Global mental health and its critics: moving beyond the impasse

The last decade has witnessed the emergence of a strong international movement with the ambitious goal to address mental health needs and reduce disparities worldwide, but particularly in low- and middle-income countries and amongst vulnerable populations within wealthy nations (Horton, 2007; Patel & Prince, 2010). This movement, led by the international psychiatric community but engaging a wide assemblage of actors, has given rise to a new field of research and practice, now known as Global Mental Health (Patel, 2014). Aligning itself with the wider area of Global Health, the field has been vocal in highlighting the burden and impact of untreated mental disorders, and has made both a scientific and ethical argument for a global approach to redress the situation (Global Mental Health Group, 2007). At the core of this approach is the promotion of evidence-based interventions, human rights, and novel frameworks for scaling-up mental health services, such as ‘task sharing’.

The field of Global Mental Health has very quickly engendered a new institutional and research landscape, having recently established a number of its own research centres and training programmes. Under the banner of this field, there has also been an explosion of international research programmes and interventions which have received significant financial backing from a range of international donors, development agencies, and governments.¹ In sum, Global Mental Health has increasingly captured the imagination of a wide range of stakeholders and has made major strides in establishing mental health as a priority within the global health arena. Indeed, a recent Google search for ‘Global Mental Health’ on 1 November 2009 identified approximately 62,300 related sites, of which over 85% of them were registered since 2008 (Patel & Prince, 2010). This increasingly powerful field has, however, also elicited a range of critical responses, with growing controversy over its conceptualisations, goals and imagined outcomes (Campbell & Burgess, 2012; Kirmayer & Pedersen, 2014; Mills & Fernando, 2014).

Critiques of Global Mental Health have emerged most particularly from the ranks of transcultural psychiatrists and anthropologists. These scholars have argued that the field is transporting and applying what are essentially ‘Western’ psychiatric categories, concepts and interventions. For them, this ‘neo-colonialism’ or ‘medical imperialism’ ignores the culturally determined nature of mental illness, and as such is leading to inappropriate diagnoses, locally incongruent solutions and the marginalisation of ‘traditional’ systems of mental health and healing (Fernando, 2011; Summerfield, 2013). Another prominent theme of critique centres on what is seen as the biological determinism underpinning Global Mental Health and associated embroilment with the economic agendas of the pharmaceutical industry. Here, many problems and negative consequences of these underpinnings and interests have been highlighted, including the medicalisation of everyday distress (Mills & Fernando, 2014; Summerfield, 2013) and the side-lining of more socio-economic and structural determinants of mental health (Ingleby, 2014; Mills, 2014).

Many Global Mental Health advocates have been outraged by the kinds of critiques currently being put forward, and have published a number of fervent responses (see e.g. Cohen, 2014; Patel, 2014). In an attempt to foster a more hospitable dialogue between proponents and critics of Global Mental Health, the Division of Social and Transcultural Psychiatry at McGill University recently organised a workshop which brought together scholars on both sides of the divide.² Despite its intention, this initiative was characterised by widespread personal attacks and denunciations from one side to the other, arguably widening current schisms.

We are thus currently witnessing a hostile intellectual climate within the international mental health arena with echoes of the so-called science wars of the 1990s. That is, the debates are increasingly becoming trapped within a hermeneutics of stark polemics and choices, making it difficult for people involved not to take sides. And in taking sides, it is hard not to get locked into the constrictive terms of the competing perspectives as they are emerging. Whilst undertaking my PhD research within critical public mental health, I was so often asked whether I am ‘for-or-against’ Global Mental Health. In most cases, I felt forced to choose, and if I did not, a choice would typically be imputed. Thus, while the polemics in this field may be productive in propelling debate, they are also obscuring emergent concepts and spaces of enquiry between and beyond divides.

Although not wishing to oversimplify matters, what has been characteristic of ensuing debates is the very similar rhetorical structures underpinning dominant and seemingly opposing ‘mainstream’ and ‘dissident’ positions. For example, a reified view of ‘culture’ as ‘given’ has become the cornerstone of debates, a view that is intimately bound up with the origins of European romantic nationalism and the intellectual heritage of European Colonial Modernity. Moreover, the terms of engagement are increasingly being conditioned by the power of Cartesian dualisms: the biological vs. the social; nature vs. culture; global vs. local; the universal vs. the relative; the biomedical vs. the traditional and so on. Again, these polarities are deeply entangled with the metalanguage of colonialism and epistemological gaze of European modernity.

