Global Mental Health: A category benefiting from its contesting?

By Ross White, University of Liverpool

On the 5th and 6th June Kings Health Partnership in conjunction with King’s College London hosted a conference entitled: ‘Global Mental Health and Psychosocial Support’ that was held at the KCL Waterloo campus. The conference was well attended with over 300 clinicians, researchers and students present. True to the focus of the conference there was also a good range of overseas speakers from countries such as Libya, Palestine, Zimbabwe, Uganda, and Sierra Leone.

I was invited to speak about work that I have been involved with relating to the adaptability of Acceptance and Commitment Therapy in sub-Saharan Africa. My presentation was part of the ‘Interventions in Global Mental Health’ session on the first day. Other sessions at the conference focused on themes such as ‘Reverse Innovation & Mutual Learning’, ‘Models of Partnership’, ‘Working with Trauma and in Conflict Situations’, ‘Helping the Helpers’, ‘Insights from the Field: NGO work’, ‘The Ethics and Politics of Global Mental Health’, ‘Training and Sustainability’, ‘Working with International and National Policy’ and ‘Acceleration and Scaling Up’. It was a very rich 2 days with a lot of thought-provoking material presented. In particular the panel discussions that were sprinkled liberally through the programme facilitated interesting discussion and, sometimes frank, exchanges of views. The organisers (Elaine Hunter, Alison Beck and Tope Ademosu) deserve great credit for ensuring diverse perspectives on GMH were presented.

This blog entry is intended to summarise some of the key points for reflection that arose for me across the two days. Readers who are active on Twitter may also wish to check out #KHPGMH2017 which captures the thoughts of others who attended.

Should we be doing global mental health at all?

GMH as an area of study, research and practice is principally concerned with addressing inequities in mental health provision across the globe. The lack of infrastructure (as recognized by high-income countries) for managing mental health problems in low- and middle-income countries (LMIC) has meant that a great deal of GMH attention thus far has fallen on LMIC. But this has led to accusations that GMH is founded on skewed, ethnocentric assumptions about what mental health services should be and that GMH is a Trojan horse that seeks to globalize psychiatric systems of care. However, these accusations have in turn been criticized as reductive misrepresentations of diverse approaches that are increasingly sensitive to the needs and views of local stakeholders. For those interested to read more about the development of GMH and related debates, the introductory chapter to The Palgrave Handbook of Socio-cultural Perspectives of Global Mental Health which is entitled ‘Situating Global Mental Health: Socio-cultural Perspectives’ may be of interest.

It was clear that many of the presentations, my own included, focused on the adaptation and/or scaling-up of psychosocial/psychological interventions that had been developed in high-income countries that were now being countries. This may be attributable to the fact that a wealth of psychological interventions have been manualised in high-income countries, and the evidence-base for these interventions has largely been established in high-income countries. Inevitably the content of these interventions has been influenced by the way in which people living in high-income countries experience, conceptualize and articulate their experiences. The suggestion is that these processes vary according to the local cultural and linguistic context, which gives rise to diverse ‘ethnopsychologies’. Unsurprisingly, an issue that arose at the conference was the extent to which it is appropriate to ‘export’ psychological interventions from HIC to LMIC, and whether it is appropriate for people from HIC to even work in LMIC. The possibility remains that there are approaches that originate in LMIC that may be effective for addressing distress that people experience there. In particular, approaches that are different from the allopathic approaches of the West, which from a Western perspective are some-what dismissively referred to as ‘alternative’ or ‘complementary forms’ of support (e.g. traditional healing, or faith healing) may represent affordable, acceptable, culturally appropriate, and effective strategies for managing distress.

