Globalization and Neoliberalism: Structural Determinants of Global Mental Health?

Inequality

The relationship between globalization, neoliberal economics, poverty, and inequality is a point of contention and politicized debate. Predominately, neoliberal institutions such as the World Bank, World Trade Organization (WTO), and International Monetary Fund (IMF) generally hold that globalization has increased incomes and boosted economies around the world, while more left-wing and anti-globalization arguments hold that globalization has increased poverty and inequality (Wade 2004).

An example of the former argument is Dollar (2001), who presents evidence suggesting that trade liberalization increases the growth rate of countries’ economies and per capita income, without contributing to increased income inequality within those countries. However, Wade (2004) argues that positive portrayals of the economic effects of globalization are based on unreliable data and misleading metrics, pointing to several studies and metrics demonstrating a rise in world income inequality in the 20 to 30 years prior to the article, with even a more generous metric demonstrating widening inequality if China is not included.

More recently, in an article discussing why the realities of globalization do not appear to fit with neoliberal theory, Maskin and Kremer (2015) theorize that globalization creates inequality both through disparities in rates of income increase between workers but also by driving absolute income decrease for lower skilled workers as a result of the reduction in demand for their labor. Furthermore, there are compelling arguments that global income inequality has itself been underestimated (Hickel 2016) and that income inequality is not adequately calculated by common measures such as the Gini coefficient (Wade 2013).

But how does this inequality interact with mental health? Using data from eight high-income countries (HICs), Pickett, James, and Wilkinson (2006) demonstrated a strong linear association between income inequality and the prevalence of any mental illness, with an equally strong effect size for serious mental illnesses. Taking a less direct metric of mental health, greater income inequality within a country correlates with poorer community cohesion and trust (Wilkinson 2005). Such findings suggest a sociopsychologically corrosive nature of income inequality and provide context—and one possible mechanism—for the findings of Pickett et al. (2006). Several further studies have investigated associations between inequality and mental health. For instance, schizophrenia rates are higher in countries with greater inequality (Burns, Tomita, and Kapadia 2014). Similarly, within countries, higher inequality correlates with increased rates of depression (Messias, Eaton, and Grooms 2011; Pabayo, Kawachi, and Gilman 2014).

While the literature largely supports the association between inequality and mental illness, there have been some studies that challenge this link. For instance, the analysis of the World Health Organization (WHO) World Mental Health surveys found no association between inequality and rates of depression (Rai et al. 2013)—however, this analysis excludes countries with extremes of high or low inequality. In the United Kingdom (UK), income inequality was associated with higher rates of common mental disorders (CMDs) in higher income groups, whereas in lower income groups, higher income inequality was associated with lower CMD rates—although low income was itself independently associated with higher CMD rates (Weich, Lewis, and Jenkins 2001). However, this may be partially a factor of the particular characteristics of London, where the highest income inequality in the study was found. There is also evidence of a gender effect—with some studies finding that inequality exerts a greater effect on mental health for women (Pabayo et al. 2014; Pickett and Wilkinson 2010). These studies suggest a further layer of complexity that remains to be fully explored—nevertheless, the literature, as a whole, supports the theory that inequality is associated with poorer mental health outcomes.

The weakness of these articles is their limitation to HICs—they cannot tell us a great deal about low- and middle-income countries (LMICs). However, taking an indirect metric for mental health, Machado et al. (2015) found evidence that income inequality in Brazil was a risk factor for suicide. Furthermore, the WHO Social Determinants of Mental Health study demonstrated that the effect of inequality on mental health persists in LMICs (WHO and Calouste Gulbenkian Foundation 2014). Similarly, the analysis of a sample of 3,542 Brazilians in São Paulo found that living in areas of middle- or high-level income inequality was associated with increased rates of depression (Chiavegatto et al. 2013).

Recession and Austerity

A defining feature of capitalism is the phenomenon of recession. Recessions, commonly defined as a year in which the growth of real gross domestic product is lower than zero, have occurred in capitalist economies for centuries. Ormerod (2010) estimates that between 1871 and 2007, there were 255 recessions across 17 Western countries. Indeed, some have argued that episodic recessions are an inherent feature of capitalism (Martin, Sunley, and Tyler 2015), a standpoint found both in Keynesian (1936) economics and Marxian “crisis theory” (Heinrich 2013). However, the impact of globalization has been an upsurge in economic interconnectivity and interdependence, with the consequence that recessions have become global events (Tuca 2014).

Neoliberal “austerity” theory compounds the societal impact of recessions, deploying compensatory cuts to public spending implemented as part of austerity measures (Financial Times 2017). The rationale of austerity is that a reduction in public spending ultimately reduces national debt and benefits economic growth. Nevertheless, the economics of austerity has been widely critiqued, with even an article by IMF economists concluding that austerity is ineffective in stimulating economic growth and recovery (Ostry, Loungani, and Furceri 2016). The globalization–neoliberalism intersection is illustrated clearly in the role of supranational organizations such as the IMF in enforcing austerity-equivalent measures on LMICs. This is achieved through structural adjustment programs, through which loans are provided to countries in need of financial assistance with the precondition of implementing neoliberal economic policies, including cutbacks to public service funding (Shah 2013).

Substantial literature has connected recessions and austerity with poorer mental health outcomes (Cooper 2011; Martin-Carrasco et al. 2016). Barr, Kinderman, and Whitehead (2015) found that increased reporting of CMDs in the UK correlated with a period of recession and austerity. Similarly, studies in Greece, Spain, and Hungary all found evidence of higher rates of CMDs during the recession (Van Hal 2015). Suicide rates act as a visible and measurable proxy for the mental health of a population (Bray and Gunnell 2006) and provide another angle from which to examine the impact of recession. Reeves et al. (2012), examining the United States between 2007 and 2010, calculated that the greater rate of increase in suicide rates during recession accounted for 1,580 excess deaths per year. Similar correlations have been observed in Spain (Isabel et al. 2017), Greece (Kentikelenis et al. 2011), and Ireland (Corcoran et al. 2015). It is worth noting, however, that this literature exclusively stems from HICs. The mental health implications of recession for LMICs have received markedly less research—this may reflect the difficulty of gathering data in these settings, as well as the general focus of research into recessions being centered on HICs.

