Balancing the Local and the Global: Commentary on 'Globalizing Mental Health: Challenges and New Visions' Section

Crick Lund

The nine chapters in Part II of this volume provide a rich insight into the challenges facing the practice of mental health in diverse global settings. A major strength of the part is the multidisciplinary perspective that the authors bring, and their willingness to engage with the complexities of this diverse and growing field of research and practice. The purpose of this commentary is to summarize the content of the chapters in the part, to draw out common ground as well as distinctions between the chapters and to provide some critical reflections on the content.

Summary of Chapters

Mills and White pose a number of critical questions regarding efforts to scale up mental health services in low- and middle-income countries (LMICs). These include questions regarding whether the validity of psychiatric diagnosis is being over-emphasized, whether a preoccupation with eliminating symptoms obscures what may be ‘positive outcomes’ for people who experience mental health difficulties, whether the treatment gap is as large as it is reported to be, whether alternative forms of treatment are being neglected, whether social determinants of mental health are being adequately considered

C. Lund (*)

Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa

© The Author(s) 2017

R.G. White et al. (eds.), The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health, DOI 10.1057/978-1-137-39510-8_20

and whether the evidence base for Global Mental Health (GMH) is sufficiently supported, particularly in relation to task shifting. The authors cite a variety of studies and opinions to present a robust criticism of current GMH efforts, arguing that such efforts assume a uni-directional flow of expertise (from high-income countries to LMICs) that does not pay adequate attention to alternative and indigenous knowledge and healing systems.

Burgess and Mathias present a conceptual framework for ‘community mental health competency’ to guide community engagement in GMH practice. Drawing on case studies from settings in India and South Africa, the authors begin by critically engaging with the notion of community and how it is defined in structural and symbolic terms. In the context of fluid and plural notions of community, the authors emphasize the need for caution and an awareness of power and social forces when engaging in community mental health interventions. Furthermore, they criticize WHO and Movement for Global Mental Health (MGMH) discourses of community for focusing on the pragmatics of biopsychosocial service delivery, rather than addressing wider social environments that contribute significantly to mental distress. To address this oversight, the authors propose a ‘community mental health competency’ framework, for engaging with and promoting community mental health. This framework includes four principles: knowledge; recognition of individual and group-based skills, and solidarity to tackle the issue; safe social spaces and dialogue; and partnerships for action. This framework is illustrated in two case studies: engaging with traditional healers in a rural community mental health setting in South Africa and partnership in a community mental health program in Uttar Pradesh, India. The authors call for a transfer of power about definitions of mental illness from high-income countries to the hands of local communities.

Watters presents three specific challenges to the ‘life-course’ approach advocated by the MGMH. The first is that the life-course approach represents a form of ‘epistemic violence’ in which the diagnostic systems of western psychiatry, with its notions of mental health literacy, are imposed on indigenous knowledge systems. The second is that of ‘temporality’ in which the life-course approach assumes a normative developmental trajectory, thus undermining culturally meaningful understanding of rites of passage and life stages. The third is that the life-course approach does not take into account the current and unprecedented reality of human migration, which disrupts standardized notions of the life course and presents multiple trajectories.

White, Ramachandran and Kumar synthesize the evidence on the effect of mental health stigma on a range of life domains globally. In so doing, they emphasize the dynamic interaction between local explanations for mental health difficulties and experiences of stigma in those settings. For example, the role of explanatory models and patterns of self-stigma vary significantly across cultures. The authors draw attention to the paucity of evidence from LMICs regarding interventions to reduce stigma and highlight promising contextually sensitive approaches. They also warn against global anti-stigma campaigns that do not pay careful attention to local culture and meanings, pointing out that such initiatives could do more harm than good. The chapter provides a rich and densely referenced overview of the multifaceted and complex area of mental health stigma.