Unfortunately, presentations focusing on indigenous forms of (psychosocial) support were sadly lacking from the conference schedule. This was disappointing given the findings of the review conducted by Nortje et al. (2016) that synthesized findings from 32 studies (conducted in 20 different countries) that investigated the efficacy of traditional healers for addressing mental disorders. The review concluded that traditional healers ‘might help to relieve distress and improve mild symptoms in common mental disorders such as depression and anxiety’ (Nortje et al., 2016, P154). There is increasing recognition of the importance of working with alternative/complementary practitioners as they represent a group of stakeholders that people in LMIC have engaged with for generations to address distress. Collaborations of this type must reflect on the merits and demerits of each other’s respective approaches whilst guarding against of the risk of ethnocentric subjugation of ways of knowing and practicing that are unfamiliar to them. Navigating these challenging metaphorical waters will be tricky. However, adhering to a rights-based approach that prioritizes opportunities for enhanced citizenship of people will be helpful.

For a number of presenters at the conference (particularly some of those in ‘The Ethics and Politics of Global Mental Health’ session) were of the opinion that GMH as an endeavor was a potentially flawed project due to the inherent skewing towards Western perspectives. Angela Byrne’s presentation bore the forthright title ‘Why I chose to stop working internationally’. Angela expressed with great honestly and authenticity her concerns about the risk of harm being wrought by, albeit well intentioned, people intervening in cultural contexts that they are unfamiliar with. She highlighted the risk that the potential to ‘the silence of local people’ in supposed collaborative international partnerships bears testament to these issues. In highlighting a range of cultural and linguistic barriers to doing international mental health related work, Angela noted that if you cannot speak the language(s) of the place where you are going to be working, then you are a drain on their resources. Angela’s presentation highlighted the importance of people paying close attention to their reasons for engaging in international work and the costs, as well as the benefits, of this involvement. Practitioners will need to be mindful of the implicit, as well as more explicit, assumptions and biases that they bring to this work. In particular, it will be important to be vigilant to the positions of power that can emerge when identifying closely with professional and disciplinary knowledge. All forms of professional training have blind-spots, which may become particularly exposed when applied in different contexts. The lack of flexibility that professionals adopt has been referred to as the ‘tyranny of experts’ by William Easterly. Local stakeholders can also contribute to these power dynamics by adopting an attitude of resistance to interventions, or indeed by taking an overly deferential position to international experts [i.e. Kristen Edquist (2008) highlighted the risk that international agencies might constitute ‘mental health assemblages’ that could serve to globalize pathologies]. Where possible, it will be vital to make explicit the assumptions that are inherent to the theoretical models that are informing international work. Discussing these assumptions with a diverse range of relevant stakeholders should be a key feature of the preparation for the work.

The harm of doing vs. the harm of not doing

Whilst acknowledging the need for cultural sensitivity, and caution with regard to the power dynamics in how knowledge is brokered, I would counter that people should not exclude themselves from international mental health related work on the basis that they not from the local cultural and linguistic context in which the work is taking place. This could amount to what I would term ‘ethnopsychological acquiescence’, where people prefer not to act or intervene on the basis that they do not know enough about how distress is experienced, conceptualized and articulated in that context. I agree that there is a need to progress with care, but by working in partnership with local stakeholders and adopting paradigm humility (where we hold our world view and associated assumptions about paradigm lightly) opportunities for fruitful, enriching and productive collaborations exist. The nature of the work itself is a central consideration, but equally the attitude that people bring to this work is key. In being mindful of the risk of doing no harm, we must also be aware of the limiting impact that inaction may have on efforts to improve mental wellbeing across the globe.

The Politics of Identity

Over the course of the two days the politics of identity, and the privilege that particular identities can imbibe, was a theme that emerged in a number of presentations and associated discussions. Nimisha Patel in her talk entitled ‘The mantra of do no harm: International healthcare responses to refugee people and human rights violations’ spoke passionately about the need to acknowledge the long-shadow that ‘whiteness’ casts over international mental health work, and how power is disproportionately distributed in this work. She argued, persuasively, for the need to prioritise a human-rights based approach that tackles the social injustices that underlie the distress that people experience across the world, and for people to eschew the inclination to be a bystander to injustices being committed.

