Elena Popa
Affiliation: University of Seville
Category: Philosophy
Keywords: philosophy of psychiatry, social determinants of health, pluralism, psychotherapy, evidence-based medicine, global mental health
Date: Wednesday 3rd of September
Time: 15:00
Location: GSSR Plenary Hall (268)
View the full session: Psychotherapy & Psychiatry
Questions of cultural variation are particularly important in understanding and approaching mental health problems. One instance concerns assessing psychiatric interventions in a global setting where historical power imbalances and an unjust status quo may lead to the neglect of local manifestations of mental health problems and the promotion of interventions that do not work well in low-income contexts or, more broadly speaking, the Global South. Despite relevant debates within fields such as cultural psychiatry or medical anthropology, particularly around whether the Global Mental Health Movement does more than export mainstream psychiatry, these issues have received comparatively little philosophical attention. Emerging philosophical work on the topic has employed insights from scientific pluralism, naturalism and normativity, and epistemic justice with regard to notions of mental disorder to sketch out how the conceptual challenges may be overcome (Popa 2020, 2024; Ludwig & Ruphy 2021). This paper will use and further develop these insights, particularly the support for multiple approaches and the call for a less rigid stance towards evidence through investigating a type of problem-solving therapy developed in low-income setting and adopted beyond this context due to its success. The ‘friendship bench’ approach has been introduced in Zimbabwe (Chibanda et al 2015) and subsequently used in other countries in Africa, but also in a pilot study in the US (Muetsi et al. 2021). As initially introduced, the friendship bench involved lay health workers, specifically elderly women (‘community grandmothers’) from the communities of patients in psychiatric hospitals meeting patients once a week to talk through the problems they faced and find solutions. Its success rate, which overcame the standard psychiatric treatment has lead to its use in different countries facing similar challenges with regard to the provision of mental health support, but also in marginalized communities in high-income countries (Muetsi et al. 2021). Still, some differences between these uses should be pointed out. Notably, in the pilot study in New York, the lay health workers were deemed ‘peers’ and shared some of the life experiences of the marginalized individuals in need of support (cf., Dewison 2021). Unlike in other uses of this method, the purpose was to help the affected individuals access the mental health or social services instead of being primary providers of psychological support. This raises further questions about the relation between lay health workers and mental health professionals and how to integrate the two while giving sufficient weight to the role of lived experience and connection to the patients. The case study is interesting because it points to an alternative to framing psychotherapeutic interventions as ‘exports’ from the Global North and assumption that the psychological features of individuals living in these contexts are universal (Cox & Web 2015, Summerfield 2013). At the same time, the fact that specific features of this approach cut through distinct contexts also challenges a thoroughly relativistic approach to cross-cultural issues in psychiatry and psychotherapy. For instance, this approach purposefully avoids a medicalized framing of the problems faced by the patients, which is particularly fitting in communities where mental health problems are stigmatized due to cultural and historical factors, but also broader social ones. Another feature is that the lay health workers share the background of the patients – culture and community in the case of the community grandmothers in Zimbabwe, or a history of social exclusion in the case of lay workers in the New York pilot study. Thus, there is a deeper connection to be highlighted between integrating concerns about (mental) health and helping solve social problems that patients are facing. The importance of connection and the personal nature of the therapy also provides a counterpoint to overly medicalized approaches that have been criticized even in narrower uses. Another important thing to point out concerns evidence. The success of the method has been assessed through randomized controlled trials (Chibanda et al 2015), which falls in line with the tenets of evidence-based medicine. This can at least in part explain its uptake in different contexts, which may be more difficult in the case of interventions that do not lend themselves to assessment through these kinds of methods. Still, it should be also stressed that qualitative work, which is not so easily reconcilable with the preferred types of evidence in evidence-based medicine is also needed to explain how this approach works and potentially draw wider conclusions (see Verhey 2018 for mixed methods). At the same time concerns about justice, broadly constured still arise. As mentioned earlier, the relation between the medical and social support systems that exclude marginalized patients and the role played by lay health workers (cf., Dewison 2021) needs a to be re-thought so as not to diminish the importance of this intervention and the reasons why it works. Similar issues arise when considering how the friendship bench intervention can be used alongside methods that have been shown to work in the case of post-traumatic stress disorder (Verhey et al 2020). Employing both approaches could further help the patients, but in doing so, one should be careful not to enforce a dominance of the ‘mainstream’ approach. More broadly, the case of the friendship bench provides reasons for pursuing the integration of medical research and work on social determinants of mental disorders, while also highlighting some of the challenges of this project. Perhaps the most important one is how to maintain a pluralistic outlook without marginalizing the social approaches and without medicalizing social problems.