Global mental health: training in an international context

This special edition is devoted to the theme of Global Mental Health: Training in an International Context. The idea for the special edition arose out of a conference with a similar title held at the University of Leicester, UK, in 2018, where a number of the journal contributors presented papers.

Global Mental Health (GMH) is a broad term that encompasses areas of research, education, practice, and policy concerned with issues of equity and access to mental health care across the globe. The term “GMH” first appeared in a publication titled, Global Mental Health: Its Time Has Come (Satcher, 2001). Satcher (the then U.S. Surgeon General) proposed that the United States should take a lead on developing GMH with a “shared vision” for improving mental health services worldwide. However, the subsequent rapid growth of the GMH field followed the publication of a series of articles in the Lancet journal in 2007. This series of articles called for action on the provision of universal access to mental health care through the “scaling up” of services and expertise in low- and middle-income countries (LMICs). This focus on action was taken up by the World Health Organization (WHO) in the form of the Mental Health Global Action Program (MhGAP). Around the same time, the Movement for Global Mental Health (http://www.globalmentalhealth.org) was formed as a campaigning organization, aiming to mobilize stakeholders and lobby governments for policy change in terms of a fairer distribution of mental health resources. These calls to action drew on a rights-based narrative about social justice addressing the stark historical inequities between the Global North and the Global South.

Training and education were, and continue to be, key components of the “scaling up” of mental health provision, and there have been a wide range of innovative projects undertaken in many LMICs countries to develop psychosocial interventions and creative ways to overcome the lack of trained specialists in mental health. The articles in this special edition detail innovative work in different countries. These include: work on psychosocial capacity building in Turkey, Brazil, Pakistan, Indonesia, Kenya, and Rwanda (Panos Vostanis); an article looking at indigenization vs. westernization in mental health training in Ethiopia (Yemataw Wonde and Mastewal Abawa); and a report on a project looking at community-based work with refugee groups in the UK and an international partnership between mental health professionals in the UK and Sir Lanka (Rachel Tribe).

Although these projects were not specifically developed under the auspices of GMH, they are examples of training and education initiatives that have been developed to address social suffering in contexts of poverty, structural violence, and humanitarian emergencies. While some GMH training has been about the establishment of mental health professional training courses in LMICs to train mental health professions, other training has been about developing community-based initiatives that work in partnership with local community organizations to train non-specialists to deliver specific mental health and psychosocial interventions.

The development of the GMH field and the involvement of Western mental health professionals in delivering training has attracted contention and controversy. There is concern that GMH legitimizes the inappropriate export of Western theories and models and so contributes to the marginalization of indigenous knowledge systems. This theme is addressed in the article by Kat Taylor and Gerald Burgess looking at the views of non-Western psychology practitioners on the import of Western psychology into their indigenous cultures. Also, Suman Fernando, in his article on “Developing mental health services in the Global South,” traces the colonial origins of Western systems of mental health. He reflects that while the asylum psychiatry imposed under colonial rule had little lasting impact on cultural ways of thinking about emotional distress, the promotion of Western mental health thinking, under the auspices of GMH, places the plurality of mental health systems in the Global South under threat.

Power and resource differences between the Global North and the Global South have led to an asymmetrical cultural flow of ideas from the Global North, and so it is not surprising that in the field of mental health training and education a similar pattern is found. The article by Julian Eaton on “Rebalancing Power in Global Mental Health” discusses issues around power and how to involve local stakeholders. He discusses the importance of a human rights approach that is based on the participation of people affected and involves local actors in developing services. He believes that advocating such an approach will help towards rebalancing power. This theme of involving local stakeholders is also addressed in the article by China Mills and Kimberly Lacroix. They examine the complexities within GMH of rolling out standardized training based on the WHO’s MhGAP-IG to non-specialists across the globe. They use an ethnographic approach to examine how the training is “done” and who enacts it. Specifically, these articles raise important questions about how training is delivered and by whom, how training is shaped to local contexts, and whether the standardization of training privileges particular “treatments” or interventions.

As is evident from the articles in this special issue, GMH is a diverse field that encompasses research, social action and justice, and debate, and covers a wide range of cultural, disciplinary and personal perspectives. This special issue reflects the heterogeneity of GMH and touches on some of the complexities and controversies that have emerged. In this introduction, we highlight two key themes that underpin the current debates around GMH. These are the relationship between global and local in terms of how emotional distress is conceived, and the question of epistemology and how new knowledge is constructed.