As a white male, aspects of Nimisha’s presentation made for uncomfortable but important listening.

It provided an opportunity to acknowledge how the ‘privileges’ that come with being white, male and born in a HIC have afforded me with particular opportunities to learn about mental health in international contexts. My circumstances also provided me, but not others (particularly my LMIC-based collaborators), with the opportunity to attend this particular conference. Nimisha’s points were very well made. She speaks with great grace and wisdom. But in recognising the power imbalances that various forms of privilege can bring (and endeavouring to address injustices associated with this), we need to be aware of the importance of avoiding stereotyping in all its forms. Efforts aimed at promoting the rights of disenfranchised groups  (e.g. minority groups, those living in low resource settings, and those experiencing mental health difficulties) should not denigrate the humanity of other groups. My upbringing in Northern Ireland brought into sharp focus the importance of reconciling injustices and transforming conflict, but it has also made me very wary of discourses that can serve to ‘other’ groups of people.

I addressed issues relating to GMH and identity politics in the final panel discussion of the conference when I spoke about how these discussions had impacted on me. Whilst being aware of the crucial importance of acknowledging injustices that have been perpetrated against particular groups of people, and the need to respect diversity, I also feel that it is vitally important we acknowledge the common humanity that is shared across different identities. These issues were discussed in the aftermath of the last US election with some commentators reflecting on the need for what has been termed ‘post-identity liberalism’ i.e. a move towards acknowledging diversity, whilst embracing commonality and promoting solidarity. I think it is fair to assume that the vast majority of people who were present at the conference share a commitment to making a positive impact on the lives of people experiencing distress across the globe – a common cause that people can work together to advance. I think the organisers of the conference deserve enormous credit for trying to create a space for different diverse discourses to be shared, but moving forward the challenge for GMH will be to ensure that marginalised voices (many of which were not represented at the conference) are also heard, and that this can make a meaningful contribution to shaping the sense of shared humanity and solidarity it can engender.

‘Flows’ of Knowledge

In acknowledgement of the need to improve mental health services in HIC, interest is growing in how insights from GMH can help to promote innovation and improved effectiveness of mental health services in HIC. This is a topic that colleagues and I have reflected on in recent papers that we have published e.g. the editorial in the British Journal of Psychiatry by Sashidhrana et al. (2014) entitled ‘Global Mental Health in High-income Countries’ (http://bjp.rcpsych.org/content/209/1/3). Despite the hard work and commitment of various stakeholders, if a school report was to be issued about mental health services in HICs it would read ‘Could do better’. Martha Nussbaum (2011) has previously commented that ‘All nations are ‘developing’…All are failing at the aim of ensuring dignity & opportunity for each person’. This is exemplified, by the fact that there are large proportions of the population in the UK who are underserved by mental health services. Angela Byrne’s presentation included a quote that debunked the myth (perpetuated by policy makers and services) that these populations are ‘hard to reach,’ – it stated ‘we are not hard to reach, we’re just easy to ignore’. It may be that mental health services in the UK could be more inclusive of diverse explanatory models of mental health difficulties, and work more closely with stakeholders who are knowledgeable about these explanatory models (e.g. religious leaders, practitioners of Chinese Traditional Medicine etc.) to deliver forms of intervention that are acceptable to greater proportions of our populations can engage with. It will be important for there to be an open and equitable exchanging of knowledge between different stakeholders to avoid what Miranda Fricker (2009) has referred to as ‘epistemic injustices’ i.e. when people are wronged in their capacity to be knowers.

Consistent with this idea of HIC learning from LMIC, the conference had a dedicated stream called ‘reverse innovation’. This has been referred elsewhere as ‘reverse engineering’. Angela Byrne, a clinical psychologist who has experience of international work, stated at the conference that the use of the word ‘Reverse’ takes for granted that there is a normative direction of innovation and that this may be problematic. Similarly, Lord Nigel Crisp in his key-note speech indicated that he does not like the term and the condescending connotations that it conjures. In my writing about GMH, I along with my colleagues have introduced the term ‘counterflows for global mental wellbeing’ (White et al., 2014) to specifically capture the way in which for too long people living in LMIC have been regarded as recipients of knowledge rather than generators of knowledge about mental health, and that there is a need for people in HIC to be receptive to potentially helpful knowledge that runs counter to the prevailing direction of knowledge (i.e. from HIC to LMIC).

