Placebo effects and non-evidence based practice (December 6 post) have direct relevance for cross-cultural psychology, including post-disaster mental health in non-Western contexts. There’s a healthy debate occurring in trauma psychology concerning the most appropriate modes of service delivery following mass violence. Specifically, the debate revolves around whether disaster mental health professionals s should upport traditional (or at least local) healing or import Western psychological practices into the local context.
First, a few basics. When psychologists talk about traditional healing, they usually mean the treatments applied by traditional healers, locally-identified experts specific to the cultural context in which they are working. So, for example, in eastern Chad where there are lots of refugees from Darfur, traditional healers are marabouts, or fakir, people who have studied healing practices, including the use of local medicinal plants and spiritual practices (e.g., incantation of verses from the Koran, for instance). You can include Inuit shamans, Tibetan emchis, etc. in this category. In general, traditional healers are usually thought of as separate from medical and psychological professionals trained in Western medicine. In other words, they are “culturally bounded.” (Of course, the reality is that traditional healers may integrate many aspects of Western medicine, and may even be Western-trained professionals who use culturally-bounded practices as well as those they learned in their Western professional training.)
Usually we think of traditional healing as easy to “respectfully dismiss,” as clearly it’s not evidence based… right? Well, actually, there is some evidence supporting traditional healing. Joop de Jong, one of the founders of the global Transcultural Psychiatry Organization, presented some evidence just over a year ago that in a randomized clinical trial of counseling versus traditional healing in Burundi, the traditional healers had a much greater healing effect. In other words, traditional healing is evidence based practice for mental health problems (at least in Burundi). Of course you’ll want to know more about this study… but for that you’ll have to ask Joop.
So what does traditional healing have to do with the placebo effect? In the US, dismantling studies have shown that some 30-40% of the efficacy of therapy is just showing up for that first appointment. Patients have a belief – a culturally-grounded belief – that going to therapy is the right thing to do, so it works. This is essentially a placebo effect (of course, if you read the December 6 entry, you knew that). Cross-culturally, the placebo changes. Placebo effects are culturally-bounded.
An example: In eastern Chad traditional healers from Darfur told me that they cured “madness” (majnun) by writing Koranic verses on a tablet of wood with charcoal, then washing the tablet and making the patient drink the water that they washed the tablet with (which presumably holds the power of the verses as well as charcoal dust and whatever else was on the wooden tablet). Do patients get better? Some seem to, at least a little bit, in the short term. Would anyone reading this blog get better in a similar situation? Probably not. Why? Because the placebo effect depends on whether or not you accept the practice/practitioner as medically legitimate.
Of course, with globalization, healing practices are not necessarily unique to specific medical cultures. An example from a little closer to home: In the clinic where I work in New York, which serves patients from all over the world, we find that patients from countries where psychology is not known as a mode to treat common mental disorders often need a lot of convincing that counseling will help them in order for it to stick. Counseling is still a pretty culturally-bounded practice — culturally-bounded within Western medical culture. However, prescribing pills that make them feel better (and then maybe using some evidenced based CBT or relaxation techniques) is a lot more acceptable. Taking pills to relieve symptoms is a practice that seems to have gone cross-cultural.
The challenge for those setting up health systems in cross-cultural or multicultural settings, then, is to figure out how to utilize existing service delivery modes and networks to deliver evidenced based treatments without disrupting culturally-bounded placebo effects.