Challenging the Biomedical Imperative in Global Mental Health with Clinical-Community Psychology

Clinical psychologists from South Africa reflect on their training experiences and suggest that a clinical-community psychology curriculum may be the way forward.

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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
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 color and practicing 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” behavior 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 Society, 65(1). https://doi.org/10.57157/pins2023vol65iss1a5817 (Link)

10 COMMENTS

  1. The vast majority of psychologists realise soon enough that if you want to earn a living you will have to adopt the simplistic and mechanistic biomedical approach. People need to be seen divorced from their lives so that “therapy” can focus on fixing the individual whether these are their chemical imbalances, rewiring of their brains, changing faulty thinking or learning skills that were absent such as breathing, time management and problem solving. The latest fad in psychology is to help an ever growing cohort to appreciate that their “neurodevelopmental disorders” are in fact superpowers that require mere tweaking. Since the aim is not to improve anyone’s life or circumstances but to create a revolving door, the money keeps coming in and the real reasons for distress and behaviour such as poor parenting, childhood trauma and adversity, inequality, poverty, etc. can remain hidden. It is a perfect system for the profession and it is not surprising then that these two clinical psychologists concluded that they were unsure if they wanted to be associated with it.

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    • I’ve had three individual therapists and two marriage counselors. I even studied Counseling for awhile at the graduate level. I don’t have any huge complaints about the therapists, but I was pushed out of the Counseling program on account of my anti-Psychiatry views

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    • I’ve been thinking the past few days/weeks about gratitude.

      Around the idea that gratitude can be an opposite to pain, grief, sorrow, regret, spite, vengefullnes, resent, hopelessness and victimization.

      You speak of “poor parenting, childhood trauma and adversity, inequality, poverty”, not all in the past, but in the mental disorder field almost always there. In the real world adversity, inequality and poverty are difficult to address. Poor parenting and childhood trauma are in the past, I can’t change that!.

      So, to me, as a thing that has potential: gratitude. I am gratefull I don’t have to believe psychiatry nor clinical psychology, for example. That to me takes the edge off the nonsense. It gives me freedom without pushing me into a particular direction like redress, justice, equality, wealth or knowledge. And without giving up on any of that.

      And, if I had adverse childhood experiences and/or poor parenting, within bounds, being gratefull that I don’t have to be defined by them gives me a leg up.

      It does not give me a choice in many cases, but it gives me freedom from epistemic injustice and oppresion, just, I think, by acknowledging that I am gratefull that I don’t have to think it oppressive or defining, let alone sentencing me to do anything: I am gratefull my gratitude does not force me to do anything. Like a swiss army knife.

      And I can be gratefull for things that are not related to my current problems: I am gratefull for the beautifull puppies that express affection for me, and for which I express not only gratitude, but affection, without anything else one way or another.

      And that makes me happy, makes me free, and does not give me an obligation as wealth, equality, reddress, overcoming adversity give me: being poor pushes me to do something about it if I feel it’s part, let alone determinant of my “problems”, or mental distress. Let alone it will be for problems in my future!.

      And gratitude does not give me an obligation nor pushes me to not seek justice, or to not seek punishment for those that did me wrong and by law must be sentenced to decades in jail for instance. It gives me, I think equanimity to pursue those goals. I am gratefull my gratitude gives me equanimity to pursue my goals. Easy!.

      Gratitude for me implies no long term commitment to anything, but, perhaps, worst case scenario, to be gratefull no matter what may come. But, maybe no matter what may come, I could be still gratefull for all the things I am gratefull now in my past!. Those things in my past for which I am gratefull now will still be in my future!. Easy!. It gives me security, confidence to face what may come…

      Gratitude to me does not imply resignation or acceptance of the bads or ills around me, not even those inside me. I am gratefull my vindictiveness does not define me!.

      And more practically, if I had lots of things to be gratefull, which I do, my gratitude list would be as large, euphemistically to circle the globe, despite all the bad things not happened to me, but done to me, then I would be in a better position to let my childhood adversities inconsequential for my present me.

      Whom who has the riches of the world now, would dare to hold on to the past?. Aware the psy rhetoric pushes in that direction: no matter how much a person has to be gratefull, there’s always a mental disorder to make one person feel worse, no matter what.

      And I think, I hope, that gratitude can do the same for many people.

      If I had many things that made me feel better, I probably would not be “mentally disordered” by all the things you mentioned: worst case scenario I could move one. Despite, I think, the opressive sentencing rhetoric of the psy disciplines.

      Gratitude as a gift to self, that can be received in advance, and that only me, can give to myself. Got it before I said: I am gratefull. Easy…

      And to me, gratitude is different from thankfull. To be thankfull someone else has to cause me to be thankfull. I can be gratefull all on my own, regardless if I can be thankfull or resentfull. I can be the three at the same time, for instance.