Treatment and Prevention

During his key-note speech, Vikram Patel reflected on the tensions that exists between focusing resource on ‘treating’ mental health difficulties vs. investing in preventive approaches aimed at addressing the social determinants that contribute to mental health problems. He suggested that claims that all resources should be directed to preventative strategies, is like saying TB should be controlled simply by ending poverty. Equally, however, he could have observed that focusing on ‘treatments’ without adequately addressing the social contexts in which people live their lives (and the associated poverty, marginalization and disempowerment that large proportions of the global population experience) would be akin to treating someone for cholera without addressing the source of the infection. One of the slides used by a presenter in their PowerPoint presentation captured this sentiment by including a quote from the WHO European Office that stated that ‘Modern societies actively market unhealthy lifestyles’. Careful attention needs to be paid to striking a balance between investing in treatment and prevention programmes.

The ethics of diagnosis

The key-note by Vikram Patel was also cause for reflection on the ethical ‘elephant in the room’ that has loomed large in debates relating to the merits and demerits of GMH initiatives. This relates to the concerns have been expressed by people such as Derek Summerfield, China Mills (who both presented at the conference) and myself, about the use of psychiatric diagnosis in LMIC when concerns have been raised about the validity and reliability of these systems in HIC. Indeed, concerted efforts are being made by clinicians and academics in the UK to propose alternative frameworks to diagnosis (e.g. the Power-Threat-Meaning framework). Patrick Hughes who presented in his capacity as a WHO consultant for the mhGAP programme remarked that there is considerable pressure to make diagnoses in international mental health work that he has undertaken because this fits into the recording systems that international agencies use. Vikram Patel noted that in spite of concerns about concerns about the validity of psychiatric diagnoses (that can mean that some researchers decide not to share diagnoses with research participants recruited in LMIC), there are also imperatives for using diagnostic categories in research settings as this ‘gets papers published’. There is an urgent need for the scientific community to engage in dialogue about this unsatisfactory and potentially harmful approach. Perhaps this is an issue that the upcoming Third Series on Global Mental Health commissioned by The Lancet will address. It is too important an issue not to be focused on.

I would like to express my deep gratitude to Dr Nargis Islam (Clinical Psychologist) who also attended the conference, and who provided helpful comments and suggestions about the content of this blog entry.

References

Edquist, K. (2008). Globalizing pathologies: mental health assemblage and spreading diagnoses of eating disorders. International Political Sociology, 2(4), 375-391.

Fricker, M. (2009) Epistemic Injustice: Ethics and the power of knowing. Oxford, Oxford University Press.

Nortje, G., Oladeji, B., Gureje, O., & Seedat, S. (2016). Effectiveness of traditional healers in treating mental disorders: a systematic review. The Lancet Psychiatry, 3(2), 154-170.

Nussbaum, M. C. (2011). Creating Capabilities: The Human Development Approach. Harvard University Press: US.

Sashidharan, S.P., White, R.G., Mezzina, R., Jansen, S., Gishoma, D. (2016). Global Mental Health in High Income Countries (Editorial). British Journal of Psychiatry, 209, 3-5.

White, R.G., Jain, S., and Giurgi-Oncu, C. (2014) Counterflows for mental well-being: What high-income countries can learn from Low and middle-income countries. International Review of Psychiatry, 26, 602-606.

White, R.G., Jain, S., Orr, D., & Read, S. (Editors) (2017) The Palgrave Handbook of Global Mental Health: Socio-cultural Perspectives. Palgrave-Macmillan. Download here.

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