In the Journals

Global Mental Health — Two Special Journal Issues

Two journals recently published special issues on the emergence of Global Mental Health as a coherent, recognizable “formation of knowledge and practice seeking to address mental illness on a global scale” (Bemme and D’souza 2012). Together, the articles address the contours of the category, as well as the challenges and possibilities it presents, from a range of perspectives.

irp coverFirst, the October issue of the International Review of Psychiatry is a special issue, “Globalization, Culture and Mental Health,” guest edited by Rachel Tribe and Stephen Melluish. The issue and its content arise out of a conference held at the University of Leicester in 2012. As Tribe and Melluish write in their editorial:

While much of the tone of this special edition is critical of globalization as aligned with neoliberal capitalism, there is acknowledgement that globalization has also created new momentum for defending local uniqueness, individuality and identity. Psychology and psychiatry in the West has obviously reflected the norms and values of this region, but there are increasing calls for psychology and psychiatry to concern themselves more with global issues and culture, and a call for protecting indigenous psychologies. This special issue aims, in a small way, to develop awareness of applied psychology and psychiatry across the globe. It offers a critical perspective on any universalizing approach or any misguided imposition of westernized notions and raises the importance of a psychological perspective on how cultural and social differences play out in a global context and impact on people’s mental health and well-being. The message from the papers in this edition is that applied psychologists can make a contribution to the debates and discussions around globalization by offering more nuanced understandings of cultural differences and of indigenous psychologies.

The twelve articles that follow, along with Dinesh Bhugra’s closing commentary, productively explore this tension of globalization and mental health.

Globalization, culture and psychology
Steve Melluish

This article outlines the cultural and psychological effects of globalization. It looks at the impact of globalization on identity; ideas of privacy and intimacy; the way we understand and perceive psychological distress; and the development of the profession of psychology around the world. The article takes a critical perspective on globalization, seeing it as aligned with the spread of neoliberal capitalism, a tendency towards cultural homogenization, the imposition of dominant ‘global north’ ideas and the resultant growing inequalities in health and well-being. However, it also argues that the increased interconnectedness created by globalization allows for greater acknowledgement of our common humanity and for collective efforts to be developed to tackle what are increasingly global problems. This requires the development of more nuanced understandings of cultural differences and of indigenous psychologies.

‘Nothing about us, without us’ – A user/survivor perspective of global mental health
Premila Trivedi

Surprisingly little has been published directly from user/survivors in the burgeoning (and sometimes contentious) field of global mental health (GMH). This is important both ethically and practically if GMH is to benefit from the experiential expertise that user/survivors can bring, especially when they come from those lower or middle income countries (LMICs) where GMH programmes are targeted. Whether user/survivors from higher income countries (HICs) (whose experiential expertise has usually been developed in cultural/social/health/ economic/political contexts which are very different to those in LMICs) could also provide useful input to GMH is less clear. In this article I consider this directly from my perspective as a user/survivor in a HIC. I discuss how, in spite of contextual differences, there appear to be striking resonances between GMH in LMICs and mental health in HICs, particularly areas of concerns, e.g. diagnosis, treatment and cultural difference. I illustrate this using aspects of my own personal experience in a reflexive narrative way, and suggest that such narrative-illustrations could provide useful input in GMH. I also touch on other ways in which HIC user/survivors might become involved in GMH. I conclude by stressing that, however HIC user/survivors become involved in GMH, they must do so ethically, ensuring that those in LMICs always remain at the forefront.

Globalization of psychiatry – A barrier to mental health development
Suman Fernando

The concept of globalization has been applied recently to ways in which mental health may be developed in low- and middle-income countries (LMICs), sometimes referred to as the ‘Third World’ or developing countries. This paper (1) describes the roots of psychiatry in western culture and its current domination by pharmacological therapies; (2) considers the history of mental health in LMICs, focusing on many being essentially non-western in cultural background with a tradition of using a plurality of systems of care and help for mental health problems, including religious and indigenous systems of medicine; and (3) concludes that in a post-colonial world, mental health development in LMICs should not be left to market forces, which are inevitably manipulated by the interests of multinational corporations mostly located in ex-colonizing countries, especially the pharmaceutical companies.

