Hi Michael! I'm an EA from Sheffield. Thank you for all this! :)
I just wanted to introduce into this discussion some broader critiques about the concept of 'global mental health'. Because I think this article rests on some fundamental assumptions about the 'universalism' of mental disorders, such as depression. Assumptions like this are increasingly regarded as problematic by many critical psychiatrists and anthropologists. I will split these into three main criticisms - firstly to do with the framing of the problem of global mental health, then the proposed solutions. This is all very relevant to arguments about scale, neglectedness, tractability and your example of the StrongMinds intervention. ..The final section is about the nature of the global mental health movement and may be less directly relevant but worth putting down anyway!
I think it's super important that we engage with these debates !!!
Critiques of the 'PROBLEM'
The most widely cited prevalence figures on mental disorders globally are sourced from the WHO World Mental Health Survey (Kessler et al., 2009). This is based on diagnosis using the Composite International Diagnostic Interview, which assesses mental disorder based on criteria from the US Diagnostic and Statistical Manual of mental disorders (DSM), and the WHO International Classification of Diseases (ICD) (Kessler et al., 2009). These classification systems were both developed in the ‘West’, and are representative of ‘Western psychiatry’ – which this essay defines as “psychiatry developed in specific high-income countries of the Global North” (Mills, 2014a, p. 2). Diagnoses used in the World Mental Health Survey are therefore defined by Western psychiatric nosology.
However, decades of anthropological and ethnographic research suggests that understanding, classification, presentation, and prognosis of ‘mental disorders’ varies greatly between cultures (Summerfield, 2012). As a result, the universal application of Western classifications is regarded by critics as deeply problematic. Fernando (2012), for instance, writes of the ‘etic-emic balance’. The term ‘etic’ refers to the approach of studying behaviours from outside a culture, aimed at finding broad culture-general patterns. ‘Emic’, however, refers to the approach of studying behaviours from within a culture, aimed at understanding culture-specific aspects. Fernando argues that the ‘etic-emic balance’ is “largely missing” from current GMH model, which leans heavily towards an ‘etic’ approach of identifying culture-general patterns, whilst importing Western measures to other cultures – in what constitutes an ‘imposed etic’ (Fernando, 2012, p. 401).
Arthur Kleinman has been making similar observations on the pitfalls of cross-cultural psychiatric research for over thirty years – accusing mainstream research of regularly committing a ‘category fallacy’. He describes a ‘category fallacy’ as:
The reification of a nosological category developed for a particular cultural group that is then applied to members of another culture for whom it lacks coherence, and its validity has not been established (Kleinman, 1987, p. 452).
Kleinman (1987) argues that rather than using Western nosological categories, experiences of distress globally may be better understood through the anthropological model of ‘idioms of distress’: “culturally prescribed ways of communicating that someone feels bad and/or unhappy” (Ventevogel, 2016, p. 247). These ‘idioms of distress’, though perhaps sharing similarities with Western categories, should not automatically be assumed to align with them in a meaningful way. Many authors argue that today’s GMH approaches continually misalign ‘idioms of distress’ into Western categories, hence subscribing to Kleinman’s ‘category fallacy’ (Miller et al., 2009; Summerfield, 2013; Mills, 2014a; Ventevogel, 2016). It is argued that cultural understandings are too often an “after-the-fact consideration”, when in fact they ought to represent the starting point for capturing the experiences that mental health research seeks to understand (Bass, Bolton and Murray, 2007, p. 918).
For many critics, these epistemological problems are fundamental – so far as to render claims about worldwide prevalence of mental disorders invalid (Fernando, 2012). In fact, Summerfield (2013) argues that the very concept of ‘global’ mental health should be considered an oxymoron for such reasons.
Critiques of the 'SOLUTIONS'
Secondly, there are criticisms of ‘The Solutions’ as presented by GMH advocates – that is, the urgent scaling up of evidence-based interventions worldwide (Patel et al., 2018). The roots of many criticisms lie in the ways in which these evidence-based ‘Solutions’ may act as a vehicle for exporting the ‘biomedical model’ which dominates Western psychiatry, with potentially harmful consequences.