There is strong evidence that a key mediating factor for increases in suicide and CMDs during the recession is unemployment (Haw et al. 2015; Reeves et al. 2012), an effect that predominately affects males (Norström and Grönqvist 2015). However, it is likely the full mechanism is multifactorial. There is clearly a role played by austerity measures—suicide rates of 65- to 89-year-old men from 1968 to 2012 across five European countries increased by 1.38 percent in the short term per 1 percent reduction in government spending, 2.42 percent in the medium term, and 3.32 percent in the long term (Antonakakis and Collins 2015). Similarly, evidence from Scandinavian countries suggests that increased public spending during recession is protective against rises in suicide rates (Norström and Grönqvist 2015). Further studies on the independent effect of austerity measures are lacking, with most research examining recession and austerity together. Nevertheless, there is literature that examines potential mediators of austerity’s influence on mental health.

These mechanisms are arguably generalizable to neoliberalism in general, for the goals of austerity—reduced taxation and public spending—are fundamentally goals of neoliberalism. For instance, a critical element of austerity measures are cuts to public services, including welfare and mental health services (Quaglio et al. 2013). However, expenditure on such services also conflicts with the small-government, low-public spending, individualistic values of neoliberalism (Harvey 2005). Thus, both austerity and neoliberal policies promote funding reduction for public services, with subsequent implications for mental health.

UK austerity measures resulted in at least 40 percent of mental health trusts facing yearly budget cuts between 2012 and 2016 (Gilburt 2016), with an overall countrywide decrease in mental health funding of 8.25 percent between 2011 and 2015, accompanying a 20 percent demand increase (McNicoll 2015). Furthermore, welfare cuts appear to be associated with increased CMDs, although much of the evidence for this originates from the UK: For disability benefits claimaints, being subject to reassessment of, or disqualification from, disability benefits was independently associated with increased rates of suicides, antidepressant prescriptions, and self-reported mental health problems (Barr et al. 2016). Qualitative studies have also pointed to a link between poor mental health and cuts to unemployment and housing benefits (Barnes et al. 2016; Moffatt et al. 2015).

Job Security and Conditions

Job insecurity is a feature of both recession and globalization in general. Quak and van de Vijsel (2014) estimate that half of the global workforce is in “precarious” employment, a term used to describe jobs with poor working conditions and pay and high degrees of insecurity.

There are established links between perceived job insecurity (PJI) and poor mental health. Reichert and Tauchmann (2017) found that workforce reduction, and consequent PJI, had a negative impact on mental health and life satisfaction. Persistent PJI was a predictor of depressive episodes for workers in the United States (Burgard, Brand, and House 2009), and among Greek civil servants, PJI produced increases in stress, anxiety, depression, and low mood (Nella et al. 2015). Similarly, precarious employment was a predictor of mental illness in previously healthy Swedish youth (Canivet et al. 2016).

Several studies have directly examined the role played by globalization in exacerbating perceptions of job insecurity and consequences for mental health. A study of Malaysian workers found that nearly a quarter believed their job was no longer secure as a consequence of global trade (Idris, Dollard, and Winefield 2011). Separately, Cheng et al. (2005) reported a strong association between job insecurity and poor physical and mental health for Taiwanese workers, where the prevalence of job insecurity stood at 50 percent.

As Cheng et al. (2005) describe, job insecurity is generally accompanied by lower job control and greater job demands. Idres et al. (2011) reported how increased competition and decreased organizational resources arising from globalization increased material and emotional job demands, along with reduced job control, for Malaysian workers. This created stress, exhaustion, and cynicism. D’Souza et al. (2005) found that higher job strain was independently linked with increased rates of depression. Overall, as Neilson (2015) notes, globalization has created a substantial degree of precarity, promoting anxiety and psychological distress. Professions that are more exposed to the direct effects of globalization are particularly vulnerable.

One of the best illustrations of this is agriculture. Using an example of South Australian dairy farmers, Wallis and Dollard (2008) illustrate how, as a consequence of globalization, farmers now sell to a global—rather than local—market, and as such are exposed to the uncertainties of trade liberalization and the free market. This uncertainty and job stress are associated with distress and psychological ill-health (Wallis and Dollard 2008). This effect persists in LMICs: Several studies link the surge in suicide rates of Indian farmers—rising in Maharashtra state from 15 per 100,000 in 1995 to 57 per 100,000 in 2004 (World Bank 2006)—to correlates of globalization, including trade liberalization, the growth of cash crops, and reliance on patented genetically modified crops (Chowdhury et al. 2007; Merriott 2016).

The psychological consequences of the unemployment that can arise from job insecurity are considerable. For every 1 percent rise in unemployment, nationwide suicide rates increase by 0.99 percent in the United States (Reeves et al. 2012) and 0.79 percent in Europe (Stuckler et al. 2009)—with the difference in effect size potentially attributable in part to stronger active labor market programs in Europe. Similarly, job loss was associated with a doubling in psychological distress in Australian manufacturing workers (Myles et al. 2016) and with a range of negative self-reported psychosocial outcomes in South African workers (de Witte, Rothmann, and Jackson 2012). Notably, 44.9 percent of unemployed South Africans felt they were no longer a part of society (de Witte et al. 2012).

There are two important critiques here. Firstly, the causal relationship may not be unidirectional—mental illness may predispose to unemployment and to subsequent worsened mental health outcomes. For instance, Milner, Page, and LaMontagne (2014) found that controlling for prior mental health reduced the relative risk of suicide following unemployment from 1.58 to 1.15. Secondly, there is continuing debate over whether globalization improves or worsens unemployment. International Labour Organization (ILO, 2016) statistics show that the “Great Recession” that began in 2007 resulted in a sharp increase in the global unemployment rate, which has subsequently decreased. Nevertheless, total global unemployment remains 27 million higher than pre-Recession and has been increasing since 2014 (ILO 2016). Ukpere and Slabbert (2013) argue that globalization has a positive correlation with unemployment, driven by factors such as outsourcing, downsizing, and widespread automation. However, other academics have argued that, particularly for emerging economics, globalization has reduced unemployment. For example, Awad and Youssof (2016) note that trade liberalization from 1980 to 2014 had a positive impact on unemployment rates in Malaysia. Overall, it is difficult to conclusively establish the net global effect of globalization on unemployment; however, globalization does appear to be linked to increased job insecurity and stress and certainly drives unemployment for some sectors of the population—all of which have established consequences for mental health.

