Mental health and psychosocial support (MHPSS) programmes’ effectiveness in alleviating mental health and psychosocial burdens is contingent on multiple factors, including socio-cultural relevance to the local population. Culture bias – which entails interpreting, judging or acting based on one’s own cultural standards – can have a negative effect on socio-cultural relevance and can impact all stages of MHPSS programming, including design, implementation and evaluation.
Providing MPHSS services for people affected by the Syrian conflict has been fraught with cultural challenges, including cross-cultural application of trauma screening tools without local validation. Mental health providers in Lebanon viewed refugees’ cultures as an ‘obstacle’ to discovering underlying psychiatric disorders. Also, refugees’ strategies to adapt to a discriminatory environment were considered by mental health practitioners as dishonest and manipulative behaviour, and this affected the ability to build trust between mental health practitioners and refugees.
Culture bias in humanitarian MHPSS programmes is not new. During the war in Angola, many Western NGOs focused almost exclusively on Post-Traumatic Stress Disorder (PTSD). During one of the authors’ fieldwork in the mid-1990s, child soldiers reported that their main challenge was spiritual contamination by the unavenged spirits of the people they had killed. Although traditional healers had cleansing rituals for this specific problem, psychologists and international NGOs did not work with them to address this spiritual distress or contextualise their own approaches to this local concern, thereby limiting the success of the MHPSS programming. Eventually, the rituals were included in the reintegration programme, significantly increasing community acceptance of the former child soldiers.
Missed opportunities and harmful effects
While it may be more convenient to implement universalised approaches to MHPSS, this runs the risk of limiting the effectiveness of MHPSS work by disregarding essential contextual elements when addressing problems that are a high priority for the affected people. As a result, MHPSS programmes may miss important opportunities to support the health and well-being of communities. In the Philippines, one of the most disaster-prone countries in the world, humanitarian responses to MHPSS needs are often narrowly focused, with little or no attention given to Filipino idioms of distress or to local and indigenous practices that could complement external support.
Overlooking the need to contextualise MHPSS within local settings can result in an insufficient understanding of the mental health needs of, and forms of resilience among, individuals and family and community members. Outsider approaches may also feel alienating to local people, resulting in low levels of acceptance and uptake of MHPSS supports and services.
More concerningly, culturally inappropriate interventions can cause unintended harm to people. Culture is a defining feature of human identity that confers a sense of meaning and acts as our anchor in the world. When outsiders impose culture biases, people may experience a sense of loss or marginalisation of their dignity and identity, reflecting a damaging colonialist pattern that treats local people and their cultures as inferior.
It is important to recognise that the negative outcomes of culture bias are not necessarily deliberate. Humanitarian actors inevitably bring culture biases into individual conversations with community members, meetings with grassroots organisations, and conferences with international organisations. This can be exacerbated by the relative power held (and ignored) at times by humanitarian actors. Having little power, and fearing for survival, conflict-affected people may reposition their beliefs or reshape their identities in potentially harmful ways, just to fit within the cultural lens of a humanitarian organisation.
Within MHPSS, culture bias occurs mostly through the imposition of presumed universal categories and through standardised (Western-derived) research and treatments that do not adequately take into consideration other cultures and contexts. Frequently done in the name of evidence-based practice, this approach assumes that MHPSS needs such as depression and PTSD have common interpretations, origins, symptoms and impacts across all cultures and can be treated using the same interventions. This assumption is questionable, and so too is the parallel, often tacit, assumption that culturally defined maladies and stresses do not warrant significant attention. This dominant ‘one-size-fits-all’ approach is inappropriately generalised for populations within the humanitarian arena.
Addressing culture bias
Systematically attending to and becoming aware of our own and others’ cultural beliefs and practices may be important in operationalising the Do No Harm principle. More thoroughly contextualising MHPSS interventions helps to recognise and support people’s dignity and identity in times of dire need. While there is no quick fix for reducing culture bias in MHPSS programming, there are some useful strategies.