Increasing mental health capacity in a post-conflict country through effective professional volunteer partnerships: A series of case studies with government agencies, local NGOs and the diaspora community
Rachel Tribe, Dilanthi Weerasinghe, and Shanthy Parameswaran

The focus of this paper is on working in partnership with local practitioners and communities to strengthen local capacity building in the area of mental health and well-being in Sri Lanka. This paper will examine the context, organizing concepts, organizational processes, and the development of good working relationships and partnership building behind this work. Our involvement was based on requests which came to the authors as a result of their previous work in Sri Lanka over several decades. This work had been undertaken on behalf of the UK–Sri Lanka Trauma Group (UKSLTG), a UK-based charity which was set up in 1994, and of which the authors are founding members (www.uksrilankatrauma.org.uk). In the first section of the paper, contextual issues will be discussed. The second section of the paper provides details of the training undertaken on mental health promotion among young people in Sri Lanka for the Directorate of Mental Health. The third section of the paper reviews work undertaken with a major psycho-social/mental health organization on issues relating to writing and implementing an ethical code for mental health practitioners and briefly discusses some of the dilemmas associated with this.

Current status of psychology and clinical psychology in India – An appraisal
Baboo Sankar Virudhagirinathan and Subbiah Karunanidhi

This paper provides an overview of the social and cultural context for the emergence and development of psychology in India and also more specifically of the development of clinical psychology. It details the range of universities offering psychology programmes and the various bodies involved in supporting the development of the psychology. The paper also describes the development of clinical psychology in India and the variety of roles undertaken by clinical psychologists. Finally, it raises a number of issues facing the development of Indian psychology into the future.

Developing cognitive behaviour therapy training in India: Using the Kolb learning cycle to address challenges in applying transcultural models of mental health and mental health training
Andrew Beck, B. S. Virudhagirinathan, Sangita Santosham, and Faiz Jahan Begum

Although mental health workers in India across all major professional groups have identified an unmet need for training in cognitive behaviour therapy (CBT), the uncritical export of models of mental health, therapy provision and training to low- and middle-income countries is a problematic process. This paper describes the context for the first stand-alone CBT training programme in India, based in Chennai. This paper includes an evaluation of the first phase of the training and information from trainees regarding the quality and applicability of the training to their working context. The paper provides an overview of some of the critiques that are pertinent to this process and considers the way that the Kolb learning cycle can be used as a framework within training to go some way to addressing these difficulties.

Globalization of psychology: Implications for the development of psychology in Ethiopia
Rachel Swancott, Gobinderjit Uppal, and Jon Crossley

The present article reports on the variation of mental health resources across the globe and considers the merits or otherwise of the process of globalization in low- and middle-income countries (LMIC), with a specific emphasis on Ethiopia. Although globalization has gained momentum in recent years, there is a concern that the globalization of Western mental health frameworks is problematic, as these concepts have been developed in a different context and do not accommodate the current diversity in understanding in LMIC countries. The importance of understanding the mental health frameworks of LMIC like Ethiopia, prior to considering if and how aspects of high-income countries (HIC) conceptualizations may be appropriately imported, is therefore reflected upon. Traditional approaches in managing mental health difficulties and possible reasons for the limited engagement with clinical psychology in Ethiopia are considered. Current developments within the fields of mental health and clinical psychology in Ethiopia are discussed, and the need to develop more local research in order to increase understanding and evaluate treatment interventions is recognized. Further consideration and debate by Ethiopian mental health professionals as well as those from HIC are recommended, to promote both reciprocal learning and new local discourses about mental health.

