Challenging the biomedical imperative in global mental health with clinical-community psychology

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A new article titled “Reflexivity on the medicalization of the mind and the biomedical invasion on being human,” published by Psychiatry in Society, provides an autoethnographic reflection from two clinical psychologists in South Africa.

It calls into question the dominant biomedical approach in clinical psychology, which often reduces mental health to biological factors and pharmacological interventions. By advocating for a clinical-community psychology approach, the authors emphasize the importance of understanding psychological issues within their broader social and cultural contexts. Their work challenges traditional methods of assessment, diagnosis, and treatment and highlights the need for psychology to draw upon a diverse range of knowledge, including often overlooked or marginalized perspectives. This approach can potentially revolutionize how psychological services are rendered in South Africa, making them more inclusive, holistic, and culturally sensitive.

Curwyn Mapaling, a researcher in the Department of Psychology at the University of Johannesburg, and Thirusha Naidu, a clinical psychologist at the University of Kwa-Zulu Natal Discipline of Behavioral Medicine, reflect on their training experiences and investigate the three primary functions of their work: assessment, diagnosis, and treatment.

The authors write,

“We believe that psychology is a discipline in its own right that has inherent tools to:
a) Not only work in a contextually responsive way with people to whom it renders service to, but also,
b) Draw on subjugated knowledge to counter biomedicine’s epistemically arrogant, colonial, foundationalist, and attenuating assumptions about the whole of a person’s psychological being – trying to reduce it to physiology etc. – while the discipline of psychology is so much more than that.”
Johannesburg, South Africa – April 30, 2015: Woman’s protest march in suburban street

The authors aimed to question the effectiveness of their training and to weigh in on the ongoing debate on the relevance of psychology. They begin the article with a personal self-reflection, using the autoethnographic method to narrate their experiences as clinical psychologists. The authors suggest that such grounded theory research can lead to novel psychological frameworks more attuned to people’s needs and promote decolonial practices. They also hope to share their experiences with future generations of psychologists.

They support their use of autoethnographic methodology with the following:

“As people of colour and practising clinical psychologists, it is imperative that we contextualize the three core clinical functions mentioned previously. Our lenses, shaped by our individual journeys, memories, and interactions, offer a unique insight into these functions, grounding them in our personal realities. A deep and meaningful contextualization is not just a scholarly exercise but is essential to truly grasp the nuances of our lived experiences. It bridges the gap between clinical terminology and the real-world implications it has on our daily lives.”

Drawing from clinical psychology and global mental health discussions, the authors use their autoethnographic insights to emphasize how the overarching biomedical model may not align with local customs and may disregard culturally unique manifestations of varying mental states. They accomplish this by exploring the fundamental clinical applications of psychology.

Mapaling was surprised to find that the first lesson in his training was based on a Western perspective of psychology, despite being trained in community psychology in the South African context. He noticed a tension between clinical psychology’s focus on individual psychodynamics and community psychology’s emphasis on socio-cultural and economic determinants of mental health. As he reflected on his training experience, Mapaling realized that the different approaches to psychology highlight the need for a more holistic, culturally sensitive, and community-based approach to mental health care in South Africa.

Naidu attended a university that was initially established exclusively for white students. She found the institution’s structures to be colonial and noticed that it presented modern Western psychology. Eventually, she chose to attend a graduate school that was previously exclusive to Black students. Here, she found teachers who shared her history, activists for change in the profession, and individuals who saw her as a person. While studying Western clinical psychology, Naidu also began questioning the foundations of the profession. Her work with local Zulu communities taught her about the diverse ways that people seek healing and support, especially in the aftermath of the imposition of Western health systems and apartheid. Naidu believes that her journey with psychology is characterized by rebellion and questioning, and she continues to practice this approach.

Assessment, Diagnosis, & Treatment

In interrogating the core functions of their training as clinical psychologists, the authors describe the problems with the reliance on the biomedical in clinical psychology. They address how “normal” behaviour is defined by what is acceptable in a social context, where one social group dominates another to determine the pathological by what does not fit within dominant ideals. The authors have both felt the tensions and contradictions when feeling the pressure to apply traditional clinical psychology models rooted in biomedical and Western science to diverse South African contexts and the harm that comes with too much focus on chemical imbalances rather than societal imbalances.

The authors express their disappointment and disillusionment with the way they were taught to diagnose. They felt torn between adopting a clinical model for diagnostics or an empathetic approach. They were unsure if they wanted to be associated with the profession and questioned how their training had prepared them to assess, diagnose, and treat patients while acknowledging that the approach followed by them was still colonial psychology.

Further, registering with the HPCSA and adhering to its many standards perpetuated colonial methods and upheld the biomedical façade. As a result, they believe in integrating positive psychology, individual clinical interventions, and systemic community strategies to lead a more holistic approach to mental health care and culturally appropriate models for South Africa.

Clinical-Community Psychology & Decolonizing Mental Health

The authors provided various examples to demonstrate the dire need for equitable and inclusive clinical psychology training and services in South Africa that meet the culturally specific needs of the community and move beyond traditional models.

The authors discuss community psychology, which focuses on health promotion and preventative measures, a practice that emerged as a response to the discipline’s past failures to address social inequalities. They suggest the potential of multidisciplinary teams that include various health professionals, traditional healers, and religious leaders. An emphasis on community elements in psychology allows psychologists to take less conventional roles in differing contexts.

Mapaling and Naidu emphasize the need to decolonize the knowledge in academic institutions within the Global South, where the historical, cultural, and socio-political contexts that shape mental health in South Africa are acknowledged and addressed, and the dominant paradigms are challenged. Instead, local knowledge, beliefs, and practices are promoted to meet the needs of the context in which the knowledge is operating.

 

In conclusion, the authors feel that psychology is not and should not be regarded as a biomedical science; instead, it is a discipline in its own right. The authors write that the biomedical narrative in clinical psychology borrows its legitimacy from science, which they argue is a pseudo-legitimacy and has no place in psychology. Decolonial psychology contends that it is irrelevant and leads to oppressive practices.

Mapaling and Naidu provide an essential contribution as clinical psychologists critiquing the biomedical model in mental health care as it is associated with discrimination amongst many other mental health professionals. They also speak to the debates of the Global Mental Health movement, which needs urgent transformation.

The author’s reflections align with other research on decolonizing efforts that interrogate Western notions of mental illness and knowledge-making processes in the Global South. They provide a new and unique perspective through autoethnographic methodology to pave the way for more appropriate frameworks and epistemologies.

 

 

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Mapaling, C., & Naidu, T. (2023). Reflexivity on medicalisation of the mind and the biomedical invasion on being human. PINS-Psychology in Society65(1). https://doi.org/10.57157/pins2023vol65iss1a5817 (Link)

 

Editor’s Note: Part of MITUK’s core mission is to present a scientific critique of the existing paradigm of care. Each week we will be republishing Mad in America’s latest blog on the evidence supporting the need for radical change.

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Ally is pursuing a master's in interdisciplinary studies through New York University's XE: Experimental Humanities & Social Engagement. She uses the relationship between anthropology, public health, and the humanities to guide her research. Her current interests lie at the intersection of literature and psychology as a method to reframe the way we think about different mental states and experiences. Ally earned a bachelor's degree from the University of Minnesota in Biology, Society, & Environment.