Key Issues in Medical Pluralism
GMH and psychiatry have thus at different times either engaged with or attacked traditional healers, but they have rarely been neutral. A number of factors potentially influence how their interactions unfold as collaboration, competition or clash. Here we consider three. The first is ‘epistemology’ (the approach to knowledge favoured by different healing approaches) and how the paradigms underlying GMH and traditional healing bear on the explanations and experiences emerging from help-seekers’ encounters with healers. We then offer an account of how features of effectiveness may be conceived differently between paradigms, highlighting some of the complexities of this question but also some of the dangers. Finally, consideration is given to how power and politics impinge on the interactions between healing practitioners and institutions, and between healers and their clients.
Epistemology, Explanation and Experience
GMH and traditional healing are generally considered to be characterised by contrasting epistemological frameworks. GMH’s favoured ‘way of knowing’ derives from Evidence-Based Practice (EBP) (Thornicroft and Patel 2014), which promotes the use of rigorously operationalised empirical methods—mostly Randomised Controlled Trials, meta-analyses and systematic reviews—in building a research base that should guide professional practice in medicine and related disciplines and guard against the influence of practitioners’ unfounded habits, cognitive biases or vested interests in particular therapeutic methods. By contrast, traditional healing—or at least its ritual forms—has been referred to as ‘the original non-evidence-based medicine’ (Sax 2014, p. 831). While many traditional healers value empirical observation, they are not usually afforded the opportunity to carry it out on a systematic scale, and intuition, spiritual revelation or divination may be at least as important for them as testing out results. In absolute contrast to EBP, West and Luedke (2006, p. 11) note that some traditional healers are actually highly reluctant to ‘know’ very much about the potentially dangerous spiritual forces that they draw on or reckon them to be unknowable. The diversity of practices, styles and bodies of knowledge to be found within traditional healing are not easily captured by approaches operating within the methodological assumptions of EBP, which potentially marginalises or invalidates epistemologies that do not conform to mainstream psychiatric and psychological models of mental health (Kirmayer 2012). For example, trials of therapies for depression already assume the validity of a particular diagnostic perspective that tends to locate a problem within an individual, rather than in social relationships or socio-economic hardships. Alternative epistemologies that give greater prominence to the role of social factors, to say nothing of those that emphasise the relationship between humans and the spirit world or rely on different conceptions of personhood, are more rarely incorporated and tested within an EBP model. Though it may in some circumstances be possible to imagine doing so, dominant epistemologies exercise very real constraints over what is prioritised and tested within GMH and on what terms this is done (Orr and Jain 2014).
These limits have led to calls for greater ‘epistemic pluralism,’ which is suggested will in turn lead to ‘methodological pluralism’ and ‘new forms of political recognition and engagement’ (Kirmayer 2012, p. 254). Leading figures in GMH have shown themselves willing to engage with this agenda to a degree, as demonstrated by the insistence on identifying the movement with ‘mental health’ rather than primarily with ‘psychiatry’ and its associated epistemologies (Whitley 2015) and the further links it has sought to forge beyond standard mental health paradigms, notably with development studies (Patel 2014). Increasing use of realist evaluation of complex interventions is to some extent counterbalancing simplistic interpretations of biomedically based EBP, though it remains to be seen how far the commitment to ‘scaling up’ interventions (Whitley 2015, p. 3)—with its basis in generalisable principles and interventions—can engage with the diversity of epistemologies and cosmologies that may be present within a population. Indeed, many would question whether GMH even should, for fear of casting aside the undeniable benefits that EBP has brought to medicine, for what Kirmayer calls ‘an epistemological melee in which anything goes’ (2012, p. 253).
Views differ on how much these grand theorisations of epistemology affect what healers actually do in practice. Patel (2011), for example, argues that the contrast between the epistemologies of GMH and those of other forms of healing has been exaggerated. Pointing to evidence that Ugandan traditional healers identified similar patterns of symptoms as did psychiatrists, he suggests that the paradigms may not always in fact be especially different in use, as opposed to in theory. However, his interest in exploring whether traditional healers might be enlisted for a screening and referral role to psychiatric services means that he gives less attention to differences in the interpretation given to those patterns and in how healers approach resolving the presenting problems. A number of researchers have argued that these are the key aspects where commensurability between the values, assumptions and ways of knowing about the world of healer and client is essential for any kind of serious success. Sax (2014) points to significant issues for Western-derived mental health therapies in India, stemming from how the ‘individual’ is understood; he suggests that individualisation (self-realisation), rather than being the goal of healing, may instead be seen as constituting the very problem to be resolved.
Calabrese (2008) has raised related issues from his clinical/anthropological work with the Native American Church, where he found that profoundly different orientations to epistemology, sociality and spirituality were at the root of a cultural clash which greatly attenuated the success of standard Western psychotherapeutic treatments and made the value of traditional healing methods undeniable. These ethnographic studies suggest that at least some cases and settings call for a broader, flexible approach to what might constitute appropriate forms of EBP. Indeed, Halliburton (2004, 2009) has argued that best outcomes are actually facilitated by greater plurality of therapeutic principles among available healing traditions. He suggests that pluralism is worth preserving precisely because it allows individuals and their families to explore and find the best match among the treatments on offer, bringing into question the approach of EBP and growing attempts to standardise traditional medicine (see Sax 2014; Ranganathan 2014). A cautionary note is sounded by Jacorzynski (2006), reminding us that plurality of therapies might also have negative effects. Jacorzynski’s account of an individual case of mental disorder in Chiapas, Mexico, raises the question of whether the availability of multiple interpretive frameworks is always helpful, or whether it might sometimes present a bewildering epistemological maelstrom in which the client, feeling buffeted by the competing views of the healers and those around him or her, is unable to find firm footing. Caregivers too may be looking for authoritative judgement, not uncertainty and diversity of views.
The extent to which reaching an ‘understanding’ of the problems in question actually matters for help-seekers’ choices among medically plural options—and its implications for therapeutic communication—has also been much debated. Burns and Tomita (2014) report that studies in parts of Africa suggest traditional practitioners are considerably more likely to provide people consulting them with an explanation of their situation than mental health practitioners, who may prioritise treatment over communication. They suggest that a possible reason why the traditional healers are often more consulted than the mental health practitioners lies in this attention to providing help- seekers with a framework for understanding. Other authors feel that there is an overemphasis in the research literature on help-seekers’ explanations which amounts to ‘scholastic fallacies’ (Quack 2013, p. 403); they argue that most people are relatively unconcerned with understanding what a condition is or what caused it and simply want to know if a treatment works. Where mental health problems are complex and difficult to resolve entirely in a short space of time, it is often likely that people may feel the need to find some satisfactory way of understanding what is happening. However, any search for meaning is unlikely to continue indefinitely if it does not seem likely to lead to pragmatic results (Benoist 1996), which brings us to the question of effectiveness.
-  Kirmayer (2012) argues that even the wealth of research available on mental health in the USA neglectsthe extent of cultural diversity there and bases its studies on samples that do not reflect the general population. It seems likely that the much smaller volume of research on mental health in LMICs suffers fromthe same issue (Orr and Jain 2014).
-  Not all traditional healers share this concern to provide diagnoses or explanations, with some (e.g.,Q’eqchi healers in Guatemala) affording it little priority at all (Waldram 2013).