Introduction

Watson (2006) in her keynote address at the World Federation of Occupational Therapists’ world congress in Sydney in 2006 gave a thought-provoking address on the cultural identity of occupational therapy, addressing the essence of the profession. She asked the question, ‘What is valued by the profession, who does the valuing and why do we need to be vigilant about culture?’ (p. 152). Whilst not specifically focusing on the area of mental health, Watson gives in-depth answers to the aforementioned questions in the address by discussing issues such as why culture matters, changing the culture of occupational therapy education and promoting culturally relevant practice.

Feros (1959) describes culture as ‘the total of socially inherited characteristics of a human group that comprises everything which one generation can tell, convey, or hand down to the next; in other words, the non-physical inherited traits we possess’ (p. 43).

The field of mental health is a complicated socially constructed area of health concern, which is partly dictated by cultural and religious norms. Mental illness carries with it a host of different theories and beliefs, which differ in their conceptualisation of the illness according to societies, groups, cultures, institutions and professions. Christiansen and Baum (1997) stated that ‘culture affects performance in many ways including the prescribing of norms, for the use of time and space, influencing beliefs regarding the importance of various tasks, and transmitting attitudes and values regarding work and play’ (p. 61).

The ethnicity, training, culture, class and political and religious backgrounds of professionals will dictate what intervention, if any, is appropriate and which methods will be applied during treatment. When addressing the profession of occupational therapy, Gujral states that:

Cultural factors have potentially far-reaching effects on the provision of care, including selection and interpretation of assessment instruments, interpersonal communication, intervention and outcome expectations (Gujral in Creek 2002, p. 472).

Culture, mental health and mental illness

Cultural awareness is necessary for the provision of all quality health care, but it has particular importance for the mental health field because of the nature of practice (Dillard et al. 1992, p. 721).

In Africa, mental health problems amongst people are usually understood and perceived within traditional and religious contexts. Variations in a person’s behaviour may be considered normal or abnormal depending on cultural norms. Psychotic behaviour is known as ‘strange behaviour’, and depression is often expressed in bodily pains such as abdominal and chest pains (Voce & Ramukumba 1997 in Crouch & Alers). A depressed person may say that he/she has a pain in the heart. The mentally ill client may express himself/herself within the cultural norms, for example, a paranoid patient from a Western culture may explain that someone is trying to harm him through radar waves. ‘A patient, who is influenced by a traditional African belief, may presume that he has been bewitched or cursed’ (Voce & Ramukumba 1997, p. 126, in Crouch & Alers).

Spector (1985) discusses health care problems with Native Americans who lived in a state of abject poverty at the time. Many of the old ways of diagnosing and treating illnesses did not survive the migration and changing lives. Because these skills had been lost and modern medicines often not available, people were often in limbo when it came to obtaining adequate health care. Many of the illnesses that are familiar to white patients may have manifested themselves differently in Indian patients. The factor that inhibited the Indian use of white-dominated health services at that time was a deep cultural problem where there were differences in perception of illnesses and also factors as separation from their families and the unfamiliar environment of the hospital and attitudes of the staff. Some patients were silent and others left and did not return. Spector (1985) stated that ‘the patient is a passive recipient of disease when the disease is caused by an external force. This external force disrupts the natural order of the internal person, and the treatment must be designed to restore this order. The causes of disharmony can be evil and witches’ (p. 166).

Beliefs amongst people in any culture are also influenced by factors such as the socio-economic status, the environment and the educational standard of a person. However, even within the most educated societies, strong traditional beliefs and healing systems influence a person’s perception of mental illness (Swartz 1998). ‘Clients are diagnosed differently by different diagnostic systems’. Lesunyane (2010) describes a client ‘being diagnosed as schizophrenic by the local hospital and the biomedical system, bewitched by the traditional healer, and possessed by the devil by the Pentecostal church’ (p. 290). This is indeed confusing for all concerned! Lesunyane also discusses the fact that treatment in Africa is often sought in the following order: the traditional healer, then a church and lastly the hospital when the condition is out of control. Language barriers obviously contribute to the difficulties of interpreting what the patient’s symptoms and problems are, and making a diagnosis is difficult.

Although belief that traditional practices may affect the treatment outcomes, it should be noted that often traditional practices serve cultural and therapeutic purposes (Lesunyane 2010). They therefore should not be disregarded, especially that professional mental health care services are scarce, particularly in a rural community. ‘Some people still opt for traditional healing even if modernised health care resources are available to them’ (Lesunyane 2010, p. 292). Lesunyane also stresses that Western-trained professionals should recognise good traditional healers and their contribution to dealing with mental health problems within the broader context of the sociocultural context of their clients.

Culture has long been defined with respect to its underlying influence on individual views, or in terms of its artistic or scientific expression. It is, however, unfortunate that culture in today’s society is often immediately replaced with the idea of race or ethnicity, as well as the prejudgements that may accompany those ideas. It is important to note that neither race nor ethnicity is synonymous with culture (Townsend & Polatajko 2007, p. 52).

Culture also plays a very important role in the interpretation of the cause of a mental illness. A modern-day approach attributes a mental illness to stress, viruses, chemical causes such as drugs and alcohol, family background, living conditions and genetic disposition. The client and family (including parents and grandparents) may attribute it to ancestors, witchcraft, magic, spells and the ‘evil eye’ in which ‘hate, envy or jealousy may exist’ (Spector 1985, p. 72). These beliefs often lend comfort to them. ‘In the minds of people who still believe and practice traditional health beliefs, these contributing factors are as real as the bacteria and viruses of modern epidemiology are to health care providers’ (Spector 1985, p. 72).

In some cultures, options are not communicated directly, and feelings are not expressed verbally. People are conservative in acting out or talking about their problems, and as a result, body reactions and somatic symptoms are common. Hallucinations often are a reflection of the preoccupations of the family community and culture. ‘The approach to cross-cultural work must be that of open-mindedness, acceptance and positive attitude towards different cultures’(Voce & Ramukumba 1997, p. 127).

The stigma of mental illness exists in most cultures but is greatly influenced by education and familiarity with the reality and the nature of the illnesses. In some ways, the media has helped in this regard in educational films and programmes, and in other cases, the media often reports on crime as being related to conditions such as types of personality disorders, conduct disorders in young people, schizophrenia, hypomania and drugs. In Africa, ‘A lack of mental health policy, as well as social stigma, has meant that in much of Africa mental illness is a hidden issue’ (Gordon 2011, p. 1). There is no doubt that ignorance contributes greatly to abuse, discrimination and human rights violations both from those in the field of health care and by the community (Gordon 2011). The World Health Organization mhGAP Intervention Guide (2013) can act as a guide to the projects that are in place to try to combat this problem.

Cultural competence in mental health is often discussed from a medical and occupational therapy perspective in both Web based articles and research papers. It basically covers issues such as homophobia, classism (to do with prejudice against certain social classes) and religious intolerance but also addresses cultural bias and stereotypes which include racism, ageism, sexism and heterosexism as well as ethnicity, language, gender, disability and education (Dillard et al. 1992).

Cloutman (2001) gives good examples of different cultures and their reactions to mental illness. He states that ‘Chinese elders typically don’t seek help for depression and other mental disorders, …You go along with what your culture tells you: tough it out or let time heal the problem…They don’t know depression can be treated… (Some) end up as an in patient or locked in a locked Facility’ (p. 4).