This ‘biomedical model’ understands mental illness as the result of “faulty mechanisms”, arising from “abnormal physiological and psychological events occurring within the individual”, which – like the rest of medicine - can be understood with causal logic, and captured with scientific tools (Bracken et al., 2012, p. 430). This model works within a positivist orientation, which critical psychiatrists describe as the ‘technological paradigm’. Many critical psychiatrists assert that the primacy of this paradigm is problematic in the West, let alone elsewhere. It is argued that the ‘technological paradigm’ does a disservice to the specialty through reducing its scope to that of an ‘applied neuroscience’. This approach, termed by some as ‘psychiatric reductionism’, valorises the individual brain and specific technical interventions (such as medication or CBT), whilst comparatively neglecting the complicated interplay of psychological, social and cultural forces which underlie mental disorder (Bracken et al., 2012). Generally then, it seems that the application of the Western psychiatric model is not without its controversies.
Nevertheless, the GMH movement was born out of this dominant paradigm, and so naturally promotes ‘Solutions’ that are reflective of it. This is seen as problematic for several reasons.
One concern is that the GMH movement, through exporting the ‘biomedical model’, may become an “unwitting Trojan horse” for mass medicalisation in the Global South (Whitley, 2015, p. 288) – paving the way for exploitation by large pharmaceutical companies with corporate interests to market psychotropic agents in ways that are potentially harmful (Fernando, 2011).
More broadly, there is serious concern over how GMH is framed, within the ‘biomedical model’ – or what Mills calls the “GMH within-brain approach” (Mills, 2014a, p. 11). This model puts the focus on individuals, and so accordingly promotes technical, individual solutions. This idea of effective technical solutions is a strong narrative of the GMH movement - well captured, for example, by the WHO’s assertion that “unlike many large scale international problems, a solution for depression is at hand” in the form of amitriptyline, fluoxetine, or talking therapies, as guidelines recommend (Marcus et al., 2012, p. 8; WHO, 2016b). However, framing GMH in this way can have the result of deflecting attention away from crucially important determinants of mental health which go far beyond individuals.
The anthropological theory of ‘social suffering’ helps to emphasise the profound influence of these wider factors - conceiving of suffering in the context of “what political, economic and institutional power does to people” (Kleinman, Das and Lock, 1997, p. 9). A shocking example is illustrated by Mills (2014b), in her chapter ‘Suicide Notes to the State’. Mills describes the devastating impact of agricultural reforms on small-scale farmers in India, which have led to socioeconomic crisis and unprecedented levels of suicides among this group – 87% of which are linked to debts (Mills, 2014b). While farmers write suicide notes to the government, GMH calls for increasing their access to anti-depressants. Mills argues that reducing intervention down to this biochemical level completely fails to address the systemic ways in which global power imbalances and socioeconomic inequalities are making people’s lives unliveable.
Additionally, Paul Farmer’s (2009) theory of ‘structural violence’ is useful in describing how macro-level social arrangements can systematically put individuals and populations in harm’s way; thereby creating the conditions for both psychical and mental suffering.
Nevertheless, it should be noted that the most recent Lancet Commission went some way towards responding to these criticisms, with authors acknowledging that the “biomedical framing of the treatment gap has attracted criticism from some scholars and activists”. The report notably placed stronger emphasis on the “social determinants of mental health”, as well as the need to strike a balance between pharmacological and psychological interventions - steps which were met with approval by several of the movement’s critics (Patel et al., 2018, pp. 1557, 1560).
Critiques of the nature of the 'global mental health' movement
Thirdly, the nature of the GMH movement itself has come under attack from several quarters.
Through a postcolonial lens, Mills (2014a) calls for a wider analysis of the mechanisms which allow the ‘global norms’ for mental health, as stated by GMH and WHO, to circulate as ‘true’, whilst foreclosing other ways of thinking from circulating. Indeed, the movement is seen by Mills and others to constitute a form of ‘psychiatric imperialism’ (Summerfield, 2013; Christopher et al., 2014; Mills, 2014a).
These critiques are closely tied up in global power relations, and both Kleinman (2010) and Summerfield (1999) invoke the theories of Foucault in the context of GMH. Foucault theorized an inseparable relationship between knowledge and power - suggesting that those in control can create norms and categories which become the basis of knowledge. This knowledge can then serve to legitimise political and socioeconomic conditions, as modes of power (Gutting and Oksala, 2003). Foucault’s knowledge/power relationship seems highly relevant to previous critiques of GMH – including notions of category fallacies, dominant paradigms, and Western psychiatric hegemony.
The aforementioned call by Patel to make “mental health for all a reality” therefore merits deeper questioning. In this discipline, whose ‘reality’ counts? Who has the power to define it? GMH’s current ‘psychiatric reductionism’, Mills (2014a) argues, is far from offering a reality check. On the contrary - GMH proceeds to put people in biological and epidemiological boxes, whilst failing to adequately understand or represent the complex multiple realities of their lived experiences.
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