      “I am gratefull that I can give a hoot about the poor parenting during my childhood”, empowering and liberating, free as in beer…

      And if a psy pro claims otherwise: “I am gratefull I don’t give a damn about this cucu’s opinion”. Easy, and I most surely will feel better just for that.

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  2. Excellent article.

    Not nearly enough practitioners have the insight needed to see through psychiatry’s biomedical bullshit as well as psychology’s seriously flawed approach.

    There needs to be lots more people who have enough brains, guts, and common sense to challenge the value and validity of a current psych industry that thrives in prestige-driven economies that seek to dominate, control, and exploit people’s lives.

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  3. I haven’t read the papae reviewed, but I think the authors are confusing narrative, perspective, framework and epistemology with the word, the concept IDEOLOGY:

    From wikipedia:

    An ideology is a set of beliefs or philosophies attributed to a person or group of persons, especially those held for reasons that are not purely epistemic, in which “practical elements are as prominent as theoretical ones.”

    From The American Heritage® Dictionary of the English Language, 5th Edition:

    A set of doctrines or beliefs that are shared by the members of a social group or that form the basis of a political, economic, or other system. [implied system of beliefs or worse yet: doctrines]

    From wikipedia:

    Doctrine

    Doctrine is a codification of beliefs or a body of teachings or instructions, taught principles or positions, as the essence of teachings in a given branch of knowledge or in a belief system. [notice the word knwoledge here, it does not say scientific, the next phrase clears why: “The etymological Greek analogue is “catechism”.”]

    From The American Heritage® Dictionary of the English Language, 5th Edition:

    doctrine /dŏk′trĭn

    A principle or body of principles presented for acceptance or belief, as by a religious, political, scientific, or philosophic group; dogma. [it does use the word scientic, but is there a scientific dogma?]

    So they, to me, not unappreciative of the value of diverse opinion, seem to be arguing against a falsehood: biomedical model, with another: an ideology. Also equivocating the word ideology with at least: narrative, perspective, framework and epistemology.

    Maybe the authors, and any believer in clinical psychology should be mindfull, in vogue word in it’s other meaning, not entirely out of place in the sense: be aware of the scientific world and it’s words around around you!.

    Clinical psychology is a set of ideologies, not of knowledge in the scientific sense of the word, even if a doctrine could be scientific, and if at all knowledge beyond the sense of “catechism”.

    And therefore, when describing the real word, a FALSEHOOD. A hood on one’s mind in the other meaning of hood. Or is there a scientific ideology?. To throw away the word “scientific”, hanging in the definitions of ideology and doctrine when it comes to clinical psychology*.

    But I agree with the authors: their colonial training did not educated them enough in how to use the actual meaning of words used by their discipline, be it scientific, doctrinnaire, philosophical or ideological. To paraphrase: they are not mindfull of the scientific words around them…

    And that probably goes the same for all clinical psychologists and psychiatrists, even colonizer ones. I am not picking on the authors, but on the whole ideology of psychiatry and clinical psychology, particularly in it’s training. Which is, as far as I understand, what motivated the reviewed papae.

    So I partially agree with the authors, but for different reasons, hopefully better ones. I apologize if I write annoying…

    *To clear up why there is no scientific dogma, scientific catechism or scientific doctrine: it is not a matter of faith or belief, but of proof!.

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    • Doctrine is also made for a purpose: to be believed or to be accepted.

      Science, as in Scientific Theory does not seek that: It is a naked truth, take it or leave it. It is convincing beyond doubt, that is in the definition of Scientific Theory. Disbelieve it or don’t accept it at one’s peril, sort of thing.

      Science seeks understanding and ALL that comes from that, not acceptance nor belief. Scientists want to be believed and accepted, they want their conclusions believed and accepted, but that is not Science in the Scientific Theory sense of the word. It is scientific activity which is a human activity, and therefore amenable to seek acceptance and belief.

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  4. AKA, the global dominance orchestrated by Europeans can be regarded as a form of psychological warfare. It is imperative for us to acknowledge that the strategies employed to subjugate diverse cultures through colonization, slavery, and, in some cases, genocide were effective in shaping the narrative according to their rules. Given this historical context, it is incumbent upon us to critically examine whether comparable methods and tactics are currently being applied within our own societies. Although we can readily consult historical texts detailing the consequences of colonization, oppression, and genocide, it is fallacious to assume that analogous strategies are not being employed against those who resist conformity to prevailing power structures. Engaging in a nuanced examination of perspectives beyond our own is an essential step towards a more insightful understanding of our contemporary reality.

    In short, how could we subjugate and colonize so many people around the world and think the same tactics will not be used against us when we stir the pot internally? com’n!
    ps. when we take the perspective of the minority, we see what we do so well if we are being truly honest with our own state of mind. We go mad because we do not want to believe the reality that we benefit at some point – it is too painful to acknowledge.

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