Changing Spaces

Globalization is restructuring the environments in which we live. A major effect of this has been a seismic shift toward urban life. Over half of the world now lives in urban areas (Gruebner et al. 2017). By 2030, all permanently habited continents are expected to have a majority of their population in urban areas—the global urban population is projected to reach 5 billion, 81 percent of which will live in LMICs (Castells 2010).

Urbanization changes both lifestyles and environments, with mental health important implications. Gruebner et al. (2017) found that living in cities was associated with increased risk of anxiety, mood disorders, addiction, and psychotic disorders. This may appear to contradict earlier findings on the vulnerability of agricultural workers—however, a synthesis of these findings is that while city living may pose a greater overall risk to mental health, the dynamics of globalization are also driving a separate increase in mental illness in rural agricultural contexts.

The principal social risk factors for urbanization are social segregation, diminished social support networks, and spatial concentration of low socioeconomic populations (Gruebner et al. 2017). There is, however, a question of causality. The nature of the well-documented increased risk of schizophrenia in urban areas—2.37 times higher than in rural areas (Vassos et al. 2012)—has in particular been questioned. It had been posited that the development of schizophrenic symptoms causes people to migrate to urban areas, creating the discrepancy. For instance, Pedersen (2015) found that people with schizophrenia spectrum disorder are indeed more likely to migrate to urban areas. However, as Pedersen acknowledged, this has a limited impact on the differential, and a number of studies have established a dose–response relationship between urban living and schizophrenia—suggesting that urban living is a driver of schizophrenia (Gruebner et al. 2017).

It is important to note, as Gruebner et al. (2017) point out, that urbanization also has the protective effect of concentrating populations in areas with greater access to health care, public services, and resources. Furthermore, the relationship between urbanization and mental illness is not always straightforward—particularly with regard to suicide. In China and Japan, urbanization accompanied a reduction in suicide rates, although this effect is diminishing in China (Otsu et al. 2004; Sha, Yip, and Law 2017), and in the United States and Austria, suicide rates are rising faster in rural areas (Kapusta et al. 2008; Kegler, Stone, and Holland 2017). In South Korea, suicide rates were higher in urban areas for younger populations but much higher in rural areas for the elderly (Chan et al. 2015). Interpretation of these variations is largely speculative, but they may represent the diverse changes wrought by globalization. For instance, in Western countries, the decline of rural regions in favor of large urban centers of capital, coupled with lack of access to mental health care services, may drive rural suicide rates. For instance, rural areas in the United States face out-migration and a much lower growth of new business (Anderlik and Cofer 2014; Economic Innovation Group 2016). In China and Japan, urbanization may have increased employment, with consequent economic stability acting as a protective factor. In South Korea, the increased global labor market competition for young urban Koreans, coupled with the socioeconomic consequences of out-migration of the young for remaining elderly rural Koreans, may drive their respective suicide rates.

The design of cities also influences mental health. Several studies have suggested a role for “green spaces” and “blue spaces” in improving urban mental health outcomes (Cohen-Cline, Turkheimer, and Duncan 2015; Gascon et al. 2015; P. James et al. 2015; Maas et al. 2009; Nutsford et al. 2016). Greater accessibility of resources, services, and public spaces—improved by urban density and worsened by urban sprawl—also act as protective factors (Melis et al. 2015).

In addition to migration between rural and urban settings, globalization has created a surge in migration between countries. A number of mechanisms link this with poorer mental health, including poverty, acculturation, racism, cultural tensions, poor adaption of host societies, and loss of self-identity and support networks (Bhugra and Minas 2007). A full exploration of the mental health implications of migration would require a separate article; nevertheless, a substantial body of literature has linked migration with stress and negative mental health outcomes (Bhugra 2004b; Bhugra and Ayonrinde 2004; Carta et al. 2005; Harrigan, Koh, and Amirrudin 2017; Virupaksha, Kumar, and Nirmala 2014).

This association has been contested by Stillman, McKenzie, and Gibson (2009), who argued that migration actually has a beneficial effect on mental health. They compared the mental health of migrants whose applications to enter New Zealand were randomly accepted with those whose applications were randomly rejected, finding that successful migrants had improved mental health outcomes. There are, however, flaws in this methodology: Firstly, it ignores the deleterious mental health outcomes of having one’s immigration application rejected and remaining in the environment that one was trying to migrate away from; secondly, it compares two groups in significantly different environments and uses this to draw a conclusion about just one of the variables. Furthermore, it is disingenuous to argue that less bad but still comparatively poor mental health outcomes for “successful” migrants means that the process of migration does not have negative effects on mental health.

Marxian Alienation

A discussion of the implications of the globalization of neoliberal ideology and culture requires an examination of the concept of “alienation.” “Alienation” has been used to refer to a variety of phenomena; however, in this context, the most relevant and widely discussed conception is that developed by Karl Marx.

Fundamentally, Marx’s alienation describes a process by which a worker is separated from the product of their labor, from the process of labor, and from their fellow humans (Wendling 2011). For Marx, objectification describes the natural, positive, and self-actualizing form of labor, by which humans collectively express their “species-being” through production, creating products that are their own to enjoy and contemplate, and expressing themselves upon the world. In alienation, however, workers do not appropriate or appreciate the product of their labor but instead appropriate money that they exchange for the needs of survival. Hence, they lose their self-determination, and their activity becomes not a creative process but a “detested chore undertaken only to meet physical need” (Wendling 2011:16).

As Shantz, Alfes, and Truss (2014) demonstrate, alienation in relation to work is associated with emotional exhaustion and lower levels of well-being in workers. They examined three components of alienation—the lack of control over the process of work, the lack of a sense of meaningfulness of the work, and a feeling that one’s skills and talents are not being utilized. These three components led to alienation, which was in turn strongly associated with the outcomes of emotional exhaustion and poorer well-being. Similarly, Arnold et al. (2007) described the protective effect on psychological well-being of the ascription of meaning to work.