The relationship between global and local

The first area of contention is around the notion of “global.” Within GMH, the term global is often contrasted to the term local. One reading of the idea of global is that it connects to ideas of universalism, i.e., that concepts and principles have universal application. The idea of universalism was born out of modernity and the European enlightenment, and in this, modernity is often opposed to notions of the pre-modern. As such, European/Western ideas are often seen to represent the universal and ubiquitous. The West is positioned as the universal point of reference, and hence those regions and peoples associated with modernity are seen to appear politically or economically superior to other regions and peoples.

The language of mental health has developed within Western systems of knowledge and the terms and concepts used within psychiatry and psychology have, since the 1970s, become globally used. As Fernando (this issue) points out, while Western systems of mental health were imposed on countries of the Global South during colonial rule, the way these concepts are understood and interpreted is often different in non-Western cultures. For example, emotional distress may be understood as a personal, social or spiritual problem, and not as an illness or mental health condition. However, the dominance of biomedical approaches to mental health in the West means that this approach is the one that has been influential in informing GMH. There is concern that GMH is a convenient vehicle through which biomedical approaches are promoted, and this serves to expand the market for drug companies selling psychotropic medication to new markets in LIMCs.

While vested interests no doubt play a part in shaping the thinking around mental health, these interests are no less present in the Western mental health systems than they are in LMICs. Yet within the West, the field of mental health is highly contested, and there is increasing acknowledgement of the scientific limitations of applying a biomedical frame to emotional distress. Psychosocial approaches are finding a prominent place in informing mental health theory, practice, and policy in the West, and there is a much wider acceptance of the place of trauma in the etiology of emotional distress.

The “scaling up” of mental health training raises questions about whether mental health concepts (biomedical or psychosocial) are universally valid, and whether evidence generated predominantly in high income countries can be effective in LMICs. It also raises questions about whether such concepts/practices can be applied in other cultural contexts in an appropriate and acceptable way and whether it risks positioning those in LMICs as simply recipients of knowledge generated in higher income countries. While this is an important consideration, other commentators have pointed out that the flow of knowledge is not unidirectional. There also exists counter flows of knowledge and ideas generated in LMICs that can influence mental health thinking and practice in higher income countries.

A further issue is that the dominant narratives around GMH simultaneously incorporate Western notions of human rights, capacity, and insight, and it is implied that these are transferable to mental health practice within the Global South. The cultural “ways to be” in the global North reflect the obligations of Western life, and it is within this discursive context that Western mental health practice is situated. Self-sufficiency is privileged and people’s success or failure to live an independent life is often associated with whether they, and others, judge them to have a psychological or mental health difficulty. In cultures within the Global South, the capacity “to know” may be possessed by authoritative members of the community and there may be a more collective or social conception of the self and a different value placed on dependence and independence.

A further concern of some critics of GMH is that the focus on mental health shifts attention away from the other urgent social and economic problems faced by people in the Global South. A contextualized understanding of mental health, however, would seem to acknowledge that emotional distress is a consequence of these wider environmental determinants of distress such as poverty, social inequalities, and economic injustice, and that the design of any intervention needs to involve collaboration with the local stakeholders to address these factors and the impact they have on well-being.

As the GMH field has expanded, the simplistic dichotomy between global and local has been replaced by more nuanced framing of GMH as a heterogeneous field that encompasses the notion of health pluralism. As illustrated by Julian Eaton’s article, there is shift in focus within GMH towards thinking more about community engagement, social inclusion, citizen authority, and user/consumer centered involvement and consideration of how communities and their members can be encouraged to act authoritatively.

How knowledge is constructed

The World Health Organization lists evidence-based practice (EBP) as one of its informing principles in best practice, and the dissemination of this approach has been key in shaping the standardization of GMH interventions and their evaluation. Many argue that EBP as currently understood and practiced is a technology of power for Western medicine. EBP as a paradigm has been criticized for using a positivist approach that disregards the social nature of science and the cross-cultural nuances of emotional distress in different contexts within the Global South.

Within the field of GMH, there has been a call for a more pluralistic view of knowledge (Kirmayer & Swartz, 2013) that sees GMH interventions as interacting with context to influence outcomes. This has meant some arguing for a different paradigm of research that can deliver locally meaningful health interventions in LMICs and using more qualitative ethnographic approaches rather than randomized controlled trials.

Running through all these epistemological issues is the issue of power. It is about asking who is defining the problem? And who is being defined? Who is facilitating the training? How is the training that is given by Western professionals then used in practice? How do local understandings and practices influence the way training is incorporated?

As Julian Eaton, China Mills, and Suman Fernando all advocate, the frameworks used in the GMH field need to be based on strong human rights’ principles that provide a basis for distributing power and influence. It is important for GMH training to be developed in consultation with local people and that GMH training is sensitive to cultural values and norms.