2012 Advanced Study Institute

Division of Social & Transcultural Psychiatry, McGill University
Advanced Study Institute in Cultural Psychiatry

Global Mental Health: Bridging the Perspectives of Cultural Psychiatry and Public Health

July 5 - 7, 2012
Montreal, Québec

Advanced Study Institute Workshop (July 5 - 7, 2012)

The 2012_ASI_Conference_Program is now available.

The emerging field of global mental health aims to address the enormous disparities in mental health outcomes that beset low and middle-income countries. A growing body of research has established mental health as a priority for global health research and intervention. Significant advances have been made in identifying targets and strategies for intervention. However, there continues to be controversy and debate about the appropriate methods for establishing priorities, research themes and approaches, and modes of developing and/or adapting interventions in global mental health. In particular, there are tensions between a public health approach grounded in current evidence-based practices (which are still largely produced in high-income countries) and a culturally-based approach that emphasizes starting with local priorities, problem definitions, community resources and solutions. The cultural critique of global mental health has raised basic issues that will be explored in this workshop and conference: (1) the priorities of global mental health have been largely framed by mental health professionals and their institutional partners located in wealthy countries, and therefore reflect the dominant interests of psychiatry and may give insufficient attention to local priorities; (2) global mental health tends to assume that the major psychiatric disorders are biologically determined and therefore universal; (3) in focusing on existing evidence-based treatments, global mental health assumes that standard treatments can be readily applied across cultures with minimal adaptation; and (4) global mental health tends to emphasize mental health interventions and may marginalize indigenous forms of helping, healing, and social integration that can contribute to positive outcomes and recovery. This workshop will bring together experts in cultural psychiatry and global mental health to consider ways of bridging these perspectives. Sessions will address four broad themes: (1) setting the agenda in global mental health; (2) understanding the relationship between local and universal aspects of mental health problems; (3) developing culturally and community-based interventions; and (4) implementing and evaluating culturally and community-based interventions to foster resilience and recovery. The aim of the workshop is to develop some consensus on a research program that integrates social, cultural, primary care and public health perspectives. The one-day conference will focus on ways to generate an ongoing constructive critique of the global mental health movement to insure its goals and methods are responsive to diverse cultural contexts and communities.

The format will be a two-day workshop for researchers in these areas (July 5-6), followed by a one-day conference (July 7) oriented toward mental health practitioners and policy makers.

Guest Faculty
Gilles Bibeau, Suman Fernando, Joop de Jong, Byron Good, Kwame McKenzie, Harry Minas, Mark Nichter, Vikram Patel, William Sax, Rachel Tribe, Derek Summerfield

McGill Faculty
Ellen Corin, Jaswant Guzder, Laurence J. Kirmayer, Marc Laporta, Ashok Malla, Duncan Pedersen, Cécile Rousseau, Monica Ruiz-Casares, Rob Whitley

Selected recordings and abstracts below:

Why mental health matters to global health

Vikram Patel, Sangath, Goa

Global health is the new avatar for what we once called “international health” and, going back further in time, “tropical medicine”. Global health stands out from its predecessors in three key respects: first, its priorities are determined by the science of the burden of disease; second, its driving philosophy is equity, i.e. justice and fairness in the distribution of health in society; and third, its scope is global, i.e. it concerns actions which can benefit the health of people globally. This presentation will present evidence to make the case that mental health is not only relevant to global health in all these respects, but in fact lies at its very heart. The presentation will then address some key road-blocks to global efforts to improve access to care for people with mental disorders, in particular the grave shortage and iniquitous distribution of mental health specialist resources. New evidence from low resource settings is showing how task-sharing of mental health care with lay and community health workers is an effective model for delivery of evidence-based treatments
for mental disorders. Armed with the knowledge that one can unpack complex mental health treatments, and train and support non-professionals to deliver them, perhaps the promise of mental health for all is realizable. In particular, we will need to empower those who are affected by mental disorders to assure their right to receive care that enables recovery and live a life of dignity. We can attain the lofty goal of “mental health for all” only if we involve all in the process.



Against “global mental health”

Derek Summerfield, London

Psychiatry has no answer to the question “what is a mental disorder?”, and instead exalts a way of working it has devised: if there are sufficient phenomena at sufficient thresholds, a mental disorder is declared to exist! Nonetheless, an emergent global mental health field, including the WHO, claims that annually up to 30% of the global population develops a mental disorder, representing a substantial “though largely hidden” proportion of the world’s overall disease burden. Are these figures credible? What exactly is “global mental health”? Can any definition or standard of mental health be definitive universally? This paper will critique the knowledge base for global mental health in light of the routine use of methodologies not validated for the populations under study, largely non-Western. To assume that Western knowledge is universal, whereas indigenous knowledge is local, casts culture as an obstacle and ignores the plight of huge numbers of non-Western peoples mired in bare survivalist ways of life. This is a form of imperialism, with global mental health workers as the new missionaries. The paper asks whether it is axiomatic that mental health services are a good thing worldwide, albeit with adaptations in culturally diverse, resource-poor settings. Or, is the question still open as to whether non-Western societies do need mental health services at all as we recognise them in the West?


