors have the power

Challenges: difficult to find committed employees and volunteers; resources spent on trainings with questionable outcomes; Western standards/expectations imposed which may not be needed/realistic/sensible in the context

Evidence

Digital divide: how many people in this world have internet access?

Imported evidence

Validity of tools: cultural bias

Capacity for research

Outside researchers

Challenges: Difficulty measuring outcomes—building an evidence base; relying on imported evidence; alienation of our colleagues across the digital divide

What works?

Examples of practices...

Sensitization

Employers Police and prison workers Churches Traditional/community leaders Community-level

Relationships with Traditional Healers

Early identification of problems Using as part of the team

Skills training

Adapting to language and culture Examples: conflict management, problem

solving, stress management

Food Security Program

“Supported farming” Involves family and community Gives client status/fights stigma Links with housing

Vocational training

Various trades for self-employment or community employment

Educational support

Business/supported employment

“supported employment”--not same as US model

Business raises money for service Gives clients work experience Fights stigma

Community-Based Rehabilitation CBR Model for rehabilitation and social integration for

people with disabilities See WHO references in handout

Plea for Advocacy:

Remember the Majority World Be an advocate for making mental health a

global priority “No health without mental health.” Celebrate World Mental Health Day on October

10.