Reflections on the development of psychology in Ethiopia and future directions
Yemataw Wondie

The introduction and development of psychology in Ethiopia has been mainly limited to Addis Ababa University in the capital city, and also to educational and school psychology which was highly influenced by the field of education at this pioneering university. Similarly, mental health services have been principally developed at the Amanuel Mental Hospital in Addis Ababa that has existed since the 1950s. However, the expansion of higher learning institutions on one hand, and the apparent growing prevalence of mental illness on the other, seem to have contributed to the development of both mental health training and services in other regional cities and towns. Although the influence of the education-oriented psychological training of the Addis Ababa University is still present, clinical psychology education and services are now being started in other universities. One of these is the master’s programme in clinical psychology opened for the first time in the University of Gondar. This article sheds light on the development of psychology in Ethiopia and addresses some of the issues raised about the factors that have influenced its development such as traditional beliefs, poverty and comparisons between mental health in lower middle-income countries and higher middle-income countries (Uppal et al., 2014). The paper also proposes future directions for the education, research, infrastructure and services of clinical psychology and mental health in Ethiopia.

The impact of globalization on subjectivities in Cuba: A gender perspective
Ania Pupo Vega

Globalization has created great transformations, not only in economics, but also in social and cultural relations, and has influenced political practices and governments. If not critically analysed, globalization may at first appear positive, but, in parallel with its development, high levels of poverty and exclusion have occurred and these may affect men and women differently. The objective of this article is to reveal the subjective or individual consequences that derive from globalization and the contexts it creates. This analysis centres on a gender perspective within a Cuban context and tries to challenge the prevailing view of the most poor and excluded groups. Psychiatry and psychology have a long way to go in the search for an understanding of the impact of globalization on human well-being, but critical thinking and the social sciences can offer an alternative to the transformation of this constructed order by giving prominence to people’s own subjectivities and experiences.

Cuban internationalism – An alternative form of globalization
Maria Castro, Steve Melluish, and Alexis Lorenzo

This paper looks at how the principles of internationalism have been integral to the Cuban healthcare system and to Cuba’s cooperation and medical support in other countries around the world. The paper details the range and scope of Cuban health internationalism and the principles that underpin the Cuban approach of long-term collaboration, humane care, contextualization, trans-disciplinarity, respect for collective/historical memory and an ethical stance. The paper details the role of Cuban psychologists who have contributed to disaster relief work and gives an example of the Cuban approach in relation to Haiti following the earthquake in 2010.

Counterflows for mental well-being: What high-income countries can learn from Low and middle-income countries
Ross White, Sumeet Jain, and Catalina Giurgi-Oncu

Global mental health is a comparatively new area of study and research that is concerned with addressing inequities and inequalities in mental health provision across the globe. In recent years concerted efforts have been made to scale up mental health services in low- and middle-income countries (LMIC). As such, there has been tendency to view LMIC as recipients of mental health-related knowledge, rather than providers of knowledge. Critics have referred to the prevailing flow of information from high-income countries (HIC) to LMIC as a form of medical imperialism. To redress the apparent imbalance in knowledge exchange, this paper reflects on valuable lessons that HIC can potentially learn from LMIC in terms of supporting mental well-being. Specifically, the paper reflects on how a greater willingness to embrace pluralism in HIC may facilitate people to engage with forms of support that they believe to be appropriate for them. The paper also explores examples of what are termed ‘counterflows’ of knowledge; ideas that have originated from LMIC that are influencing mental health-related practice in HIC. Barriers to potential counterflows are discussed.

Using a cultural formulation for assessment of homicide in forensic psychiatry in the UK
Ali Ajaz, John Owiti, and Kamaldeep Bhui

Healthcare inequalities for black and minority ethnic (BME) patients in forensic mental health services in the UK are stark. Despite the level of attention given to this over the last 15 years there has been little progress to address disparities. There is a great deal of confusion over what is understood by culture, and what aspects of culture signal specific needs of BME patients. In addition, we have a lack of empirical research demonstrating what it means for psychiatrists to be culturally competent. These are all important barriers against progress in this area. Using a homicide case study that illustrates the typical issues encountered in practice, we explore how to use a cultural formulation in order to assess the role of culture within a forensic psychiatry setting. Finally, practical advice is offered to assist expert witnesses in preparing court reports that adequately consider the significance of defendants’ cultural beliefs and practices.