However, alienation more broadly describes the consequences of existing in an environment in which the primary human purpose is the appropriation of wealth, and labor for this purpose is defined as both the natural state of being and the act which entitles a person to political and social rights (Wendling 2011). As part of this process, humans themselves are reduced to commodities, to be bought and sold as part of the apparatus of wealth creation like any other resource, and come to identify themselves in terms of the labor they undertake, or what they can purchase with what wealth they appropriate.

Materialism

But how can we empirically assess whether this broader conception of alienation truly acts as a structural determinant of mental health? One method is to examine the characteristics assigned by Marx to the process of alienation and their relationship with mental illness. One of these characteristics is materialism—the reorientation of society’s purpose and values around the accumulation of wealth and material goods.

To investigate the link between materialism and mental illness in over 14 countries, Kasser used the “Aspiration Index” model—which assesses the nature of an individual’s goals (Kasser and Ryan 1996). Materialism—high valuation of money, appearance, and fame—was found to correlate with depression, anxiety, substance abuse, and personality disorders, as well as failure to meet the basic human needs of security, community participation, feelings of competence, and autonomy (Kasser 2002). Similarly, a meta-analysis by Dittmar et al. (2014) found materialistic orientation to be associated with lower well-being and negative self-appraisal. While capitalism and materialism are not necessarily synonymous, Kasser et al. (2007) present evidence that capitalism promotes materialism and individualism, particularly in “corporate capitalism”—a term analogous to capitalism that is influenced to a greater degree by neoliberal ideology and culture. A study across 20 capitalist countries by S. H. Schwartz (2007) reinforced these findings on the cultural correlates of capitalism.

In The High Price of Materialism, Kasser (2002) proposes a number of mechanisms by which materialism in neoliberal societies can promote mental ill-health. Materialism, Kasser argues, foments deep-seated insecurity, creates a perpetual need to prove one’s worth, interferes with personal relationship, and diminishes personal freedom by encouraging conformity. It could be argued that these characteristics are not unique to materialistic modes of life. However, Kasser presents a variety of studies to support his argument that there are specific ways in which materialism particularly promotes these characteristics. As an example, Kasser’s argument on personal relationships cites several studies demonstrating an association between high valuation of materialistic pursuits and low valuation of high-quality relationships and community contribution. Similarly, Kasser (2002) argues that the drive to prove worth is amplified and rendered perpetual by the materialist approach that defines worth in terms of material possessions and goals and presents evidence that successfully pursuing these materialistic goals fails to increase long-term happiness.

Oliver James’s (2007) model of “selfish”—versus “unselfish”—capitalism is similar to that of “corporate capitalism” (Kasser et al. 2007), with James suggesting that the “selfish capitalism” typically found in those Western nations with greater inequality may be linked to mental illness. Nevertheless, this proposal does not entirely fit with statistics on antidepressant use in Organization for Economic Cooperation and Development (OECD) countries. For instance, while both Iceland and Denmark have high levels of income equality (OECD 2015), Iceland has the highest rates of antidepressant consumption of any OECD country, with Denmark being the fifth highest (OECD 2017). However, it is worth noting that antidepressant consumption is not necessarily an accurate comparative metric of mental illness, as it may be influenced by other factors such as local prescribing and treatment practices.

Individualism

Neoliberal thought is underpinned by an ideology of individualism that holds each person individually responsible for their well-being and rejects social solidarity, collectivism, and the notion that sociostructural factors are significant in determining one’s life-course (Harvey 2005). Individualism is also a facet of Marxian alienation, driven by the transmogrification of work and human activity from a social, collective process of self-actualization into a solitary and disconnected process of survival, with the ability to produce the metric by which human worth is valued. For Marx, alienation of person from person was the ultimate consequence of capitalist alienation (Wendling 2011).

The individualistic transformation of societies can be observed as globalization progresses. García, Rivera, and Greenfield (2015) charted cooperative behavior as Mexico was exposed to globalization and the consequent sociocultural changes associated with urbanization, population increase, and loss of agricultural activity. Across three decades of this process, the behavior of children shifted from cooperative toward competitive, with children in urban environments more inclined toward competitiveness. Furthermore, the process of globalization drives global migration between societies, with migrants often leaving collectivist, or “sociocentric” societies, for individualistic—or “egocentric”—societies. This process is accompanied by an increased risk of developing psychiatric disorders, particularly in the absence of a local community with shared values and backgrounds (Bhugra 2004a).

Individualism may itself be a risk factor for mental illness when compared with collectivism. Chiao and Blizinsky (2010) presented evidence from 29 countries that collectivism in societies correlated with lower rates of mood disorders and anxiety. Eckersley (2006) argues that individualism, particularly when it becomes a socially obligatory aspect of society rather than a choice, leads to a heightened sense of risk, uncertainty, and insecurity. This would seem to be reinforced by Twenge (2000), who found that rising anxiety and decreased sense of life control correlated with social indices such as increased individualism and declining social interconnectedness. More theoretically, Timimi (2005, 2012) argues that the individualistic, or “narcissistic,” value system of neoliberalism fosters goals of gratification and discourages deep interpersonal relationships. This in turn is held to affect the development of children, driving the increases in rates of psychological problems such as behavior disorders, substance misuse, and eating disorders.

Nevertheless, the effects of individualism may not be straightforwardly or entirely negative for mental health, as there is tentative evidence to suggest that collectivist cultures are also more stigmatizing of mental illness (Papadopoulos, Foster, and Caldwell 2013)—although this effect was not consistent across the countries included in this study. Furthermore, a neoliberal argument would be that any consequences of individualism are a necessary accompaniment to the promotion of personal freedom. Nevertheless, it is important to note that the neoliberal conception of “freedom” principally relates to freedom from regulation and control, rather than, for example, freedom from suffering or deprivation (Harvey 2005). Given the lack of literature on the topic, the role—if any—of this form of freedom in promoting mental health is unclear.

Cultural Interactions

An obvious and inescapable facet of globalization is the globalization of culture. Ever-increasing global interconnectedness means that cultures interact and are redefined by their interaction more than ever. It would be far too reductive to claim that this is an intrinsically bad or good thing, but there are without doubt consequences that must be considered.

