Global Mental Health: Interdisciplinary challenges for a field in motion

Introduction

Over the past decade, efforts in Global Mental Health (GMH) have significantly evolved in parallel with critical commentary on its claims and interventions. The initial debate between global and local, universalist and culturalist, emic and etic perspectives on mental health has given way to more collaborative conversations and complex interventions that consider issues of cultural and epistemological diversity in many ways. The latest GMH agenda set by the Lancet Commission 2018 (Patel et al., 2018) is informed by the concerns articulated by early critics, while some of these critics themselves have begun to develop socio-culturally informed GMH programs. As GMH has shifted its agenda and epistemological underpinnings once more, grown its evidence base, and joined other global policy platforms such as the Sustainable Development Goals (SDGs) (UN, 2015), new issues and opportunities have emerged. This editorial reflects on GMH’s evolution and the implications of its new agenda.

The articles in this thematic issue stem, in part, from the 2016 McGill Advanced Study Institute in Cultural Psychiatry, Psychiatry for a Small Planet: Ecosocial Approaches to Global Mental Health. ¹ Other papers have been received by the journal as independent submissions. We draw from these articles, the larger literature, and insights from the first author’s ethnographic work among GMH advocates to look beyond the field’s official discourse and consider GMH knowledge practices and epistemic assumptions. In this introduction, we aim to: 1) trace the field’s evolution and current assemblage; 2) discuss the changing contours of the construct of “mental health”; 3) discuss the social, cultural and historical dimensions of current GMH interventions; and 4) problematize persistent and emergent lines of critical inquiry.

Moving beyond a polarized debate

A contentious debate emerged in response to GMH’s inaugural Lancet Series (Patel et al., 2007) and its agenda-setting global consensus exercise to identify the “Grand Challenges in Global Mental Health” (Collins et al., 2011). After GMH’s call to action to scale up evidence-based mental health care in low- and middle income countries, critical voices raised concerns regarding the cross-cultural validity of psychiatric evidence (Summerfield, 2008), the ways in which GMH priorities and practices may amount to a neo-colonial imposition of Western knowledge that threatens traditional and indigenous forms of care and healing (Fernando, 2014; Mills, 2014; Summerfield, 2013), and the likelihood that pharmaceutical companies would use GMH as a vehicle to expand their markets (Fernando, 2011). The notion of a global “treatment gap”, advanced as a central tenet of GMH, proved particularly contentious as it seemed to ignore the extensive observations by medical anthropologists and cultural psychiatrists of culturally specific forms of suffering, coping, care, and resilience. While both GMH advocates and those working in cultural psychiatry shared a concern for understanding and addressing mental distress in diverse populations, they came to this with different epistemological assumptions and investments in projects of “global” or “local” scale (Bemme & D’souza, 2014).

Transcultural Psychiatry provided a platform for this debate from the start, publishing two special issues on the topic after the McGill Advanced Study Institute in 2012 during which advocates and critics discussed their conflicting positions (Bemme & D’souza, 2012). The 2014 issue featured Vikram Patel’s (2014) passionate case for mental health as a global health priority alongside articles advocating for a stronger articulation of GMH’s ethical underpinning and focus on the social determinants of mental health (Kirmayer & Pedersen, 2014; Ruiz-Casares, 2014), a critical appraisal of the role of “community” in GMH (Campbell & Burgess, 2012), a discussion on how ritual healing practices may be incommensurable with Western psychiatry (Sax, 2014), and the reflections of a seasoned practitioner on the challenge of cultural psychiatry and GMH working together given their different lineages (de Jong, 2014).

The second special issue in 2016 offered further counterpoint to the public health oriented GMH approach through ethnographic accounts highlighting the cultural specificity of mental health in context (Ecks, 2016; Jain & Orr, 2016). Efforts to harness social science insights to critique and refine GMH practice have led to important edited volumes (Kohrt & Mendenhall, 2015; White, Jain, Orr, & Read, 2017) and a thematic issue of Culture, Medicine and Psychiatry (Lovell, Read & Lang, 2019) that takes the field itself as its empirical object, and analyses the history of its institutions (Henckes, 2019; Lovell, et al., 2019), its interventions as they unfold (Bemme, 2019; Kienzler, 2019; Read, 2019), and the sometimes paradoxical effects of public mental health surveillance (Béhague, 2019; Lang, 2019).

This special issue of Transcultural Psychiatry provides a snapshot of current interdisciplinary work that reflects the complexity and ongoing evolution of GMH. The authors reflect on the histories and colonial legacies of violence inscribed in mental suffering and programming (Capella, Jadhav, & Moncrieff, 2020; Hickling, 2020; Ortega & Wenceslau, 2020), on current models of culturally responsive intervention and implementation (Bustamante Ugarte et al., 2020; Hatcher et al., 2020; Honikman, Field, & Cooper, 2020; Mascayano et al., 2020; Shehadeh et al., 2020; Verhey et al., 2020) and on the challenges to mental well-being from the impending conditions of catastrophic climate change (White, 2020). Another set of contributions challenge established narratives on psychological suffering and trauma after war (Medeiros, Nanicha Shrestha, Gaire, & Orr, 2020), natural disaster (Newnham et al., 2020), and cultural practices of female genital cutting (Omigbodun, 2020). What all of these papers have in common is their effort to grapple with the specificity of mental health in context, advancing and problematizing GMH’s efforts to scale-up mental health care.