Global mental health: The right problem but the wrong solution?

Kwame McKenzie, University of Toronto

Globalisation is leading to rapid urbanization. This is bringing with it new environments that have significant impacts on mental health. The burden of mental health problems and illnesses is increasingly being identified in low- and middle-income countries, but its clear link to poor infrastructural planning and the poor investment in social capital has not received as much attention. In new urban environments communication, competition and consumption are key values. These lead to predictable stresses on individuals and their communities. The solutions are varied, but the development of more services is not an efficient or even desirable answer. If needs have been generated by inadequate planning of the urban environment, scaling up services to meet the needs to "consumers", professionals and governments is not the solution. The commodification of illness may be understandable in this context but does not speak to the real issue which is how to convince the globalization movement to develop societies that promote health and how business can be made to bear the true costs of their initiatives.


Halt to the abuse of globalization in the field of mental health

Gilles Bibeau, Université de Montréal

The notion of culture has been under attack in anthropology during the last decades. People have particularly denounced what appears as a double process of objectification: internally, when cultures are presented as coherent and homogeneous entities; externally, when societies and cultures are presented as well-bounded and clearly separated from one another. These critiques have been formulated against a double horizon: (i) a historical one where colonization is analyzed as having produced a certain vision of the Otherness of the alien cultures: a vision built on processes of exoticization that facilitated the colonizer’s domination and the play of power relationships; and (ii) a transversal horizon with the current awareness of the power of globalization forces including the importance of large-scale movements of populations, the circulation of images and products through trade and the media, and individuals’ concrete and imaginary travels throughout societies and cultures where they can live and imagine themselves as participating in multiple worlds. It is striking to see that at the very same moment when anthropology was criticizing the notion of Culture, mental health clinicians and researchers seemed to have discovered Culture. However, most of them seem unaware of the traps that this notion entails. Cultures are generally heterogeneous, plural and paradoxical; they are infused and modulated by power relationships at the global and local levels. Individuals circulate between various cultural worlds and often belong simultaneously to several of them. This paper will discuss the implications of a critical medical anthropology for global mental health.


The “folie à trois” between global mental health, anthropology and psychiatry

Joop de Jong, Free University Amsterdam

Mitigating the global mental health gap is complicated by controversies around the need to address psychiatric versus psychosocial problems, the professional disciplines and societal sectors being involved, the collaboration between community, (non-) governmental and international actors, the applicability of “talking therapy”, the emphasis on vulnerability versus resilience, the way to deal with complex health systems and with culturally-diverse groups, or the question whether day-to-day care is different in times of disaster or political violence. This presentation will first argue that a public mental health paradigm may help to transcend many of these contradictions that often seem to be more relevant for professionals and scholars than for people coming to terms with their plight. Secondly, this presentation will elaborate the complementarity of a universalistic view of mental health versus local perceptions and expressions such as idioms of distress. The choice between these perspectives is highly relevant for the type of practitioners that is likely being involved in solving socio-psychological or more serious afflictions. This implicates a need for research into the efficacy of local healing methods and into the healers’ contribution to bridge the mental health gap. Thirdly, the perennial debate between universalism and relativism may be solved with cultural neuro-scientific and neuro-anthropological research. The paradigm of cultural neuroscience may help us refine our global psychiatric diagnostic classification system and assist in bridging the worlds of global mental health, anthropology, psychiatry and epidemiology.


Challenges for mental health development in low- and middle-income countries

Suman Fernando, London

Community mental health services everywhere in the world should: aim to meet the mental health and social care needs of people as perceived by people themselves; be relevant and sensitive to local conditions and cultures; involve all stakeholders including marginalised groups; and be culturally and economically sustainable. In planning services in LMI countries, cross-cultural psychiatric research carried out using psychiatric diagnostic categories are of limited use, but there are some pointers that may help. “Mental illness” identified in a psychiatric model, during the 1960s and 1970s, had better outcomes in LMI countries (compared to that in the (then) industrially- developed countries) although this “better outcome” may no longer be as evident, since the spread of westernisation. It seems that attendance at healing centres in South India may provide as much benefit for people diagnosed as “schizophrenic’ as psychiatric treatment, and that the best system may be one where people suffering psychological distress and their relatives have a choice as to what system they access for help. The “global mental health” movement being pursued by the US NIMH requires considerable modifications if it is to be ethically acceptable in a post-colonial world. Otherwise, the result will be the imposition of Euro-American psychiatry en masse, amounting to cultural imperialism. The present priorities for alleviating mental distress in LMI countries include: developing social support and community development – for example, to re-build communities disrupted by the effects of war, civil conflict and natural disasters; addressing breakdown of social systems resulting from rapid industrialization and urbanization; counteracting the effects of poverty and oppression; and providing human-rights sensitive ways of controlling people who are behaviorally disturbed. Also, there is an urgent need for regulating the marketing of psychoactive drugs in order to prevent the exploitation of vulnerable people in LMI countries.