One of these consequences is the phenomenon of acculturation—the process by which a minority adopts the values and beliefs of the majority culture. The global migration that characterizes globalization produces large migrant populations that face pressures to adapt to the culture of their host community (S. J. Schwartz et al. 2010). Sam and Berry (2010) describe four principal responses to acculturation pressures: Assimilation refers to the full adoption of the host culture, separation describes the reverse process of rejection of the host culture, marginalization occurs when an individual withdraws from both cultures, and integration, conversely, is a synthesis of both cultures into a combined identity. These responses can either be chosen by a population or chosen for them by the environment and host community. Importantly, the form of response has implications for psychosocial health, with integration appearing to be the most beneficial (Sam and Berry 2010). However, it is crucial to reiterate that migrants often do not have the luxury of choosing what form their own experience of acculturation takes.

The processes of cultural interactions can in turn lead to “culture shock” and “culture conflict.” Culture shock describes psychological distress arising from the transition into a new culture, where familiar sociocultural cues are absent. It was defined by Oberg (1960) as being characterized by strain; a sense of loss or feelings of deprivation; rejection by members of the new culture; role expectation and role confusion; surprise, anxiety, and indignation; and feelings of impotence. While Oberg’s conception was undoubtedly Western-centric—mostly grounded in American experiences—it nevertheless retains validity as a conceptual framework. Culture conflict describes the tension that arises from competing cultures in an individual—if a person associates with both a minority and majority culture, it can create competition between their respective values and beliefs. This in turn can lead to a sense of alienation, isolation, and exclusion from both cultures (Bhugra and Ayonrinde 2004). As Bhugra and Ayonrinde (2004) demonstrated, these processes of culture shock and conflict can be involved in the development of CMDs among migrants. A number of other studies have similarly linked culture shock, culture conflict, and mental illness (Hamboyan and Bryan 1995; Lui 2015; Yeh 2003).

The effects of globalization-driven culture change are illustrated by Kirmayer, Fletcher, and Watt’s (2008) ethnography of Inuit Canadians. Rapid cultural change was a cause of concern for Inuit people and was identified by the community as a driver of increases in suicide, depression, and mental health problems. This process was seen to be mediated by the expansion of non-Inuit values into their communities through mass media and exacerbated by the tensions between the affluent lifestyles portrayed in mass media and the reality of the limited opportunities available to young Inuits. A further concern was the erosion of traditional land-based lifestyles as the influence of globalization restructured Inuit society into a more capitalist, waged-based system. Very similar findings on the clash between globalized ideas and ideals of lifestyle, and the realities available, were documented by Chenhall and Senior (2009) in a study of young Aboriginal Australians.

In the above example, cultural tensions arise not due to the movement of peoples but due to the movement of culture itself. Globalization allows influential cultures to spread into new regions, where the processes of culture clash, conflict, and acculturation occur in the absence of migration. This is illustrated by Ferguson, Ferguson, and Ferguson’s (2015) work with adolescent urban Zambians. Using qualitative and quantitative metrics, they demonstrated a phenomenon of “remote acculturation,” by which the global spread of influential cultures into a country—in this case from the United States, UK, and South Africa—results in the assimilation of individuals in that country into multiple cultures simultaneously. This process created two distinct groups: one orientated toward Zambian culture and associated values of family obligation and the other undergoing a greater degree of acculturation into the United States, UK, and South African cultures. Furthermore, the “acculturation” group was both more inclined to individualistic self-construal and more likely to have lower life satisfaction—although the second effect was small, and no difference was found in the prevalence of psychological problems.

Movement for Global Mental Health (MGMH)

At the forefront of this change in recent years has been the “MGMH”—catalyzed by two Lancet series on global mental health in 2007 and 2011 (Patel et al. 2016). These series highlighted the global neglect and uneven distribution of mental health care, and the centrality of mental health to human well-being, and called for a scaling-up of evidence-based mental health care worldwide, particularly in LMICs (Horton 2007). One of the leading figures of MGMH, Vikram Patel, has spoken and written extensively on the topic and provides an overview of the movement along with MGMH colleagues. According to Patel et al. (2011), MGMH, inspired by the global HIV movement, aspires to action for global mental health that is evidence-based and human rights-based. MGMH also focuses on novel approaches to mental health care that accommodate the funding deficit, with task-sharing being one example (Patel 2012b, 2014). MGMH has undeniably had a great impact, evidenced by the increased attention, action, and funding for global mental health it has garnered (Bemme and D’Souza 2014; Patel et al. 2016).

Nevertheless, MGMH is not without its critics. Many of these critiques focus on its “global” nature, arguing that it treats different cultures as homogenous and ignores the unique local and cultural dimensions of mental health. Bemme and D’Souza (2012) provide an illuminating account of an Advanced Study Institute workshop in which a number of prominent figures from both perspectives on the MGMH debate discussed these critiques. Here, it was argued that MGMH represents a continuation of the asymmetrical Global North–South relationship, in which Western/Global North knowledge and practices are exported to the Global South. Furthermore, MGMH was accused of not including the voices of service users and people in poverty, despite using culturally sensitive language. Patel responded to these critiques, arguing that MGMH included women and people from LMICs in its agenda setting and is based on a postcolonial framework that aims for collaboration, not Western imposition.

Another contentious element of MGMH is its perceived focus on biological determinants of mental illness. Patel acknowledges a current lack of biomarkers for mental illness but nevertheless believes that establishing a firm biological underpinning for CMDs is simply a matter of time (Bemme and D’Souza 2012; Patel 2014). This can be seen reflected in some of the aspirations of MGMH, such as closer integration with neuroscience (Patel et al. 2016). This approach has been critiqued from proponents of a transcultural psychiatry approach, who argue that preoccupation with a universal biological foundation ignores the culturally contingent expressions of disease and diverts attention from sociostructural determinants of mental health (Bemme and D’Souza 2012; Clark 2014; Kirmayer and Pedersen 2014). In other words, a given nosology of psychiatry is enmeshed with the culture and experiences of those who create it; thus, each experience of illness must be understood in its own context. A universalistic MGMH approach, it is argued, will fail to do this, as it is based on Western constructs of illness—such as “depression”—which do not necessarily have cross-cultural validity. A counterargument is that MGMH is not based on Western nosologies such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), but on the WHO’s globally derived Mental Health Gap Action Programme (mhGAP) framework (Patel et al. 2011). Nevertheless, the extent to which the WHO is not itself a largely Western-aligned actor in practice, and thus its nosology an extension of Western nosologies, is debatable.