For an organisation: Firstly, build evidence for the impact of culture bias in MHPSS programming. Assess how culture bias has potentially impacted past and current MHPSS programme implementation and the targeted population. Make use of various knowledge resources, including mental health workers assessment surveys, focus groups with programme participants, and community advisory groups. Secondly, assess and continuously build MHPSS workers’ cultural humility and relevant skills. Prioritise the importance of addressing culture bias – during recruitment and throughout deployment of MHPSS workers – and consider in-depth reflection sessions on this topic when evaluating programmes; include both international and national workers, and be aware of local power differentials and inequities.
For a programme: Enable an iterative process for cultural adaptation of ongoing MHPSS programmes. Support local ownership of MHPSS interventions through all programming stages, engaging with local healers, grassroots organisations and local MHPSS workers.
For an MHPSS worker: Seek to acquire the ability to reflect on problems caused by cultural disrespect and marginalisation. Consider how to systematically improve your programme by including cultural dimensions that are not harmful and that may contribute to well-being and resilience even if they do not fit dominant MHPSS schemes. In general, work with cultural humility. Think appreciatively about the knowledge, resources and understanding that people have of their own culture, the current context and the problems that they face, and reflect on the limits to outsiders’ knowledge.
With deep appreciation for cultural differences, we should ponder how to most effectively balance local cultural views and approaches with outsider or universalised approaches within MHPSS. Our quest to find a balance is also likely to be contingent upon available resources, an agency’s mandate, the political climate, and a host of other considerations. These complexities, however, can serve as a productive springboard for continuous reflection, learning and adjustment.
Another critical question for MHPSS practitioners is how to avoid causing unintended harm. It is helpful to assume that every culture has a mix of positive and negative aspects that promote or undermine people’s health and well-being. This understanding will help humanitarians to avoid supporting harmful practices and to engage with and strengthen positive cultural resources and practices. Similarly, they should beware of cultural tokenism, by being, for example, sensitive to issues of language and translation while privileging Western approaches and reducing cultural idioms of distress to Western categories without adequate justification.
A third question to consider is how local power structures influence discussions about which local approaches are valuable, or even culturally appropriate. Blindly engaging with cultural interlocutors without appreciating local power dynamics may provide a skewed image of local beliefs and practices. Most important to keep in mind is the reality that international humanitarian actors may interact in a way that itself affects, reflects or shapes local power dynamics and influence. It is essential for external MHPSS workers and their agencies to attempt to understand the nuances of local power structures and to learn from people, including those living at the margins of society, who seldom have a voice or influence key decisions or actions. Action that supports local discriminatory use of power can increase MHPSS needs.
Addressing culture bias has powerful implications for people’s dignity, identity and well-being, and affects the quality and implementation of MHPSS programming in humanitarian settings. At a time when there are pressures for decolonisation and also strong donor and institutional pressures urging conformity to standardised (Western) approaches, there remains a great need to improve integration and contextualisation of MHPSS programming into local cultural approaches in a way that delivers better outcomes and boosts our collective commitment to human well-being and humanitarian accountability.
Joanne Michelle F Ocampo email@example.com
Doctoral Student, Department of Population and Family Health, Columbia University
Mhd Nour Audi firstname.lastname@example.org @Nour_Audi
Doctoral Student, Department of Population and Family Health, Columbia University
Mike Wessells email@example.com
Professor, Department of Population and Family Health, Columbia University
 Mukdarut B, Chiumento A, Dickson K and Felix L (2017) The Impact of Mental Health and Psychosocial Support Interventions on People Affected by Humanitarian Emergencies: A systematic review https://oxfamilibrary.openrepository.com/handle/10546/620214
 Gadeberg A K and Norredam M (2016) ‘Urgent need for validated trauma and mental health screening tools for refugee children and youth’, European Child and Adolescent Psychiatry 25(8) http://europepmc.org/article/MED/27043846
 Kerbage H et al (2020) ‘Mental Health Services for Syrian Refugees in Lebanon: Perceptions and Experiences of Professionals and Refugees’, Qualitative Health Research 30(6) https://journals.sagepub.com/doi/10.1177/1049732319895241?icid=int.sj-abstract.similar-articles.3&