In May 2015, the Lebanese Ministry of Health launched a five-year national strategy entitled Mental Health and Substance Use: Prevention, Promotion, and Treatment. As anthropologists working on psychiatry and mental health in Lebanon, we were invited to comment on a draft of the strategy. Two years into its adoption, we publish our critique of this kind of psychologization, highlighting its social and political implications. We hope our intervention will raise much-needed questions and inform constructive debates around the national strategy, especially in the light of the ministry of health’s recent decision to provide coverage for mental health cases in Lebanese hospitals.

A reading of this strategy reveals many of the assumptions it relies on to define and treat mental illness in Lebanon. First, the strategy relies on a clinical and medical intervention model, where the recommended treatment for individuals suffering from illnesses and discomforts is often a mixture of psychotropic medication (medications used to treat psychiatric conditions) coupled with psychotherapy. Second, the strategy seeks to establish a community-based mental health service that creates better access for people who cannot afford it. This type of reform seeks a more affordable continuum of care by incorporating mental health within primary healthcare centers, in line with the World Health Organizations’ (WHO) “mental health gap” strategy outlined in 2008.  Third, the strategy frames mental health first and foremost as a human rights issue. Fourth, it conceives of vulnerable groups as the most in need for mental health. Finally, it aims to raise awareness on the importance of mental health to lessen the stigma of mental illness in society.

In light of these assumptions, we raise the following critiques of this type of mental health reform.

The National Strategy as Community-Based Mental Health Service

The national strategy conceives of mental health as a psychological and individualized issue that requires medicalization and clinical treatment. By incorporating mental health services within primary healthcare centers, the national strategy is reinforcing a type of healthcare that prioritizes the clinical and individual over the social, which it treats as a separate concern. The national strategy thereby does not adopt a community-based approach. A community-based approach is political. It does not isolate and separate mental health from community life. Rather, it approaches mental health first and foremost as an issue related to social, economic and relational dimensions, and lastly, as a clinical and individual issue.

Moreover, building community-based services should be based on a deeper interrogation of the role of medical knowledge and practice in a community. Detecting pathologies should not be the main problem, and pharmaceutical treatments cannot be the only path to be followed when treating mental health according to a community-based approach. Rather, a more comprehensive service must be established, where the role of the physician becomes part of a much larger network of patients, various care and healing practitioners,  community members and associations dealing with civil right issues, protection, etc.

Mental Health as a Human Rights Issue

By defining mental health primarily as a human rights issue, the national strategy continues to tie the issue of mental health in Lebanon with global humanitarian standards and definitions of mental health. While this reform aims to provide more access and continuous mental health treatment for people who cannot afford it, it actually reproduces a political economy around mental health based on humanitarian donations and organizations. This economy is temporary by definition and is based on shifts in donor agendas and strategies. We already witnessed an interruption of mental health services for Syrian refugees in 2015, when psychotropic medications had to be abruptly suspended because funds for mental health services were not renewed almost overnight. Therefore, adopting a pharmaceutical treatment model in this context can lead to more economic distress among patients, because the interruption of funds and treatment will affect them directly.

Second, by redefining mental health as a human rights issue, the national strategy turns mental health into a form of charity-based right, disregarding the civic, economic and political rights that define mental health within a society. Subsequently, this kind of reform adopted by the National Strategy ends up reproducing a privatization/charity dichotomy, where the public healthcare system is completely absent.

Indicators of Mental Illness or Social Conditions?

The mental health strategy cites the following five factors as indicators of mental illness: poverty; low levels of education; gender; exposure to conflict situations; stressful life events; and chronic physical health problems. While these “indicators” are part of WHO’s research on mental health, the strategy argues that mental healthcare is fundamentally needed in Lebanon because many of these factors are prominent, especially poverty, gender inequalities and conflict.  We are concerned with the use of this type of classification and correlation of mental illness with social issues that can very easily lead to pathologizing structural conditions, inequalities and violence, instead of working towards achieving social and gender equity and understanding the politics of conflicts and violence. The pathologization of structural conditions has been documented anthropologically in different societies such as China, Vietnam and Eastern Europe. (Yang 2013; 2015; Tran 2015; forthcoming; Petryna 2002)