Global Mental Health today

The current GMH literature gives the impression that the field is hurtling forward breathlessly, its velocity and trajectory made tangible by “milestones” (Lund, 2020), “birthdays” (Horton, 2019) and projections of the “next 10 years” (Barbui & Albanese, 2020; Caldas-de-Almeida, 2019; Lund, 2020). This progression is framed in terms of greater access to care, impact, scale, and coverage; terms deliberately designed to be multivalent and recruit as many actors as possible to its cause. Evoking the urgency of crisis and the moral gravity of unprecedented neglect, an earlier call to action in the 1990s went largely unanswered (Desjarlais, Eisenberg, Good, & Kleinman, 1995), but resonated with many about a decade later under the framework of Global Health (Patel et al., 2007; Prince et al., 2007). Since the inaugural Lancet Series in 2007, GMH has given rise to a complex assemblage across formerly separate disciplines, professional groups, geographies, nation states, and non-governmental actors. ² The ‘global’ in GMH, thus, is not a place, or an all-encompassing ambition for planteary reach – but an organizational project that engenders integrative labor around a new problematization of “mental health” that pivots on the technical challenge of bringing care to places where there is none. The globality of GMH, thus, is grounded in scarcity and constraint, epitomized by the “treatment gap” that the field first rendered visible and then set out to close.

GMH today involves a set of specific actors and institutions committed to the goal of developing scalable, evidence-based care strategies for people suffering from mental health problems across the globe, but especially in low-resource settings. The field is not monolithic but composed of changing actors, discourses, and alliances that remain in constant motion; it is therefore best understood not through its own unifying rhetoric but by empirically examining the actual diversity of knowledge practices and their consequences.

At first glance, most GMH publication activity emanates from a relatively small number international policy makers, academic research groups, NGOs and multi-country consortia (Misra, Stevenson, Haroz, de Menil, & Koenen, 2019). Benedetto Saraceno, one of the former directors of WHO’s mental health unit, recently commented that GMH seems to be increasingly shaped by a dominant group of Western academic institutions (with the exception of those in South Africa), eclipsing WHO’s original multilateralism, which is now merely a “minority partner” in such larger consortia (Saraceno, 2020).

This impression, however, is both confirmed and contradicted by the first author’s fieldwork. Certainly, a small number of highly visible key figures and institutions are drivers of current GMH activities. Some leading GMH scholars even playfully refer to themselves as the “flying circus” because the same group of people assembles and re-assembles under changing project banners over and over again. But these projects bring together larger networks of collaborators including researchers, counselors, students, and lay health workers from all project settings. GMH is constituted along the lines of relationships, professional biographies, training and job opportunities, institutional partnerships, and funding streams – all of which produce “situated knowledge” (Haraway, 1988) that does not emerge from an abstract global, or strictly “Western”, space but from concrete sites and interactions among actors of diverse backgrounds and trajectories. Within the virtual and locally grounded contact zones of GMH practice, the distances of geography, nationality, rural-urban divides, and social and professional hierarchies are negotiated, re-arranged, and bridged in ways that do not map easily onto a simple North-South divide. These actors come together in conference calls and clinics, but also in precarious therapeutic spaces such as prefab containers and benches outside of clinics, in training workshops, Slack channels and spreadsheets, in email chains and at international policy venues as they pursue their vision of a better world through the framework of “mental health”, as well as their own livelihoods and careers.

Boundary work: Interdisciplinarity and umbrella language

What holds GMH together and gives it coherence may be porous, contested, and always in motion, but it is not arbitrary. The field’s identity and collaborative work is framed around a set of keywords and boundary objects (Star & Griesemer, 1989; Strathern, 2007) deliberately designed to work across disciplines, resource levels, professions and non-governmental actors. As a WHO policymaker explained in an interview, GMH was not something entirely new, but its founders invented a unifying “umbrella language”, that conveyed “positive messages” and employed terms such as the “treatment gap”, “access to care,” and “scaling-up”, which were designed to unify formerly disparate actors around a common goal. Today, nearly all self-identified GMH interventions employ a combination of these terms (Misra et al., 2019). In other words, GMH strategically reframed existing programs and integrated a plethora of policy priorities into one imperative: to bring effective interventions “to scale”. As Shekhar Saxena, then director of WHO’s mental health unit, explained, this terminology reduced what countries were told to do to one key message:

The treatment gap is too large for us to tolerate. And so what you [national policy maker] need to do is to see how within your existing and likely resources you can expand care. […] One message, it works.” (Interview with DB, 2016).

Changing contours of “mental health”: The new GMH agenda

There is a much longer history to the way in which the notion of mental health was shaped in international health in the postwar period (Bemme, 2018; Packard, 2016). Here, it suffices to say that since the 2007 inaugural Lancet Series, the notion of mental health has increasingly broadened. Since mental health was to become everyone’s responsibility, the field’s main strategy became integration (Collins, Insel, Chockalingam, Daar, & Maddox, 2013; Patel et al., 2013). Rather than insisting on its specificity and pursuing vertical, stand-alone mental health programs, GMH sought to make itself relevant to other policy domains and delivery platforms, especially primary care, maternal health, HIV/TB, the non-communicable diseases, emergency responses (IASC), and the SDGs. This led to the use of language that at times foregrounds distinct mental disorders, and at others concepts like well-being, psychosocial problems, stress and distress (rather than trauma or PTSD).