Globalization, culture and mental health
Dinesh Bhugra

Individual changes due to the impact of globalization and also resulting cultural changes may be at conflicting positions, especially in the area of expressing and managing emotional and psychological distress. In this volume, Tribe, Melluish, and their colleagues have brought together a rich smorgasbord of intellectual thoughts on the subject of globalization. This topic is likely to give rise to a range of increasing possibilities, challenges, and discussions in the future and may require our continued attention as the inter-relationships between globalization, culture, and mental health continue to evolve. The heterogeneous response of cultures to globalization could be seen as a positive step. However, powerful and profitable vested interests resist criticism for their actions, but have to be challenged. As clinicians, each of us has a major responsibility to advocate for our patients to ensure that their interests are maintained and indeed protected.

trans psych coverSecond, the December issue of Transcultural Psychiatry also addresses the subject in a special section entitled “Global Mental Health“. (For a write-up in Somatosphere of the conference that led to this publication, see Bemme and D’souza 2012). Abstracts for the articles, along with an introduction by Laurence Kirmayer and Duncan Pedersen, are below.

Toward a new architecture for global mental health
Laurence J. Kirmayer and Duncan Pedersen

Current efforts in global mental health (GMH) aim to address the inequities in mental health between low-income and high-income countries, as well as vulnerable populations within wealthy nations (e.g., indigenous peoples, refugees, urban poor). The main strategies promoted by the World Health Organization (WHO) and other allies have been focused on developing, implementing, and evaluating evidence-based practices that can be scaled up through task-shifting and other methods to improve access to services or interventions and reduce the global treatment gap for mental disorders. Recent debates on global mental health have raised questions about the goals and consequences of current approaches. Some of these critiques emphasize the difficulties and potential dangers of applying Western categories, concepts, and interventions given the ways that culture shapes illness experience. The concern is that in the urgency to address disparities in global health, interventions that are not locally relevant and culturally consonant will be exported with negative effects including inappropriate diagnoses and interventions, increased stigma, and poor health outcomes. More fundamentally, exclusive attention to mental disorders identified by psychiatric nosologies may shift attention from social structural determinants of health that are among the root causes of global health disparities. This paper addresses these critiques and suggests how the GMH movement can respond through appropriate modes of community-based practice and ongoing research, while continuing to work for greater equity and social justice in access to effective, socially relevant, culturally safe and appropriate mental health care on a global scale.

Why mental health matters to global health
Vikram Patel

Global health has been defined as an area of study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. This article provides an overview of some central issues in global mental health in three parts. The first part demonstrates why mental health is relevant to global health by examining three key principles of global health: priority setting based on the burden of health problems, health inequalities and its global scope in particular in relation to the determinants and solutions for health problems. The second part considers and addresses the key critiques of global mental health: (a) that the “diagnoses” of mental disorders are not valid because there are no biological markers for these conditions; (b) that the strong association of social determinants undermines the use of biomedical interventions; (c) that the field is a proxy for the expansion of the pharmaceutical industry; and (d) that the actions of global mental health are equivalent to “medical imperialism” and it is a “psychiatric export.” The final part discusses the opportunities for the field, piggybacking on the surge of interest in global health more broadly and on the growing acknowledgment of mental disorders as a key target for global health action.

Research ethics in global mental health: Advancing culturally responsive mental health research
Mónica Ruiz-Casares

Global mental health research is needed to inform effective and efficient services and policy interventions within and between countries. Ethical reflection should accompany all GMHR and human resource capacity endeavors to ensure high standards of respect for participants and communities and to raise public debate leading to changes in policies and regulations. The views and circumstances of ethno-cultural and disadvantaged communities in the Majority and Minority world need to be considered to enhance scientific merit, public awareness, and social justice. The same applies to people with vulnerabilities yet who are simultaneously capable, such as children and youth. The ethical principles of respect for persons or autonomy, beneficence/non-maleficence, justice, and relationality require careful contextualization for research involving human beings. Building on the work of Fisher and colleagues (2002), this article highlights some strategies to stimulate the ethical conduct of global mental health research and to guide decision-making for culturally responsible research, such as developing culturally sensitive informed consent and disclosure policies and procedures; paying special attention to socioeconomic, cultural, and environmental risks and benefits; and ensuring meaningful community and individual participation. Research and capacity-building partnerships, political will, and access to resources are needed to stimulate global mental health research and consolidate ethical practice.

