Four steps to decolonising the mental health sector

Increased awareness of the scale and burden of mental disorders has shone a light on the need to decolonise the mental health sector. But what could this look like in practice?

For many people, racism remains a key barrier to realising their right to health. Resource allocation and availability, attitudes, and assumptions about patients can all reflect structurally-racist attitudes within services.

But decolonising mental health services goes far beyond ending conscious racism.

First, the collective trauma of racism and discrimination often adds an additional burden on the psychosocial well-being of minority ethnic groups, and this applies just as readily in high-income countries as elsewhere. This collective trauma is why ethnicity should be recognised as a social determinant of mental health.

Secondly, the push to recognise universal human rights, which happened after the second world war, was a well-intentioned attempt to apply rights frameworks that excluded no one. But this helped to shape standardised approaches that could be applied to everyone, and this ignored (predominantly non-white) populations’ ‘right to be different’. Assumptions were made about what constitutes wellness, as well as illness, which prioritised European and North American conceptions. Imperialism has left behind an insidious legacy by transferring these assumptions from former colonisers to post-colonial elites; in this case, mental health professionals who have assimilated apparently ‘neutral’ western approaches to both psychology and psychiatry.

But different communities across the world have very different perspectives on both mental health and mental illness. Distress can manifest itself in different ways and be perceived as having very different causes, and there are differing views on approaches to treatment.

Within many cultures, concepts such as “balance/imbalance” are key to understanding relationships within society. These may be between family or community members, of course, but can also include relationships with societal ancestors or the natural environment. It can also include violation of cultural norms or taboos or spiritual causes of distress, such as spirit possession or sorcery.

How do we begin to decolonise?

1. Open the closed circle of therapists

Mental health professionals trained in standard approaches, such as those found in the Diagnostic and Statistical Manual of Mental Disorders, often find themselves out of sync with patients, and even communities, from different cultural backgrounds. It is important to recognise the unique contribution of traditional healers and spiritual guides as community counsellors and therapists. Having a shared worldview of healer and ‘patient’ may provide a foundation that enables a discussion of problems and their origin. It can also be key to establishing a therapeutic intervention that has meaning for the patient and can therefore provide them with relief.

2. Adapt training for therapists

Due to mental health being chronically underfunded within ministry of health budgets the world over, trained mental health practitioners across the globe, whatever their ethnicity, will clearly continue to play a major role. The concept of cultural competence as part of their skill sets has become increasingly accepted – but not universally so. This should be a necessary starting point, but it is not sufficient in and of itself. In Guatemala, for instance, where Health Poverty Action works, the number of ministry of health psychologists has tripled in recent years. But not one of them speaks the dominant language of the indigenous communities where they work. Trust and sensitivity between healthcare provider and patient is arguably even more important in the field of mental health, as this relies less on diagnostic equipment and more on speech, silence and non-verbal communication than physical health services.

3. Adapt therapies to cultural contexts

Mental health practitioners who work with non-white populations in Europe and the US, for instance, have become increasingly aware that a patient’s cultural context is relevant to their treatment. This often means re-writing the ‘rules’, whether that means allowing a patient to be accompanied by a family member or an advocate in a counselling session, changing a clinical setting to an outdoor one, being flexible in how long a session lasts, or even allowing social contact outside the therapeutic environment.

Understanding and accepting non-medical therapies may include being open to spiritual ceremonies, medicinal plants, and groups as opposed to individual approaches. These may, of course, bring their own challenges, such as stigmatisation of those held to be ‘possessed’ by malignant forces. But they have the potential to provide treatments that are more meaningful to the patient and therefore more likely to provide sustained relief.

4. Listen

Before anything else, it is essential to begin by listening – to people living with mental health issues and people of colour. This is the first step to decolonising mental health services with a rights-based approach which meets people’s needs.