Kienzler and Locke focus on the area of violent conflict and its devastating impact on mental and physical health. They describe the critiques of the inappropriate transfer of western psychological assumptions to settings in which they may not be meaningful. The authors highlight what has emerged from the debate and show the need to build a richer cross-cultural understanding of mental illness in war and post-war settings. The chapter provides a broad view of violence and its impact on mental health, including structural violence, by which the chronic patterns of poverty and exclusion serve to marginalize and disempower populations. They also highlight the tensions between ‘trauma-focused’ and ‘psychosocial’ approaches to violent conflict, arguing that trauma-focused approaches may have their benefits but that these are not sufficient. They emphasize the importance of considering social suffering and local idioms of distress in the process of developing locally relevant interventions that emphasize the agency of individuals and draw attention to broader social ills.

Orr and Bindi argue that the focus of the field of GMH on the ‘treatment gap’ is misplaced and that the so-called treatment gap is not characterized by an absence but by complex and varied forms of treatment that are not easily captured within the framework of GMH. The authors present data to support the view that contemporary societies are characterized by medical pluralism: a situation where people choose (or are forced to choose) from a plethora of coexisting therapeutic options. This is presented as a challenge to the field of GMH, namely to engage with the questions that this medical pluralism raises. These questions include the epistemologies that define mental health issues, the effectiveness of different healing approaches and the politics and power of healing. During the course of the chapter, the authors provide an instructive history and overview of the study of medical pluralism and healing systems.

Stavert considers the importance of mental health law and human rights in the global context. The chapter begins with the WHO GMH action plan and its endorsement of the UN Convention on the Rights of Persons with Disabilities (CRPD). The author also provides an overview on current global legislative and human rights protection for people with mental health problems. She then summarizes mental health and human rights as they are addressed in the UN CRPD and other relevant human rights treaties. This is contrasted with the reality in many countries which offer scant human rights protection for people living with mental health problems. The author then highlights several challenges with implementing human rights standards for persons with mental health issues. These challenges include national constitutional arrangements and international law obligations, the rule of law and human rights, responsibility for the implementation of rights, the nature of rights themselves, ideological differences, societal attitudes, lack of information and resource challenges.

Boahen-Boaten and colleagues focus on suicide in LMICs. The chapter identifies risk factors for suicide in LMICs by synthesizing findings from a wide variety of data sources, including a systematic review of case-control psychological autopsy studies. A number of risk factors are identified, including intrapersonal, interpersonal and distal factors that interact in a complex manner—calling for a range of interventions from mental health service provision to broader macro-level policy interventions. The authors emphasize the importance of context in understanding the phenomenon of suicide. For example, there are marked discrepancies between countries in the prevalence of mental disorders in completed suicides, using psychological autopsy methods. The authors present a critique of the methodological weaknesses in some psychological autopsy research in LMICs. They also draw attention to the dearth of research evidence on suicide in low-income countries: while 85% of global suicide deaths occur in LMICs, only 10% of suicide research is conducted in LMICs.

Eggerman and Panter-Brick describe a study of mental health and resilience in Afghanistan. The study included a large sample of 1011 children aged 11—16 years, paired with 1011 adult principal caregivers and 358 teachers. A cohort of 364 child-adult pairs was followed over a one-year period in Kabul. They found that poor mental health, defined as probable psychiatric illness, depression and post-traumatic stress, was driven by gender, trauma exposure, caregiver wellbeing and geographical area. Everyday violence was shown to have as important an impact as militarized violence in the recollection of traumatic experiences by the children. The authors demonstrate the importance of contextual, subjective and social experiences in children’s recollection of traumatic experiences. In their one-year follow-up in Kabul (with 64% of the original sample), they report the surprising finding that child and caregiver mental health had improved, although they do not indicate what proportion of child-caregiver pairs had improved or to what extent it had improved. This was in the absence of any provision of mental health services and with the presence of ongoing conflict, poverty and social instability. The quality of family relationships and ongoing enrollment in school were key predictors of improved mental health. However, post-traumatic stress did not abate over the year, suggesting distinctive pathways for depression and post-traumatic stress. Families participating in the study clearly articulated the political, social and economic threats to their mental health and wellbeing and the importance of hope in promoting resilience. Policy implications include the need for more structural interventions to strengthen families and provide the social and economic resources that can break cycles of economic instability, domestic crowding and domestic violence.

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