Challenges of creating synergy between global mental health and cultural psychiatry
Joop T. V. M. de Jong

This article addresses four major challenges for efforts to create synergy between the global mental health movement and cultural psychiatry. First, although they appear to share domains of mutual interest, the worlds of global mental health and cultural psychiatry have distinct lineages. Expanding their horizons by learning from adjacent disciplines would be mutually beneficial. A second challenge concerns the conceptualization of a new classification system for mental health problems. Adopting a classification system that integrates new insights from socio-neurobiology and from a networks perspective could bring cultural psychiatry and global mental health closer and change the way each field addresses the mental health gap, which constitutes the third challenge. I summarize attempts to achieve comprehensive mental health coverage around the globe and question whether the strategies employed to achieve these goals have been successful, both in high- (HIC) and low- and middle-income countries (LMIC). In LMIC, the dominant strategy needs to be complemented by mobilization of other community resources including local practitioners. A fourth challenge is the lack of mathematical models to guide action and research and solve major preoccupations such as access to care or multi-level analyses in complex ecological or health systems.

Ritual healing and mental health in India
William Sax

Ritual healing is very widespread in the Indian state of Uttarakhand, and is by far the most common option for those with serious behavioral disturbances. Although ritual healing thus accounts for a very large part of the actual health care system, the state and its regulatory agencies have, for the most part, been structurally blind to its existence. A decade of research on in this region, along with a number of shorter research trips to healing shrines and specialists elsewhere in the subcontinent, and a thorough study of the literature, suggest that such techniques are often therapeutically effective. However, several considerations suggest that ritual healing may not be usefully combined with mainstream “Western” psychiatry: (a) psychiatry is deeply influenced by the ideology of individualism, which is incompatible with South Asian understandings of the person; (b) social asymmetries between religious healers and health professionals are too great to allow a truly respectful relationship between them; and (c) neither the science of psychiatry nor the regulatory apparatus of the state can or will acknowledge the validity of “ritual therapy”—and even if they did so, regulation would most likely destroy what is most valuable about ritual healing. This suggests that it is best if the state maintain its structural blindness to ritual healing.

Global mental health and its discontents: An inquiry into the making of global and local scale
Doerte Bemme and Nicole A. D’souza

Global Mental Health’s (GMH) proposition to “scale up” evidence-based mental health care worldwide has sparked a heated debate among transcultural psychiatrists, anthropologists, and GMH proponents; a debate characterized by the polarization of “global” and “local” approaches to the treatment of mental health problems. This article highlights the institutional infrastructures and underlying conceptual assumptions that are invested in the production of the “global” and the “local” as distinct, and seemingly incommensurable, scales. It traces how the conception of mental health as a “global” problem became possible through the emergence of Global Health, the population health metric DALY, and the rise of evidence-based medicine. GMH also advanced a moral argument to act globally emphasizing the notion of humanity grounded in a shared biology and the universality of human rights. However, despite the frequent criticism of GMH promoting the “bio”-medical model, we argue that novel logics have emerged which may be more important for establishing global applicability than arguments made in the name of “nature”: the procedural standardization of evidence and the simplification of psychiatric expertise. Critical scholars, on the other hand, argue against GMH in the name of the “local”; a trope that underlines specificity, alterity, and resistance against global claims. These critics draw on the notions of “culture,” “colonialism,” the “social,” and “community” to argue that mental health knowledge is locally contingent. Yet, paying attention to the divergent ways in which both sides conceptualize the “social” and “community” may point to productive spaces for an analysis of GMH beyond the “global/local” divide.


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