Abstract
Depression, anxieties, panic disorder, attention deficit, schizophrenia, other psychoses, autism, are just a few diagnostic terms used to categorise and pathologise human experience and justify psychiatric intervention, usually in the interests of the pharmaceutical industry. The number of children and young people quickly diagnosed with some type of mental illness is alarming, and their medicalisation is readily accepted by their parents and society. Within this context, institutions like the World Health Organization announced that by 2020, ‘depression will be the second leading cause of world disability’ and by 2030, ‘it is expected to be the largest contributor to disease burden’. Although psychiatric supports are used widely in many countries and the movement for Global Mental Health (GMH) and the WHO are calling to scale up access to psychiatric treatments, particularly within the Global South, worrying questions remain about whether such approaches are contextually appropriate and ethical, or whether they constitute part of the problem that they are trying to solve. Ironically, the understanding of psychiatric disorders and problems of mental illness are growing in the same proportion. Consequently, we are obliged to ask important, contradictory questions: is the number of people with mental health conditions increasing or is it the psychiatric interventions and the growing categorisation of suffering contributing to making depression a universal reality? Or both?
Any attempt to answer the overall question would be incomplete. Instead of prompting an answer, the question itself forces us to think about the worrying phenomenon of the psychiatrisation of the majority of the world. Instead of trying to find the ‘right’ answers, China Mills’ Decolonizing Global Mental Health assertively constructs the right questions and problematises the call of GMH ‘to make mental health for all a reality’. Her book acutely explores the ‘made-up-ness’ of psychiatric diagnostic categorisation and its ongoing intervention in the Global South, provoking the same feeling of anxiety in the reader that she describes having herself, in relation to the problem. Mills offers a profound critique of approaches that locate the origins of suffering and distress solely in the brain rather than also considering people’s social and political environments. Using postcolonial literature, field research, interviews, personal experience and a variety of other sources, the book offers a rich set of tools to question the aim of providing mental health for all as a neutral project that transcends politics.
Throughout the book, Mills provides absorbing stories that reveal the complexity and violence that pervades the administration of pills by NGOs and psychiatrists in low- and middle-income countries, and denounces the uncomfortable relation between psychiatry and colonialism. Inspired by the work of Frantz Fanon and Homi K. Bhabha, who were both deeply concerned with the psychopathology of colonisation, Mills similarly describes extreme mental conditions as a political category by seeing symptoms as coming from oppressive systems, rather than being inherent natural and biological features. Nevertheless, she is careful enough not to abandon completely the psychological register for a solely social structural perspective of mental health problems. Mills draws attention to the disturbing incidence of increased suicide in Indian farmers who swallow the same pesticides used on their land. Although the farmers themselves call for a political reading of their actions, mainly linking self-harming to debts, the government tends to respond through an individual and psychiatric framework, resulting in a simultaneous medicalisation. Mills shows different perspectives from this debate, outlining the continuity of a violent colonial logic where the image of the ‘destitute figure’ (the poor, the mentally ill, homeless) gives justification for psychiatric intervention globally (p. 41). Treating individuals with drugs decreases their capacity to act and, for this reason, the book’s alarm bells ought to be heeded.
This violence behind the psychiatrisation of life is an important aspect of Mills’ work to illustrate the alignment between colonialism and psychiatry in both destroying experience and deciding what counts as a life worth living. We can assume that the psychiatric medication sold by pharmaceutical companies, which are distributed by some NGOs in India and elsewhere, is a powerful and intrusive tool of colonisation − one which subjugates thousands of people to a milieu to which they can do no more than adapt themselves. It silences their voices. The question remains why some aspects of life are treated as a condition that can be alleviated by drugs rather than be understood as a broader, holistic feature of life.
Mills doesn’t give a particular answer to this question but provides some clues as to how to tackle the strange irony that shadows the call to scale up access to psychological and psychiatric treatments globally, while in the Global North psychiatry and its chemical prescriptions are under profound criticism. She emphasises how the neoliberal rationale of inequality causes distress, whilst the same neoliberal rationality is responsible for coming up with solutions, often creating the subjects of psychiatric intervention. Mills reminds us that like colonialism’s search for new markets, the expansion of the market for psychiatric drugs is hugely profitable. Like colonialism, psychiatry and the movement for GMH form a system of truth, deciding who counts as normal and who counts as pathological, what kind of treatment is best and which behaviour is acceptable, usually ignoring or denouncing as non-acceptable local understandings of distress and ways of healing. The pictures of symptoms created by western researchers portraying what shall be conceptualised as mental illness and distributed globally like cards in a deck by pharmaceutical companies is one shocking example, amongst many others in the book, that stigmatises individuals and illustrates how dangerous and intrusive the aim of providing mental health for all can be.
The process of psychiatrisation is not only violent but it also resists being seen as violent once psychiatry and its chemical drugs are sanctioned by the law and normalised in the Global South, turning medication into something natural and needed. For this reason, Mills recognises this strange place ‘where chains and cages are violent, and yet the medication that replaces them seems also to act like chains’ (p. 106). This argument enables her to turn to a terrain of resistance that refuses (but often secretly) the psychiatry codifications. Through acts of imitating, mimicking, pretending to be normal or mad, and hiding pills, Mills explores the strategies that may undermine psychiatrists’ attempts at diagnosis and treatment, and a life that refuses to be reduced to the biochemical industry’s calculus and its universalising discourse.
Mills concludes her analysis with a reflection on decolonising Global Mental Health. Gripping stories and field notes from the book have suggested that psychiatry, as a contemporary form of colonial intervention, can occlude experience acting through chemicals on people’s brain. This type of intervention − without using walls, fire or sword − seems even more. For this reason, WHO policy, NGOs and the movement for GMH that advocate for making mental health a reality for all are seen by Mills as highly problematic. Westernised diagnostics and care are part of the neoliberal dynamic that forces on people a mode of behaviour that ignores the richness of different relations and perspectives. Employing Fanon’s socio-diagnostic psychiatry, Mills understands that psychological problems cannot be dissociated from social and political conditions. If that is the case, the work of psychiatry itself can be considered harmful to people who are dissociated from their ability to act and think. Reading psychiatry as a colonial relation can contribute to rethinking GMH, working out new concepts, constructing alternative approaches and transforming psychiatry itself. Mills doesn’t stop at critique; her book provides us with invaluable ways of taking the debate further.