Vulnerable Groups and the Politics of Diagnosis

The mental health strategy defines several groups in Lebanon as “vulnerable groups” more prone than others to develop and suffer from mental illness due to their sexuality and social conditions. The vulnerable groups according to the strategy are: the elderly, families of missing persons, foreign domestic workers, LGBT, Palestinian refugees, people with disabilities, persons in humanitarian/emergency settings, persons receiving end of life care, and prisoners and survivors of torture. However, there is again a concern that these groups will be more pathologized by the mere fact of belonging to this category of vulnerability. Anthropological research on psychologization as an intervention for marginalized and oppressed groups in society showed that this can increase vulnerability, where psychologization in many instances becomes a tool to “fix” these groups and make them more normative and acceptable in society.

The example of foreign domestic workers, one of the identified vulnerable group in need of more mental health services, illustrates our point. The mental health strategy frames the mistreatment and abuse faced by domestic workers in Lebanon as vulnerability to mental illness. The strategy report quotes a research study by Zahreddine et al. (2014) that found a recent rise in psychiatric admissions of female domestic workers at psychiatric Lebanese hospitals. Many of those admitted were diagnosed with psychotic disorders. These two criteria (the rise in psychiatric admissions and psychotic diagnoses) were used by the report as indicators of group vulnerability to mental illness.

What is deeply concerning about this kind of framing is the complete omission and disregard of a couple of factors. The first is the institutional racism within which domestic workers are recognized and governed in Lebanon; health and mental healthcare is no exception in this regard. The second is the politics of the diagnosis itself, or what psychiatrist Jonathan Metzl (2009) called the race of the diagnosis: the idea that diagnoses are part of systems of racism and categorizations of the “other” as mentally ill. The rise of the number of domestic workers in psychiatric asylum hospitals and of their diagnosis with psychotic disorders constitute forms of incarceration, and disciplining of this group; something that has been documented by psychiatrist Hala Kerbage (2014), and by the Anti-Racism Movement in Lebanon (2016). Psychologization here does not help in alleviating the psychological damage resulting from abuse, but leads to further marginalization and oppression.

Finally, practitioners need to also pay attention to the “gender of the diagnosis” (Metzl 2003) as well, specifically when treating women, and LGBT in psychiatry. These groups are more likely to receive specific forms of diagnoses because they are women and LGBT, and not because there exist a natural and medical course within which diagnoses of mental illness are given.

Stigma, Culture and Psychiatry

While we agree that there is stigma in Lebanese society surrounding mental illness, we believe that providing a psychiatric diagnosis coupled with awareness campaigns on mental health education miss the point. It is the role of the practitioners in a therapeutic relationship to be aware of the context in which psychiatric labels function, and what their implications can do in society.

We have both noted in our own research on psychiatry in Lebanon a trend in locating the responsibility of stigma on the supposedly other’s cultural or social habits that require changing and sensitization. This trend has the following implications. First, the use of modernity/tradition binary, whereby psychiatry is modern and ‘culture’ is traditional, leads to an oversimplified and problematic understanding of the stigma of mental illness. Second, and based on our observations, psychiatrists and mental health practitioners tend to use culture in two ways: either as an obstacle that resists therapy and obscures the psychiatric disorder from diagnosis and treatment, or as an alternative idiom of expression for mental illness that also requires scrutiny and unraveling to see the “real” diagnosis and treatment; thereby incorporating cultural expressions of mental illness back into the nosology (the classification of diseases) of biomedical psychiatry as a western-global institution. While their main focus is to find the standardized and global psychiatric disorder that fits the Diagnostic Statistical Manual (DSM), mental health practitioners run the risk of not really capturing the complex expression of malaise and affliction into the treatment and diagnosis.

Conclusion

In sum, this type of psychologization has the following effects.