Despite these criticisms, MGMH can claim several successes. MGMH (2017) has mobilized a large global movement, with a membership of over 10,000 people and over 200 organizations. However, it should be noted that, as membership is free, this figure is not necessarily representative of the number of actively involved members—for instance, an online survey on goals and organizational sent out to the members of MGMH received a response rate of 7 percent (Minas, Wright, and Kakuma 2014). MGMH has also played an important role in promoting discussion and in shifting mental health into the mainstream of global health. This is evidenced in the impassioned debate around MGMH, the inclusion of mental health targets in the Sustainable Development Goals (United Nations 2015), and the WHO’s 2013 to 2020 Comprehensive Mental Health Action Plan (Saxena, Funk, and Chisholm 2013). From this increased focus have come several conferences, studies and interventions, and increased funding for global mental health (Patel 2012a; Patel et al. 2011).

Furthermore, despite criticisms surrounding MGMH’s perceived lack of cultural sensitivity from the field of transcultural psychiatry, there are undeniable examples of MGMH-led studies and interventions which take a culturally sensitive approach and are appreciative of regional variation. For instance, Patel et al.’s (1995) study of phenomenology and explanatory models of CMD in Zimbabwe was notable for its sensitive exploration of non-Western nosologies. This study acknowledged that most patients included in the study exhibited patterns of psychiatric symptoms that did not fit within defined Western nosological categories and that some of these symptom patterns might represent uniquely regional categories of psychiatric illness. At the same time, the study attempted to draw parallels between local and Western categories, arguing that the Shona term “kufungisisa”—“thinking too much”—was comparable with Western conceptions of neurotic illness.

Nevertheless, the debate remains ongoing, with other criticisms of MGMH including a lack of evidence base for scaling-up of services (White and Sashidharan 2014), neglect of gender concerns (Burgess 2016), and most controversially, accusations of overreliance on psychotropic medicines as first-line treatment, and influence from the pharmaceutical industry (Das and Rao 2012; Kirmayer and Minas 2000). For instance, Fernando (2014b) notes that while MGMH funding has not been disclosed, an MGMH-associated MSc course at the London School of Tropical Hygiene and Medicine received £300,000 funding from Janssen Pharmaceutica, which in turn has vested interest in psychotropic drugs. Additionally, the Gates Foundation has declined to fund MGMH projects on the grounds that the pharmaceutical industry already does so. Patel (2014), however, counters that the majority of MGMH initiatives receive no industry funding, and a greater concern is the absolute lack of treatment options for people in LMICs.

Exportation of Western Models of Psychiatry

Many of the more theoretical critiques of MGMH are rooted in broader criticism of the exportation of Western models of psychiatry—and of medicine in general—as part of globalization. This process is often construed as a continuation of neocolonialist interactions between HICs and LMICs. Summerfield (2012) and Fernando (2014a) note that the knowledge base for global mental health is based largely on Western instruments and categories that have not been demonstrated to be valid in different individual contexts. An example of this is Hollifield et al. (2002), who found that of 183 studies into refugee mental health, 80 percent used Western metrics. Summerfield argues that this is part of a process of pedestalization, universalization, and exportation of medicalizing Western practices, on a foundation that is not cross-culturally valid.

As Fernando (2014b) highlights, there is a historical precedent for the exportation of Western psychiatric knowledge and the arguably colonial nature of this interaction. Fernando notes that contemporary psychiatry originated during the period of European–American enslavement of Africans, and ideas around race were consequently mixed into mainstream psychiatry. It was this intermingling of psychiatry, racism, and colonialism that led the designation of non-Europeans as “uncivilized” and of this “uncivility” as similar to mental illness. Thus, shamans were classified as psychotic, and eminent psychiatrists such as Carl Jung espoused nakedly racist theories of “racial infection” whereby African minds were seen as not only inferior but possessed of inferiority that could infect white minds (Fernando 2014b; Jung 1930). Contemporary psychiatry has, of course, moved on significantly from these views and takes a much more culturally sensitive approach. Nevertheless, Fernando argues that remnants of these colonial attitudes have persisted, for instance, in the portrayal of Western models of psychiatry as universal/global and the gold standard. The link between racist practices in colonial-era psychiatry and the current promulgation of Western biomedical frameworks of mental health might be argued to be somewhat tenuous. However, a counterargument is that a key consequence of colonialism was to firmly instill notions of Western superiority—particularly in regard to knowledge and science—that continue to be exhibited in North-to-South knowledge transfer, including in transfer of psychiatric knowledge.

In a similar vein, Hickling and Hutchinson (2000) argue that the assumption that Western nosological concepts are universal and can be applied to the practices and reality of formerly colonized peoples is a by-product and lingering effect of the project of imperialism. A consequence of this may be that groups with culturally unfamiliar practices and behaviors may be pathologized and inappropriately marked for “treatment.” Such a mechanism may, for instance, partly underlie the racial disparities in mental illness diagnosis in Western countries (Bhugra and Bhui 2001; Escobar 2012; Fernando 2014b; R. C. Schwartz and Blankenship 2014).

A counterargument is that the broad categories of illness described by Western psychiatry—even if not the words and precise definitions—are in fact universal. It follows that these categories have a universal biological underpinning which would also explain racial disparities in mental illness. There is some legitimacy to this critique—as Patel points out, the lack of evidence of biomarkers does not equate to their nonexistence, and one can accept the role of society as a determinant without precluding the possibility of a role for biology (Bemme and D’Souza 2012; Patel 2014). Canino and Alegría (2008) note that cross-cultural validity varies significantly between CMDs, with data suggesting a universal syndrome for some—such as attention deficit hyperactivity disorder—but not for others. Nevertheless, the acknowledged extent to which socioenvironmental factors influence mental health necessitates acknowledging the heterogeneity of mental illness in heterogeneous socioenvironmental contexts. Thus, while there may be some merit in searching for universal syndromes, a wholly universalistic approach may be inadequate.