Mental health and development

The most significant reformulation of the notion of “mental health” in GMH has been its re-framing in terms of international development. This process, again, has a longer history told elsewhere (Bemme & D’souza, 2014; Brown, Cueto, & Fee, 2006; Lovell et al., 2019) but it culminated in the inclusion of “mental health and well-being” in the United Nations SDGs after extensive lobbying from the GMH community in the UK (Thornicroft & Patel, 2014; Votruba & Thornicroft, 2016) and by applied psychology NGOs at the UN in New York (Balvin, 2015). A stakeholder conference adjacent to the World Bank Spring meeting in 2016 called “Out of the Shadows: Making Mental Health a Development Priority” further solidified the mental health and development nexus. In a nutshell, this logic aims to improve mental health as “human capital” and to achieve a “return on investment” (Chisholm et al., 2016), which commensurates mental well-being with economic value for countries. While in principle, this could incorporate a large set of mental health outcomes, the only measurable indicator the SDGs specify is the number of suicides within target 3.4 that seeks to reduce premature mortality from non-communicable diseases. Some GMH actors, however, advocate for further alignment of the SDG indicators with those of the social determinants of mental health (Lund et al., 2018).

What does this mean for “mental health” as a globally conceived object of care? The recent agenda-setting Lancet Commission (Patel et al., 2018) proposes to re-conceive mental health through the logics of sustainable development by moving away from biomedical disease categories towards a dimensional model mapped along the spectrum of distress – disorder – disability. While GMH earlier focussed on a suite of globally comparable disorders enshrined in the Global Burden of Disease report (Murray & Lopez, 1996; Whiteford et al., 2013), recent work appears radically shifted from countable diseases to the spectrum of mental health of whole populations:

“This Commission grasps the opportunity presented by the SDGs to broaden the global mental health agenda from a focus on reducing the treatment gap for people affected by mental disorders to the improvement of mental health for whole populations.” (Patel et al., 2018, p. 1)

Beyond the biomedical model: Dimensional and transdiagnostic approaches

In addition, and perhaps of even more consequence, the Lancet Commission’s dimensional notion of mental health – situating everyone on a spectrum that ranges from well-being at the one end, to severe disability at the other – pushes back against the biomedical model, with its discrete diagnostic categories and corresponding treatments:

“Mental health problems exist along a continuum from mild, time-limited distress to chronic, progressive, and severely disabling conditions. The binary approach to diagnosing mental disorders, although useful for clinical practice, does not accurately reflect the diversity and complexity of mental health needs of individuals or populations.” (Patel et al., 2018, p. 1)

Another reason why biomedical framings are on the retreat is that GMH grapples not only with issues related to the provision of “access to care” but also with “barriers to demand” (Patel & Saxena, 2019, p. 1; Patel et al., 2018, p. 20), which occur when “discrepancies between biomedical framing of mental health problems and the conceptualisation of emotional distress in the community” (Patel & Saxena, 2019, p. 1) lead to limited interest in the care that is offered.

While this turn away from discrete biomedical disorders towards a spectrum of severity and an emphasis on contextual differences accommodates the local contingency of mental distress, the new approach and terminology deserve scrutiny in their own right. As disease models broaden and care practices become collaboratively stepped, shifted and shared among self, kin, lay workers, and medical providers (Patel, et al., 2018), new conceptual and relational issues arise. Transdiagnostic “elements” (Bolton et al., 2014; Murray et al., 2014), for example, may not straightforwardly medicalize suffering by applying often stigmatizing diagnostic categories with fixed criteria and cut off points, but other universalizing assumptions undergird transdiagnostic and psychosocial therapeutic practices. Motivational interviewing and CBT, for example, are underpinned by ideas about the universal value of behavioral activation or a generalizable human proclivity for coping through problem-solving. The locus of mental well-being and intervention here shifts from the assumption of an underlying biology or psychological interiority to individualized behavioral patterns that can be measured and therapeutically re-structured. Such new universalizing assumptions may be insensitive to the ways that agency is differentially stratified along cultural, gendered, material, and social lines. In transdiagnostic approaches, mental health is predominantly conceived of as an individualized behavioral pattern predicated on an agentic, responsible self that can be motivated and guided to change. Interventions, for example, focus on list-making to break down problems into solvable steps or on an increase in physical activity as part of CBT (often dropping the cognitive restructuring component as it requires more specialized practitioner skill). In other words, while GMH interventionists do adapt therapeutic models in many ways to fit the contexts they work in, the practices of adaptation themselves deserve a closer look because they are not only informed by the necessity to make interventions more locally relevant, but also by the need to make them more cost-effective and sustainable in settings with resource constraints – and these goals may be in conflict or require difficult tradeoffs.

The productivity of constraint: Adaptation and simplification

Arguably, the most productive force re-shaping psychiatric classification in GMH today is scarcity the challenge of working in settings with limited human and material resources. The resulting imperative to develop interventions that can be delivered by lay people largely determines what “mental health” can be from the vantage points of pragmatic contextual constraints. In short, mental health amounts to whatever can be taught to a lay counselor or “prescriber” in a few sessions, weeks, or months (Hoeft, Fortney, Patel, & Unützer, 2018; Jordans, Luitel, Pokhrel, & Patel, 2016). Much effort in GMH therefore goes into simplification, which can take the form of one-glance diagnostic master charts (mhGAP), or “ultra-short” screening tools (van Heyningen, Myer, Tomlinson, Field, & Honikman, 2019) that can be integrated into existing primary care stationary or the activities of often over-burdened community health workers. In this way, intervention protocols designed for low-resource settings become testing grounds for new and simplified psychiatric classifications and models of care, which, when validated in LMICs and rendered mobile as scientific evidence in the GMH literature, can travel across the North-South divide to influence practice elsewhere.

