As described in a recent Somatosphere post, there has been much debate among cultural psychiatrists and social scientists over the movement for “global mental health.” The latest issue of Transcultural Psychiatry helps to advance this discussion with a special section on “Communities and Global Mental Health.” As guest editors Catherine Campbell and Rochelle Burgess explain, the papers in this section emerged from a meeting of the Health, Community and Development Group at the London School of Economics, which sought to “begin to map out a role for social scientists, with particular emphasis on the need for frameworks of analysis and action to clarify and expand the role of communities in advancing the Movement [for Global Mental Health]’s agenda,” (2012:380).
While Campbell and Burgess endorse the overall goals and intentions of the Movement, they point to what they see as key problems in the role assigned to the social sciences, social medicine and community groups in realizing these objectives. Citing an important 2011 publication devoted to global mental health, they refer to a “a disconnect between the Lancet special section’s frequent references to the role of poverty, social inequalities and injustices as the causes of mental ill health (Lund et al., 2011; Patel, Collins et al., 2011), and their proposed solution – namely scaled-up services (with their primary emphasis on targeting physical disease at the individual level), and advocacy for the human rights of the mentally ill,” (Campbell and Burgess 2012: 381).
Arguing that “Movement’s view of the role of ‘mental health advocacy’ as that of calling for the scale-up of psychiatric and psychological services and acknowledgement of the human rights of the sick, is … too narrow,” Campbell and Burgess echo other critiques of global mental health as inattentive to the social determinants of distress, harm and sickness. “In many situations,” they write, “mental ill health is a symptom of ‘sick societies’ as much as ‘sick individuals’. The proposal of biological and psychological solutions to problems which also have social drivers draws attention away from the matched need to create social contexts that enable and support peoples’ opportunities for improved mental health. An expansion of the role of grassroots communities is core to meeting this challenge,” (Campbell and Burgess 2012: 381).
The special section includes five articles and two commentaries which take-up a range of positions in regard to global mental health and represent an important set of engagements in this emerging discussion. Below are the titles and abstracts (representative excerpts in the case of the commentaries) with links to the original articles.
Catherine Campbell and Rochelle Burgess
This special section of Transcultural Psychiatry explores the local-global spaces of engagement being opened up by the Movement for Global Mental Health, with particular emphasis on the need for expanded engagement with local communities. Currently the Movement places its main emphasis on scaling up mental health services and advocating for the rights of the mentally ill, framed within universalised western understandings of health, healing and personhood. The papers in this section emphasise the need for greater attention to the impacts of context, culture and local survival strategies on peoples’ responses to adversity and illness, greater acknowledgement of the agency and resilience of vulnerable communities and increased attention to the way in which power inequalities and social injustices frame peoples’ opportunities for mental health. In this Introduction, we highlight ways in which greater community involvement opens up possibilities for tackling each of these challenges. Drawing on community health psychology, we outline our conceptualisation of “community mental health competence” defined as the ability of community members to work collectively to facilitate more effective prevention, care, treatment and advocacy. We highlight the roles of multi-level dialogue, critical thinking and partnerships in facilitating both the “voice” of vulnerable communities as well as “receptive social environments” where powerful groups are willing to recognise communities’ needs and assist them in working for improved well-being. Respectful local-global alliances have a key role to play in this process. The integration of local community struggles for mental health into an energetic global activist Movement opens up exciting possibilities for translating the Movement’s calls for improved global mental health from rhetoric to reality.
Gaithri A. Fernando
The global mental health (GMH) research agenda should include both culture-general and culture-specific perspectives to ensure ecological validity of findings. Despite its title, the current GMH research agenda appears to be using a monocultural model that is individualistic, illness-oriented, and focused on intrapsychic processes. Ironically, issues of culture are prominently absent in many discussions of global mental health. This paper highlights some issues and concerns considered key to conducting ecologically valid and socially responsible GMH research. The concerns are particularly directed at researchers from dominant cultures who are working in low-income countries. Central to these issues is the balance between etic and emic perspectives in assessment, diagnosis, and intervention, as well as language, engagement of stakeholders and their agendas, and evaluation of the benefit of interventions to the community. New terminology is proposed that identifies broad cultural groups, and recommendations provided for a research agenda to encourage both basic and applied research that mutually benefits all stakeholders in the GMH research endeavor.
Understanding the benefits and challenges of community engagement in the development of community mental health services for common mental disorders: Lessons from a case study in a rural South African subdistrict site
Inge Petersen, Kim Baillie, Arvin Bhana, and Mental Health and Poverty Research Programme Consortium
Against the backdrop of a large treatment gap for mental disorders in low- to middle-income countries (LMICs), the 2007 Lancet series on global mental health calls for a scaling up of mental health services. Community participation is largely harnessed as one strategy to facilitate this call. Using a participatory implementation framework for the development of mental health services for common mental disorders (CMDs) in a rural subdistrict in South Africa as a case study, this study sought to understand the benefits and challenges of community participation beyond that of scaling up. Qualitative process evaluation involving interviews with service providers and users was employed. The results suggest that in addition to promoting mobilization of resources and actions for scaling up mental health services, community participation can potentially contribute to more culturally competent services and personal empowerment of recipients of care. In addition, community participation holds promise for engendering community-led public health actions to ameliorate some of the social determinants of mental ill health. Challenges include that community members involved in these activities are mainly marginalized women, who have limited power to achieve structural change, including cultural practices that may be harmful to the mental health of women and children. We conclude that in addition to contributing to scaling up mental health services, community participation can potentially promote the development of culturally competent mental health services and greater community control of mental health.