  1. It pathologizes and medicalizes social conditions, turning them into individual illnesses that require psychotropic drugs and psychotherapy;

  2. It de-politicizes the main factors considered to be indicators of mental illness (poverty, gender, conflict, chronic health problems, etc.), thereby misidentifying the reasons behind the mental illness and distress;

  3. It reinforces what Beneduce call the “politics of otherness” (2007): the essentialization, normalization and naturalizations of behaviors of individuals or groups seen as non-normative, on the basis of diagnostic instruments that correspond more to the values implied in biomedical psychiatry,  than to the patients’ own complex experience of illness and structural conditions; in many instances pathologizing them by the mere fact that they are “the other”;

  4. It over-medicalizes life. While certain individuals certainly need and benefit from psychiatric medications, others are suffering from pressures of everyday life and the solutions for that are not necessarily psychological or medical;

  5. It over-diagnoses vulnerable people. While the mental health strategy seems to pose itself as an alternative reform to incarceration in psychiatric asylums, we are concerned that an over-diagnosis of marginalized, vulnerable and poor communities could lead to a rise in incarceration in Lebanon, knowing that the target of these reforms are the same people who cannot afford decent mental health coverage;

  6. It reproduces the private/charitable dichotomy of healthcare and health inequalities. The national mental health strategy relies on WHO’s “mental health gap” policy, that sees the untreated and undiagnosed mentally ill persons as causing an economic burden on the over healthcare system. However, the psychologization process that the strategy adopts will also produce a massive market for psychotropic pharmaceuticals in Lebanon that is unsustainable, and will ultimately lead to more economic, health inequalities and pressures on the mentally ill;

  7. It disregards the politics (social, economic, political conditions and human particularities) behind neurobiological processes and the supposedly neutral biomedical model of psychiatry. If the aim of the strategy is to build a community-based mental health sector, we then need to rethink the role of the practitioners and the practice of healing; A practice that should be able to put politics at the core of the psyche, and that does not understand it only as a universal  process, but as embedded in a historically specific context.

__________

References:

Anti-Racism Movement. April 2016. Crazy, http://www.antiracismmovement.com/2016/04/crazy.html
Beneduce, R. Etnopsichiatria. Sofferenza mentale e alterità fra storia, dominio e cultura. Roma: Carocci, 2007.
Kerbage, Hala. 2014. Foreign Domestic Workers in Lebanon: The Missing Psychiatric Link,  http://legal-agenda.com/en/article.php?id=579&folder=articles&lang=en
Metzl, Jonathan. Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs. xii, 275
p. Durham: Duke University Press, 2003.
Metzl, Jonathan. The Protest Psychosis: How Schizophrenia Became a Black Disease. xxi, 246. Boston: Beacon Press, 2009.
Ministry of public health. 2015. Mental Health and Substance Use: Prevention, Promotion, and Treatment, Situation analysis and Strategy for Lebanon, 2015-2020, http://www.mhinnovation.net/sites/default/files/downloads/resource/MH%20strategy%20LEBANON%20ENG.pdf
Petryna, Adriana. Life Exposed: Biological Citizens after Chernobyl. In-Formation Series, xvii, p. 264, Princeton, N.J.: Princeton University Press, 2002.
Tran, Allen. The anxiety of well-being: Medicalization of worry in a Vietnamese hospital, Forthcoming in Medical Anthropology Quarterly.
Tran, Allen. 2015. Rich sentiments and the cultural politics of emotion in Postreform Ho Chi Minh City, Vitnam. American Anthropologist, 117(3): 480-492.
WHO. 2008. MhGap, Mental Health Gap Action Programme: Scaling Up Care for Mental, Neurological and substance use disorders, http://apps.who.int/iris/bitstream/10665/43809/1/9789241596206_eng.pdf  
Yang, Jie. “Peiliao: Gender, Psychologization, and Psychological Labor in China”. Social
Analysis 57, No. 2 (June 1, 2013): 41–58.
Yang, Jie. Unknotting the Heart: Unemployment and Therapeutic Governance in China. Ithaca, NY: Cornell University Press, 2015.
Zahreddine N., Hady R.T., Chammai R., Kazour F., Hachem D. and Richa S. 2014. Psychiatric morbidity, phenomenology and management in hospitalized female foreign domestic workers in Lebanon. Community Mental Health Journal. 50(5): 619-628.