This generative power of local adaption through both conditions of material constraint and contextual factors is reflected in several of the studies present in the current issue. For example, Verhey and colleagues (2019) discuss how the elderly lay health counselors offering problem-solving therapy in Zimbabwe, through an intervention called the “Friendship Bench” (Chibanda et al., 2011), address symptoms of trauma, which they term njodzi, in their HIV-positive clients. They show how njodzi, while involving symptoms similar to those of PTSD, broadens not only the Western construct but also the local idiom of distress used in the intervention, kufungisisa (thinking too much) into kufungisisa kwe njodzi. This construct differs from the Western notion of trauma because it can encompass both circumscribed past events such as loss or sexual violence, but also ongoing adversity, such as poverty, struggle for survival, and persistent abuse from the family due to the stigma of HIV. The term was chosen by lay health workers, who share the same community and structurally difficult living conditions as their clients and are attuned to the causes and expression of njodzi The interventions effort to work with locally relevant framings of mental distress productively enriches and displaces Western concepts of trauma, especially when the model and its practice to adapt locally brought to other sites, such as New York City and the UK (Rosenberg, 2019).

GMH’s newest doctrine of mental health unfolding on a seamless spectrum associated with an array of less specific, but nonetheless measurable, concepts such as well-being, stress, transdiagnostic symptoms, or functioning scores fundamentally reformulates current psychiatric nosology. Transdiagnostic interventions like the Friendship Bench (Verhey et al., 2020), the Common Element Treatment Approach (Bolton et al., 2014; Dawson et al., 2015), or WHO’s Problem Management Plus (Dawson et al., 2015), thus give new contours to the notion of mental health and to how it is named, known, and promoted.

Interventions and outcomes in context

In recent years, GMH funders and practitioners have become more concerned with implementation than simply “proof of concept” studies (De Silva & Ryan, 2016). This has gone along with increasing efforts to take local and cultural specificity into account when determining “what works?” in complex interventions (Bemme, 2019). Researchers and practitioners adapt scales, tools and manuals, explore the feasibility and acceptability of their projects in qualitative studies, and feed their “lessons learned” back into iterative process evaluations. Within the framework of implementation science, they pay attention to context. This commonly requires the incorporation of qualitative research and close collaboration with local partners to identify relevant features of the implementation context. One longstanding area of contention, however, has been the relevance of local knowledge, which may include different and alternate sources of authority, methods and standards for evidence (Kirmayer, 2012). This is seen, for example, in the discussions of the relevance of mental health outcome measures, which critical scholars have argued should reflect a “pluralistic view of knowledge” (Kirmayer & Swartz, 2013), that recognizes multiple voices and sources of knowledge and avoids the “epistemic injustice” (Cox & Webb, 2015; Fricker, 2003) that occurs when the knowledge of one group is validated while others are denied legitimacy.

Achieving epistemic justice requires listening closely to the experience of patients and families as well as acknowledging their priorities. This could lead to patient-generated outcome measures as illustrated in this issue by the work of Melissa Harper Shehadeh and colleagues (2020). In outcome studies of psychological interventions in Pakistan and Kenya, they found that measures derived from open-ended interviews with patients better reflected patient priorities than did conventional scales. While most patient-generated concepts were also covered by the conventional measures, no item equivalence was found for the most frequently named problems. In Kenya, the most commonly named problems were financial constraints, poor health and unemployment, while patients in Pakistan mentioned poor health and emotional problems as being of greatest concern to them.

Stigma reduction is another important target in GMH. Reviewing the stigma literature, Mascayano and colleagues (2020) found that stigma interventions are rarely culturally adapted. Their scoping review of stigma intervention in low- and middle-income countries found that only 20% of the existing interventions considered cultural values, meanings, and practices as outcome measures. They emphasize the importance of an emic approach to stigma as a social process that need to be understood and reduced within “the daily engagements that 'matter most' within a particular sociocultural environment.” (p. 141) So far, stigma interventions in LMICs have relied mostly on strategies from high-income countries and neglected non-Western perspectives on stigma, social integration, and recovery. As a main barrier to mental health help-seeking, they argue, reducing stigma in culturally sensitive ways matters greatly.

Beyond its relevance to stigma reduction, culture plays an important role in accessing mental health services. Several of the papers in this issue identify the lack of culturally appropriate mental health care as a barrier to service access and utilization. Bustamante Ugarte and colleagues (2020), for example, note that Bolivian migrants, most of who have a Quechua background and work in the informal textile industry in Sao Paolo, face barriers to mental health care that result in higher risks for psychiatric symptoms. This correlation holds independent of sex, age, or income. The main barriers identified related to the unavailability of professionals from the migrants’ own cultural group, having no one to help access professional care, and difficulties taking time off from work. Fewer of these barriers were seen in migrants who were older and had greater proficiency in written Portuguese. The availability of culturally sensitive mental health services, they argue, would therefore lower barriers to care and allow for these symptoms to be addressed.

Although most societies are culturally diverse, attention to culture in mental health services generally has not been a priority. Ortega and Wenceslau’s (2020) discuss the ways in which the public mental healthcare system in Brazil actively discounted cultural difference as a meaningful level of engagement with patients, historically focusing instead on social class. The somatic idiom of distress nervos, for example, has been attributed to low-income rural women. A social imaginary of ethnic uniformity prohibits efforts implementing explicitly culturally attuned forms of therapy in Brazil. Other forms of care within the Brazilian public health care system such as community health workers and a collective therapy called roda, do encourage the integration of cultural specificity into care, which they suggest may provide an entry point for more explicit consideration of diversity.