Campaigns to scale up mental health services in low-income countries emphasise the need to improve access to psychotropic medication as part of effective treatment yet there is little acknowledgement of the limitations of psychotropic drugs as perceived by those who use them. This paper considers responses to treatment with antipsychotics by people with mental illness and their families in rural Ghana, drawing on an anthropological study of family experiences and help seeking for mental illness. Despite a perception among health workers that there was little popular awareness of biomedical treatment for mental disorders, psychiatric services had been used by almost all informants. However, in many cases antipsychotic treatment had been discontinued, even where it had been recognised to have beneficial effects such as controlling aggression or inducing sleep. Unpleasant side effects such as feelings of weakness and prolonged drowsiness conflicted with notions of health as strength and were seen to reduce the ability to work. The reduction of perceptual experiences such as visions was less valued than a return to social functioning. The failure of antipsychotics to achieve a permanent cure also cast doubt on their efficacy and strengthened suspicions of a spiritual illness which would resist medical treatment. These findings suggest that efforts to improve the treatment of mental disorders in low-income countries should take into account the limitations of antipsychotic drugs for those who use them and consider how local resources and concepts of recovery can be used to maximise treatment and support families.
This article reviews the expanding body of literature that examines the mental health of HIV-affected children in sub-Saharan Africa. Focusing on primary research across disciplines and methodologies, the review examines the use of universalistic assumptions about childhood adversity and mental health in driving forward this body of research. Of the 31 articles identified for this review, 23 had a focus on the psychological distress experienced by HIV-affected children, while only 8 explored social psychological pathways to improved mental health, resilience and coping. The article argues that this preoccupation with pathology reflects global assemblages of definitions, understandings and practices that constitute the global mental health framework. While such a focus is useful for policy interventions and the mobilisation of resources to support children living in HIV-affected communities, it overshadows more culturally relevant and strengths-based conceptualisations of how mental health is understood and can be achieved in different parts of Africa. Furthermore, a continued focus on the psychological distress experienced by HIV-affected children runs the risk of medicalising their social experiences, which in turn may transform the social landscape in which children give meaning to loss and difficult experiences. The article concludes that mental health professionals and researchers need to take heed of the biopolitical implications of their work, and argues for more community-oriented and resilience-enhancing research that brings forward the voices of local people to inform interventions tackling the psychosocial challenges inevitably experienced by many children in sub-Saharan Africa.
Hanna Kienzler and Duncan Pedersen
This essay analyses how the relationships between Cold War and post-Cold War politics, military psychiatry, humanitarian aid and mental health interventions in war and post-war contexts have transformed over time. It focuses on the restrictions imposed on humanitarian interventions and aid during the Cold War; the politics leading to the transfer of the PTSD diagnosis and its treatment from the military to civilian populations; humanitarian intervention campaigns in the post-Cold War era; and the development of psychosocial intervention programs and standards of care for civilian populations affected by armed conflict. Viewing these developments in their broader historical, political and social contexts reveals the politics behind mental health interventions conducted in countries and populations affected by warfare. In such militarized contexts, the work of NGOs providing assistance to people suffering from trauma-related health problems is far from neutral as it depends on the support of the military and plays an important role in the shaping of international politics and humanitarian aid programs.
“Psychiatric universalism risks being imperialistic, reminding us of the colonial era when it was pressed upon indigenous people that there were different kinds of knowledge and that theirs was second rate. Socio-cultural and socio-political phenomena were framed in European terms and the responsible pursuit of traditional values regarded as evidence of backwardness (Summerfield, 1999). Said (1993) noted that a salient trait of modern imperialism was that it presented itself as an education movement, setting out consciously to modernise, develop, instruct and civilise. Global mental health workers are the new missionaries,” (p.525).
“This special section of Transcultural Psychiatry forms part of a far broader rhetorical strategy (of which I myself am part) to claim space for a new discipline which demonstrates the success and the maturity of global mental health. This supposedly newly adult discipline, to use the metaphor used by Patel and Prince (2010) is capable of achieving a great deal, but with new-found power and respectability come new liabilities, new possibilities for unintended consequences. Reading these fascinating articles, and considering the resonances but also the areas of difference amongst them, I was struck not by a unity of voices but by a cacophony of different claims to our attention. I was forced to consider what it means for a discipline to ‘‘come of age’’, and I realized that these articles, read together, helped me to understand that my assumption that coming of age means coming to one conclusion, was misplaced. Much has been achieved through the global mental health movement and through the contributions of transcultural psychiatry to this movement. But what we have at present is messy, contradictory, fragmented. This is to be celebrated rather than abhorred. Being able to live constructively with ambivalence, and to be able to put mixed feelings to good use is, after all, a developmental achievement,” (p.537).