As Western models of psychiatry are exported from North to South, so too is the Western individualistic approach to mental health. In this model, supported by an ideology that downplays the social realm and treats individuals as self-contained agents, mental illnesses are seen not as consequences of sociostructural factors but as problems with the individual—and are treated accordingly (Esposito and Perez 2014). As U’ren (1997) argues, Western psychiatry is influenced by and hence corresponds with neoliberal thought. Thus, psychiatry locates illness in the individual—while lip service is paid to the biopsychosocial model, in practice the “social” component is almost entirely ignored. This issue has been highlighted by academics in other disciplines, for instance, Link and Phelan (1995), who note that neglect of upstream factors in favor of proximate causes is often seen as a strength in a Western model of epidemiology which sees proximate causes as more scientifically “pure.” They situate this view as part of “the value and belief systems of Western culture that emphasize both the ability of the individual to control his or her personal fate and the importance of doing so” (Link and Phelan 1995:80). However, I would argue that attribution of this value system to “Western culture” is an overgeneralization; it is more specifically an aspect of neoliberal culture, which often coexists with “Western culture,” and is exported by globalization.

Brijnath and Antoniades (2016) provided a more empirical examination of this process. They highlight how the neoliberal doctrine of individual responsibility is translated into a focus on “self-care,” which in practice translates into dependency on self-sufficiency and market forces, and reduced funding for social and care services. Through 58 in-depth interviews with mental health service users in Australia, they demonstrated how the ideology of self-management was not congruent with its reality, and that while seen as positive by some patients, the high labor burden of self-management could also foster negative coping strategies such as self-medication with drugs and alcohol (Brijnath and Antoniades 2016). Teghtsoonian (2009) has also highlighted how this individualizing narrative is an intrinsic point of Western mental health policy—using the Canadian province of British Columbia as an example—to the extent that sociostructural causes are often not even mentioned in policy and training documents.

As well as individualistic ideals, Western psychiatry also incorporates other facets of neoliberalism, such as the centrality of the market. Esposito and Perez (2014) argue that a consequence of this has been increased medicalization driven by the profit-driven nature of a capitalist pharmaceutical system, the redefinition of nonproductive human behaviors as pathological, and the neoliberal identification of the individual, rather than society, as the cause of mental illness. Following a similar theme, using the example of children’s mental health, Timimi (2012) argues that the neoliberalization of society and psychiatry has been accompanied by a process of commodification, in which treatment is just another commodity to be sold and exported to a global market, and higher value is placed on “quick fixes” such as medication. Concerns over this globalized process of medicalization of mental health have been raised by a number of other academics (Applbaum 2009; Conrad and Bergey 2014; Swancott, Uppal, and Crossley 2014).

Compounding this process is another aspect of neoliberalism, best described by literature on neoliberal governmentality. As described by Larner (2006), neoliberal states produce—through policy, ideology, and organically through competing political interests that arise in neoliberal contexts—a conception of individuals as active participants in the market. Emphasis is placed on the individual as a “consumer,” seen as a self-reliant contributor to society and to the market, responsible for their own well-being. Brown (2015) argues that neoliberalism has enacted a change in the role of the individual from one who, by pursuing their own interests and goals, passively benefits and contributes to the economy to one whose goals and interests are required to benefit and contribute to the economy. Crucially, when individuals fail to benefit the economy, “they may be legitimately cast off or reconfigured” (Brown 2015:84).

In the context of mental health, a failure to be a contributing member of the economy is pathologized—this becomes part of the definition of mental illness, and returning to work becomes part of the definition of recovery. DSM-5 (American Psychiatric Association 2013), the preeminent text on mental health diagnosis, includes impairment of the ability to work—along with impairment of social functioning—in its diagnostic criteria for depression, schizophrenia, bipolar 1 disorder, generalized anxiety disorder, and obsessive-compulsive disorder, among many other disorders. Similarly, vast bodies of mental health literature examine recovery from mental health through the lens of returning to work. While this is not necessarily an unreasonable metric, it serves to reinforce the neoliberal concept of the primary purpose of an individual being a contributor to the economy.

There is an important historical aspect to consider in the exportation of Western models of psychiatry. As Fernando (2014b) notes, the imposition of Western psychiatric practices was a component of the colonial process, with indigenous forms of care either suppressed or neglected. The Western model, at the time rooted in the detention of people with mental illnesses in asylums, took a moralizing and individualistic approach, fostering guilt in aberrant behaviors and introducing ideas of the separateness of mind and body. In contrast, indigenous approaches were often more collective and community-based. For instance, Mills (2000) describes how the imposition of the asylum system in British-occupied India replaced a traditional model that focused on the reintegration of the individual into society and advocated group involvement in therapy. Ironically, these values are now often espoused in contemporary mental health discourse.

Thus, asymmetric North–South knowledge transfer could be seen as a continuation of processes that began with the proto-globalizing colonialist projects of the imperial era. Approaches to mental health in LMICs are therefore shaped both historically and currently by Western models that are not necessarily culturally congruent with the experiences and values of people with mental illnesses in those contexts. Furthermore, in this unidirectional relationship, valuable mental health insights from non-Western countries are at risk of being neglected to the detriment of mental health care as a whole.

It must be acknowledged, however, that detailed examples of traditional healing in mental health literature are very sparse. Davar (2014) discusses how the practices of various “non-Western” spiritual healing-based approaches including close connection with the healer and high family and community involvement in therapy help to enable recovery. Other examples come from LaFromboise, Trimble, and Mohatt (1990), who provided a general overview of Native American traditional healing practices, describing a holistic approach in which psychological welfare is considered in the context of the community. At least three concrete products of this approach were identified: orientation away from diagnostic labels—instead conceptualizing mental illness in terms of human weakness; emphasis on collective ceremonies that strengthen interpersonal bonds and connection to the values and traditions of the community; and inclusion of acts of self-disclosure, atonement, and formal reintegration into social units as part of the curative process—emphasizing the healing of both the individual and the community as a whole. Gone (2009) provided a more detailed account of certain Native American healing practices, where he emphasized the importance the perceived power that a healer had been granted by nonhuman entities, the common social nature of therapies, and the frequent muting or avoidance of direct references to mental health during the healing process, in favor of spiritual frames of reference.