Traditional healing and GMH

The relationship between indigenous healing systems and biomedically oriented care remains an important issue for GMH. Bethany Green and Erminia Colucci (2020) review studies on the views of traditional healers and biomedical practitioners on collaboration. The literature suggests that, although they have differing conceptualisations of mental suffering, both healers and biomedical practitioners recognize that patients can benefit from both types of treatment and, across diverse settings, both are willing to work together, despite concerns about patients’ safety and human rights, or the effectiveness of psychiatric medication.

Others have argued that traditional forms of healing cannot be integrated with mental health practices because they are located in systems of meaning that fundamentally incommensurable (Sax, 2014) or that actually contain an implicit critique of each other (Beneduce, 2019). In this rendering, traditional healing is seen as the epistemic and moral “other” to biomedicine – a direct competitor for authority and resources not merely an addition to a pluralistic health care system, as GMH practitioners often stress. Sood (2016), for example, describes how a Hindu healing temple in Rajasthan underwent profound changes in its therapeutic culture due to GMH inspired rights-based policies that led to “the disappearance of a number of key healing rituals” and reduced the diversity of “the plural mental health landscape” (p. 766).

While GMH pledges to respect traditional forms of healing and encourages collaboration with different healing systems (Gureje et al., 2015), such collaborations become rarely formalized. In conversations, interventionists do report efforts to reach out to traditional healers but cite a lack common ground and mutual interest to move forward. Despite the lack of formalization, however, different healing systems are never separate but always co-exist and interact. Chua (2013) reminds us that psychological and psychiatric knowledge is also perpetually vernacularized in context. Psy-professionals in India, for example, self-fashion as experts on TV and radio shows by perpetually blurring the boundaries between lay and expert knowledge. The demarcation or erasure of distance between healing systems is itself a context-specific performative construal.

When tensions between different technical and moral regimes of care do occur, however, especially when they involve physical restraint and human rights abuses, they are often borne by lay mental health workers (Read, 2019). As Read shows, despite recent rights-based mental health reforms in Ghana, in practice community health workers avoid the confrontation with faith-based healers in prayer camps where physical restraint occurs. Instead, they maneuver “within existing hierarchies” and preserve “a shared moral landscape” (p. 613) as they prioritize effective relationships with healers over confronting them with abuses.

Drug adherence and resistance

GMH practice aims to include a wide range of interventions and not rely on drug prescription alone – but medication delivery does play an important role in many GMH programs. Unfortunately, psychopharmaceuticals have limited efficacy, significant adverse effects, and can themselves be used in ways that limit freedom and violate human rights. Psychopharmaceuticals are not neutral, culture-free forms of treatment but enmeshed in complex subjective, social, and cultural meanings and expectations that shape how they are produced, used, experienced, and at times rejected (Etkin, 1992; Hardon & Sanabria, 2017; Jain & Jadhav, 2009; Kirmayer, 2002; Read, 2012). Intervening with psychopharmaceuticals thus requires the same careful attention to context and subjective experience as psychosocial interventions (Jenkins & Kozelka, 2017). Common public health frameworks for improving compliance or adherence to drug regimens, however, may not be adequate to capture these complexities in global mental health.

In this issue, for example, Allen Tran and colleagues (2020) argue that dominant models of drug adherence in public health tend to “focus on individual-level predictors” (p. 81) and are undergirded by the implicit assumptions about the conflict between “traditional” and “modern” modes of healing. Their qualitative study on drug non-adherence in Vietnam, which has one of the highest rates in the world, shows that the rejection of psychiatric medication is better understood within the larger political economy, changing patterns of medical pluralism, and local conceptions of selfhood and distress. As patients “pray in four directions” – consulting different biomedical and other healers – medical pluralism is explicitly endorsed, and is not seen in terms of opposing explanatory models. Greater exposure to more professionals leads to many prescriptions and little accompanying information due a doctor’s unquestioned authority. In addition to the influence of family and others in local social contexts, the fear of adverse drug effects plays an important role in non-adherence to medication.

Histories of violence: Colonialism and the asylum

Mental health care is complicated by psychiatry’s legacy and continuing role as an institution of social control, which historically has been closely linked to the interests of colonial powers and nation states (Keller, 2008; Mahone & Vaughan, 2007; Vaughan, 1991). At times, mental health institutions have been harmful to people they are mandated to care for, whether through coercive or carceral care or, more pervasively, though what Stevenson has called “anonymous care” (2014), which fails to come to grips with the life world of the people it aims to help. Practices of decolonization, Hickling (2020) writes in this issue must therefore be at the center of a postcolonial mental health practice – especially in places like Jamaica that have experienced hundreds of years of oppression and structural violence. Hickling reminds us that psychiatry’s own institutions – most notably the asylum – were brought to Jamaica through British colonialism, and that “the concept of involuntary commitment, custodialization, and compulsory detention for patients with acute mental illness is a product of modern European civilization and to this day underpins much of the contemporary European mental health agenda” (p. 20). GMH, he urges, must therefore be willing to learn from the history and care strategies of postcolonial countries. Following independence in 1962, Jamaica’s postcolonial government began a gradual process of de-institutionalization, downsizing the asylum and creating innovative community health care – well before such strategies had gained traction in other countries. Overcoming the psychological legacies of colonial violence requires developing local therapeutic strategies, such as the Paolo Freire inspired, theatre-based Psychohistoriographic Cultural Therapy Program established at Bellevue Hospital in 1977 (Hickling, 1989), or the Dream-A-World Program that runs to this day (Hickling, 2017). Therapeutic approaches, Hickling stresses, especially for the treatment of the descendants of enslaved Africans, need to include what he calls “psychological antidotes to white supremacy, racism and colonialism” (p. 22). Many psychosocial conditions such as rage, anger, and hostility which are normalized within the daily fabric of Jamaican society today must be recognized as linked to the history of slavery and colonialism, resulting in “high levels of violence, personality disorder, family fragmentation, migration, and abused and dysfunctional children” (p. 24).

