Cultural Perspectives on Mental Health and Community Based Rehabilitation in Sri Lanka

Models of disability have on occasions been based rather heavily on pre conceived notions of physical or mental ability which could be viewed as both narrow and reductionist and which appear to assume that there are universal ‘norms’ which can be measured regardless of context or individualism. These notions contained assumptions including that of a medical model of disability being the predominant and only model. These early models often failed to account for a wide range of factors which will effect the way individuals, cultures and societies construct the notion of disability. As more sophisticated and complex models have developed including the social and empowerment models which have taken into account important variables and mediating factors which include but are not limited to individual, societal and cultural meanings, context, identity and socio-cultural or political perspectives, as well as a temporal perspective. These have all allowed a richer fuller model of disability to emerge which more accurately reflects the lived experiences of people with a range of disabilities. (For a full discussion of these issues see chapter 1 of this volume). This discussion will not be reiterated further here. Although it is perhaps important to note that learning disability (a label which in itself is contested by a number of service users and service user groups), but is widely used by statutory services (Goodley, 2001) illustrates the role of socio-cultural political and cultural constructions in definitions within one specific cultural context, that of Britain. Whilst coverage by the British media TV Channel 4 in 2012 on the Para-Olympics where they have consistently used the term super-humans to describe the Para -Olympians perhaps also illustrates the way language and culture can play a part in defining and constructing notions of disability.

Whilst mental health and psychological well–being has sometimes been excluded from formulations relating to definitions of disability, it is claimed that twenty five per cent of the population will suffer from mental health issues during a one year period (Mental Health Foundation, 2012) with 1:6 people experiencing mental health issues at any given time ( Office for National Statistic Psychiatric Morbidity report 2001). The disabling effects of this, can be numerous and may include social deprivation, the inability to maintain relationships, substance misuse, self harm and homelessness. The National Institute for Mental Health in the USA have constructed a measure of disability adjusted life years (DALYS) for those suffering from severe mental illness, which includes years lost to illness, disability or premature death, there figures are a grave cause for concern. There fore the effects can be disabling both for the individual, their families, work place and the multiple communities of which we are all a part. Mental health issues are still assigned a stigma by some people which can lead to marginalisation and discrimination (Mind, 2011; Royal College of Psychiatrists, 2003; Dept of Health Information Centre, 2011).

As mentioned earlier, constructions of what constitutes disabilities and mental health across cultures may differ and may well reflect the values held within that culture or sub culture about mental health or disability. For example western notions of good mental health carry positivist notions of what comprises good mental health and may not be generalisable outside western countries as is often unquestioningly assumed by those located in the west ( Patel, 2004). “Summerfield (2002: 248) writing about the manuals used to diagnose mental illness developed in the USA and Europe claims that the: "Diagnostic Statistical Manual (DSM) and

International Classifications of Diseases (ICD) are not, as some imagine, atheoretical and purely descriptive nosologies with universal validity. They are western cultural documents, carrying ontological notions of what constitutes a real disorder, epistemological ideas about what counts as scientific evidence, and methodological ideas as to how research should be conducted." If a patient in the USA presents with a set of symptoms which do not match a diagnosis in the DSM, they can not get treatment under their health insurance and a psychiatrist or psychologist may not be allowed to treat them. Therefore the DSM is a highly political document with lobbyists advocating on a number of fronts for a particular diagnosis to be included. It is updated every few years with some new categorisations added and some left out. It also reflects socio-cultural mores, for example homosexuality was contained and viewed as an illness in earlier versions.

How we define poor mental health and well-being will always be culturally located and western notions may not adequately account for cultural differences in relation to the positioning and presentation of emotional distress (Fernando, 2011) This chapter will look at a range of community based well-being or mental health rehabilitation projects located in Sri Lanka. We have taken a position that mental health is located within a matrix of factors and is not a unitary entity. In Sri Lanka, as in most of the world, mental illness is frequently viewed as stigmatising (Samarasekera et al 2012) negatively and may be viewed as a form of disability. This chapter will look at a number of community based rehabilitation projects which we ran in Sri Lanka.