There is clearly a need for more literature systematically examining specific examples of non-Western mental health practices. Nevertheless, the existing literature does provide examples of more holistic and community-orientated approaches that are lacking in Western psychiatric models and may be missed in a unidirectional knowledge transfer.

Recommendations

Confronting the mental health impacts of neoliberal globalization is a daunting prospect. Globalization has integrated itself into the political and practical landscape of the world in such a way that any attempts at reversal would be highly unfeasible and quite likely damaging. A radical reimagining of the nature of globalization with a shift away from neoliberal values toward more communitarian and egalitarian ideals and practices would seem the optimum outcome. However, in the current geopolitical landscape, this remains a distant goal, requiring a global political shift of almost unprecedented magnitude. Nevertheless, these goals should underpin the practical steps that activists and policy makers can take in the current context.

Policy Makers

On a national policy level, a priority for policy makers should be the individualistic and inequality-generating nature of neoliberal globalization. Focus should be placed on redefining policy interventions away from individualist and market-centric approaches and toward those that focus on collective benefit and well-being. These changes can be implemented at all levels of policy.

At the broadest level, a key change should be implementing a more holistic model for policy creation, focused on multidisciplinary models of work. Decision-making teams for all national funding priorities—not just those that explicitly concern health—should include greater representation from mental health professionals, public health professionals, and community representatives. An example would be that of urban planning. Significant data have demonstrated the wide-ranging effects of urban planning on mental health—greater representation in decision making from mental health professionals and researchers, as well as representatives of the communities who would be affected by planning decisions, would lead to a policy that could mitigate or even reverse some of the mental health consequences demonstrated in this article.

Migration, already a priority for policy makers, will continue to escalate in importance in the coming years, as global warming exerts an ever-greater effect on migration patterns. Tentative estimates of the magnitude of this change have ranged from 25 million to 1 billion climate refugees by 2050 (Lovell 2007), with the most commonly known figure estimating 250 million people will be made climate refugees by 2050 (Myers 2005). Managing this change in both internal and external migration should be a major funding priority, in terms of both national infrastructure and research funding. Focus should be placed on methods for achieving “integrationist” approaches to immigration (Sam and Berry 2010). However, this also represents a major political challenge when faced with rising xenophobic sentiment in many of the HICs that are likely to experience significant immigration.

Addressing the broader consequences of neoliberal globalization, such as inequality, alienation, and materialism, presents greater challenges, with the solutions likely to require systemic change. Various economic measures have been proposed to address inequality, such as the implementation of universal basic incomes, progressive taxation on the wealthiest in society, and workplace measures such as wage ratios. These measures—while predominately targeting inequality—may also have benefits for more sociopsychological consequences of neoliberalism. For instance, a properly implemented universal basic income (UBI) could transfer greater economic independence to low-paid workers, drastically changing people’s relationship to work (Santens 2017). With more free time to devote to engaging pursuits and more freedom to choose engaging work, the psychologically destructive effects of alienation could be greatly mitigated. Similarly, while the concept of countries with “selfish” and “unselfish” capitalism (O. James 2007; Kasser et al. 2007) is relatively untested, funding further research into the economic, cultural, and policy differences between these countries could yield insights on methods for addressing both inequality and the consequences of materialist societal goals.

Finally, in the realm of mental health policy, there are several areas that would benefit from increased funding for research and intervention implementation. Internationally, increasing funding into the exploration of non-Western nosologies of mental illness and non-Western treatment methods would allow for a model of global mental health that is more flexible and globally applicable. At the same time, funding greater research into the effectiveness of scaling-up of the mental health interventions spearheaded by the MGMH would help establish if this is a practical model for a global mental health approach. Similarly, an upscaling of research into the effects of neoliberal globalization in LMICs is needed. Evidence on the effects of inequality, austerity, and recessions is greatly lacking in these contexts—funding further research in these areas would strengthen policy-making both in LMICs themselves and in supranational bodies such as the WTO and WHO.

Nationally, policy makers should consider trialing a greater number of mental health interventions that are based on collective treatment and that use techniques learned from non-Western approaches to mental health care. In concert with activists pushing for a reformed mental health system, policy makers should explore ways to move mental health care away from interventions that isolate the recipient and pathologize unproductivity. Instead, methods should be trialed which promote community engagement, and which explicitly identify subjective well-being, rather than return to work, as their end goal. In particular, in view of the strong role of socioeconomic factors identified in this article, policy makers should consider a model in which mental health services work in close tandem with social welfare services—in order to address both the individual manifestation of mental illness and its upstream contributors.

Activists

A change that is already taking place in various activist spheres, but which should continue to be developed, is to expand our critique of the economic effects of neoliberal globalization. While arguing against poverty itself is relatively simple, our arguments should include more nuanced positions that highlight the sociopsychological destructiveness of inequality itself and job precarity itself—independent of their direct effects on poverty. These are relatively new and complex concepts. Unless they are firmly introduced by activists—who are frequently the bridge between science and general knowledge—into the consciousness of the general population, they will remain merely academic observations rather than rallying points for opposition to the destructive elements of neoliberal globalization.

The link between recessions and poorer mental health outcomes is conclusive, and there is significant evidence that austerity measures underpin or exacerbate this effect. There is a growing consensus in the inevitability of a post-COVID global recession (World Bank, 2020). Activists should therefore urgently build opposition to the austerity measures that will inevitably be proposed in response to this recession, using the wealth of health and economic data generated from the past recessions.

Overall, one of the greatest challenges facing activists is the “invisibility” of neoliberalism—acting as a shroud that suffocates coordinated action against it. Activists working to combat its effects on mental health, and indeed beyond, should not just focus on highlighting and addressing the symptoms of neoliberalism. It is crucial that in our work, we continuously illuminate how all these symptoms are linked to a single central ideology. Even more importantly, we must continuously make the case that despite the ubiquity of this ideology, it is not the only possible world order. We must argue that—in the words of Roy (2005:86)—“another world is not only possible, she is on her way.”