Similarly, in this issue, a critical literature review by Capella and colleagues (2020) considers how formerly colonised nations can engage their own histories of violence in the mental health arena. Using Ecuador as a case study, they poignantly ask: “What is the place of history in the analysis of, and interventions around, violence addressed by mental health professionals?” (p. 32). If interventionists fail to engage the often violent histories of a place, they “will fail to appreciate the challenges faced by contemporary communities and be limited in their understanding of the cultural construction of health and illness” (p. 33). Mental health is shaped by specific forms of structural violence and power asymmetries – in the case of Ecuador, by poverty, drug trafficking, gendered violence, the repression of Indigenous languages, and the abolition of ritual practices through the imposition of Catholicism. Capella and colleagues advocate for the development of historically informed mental health interventions through which “collective memory and historical trauma provide a cultural alternative to orthodox biomedical or psychological theories of suffering” (p. 37). In this framework, a meaningful transformation would not be understood in terms of biomedical symptom reduction or psychosocial “recovery”, but as the possibility of “living on” (Lloyd, 2000): meaningfully contextualizing the past as an explanatory model for present suffering without, covering up contemporary structural violence (Kirmayer, Gone, & Moses, 2014).

A different kind of legacy of violence is addressed in the work of Simone Honikman and colleagues (2020), who, like Hickling and colleagues, draw inspiration from Paolo Freire’s Theater of the Oppressed to develop a culturally sensitive intervention that empowers nurses and midwives in South Africa to reflect on the obstetrics violence that has become normalized in clinical maternal environments. Nurses, themselves chronically overworked and stressed, were trained under apartheid to be subordinate to doctors, but superior to patients, in a fragile “mix of power and marginalization” that continues to play out in patient abuse. The “secret history” approach – referring to the hidden emotions and backstories everyone carries – seeks to foster empathic care through role play that allows participants to experience both the position of the oppressor and the oppressed, deconstructing the process of “othering”. Becoming more aware of “their own thoughts, feelings and actions, and those of their patients” (p. 177) through experience rather than technical knowledge reimagines and can potentially transform the nurse-patient relationship.

Mental health reform as frontier of modernity

By pointing to the legacies of violence and colonial practice inscribed in mental health care, these articles speak to another important perspective on GMH: its positioning as a project of modernization of psychiatry. This process of modernization, however, as Saiba Varma (2016) observed in a mental health hospital in Kashmir, is “neither seamless nor complete” and can have contradictory effects. The GMH inspired reforms at the hospital Varma studied strove to professionalize outpatient care in order to be recognized as a “Center of Excellence”. As the reform shifted the attention to the outpatient center, now bustling with senior staff, researchers and patient’s kin, the closed wards, where the more severely ill patients remained, were increasingly abandoned and rarely saw a doctor visit (Varma, 2016).

Varma’s careful empirical tracing of this shift in priorities, and of the consequences for those left behind, echoes internal critiques from within the field of GMH itself. During the first author’s fieldwork, these issues came up in many informal conversations among GMH interventionists, who simultaneously felt the field’s critical self-inspection was stifled due to the persistent fear that fueling external critique would be threatening the field as a whole. The most frequent concern among GMH actors was the dominance of the common mental disorders (CMDs) in the GMH agenda. This focus, driven by the epidemiological power of large numbers and the promotion of cost-effective care that could result in economically important recovery rates, was feared to sideline efforts to address more severe conditions with more complex and costly care needs, and greater exposure to human rights abuses (Barbui & Albanese, 2020), and homelessness (Smartt et al., 2019). South African policy maker Melvyn Freeman (2016), for example, pushed back against a proportional allocation of funds as “nonsensical” (p. 505) pointing out that over-reliance on economic considerations creates new inequality. If “returns would be less for a person with schizophrenia than say depression, does this mean that the person with depression should get priority?” Striking a balance, he argues, “with economics as only one of the variables considered, is critical” (p. 505). However, while the asylum is generally acknowledged to be a site of abuse by GMH and all efforts are geared toward community-based care, the asylum’s complicated infrastructures, legacies, and practices of custodial care have received little explicit attention from GMH (Cohen & Minas, 2017).

Social determinants of health

A longstanding grievance lodged against GMH has been the neglect of the structural factors that leads to mental health problems, chronicity and disability. In public health, the structural factors have been framed in terms of the social determinants of health. Issues such as poverty, war, oppression, racism, violence, poor education, unemployment, lack of housing, or other forms of structural violence, critics have argued, may be at risk of being further obscured when distress is reconfigured into a psychiatric condition and only addressed downstream (Kirmayer & Pederson 2014; Labonté & Schrecker, 2007; Mills & Fernando, 2014; Mooney 2012; Packard, 2016). While critics of the Lancet Commission notice the agenda's increased focus on the social determinants of health they suggest the “social” remains too narrowly conceived. Thought of as a set of “discrete factors” (p. 2) the broader sociopolitical conditions under which mental suffering arises and acquires meaning, they argue, continue to be left out (Cosgrove et.al. 2019). Indeed, GMH’s focus on mental health and development leaves unexamined the myriad ways in which development projects themselves contribute to the deterioration of mental health throughout the world. Chris Lyttleton (2019), for example, shows how villagers at Thailand’s border are left in “development’s slipstream,” (p. 5) after the establishment of a special economic zone in the border region brought about new stressors and affective disorders related to land reclamation, debt, gambling and substance abuse.