Global mental health: Avenues of access and epistemologies of care

Charles Watters, Rutgers University

In recent decades, debate on global mental health has focused on what Fassin has described as the “empire of trauma”. PTSD has been the center of debate concerning the potential role of psychiatric diagnosis in misrepresenting the needs of vulnerable groups. Others have argued that the critique of the diagnosis of PTSD is misguided and has provided a rationale for diminishing or diverting resources for much-needed mental health care. In this paper I argue in favor of a research framework that places the diagnostic processes within broad sociopolitical contexts of care. Drawing on examples from mental health programs for refugees and asylum seekers in Europe and internal migrants in Brazil, I argue for a critical engagement with epistemologies of care in relation to the mental health of vulnerable groups. In doing so, I offer an outline of an emerging framework for the study of global mental health in which diagnosis is examined with avenues of access to mental health care.

Countering the prevailing ethos by practice: The implementation of a community engagement model in inner city communities in Kingston, Jamaica

Geoffrey Walcott, Kingston

Involuntary commitment continues to resonate in Community Mental Health Services (CMHS), resulting in a revolving door between the community and psychiatric hospital. The forty-year-old Jamaican CMHS model is an innovative approach of community and family engagement involving negotiation between clinicians, patients, family, and the community, to achieve patient self-determination and voluntary therapeutic compliance. This presentation will describe the latest developments of the Jamaican CMHS model implemented in urban catchment parishes of Kingston and St. Andrew serving the Bellevue Mental Hospital (BVH), and to examine quantitative and qualitative data supporting its use. A record review quantitatively compared the number of acute crisis interventions by the CMHS with psychiatric hospital admissions for the years 2010 and 2011. Three case studies are also presented to illustrate the Jamaican CMHS model and its outcomes in improving patient compliance and stability. Acute crisis interventions within the community rose from 658 in 2010 to 694 (5.5%) in 2011, while acute admissions to the BVH by the CMHS fell from 131 to 61 (53.4%), resulting in a 10% reduction in total admissions. Case study findings illustrate the model’s utility for improving patient compliance and stability, and fostering active community participation in the treatment process. The model facilitates agentic participation of these persons in their treatment and demonstrates a practical community mental health service model developed in a Third World country that meets the needs of the population efficiently and cost effectively. This is a practical counter to the model foisted on the Third World by the Nature article of late 2011 on global mental health.

Ritual Healing and Psychiatry in South Asia

William Sax, Heidelberg University

Ritual healing is very widespread in the Indian state of Uttarakhand, and is by far the most common option for those with serious behavioral disturbances. Although ritual healing accounts for a very large part of the actual health care system, the state and its regulatory agencies have, for the most part, been structurally blind to its existence. A decade of research on ritual healing in this region, along with a number of shorter research trips to healing shrines and specialists elsewhere in the subcontinent, and a thorough study of the literature, has convinced me that such techniques are often therapeutically effective. Can ritual healing be usefully combined with mainstream "Western" psychiatry? I think that it cannot, because 1) psychiatry is so deeply influenced by the ideology of individualism, which is incompatible with South Asian understandings of the person; 2) neither the science of psychiatry nor the regulatory apparatus of the state can or will acknowledge the validity of "religious therapy"; and 3) social asymmetries between religious healers and health professionals are too great to allow a truly respectful relationship between them. In this paper, I elaborate on these ideas, suggesting that it is best if the state maintain its structural blindness to ritual healing.

Deconstructing Global Mental Health

Rachel Tribe, University of East London

This paper will consider the assumptions which underline the notion of global mental health, and the proposition that this is a straightforward unitary category. The paper will examine if this is the most useful way forward and the disadvantages and advantages of this position. There is no doubt that people all around the world suffer distress, but whether this is best labelled as an individual mental health disorder and individual psychiatric help offered appears open to question. The way distress is labelled has a range of consequences. The importance of politics, context and the wealth and power differentials which exist cannot be ignored in the way that the global health debate is constructed. DSM and ICD are not neutral documents but carry a range of assumptions and represent a range of interest groups, many of which are located in the West. Reification appears to have taken place on occasions, and different cultural constructions, explanatory health beliefs or idioms of distress, ignored or seen as additional layers of meaning rather than as the central organising concepts they appear to be for many people. The generalization and transfer of western psychiatric and psychological ideas, uncritically to the wider world, can unwittingly undermine the rich traditions and cultural heritage of low- and middle-income countries. It could be viewed as a form of neocolonialism. There are many angles to this debate including the use of language and the fact that some languages have concepts and long traditions around mental health which are different from those used in European languages, and which may not contain words which translate to much of the psychiatric lexicon. This in itself may tell us something.


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