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Home arrow Language & Literature arrow The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health

Critical Questions and a Way Forward

The juxtaposition of the ‘global’ with the ‘local’ raises a number of interesting questions for those of us involved in GMH research and practice. I will address each of these questions in turn, to propose a way forward and invite ongoing dialogue.

Firstly, how can we advocate to global audiences such as international development agencies about the need for global action and more resources for mental health, while remaining respectful of what is local, including local healing systems, resilience and culture? My own view is that we have to act globally, while paying careful attention to the evidence from what is local. Mental health has been neglected for too long, and many millions of people, particularly those living in poverty or civil conflict, suffer unnecessarily. To address the scale of the problem we cannot only rely on local piecemeal efforts when there is much to be gained from finding common ground and acting together. The reconciliation of the local and the global may not be as impossible as it seems (or is sometimes depicted). The key is in the doing, in becoming engaged in adapting and developing interventions using equitable and collaborative partnerships in diverse LMIC settings. We need a truly public mental health approach that simultaneously addresses the social determinants of mental health and provides culturally sensitive and evidence-based care to those in need.

The enormous challenge that we face is to build the evidence base for locally acceptable, culturally congruent detection methods and interventions. Crucially, this involves a combination of psychological, psychopharmacological, social and economic interventions that address both social causation and social drift pathways in the vicious cycle of poverty and mental ill-health

(Lund et al. 2011). In the last 5—10 years, there has been a blossoming of such research and practice in LMICs, through a diverse range of individuals, organizations and funding sources. To illustrate, we are engaged in such initiatives through PRIME and the Africa Focus on Intervention Research for Mental health (AFFIRM) (Lund et al. 2015), together with a network of research hubs in Latin America, sub-Saharan Africa and South Asia. These include, for example, a cluster randomized controlled trial of collaborative care models with traditional healers in Ghana and Nigeria, led by Oye Gureje and colleagues at the University of Ibadan. For this endeavor to move forward, it is vital that those who are critical of the MGMH and WHO engage in a constructive manner to build common ground for dialogue, rather than a wholesale rejection of global initiatives in a manner that can be extremely destructive.

Secondly, a very important criticism of the global approaches to the treatment gap is one raised by Mills and White as well as Orr and Bindi in this part, namely: is the treatment gap as large as it is reported to be? Vikram Patel has expressed a similar concern in what he calls the ‘credibility gap’ (Patel 2014a). In short, the treatment gap focuses on the supply side of the equation by calling for an increase in the provision of services, but assuming that once services are provided they will meet the needs of local populations and be taken up. The reality, as Mills, White, Orr, Bindi and Patel point out, is that frequently mental health services are not congruent with the way in which people in diverse cultural settings understand their psychological or mental suffering—hence a ‘credibility gap’.

Once again there are enormous research and practice challenges in addressing this concern. Some of these challenges are methodological: we need to find more accurate means of defining and measuring contact coverage, treatment coverage and effectiveness coverage (De Silva et al. 2014). These may, in certain instances, serve as proxies for the extent to which services are acceptable, accessible and affordable for local populations and hence taken up. But there is also a crucial need for qualitative and ethnographic research, for developing and adapting interventions locally in a manner that is culturally acceptable, for partnerships with local traditional healing practices and engaging with and mobilizing local community structures. In our work in PRIME in Ethiopia, the Ethiopian team undertook an extensive process of community resource mapping in the Sodo district which revealed that ‘the district is rich in community resources’ (Selamu et al. 2015), and these have been crucial in the subsequent development of the PRIME Ethiopia district mental healthcare plan (Fekadu et al. 2015). The gap between those who do and do not access care when living with a mental health problem is not only about supply side factors but also about demand-side factors: the acceptability and affordability of local mental health services and the extent to which they resonate with the worldview of the local culture is critical.

Thirdly, what criteria should we apply when recommending interventions in contexts of medical pluralism—is it a case of anything goes, as long as it is culturally congruent? For example, certain traditional healing practices (and religious groups in high-income countries), practice beatings or chaining to remove perceived evil spirits from people suffering from what western psychiatry would identify as psychosis. To my understanding, we do need some principles by which we can operate. Two such principles that stand out are that interventions should protect or promote human rights (e.g., should be in line with internationally agreed treaties such as the UN CRPD) and should be empirically shown to convey benefit, in other words should be evidence- based. Both of these principles can (and should) be debated extensively. In relation to the latter, evidence does not imply, as some critics believe, selling out to western ‘epistemic violence’. But it does imply a careful and respectful consideration of the needs and responses of local populations and the interventions that can promote journeys of recovery, while simultaneously drawing lessons that may be helpful to others.

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