However, it should be noted that a concern with poverty – and its conceptual and causal complexity – has long been a driving factor in Global Mental Health, especially for scholars who pursue the question whether the known correlation between mental health problems and poverty is due to “social causation” (poor people become ill) or “social drift” (ill people become poor). (Cooper, Lund, & Kakuma, 2012; Lund et al., 2011). While Lund and colleagues’ initial review was inconclusive, they noted there was greater empirical support for the “social drift” hypothesis. Recent evidence, however, provides further support for the “social causation” hypothesis, such as Hatcher and colleagues’ (2020) article in this issue on the improvement of mental health outcomes in Kenya through a livelihood intervention that provided HIV-positive and food-insecure people with an irrigation pump, farming training, and micro-loans. The interviews conducted before and after the interventions found improvements in participants’ mental health experienced as reduced stress, lessened anxiety, improved mood, fewer symptoms of depression, and a more hopeful outlook on the future. The team found that the farming intervention improved mental health through better food security and income that freed up time and improved relationships; through increased physical activity and new routines of farming; and through the experience of being an active member of the community. However, concerns over the loan repayment had some negative impact on mental health.

In addition to the conventional social determinants identified in public health, global mental health is increasingly influenced by the accelerating destabilization of the planetary ecosystem under the conditions of catastrophic climate change (Whitmee et al., 2015). Ross White (2020), in this issue, asks what it would mean to promote mental wellbeing and Amartya Sen’s (1990) capability approach under the conditions of the Anthropocene and the constraints required to ensure environmental justice. White explores how the effects of climate change, including rapid urbanization, drought, food insecurity, rising sea-levels, and limited access to “green/blue spaces”, will affect mental well-being. He proposes a “Socio-Ecological Approach to Capability Enhancement” (SEACE) that he argues can assist communities in reconciling the necessity of constraint with the drive to maximize capabilities, and the social dilemmas that could arise from this tension.

Complicating trauma

Understanding suffering in context may also challenge common assumptions about what we assume to be culturally different, but emerges as similar across contexts, just as assumptions about what is generally perceived as distressing may be complexified through nuanced empirical inquiry. Three papers on the experience of trauma and psychological distress in this issue exemplify this.

Medeiros and colleagues (2020) conducted a clinical ethnography on the expressions of distress and resilience among young people who had returned from armed conflict in Kathmandu and Rolpa six years prior. Rather than enumerating vulnerability factors, their research exemplifies a more dynamic conceptualisation of interactions between young people and their environments, focussing on factors of resilience as much as on signs of distress during the re-integration process. What made young people resilient and determined their trajectory, they argue, depended on the degree of social connectedness and secure attachment with their families and love partners, continued engagement with the Maoist values of the armed group they used to be part of, bonds with their community, and the availability of socio-economic capital to forge a path out of pervasive poverty. The team’s findings challenge the commonly held assumption that war experiences and participation in armed warfare must inevitably lead to psychological damage in young people, suggesting that the role of structural violence in the community and in post-conflict life may not be sufficiently recognized in the literature on these issues.

Newnham and colleagues (2020) found that disaster-affected adolescents in China and Nepal showed largely similar expressions of psychological distress, leading them to identify cross-cultural commonalities. “Our findings suggest that elements of adolescents’ responses to disasters may be universal – heightened levels of anxiety, worry, behavioral avoidance, hypervigilance and a desire to be closer to family” (p. 205). They also found what they call “post-traumatic growth” and strengthened connections between adolescents and their families in the aftermath of disaster in both settings. The authors acknowledge that concepts of trauma are not aligned with reported local and traditional conceptions of distress, which may be expressed as “heart-mind” problem in Nepal, and through somatic symptoms in China. However, young people affected by disaster described their experiences and psychosocial symptoms in similar terms in both regions and described generalized worries such as “fear of the dark, of being alone, and of going to school” (p. 202). The authors speculate that “adolescent conceptualizations may have moved away from traditional idioms of distress towards westernized notions of PTSD, anxiety disorders and depression” (p. 205).

Studying the psychological experiences surrounding female genital mutilation/cutting (FGM/C) among the Izzi in Southeast Nigeria, Omigbodun and colleagues (2020) found that woman had “positive experiences such as happiness, hopefulness, and improved self-esteem” associated with the rise in social status following FGM/C (not the cutting itself), but also experienced “disruption of daily activities, chronic pain, and sleep and sexual difficulties occurring in the aftermath of FGM/C” (p. 212). FGM/C used to be a non-negotiable rite of passage, but has been strongly discouraged by the Nigerian government since 2002 and is currently viewed ambivalently; over two-thirds of the women described it as “good and bad” (p. 222) pointing to the ongoing cultural change towards the practice and the need to review current campaigns in the light of these findings.