In sum, the dominant terms increasingly shaping conversations between proponents and critics of Global Mental Health alike are contributing to the continued defence of a canon of scholarship that is narrow, and largely Eurocentric. And this is setting-up conditions that are ultimately foreclosing the pursuit of alternative ways of knowing which engage with a wider intellectual heritage. The potential dangers of this narrowing of the discourse between competing perspectives is pertinently illustrated by the destructive fall-outs of the science wars which, as various critical scholars have suggested, ultimately sabotaged much-needed discussions about care and vitality and well-being (Latour, 2004; Stengers, 2003). As such, if we are to move past the impasse currently characterising debates within the mental health arena, and open-up a way to thinking outside of rigid binaries and essentialist ways of knowing, we need to re-think and re-tool our current forms of criticism and innovation. That is, it is about cultivating alternative sorts of questions, new kinds of conceptual territories and different types of conversations which nurture an ecology of knowledge that is not necessarily conditioned by the grand imperial archive.

This issue of Critical Public Health features two articles that offer important resources in this regard. The first paper, by Knibbe, de Vries, and Horstman (2016), provides a nuanced critique of the ‘reach paradigm’ dominating public mental health promotion. They demonstrate how this paradigm construes mental health inequalities as a failure of experts ‘reaching’ low-income groups and thus focuses on providing such groups with supposedly ‘correct’ clinical knowledge. The authors convincingly argue that this conceptual framework ultimately obscures both the diversity in understandings of mental distress and the power and interests embedded in the promotion of ‘evidence-based’ knowledge. Against this backdrop, they describe an alternative, community-based participatory project in low-income neighbourhoods in the Netherlands which utilised media storytelling to support public learning processes and promote mental health. The authors show how this project involved the deconstruction and appraisal of diverse idioms of distress, which enabled participants to explore individual and collective actions that might provide opportunities for mental well-being. Moreover, instead of employing didactic methods of knowledge transfer, the project utilised ways of knowing and learning that incorporated the sensorial, the emotional and the imaginary, thus legitimising modes of experience and meaning-making that go against the totalising grain of empirical science. The paper concludes with a plea for greater ‘humility’ on the part of mental health promoters so that a wider range of knowledge and capacities might enter into health promotion discourse. This is a pertinent point in light of the strong ‘we know what works’ kind of certainties increasingly pervading Global Mental Health discourse (Cooper, 2015).

The second paper, by Boyd and Kerr (2016), addresses the growth in neoliberal policies and cutbacks to mental health services, and associated increased contact between the criminal justice systems and people with mental illness in Canada and other high-income countries. Drawing on critical discourse methodologies, the authors provide an in-depth case study of four Vancouver Police Department policy reports on the mental health situation. Through a careful analysis of the taken-for-granted assumptions and their effects, they show how these reports reproduce negative discourses about the deinstitutionalisation of care and about mental illness, which tend to be associated with danger and violence. Avoiding sweeping generalisations and uninformed scepticism, the authors provide a careful reading of the epistemologies and associated politics underpinning a specific and situated set of apparatuses. The paper thus aptly speaks to Susan Haack’s (2003, p. 201) appeal, when referring to the science wars, for ‘the need for sociology of knowledge which is neither uncritically deferential to the sciences nor uncritically cynical about them, and which, rather than competing for control of the territory, cooperates with epistemology to understand the scientific enterprise’.

Both the papers offer enticing vocabularies and methodological tools, opening-up the space for potential new imaginings and understandings of public mental health critique and innovation. Cutting across the battle-lines of proponents and critics of Global Mental Health, they both provide some directions for future work in this area and a fruitful terrain for further engagement.

Sara Cooper
Division of Social & Behavioural Sciences, School of Public Health & Family Medicine, University of Cape Town, South Africa
[email protected]

Notes

1. Funding agencies include inter alia the World Health Organization, the US National Institutes of Mental Health, UK Department for International Development, the Welcome Trust and Grand Challenges Canada. See http://www.centreforglobalmentalhealth.org/projects for a summary of the kinds of research projects and interventions being executed.

2. Videos of the workshop presentations and discussions are available online at http://www.mcgill.ca/tcpsych/videos/asi-videos/2012. Bemme and D’souza (2012) also provide a summary of the workshop debates.