The promise of digital psychiatry

New digital technologies are another field of GMH activity in which novel constructs and practices of care are emerging. To some extent this is seen as expedient – driven by the problem of limited resources in low and middle income countries. “Few have access to care, but most have access to a digital device,” the common argument goes, suggesting the narrowing digital divide provides a way to close the treatment gap. The promises of technology – as is often the case – are depicted as nothing short of revolutionary: The point of care and data collection moves into the patient’s pocket; local constraint and scarcity can be circumvented and millions reached at once at unprecedented scale (Doraiswamy et al., 2019; Pickersgill 2019). However, digital approaches are diverse and this specificity matters (Heerden, Tomlinson, & Swartz, 2012). Interventions range from educational support for lay health workers and telepsychiatry, to text-message based “on demand” services, drug adherence apps and online self-help, and mood trackers with diagnostic algorithms based on passive data collection from cellphone use (Insel, 2018; Miner, Milstein, & Hancock, 2017; Naslund et al.; Torous, 2014). Due to this diversity of approaches, their epistemological, ethical, or relational effects will also differ as they each re-shape subjectivities and clinical encounters in novel ways. Questions regarding the ethical implications, cultural acceptability, and feasibility of digital technologies in GMH are currently being studied by interventionists (Maulik et al., 2017, Kohrt et al., 2019), but they also invite broader reflection on the socio-cultural worlds they are part of and helping to create. The embrace of technology changes the nature of the questions we ask. Mental health itself may be conceived of and encoded differently at the digital interface, emphasizing new criteria, thresholds and parameters, such as bodily states, mobility patterns, or samples of linguistic expression, that may become divorced from, or newly reconfigured within larger social contexts of meaning and relationality.

Conclusion

As the articles in this issue make clear, GMH today is many things. It straddles the specificity of epidemiology, exemplified by the Global Burden of Disease and an abundance of standardized survey instruments, as well as the flexibility of a view on mental health as a spectrum that encompasses well-being and resilience as well as myriad forms of stress and distress. Of course, all disciplinary ways of knowing are partial and situated – blind to some and attuned to other ways of knowing. Opening to the insights offered by other disciplinary perspectives can allow GMH to better understand the contexts that shape its practice.

Anthropologists and cultural psychiatrists have pointed to the limits of understanding mental suffering through knowledge and technical expertise alone. For example, Lovell and Diagne’s recent ethnographic work in Senegal challenges the narrow framework of care in GMH through the notion of “thick therapeutics,” bringing into relief the entanglement of kinship, the economic, political, and spiritual (Lovell & Diagne, 2019). Others approach mental distress first and foremost as relational, intersubjective experience. A crisis and event that is situated, negotiated, and sometimes mended in relationships. From this perspective, mental health comes into view as problem of social ecology (Kirmayer, 2015; 2019; Kirmayer, et al., 2015; Kirmayer, et al., 2017), which may involve crises of kinship (Pinto, 2014), of relations of reciprocity and obligation (Han, 2012), of maintaining proper relations with ancestors (Stevenson, 2014), and, importantly, the therapeutic relationships (Bracken et al., 2016). Such perspectives render visible what must escape epidemiological reason (Reubi, 2018) or psychiatric diagnostic measures. Those attuned to socio-cultural forms of care, on the other hand, may find themselves blind to the potential of numbers to convey affect and tell crucial stories about the predicament and needs of populations and communities in what Katherine Mason (2018) calls “quantitative care”. This care expresses itself for and through the aggregate. The public health workers she studied cared “about populations, they cared for their data sets and models, and they cared with their models’ outputs” (p. 202).

GMH is a field dependent on thoroughgoing interdisciplinarity for its science and practice. Given our inevitable disciplinary blind spots, Crick Lund’s call to move beyond dichotomizing “emic and etic approaches” and “towards more integrative convergent and interdisciplinary models” (Lund, 2020, p .2) is entirely apposite. However, interdisciplinarity by itself does not guarantee an awareness of the situatedness of knowledge or an integrative perspective. Without intensive collaboration and bridging theories, the “inter-” may itself entrench, rather than overcome longstanding divides (Fitzgerald & Callard, 2015), lead to a mere juxtaposition of qualitative and quantitative approaches, or silence creative ideas, heterodox positions, and dissent through processes of integration that do not consider their own internal power dynamics. We take inspiration then from Tomas Matza’s (2018) notion of “precarious care”, a term coined to capture the emergence of psychological therapies in post-soviet Russia under precarious conditions. This notion steers us away from merely asking “does psy-care help or harm?” and towards an inquiry into the ways in which care unfolds within specific contexts and constraints (e.g. of culture, kin, moral and political economy, infrastructure, or epistemological difference, to name just a few). What matters most to the continued reflection on, and thinking with, the logics of GMH is asking why, and in whose name and terms, and to what ends “mental health” is configured and intervened upon.

While there is increasing recognition of the importance of culture and context, actual application remains limited in many settings (Faregh, Lencucha, Ventevogel, Dubale, & Kirmayer, 2019). Of course, focusing on culture in mental health care may not ensure effective care, just as universalism and globality do not always lead to the erasure of meaningful difference; both cultural specificity and claims of universality can be mobilized to different ends. Cultural difference was used to justify oppression under apartheid in South Africa (Swartz, 1991) and scientific internationalism and universalism were instituted by early WHO to counter colonial and racist legacies of science (Wu, 2015). The Nigerian psychiatrist, Thomas Adeoye Lambo, for example, who worked with WHO in the 1960s to ‘80s and became its Deputy Director General, embraced universalist models of mental health in order to discount psychiatric theories that insisted on the inferiority of the African mind (Heaton, 2013). Recognition of cultural difference in GMH is not meant to essentialize or marginalize but to give professionals and communities the frameworks needed to bring their own knowledge and values to bear on responding to mental health problems. Interdisciplinarity, self-reflection, epistemic pluralism, and power sharing are all vehicles to achieve this essential collaboration in Global Mental Health.