Paper short abstract:

This analysis of contemporary debates and tensions within Global Mental Health seeks to highlight the ways in which anthropologists can contribute to creating new forms of engagement across disciplines and cultures to provide appropriate mental health care worldwide.

Paper long abstract:

The field of Global Mental Health (GMH) is an emerging formation of knowledge and practice seeking to address mental illness on a global scale. In the past decade, a growing body of epidemiological research has established mental health as a priority for global health research and intervention. Scholars have engaged in, sometimes, fierce debates about the nature and vision of the GMH agenda. The two most polar positions are those who describe GMH as a bottom-up, public health movement driven by local knowledge and priorities, with the aim of providing access to mental health care for everyone, and those who consider GMH to be a top-down, imperial project exporting Western illness categories and treatments that would ultimately replace diverse cultural environments for interpreting mental health.

In this paper, we aim to unravel the different scholarly discourses that seek to address controversies and tensions between a public health approach to mental health and a culturally-based approach. We outline the different debates ans standpoints as they were put forth by leading scholars in the field during the 2012 annual Advanced Study Institute at McGill University. Emanating from this analysis, we suggest a critical approach that moves past the seemingly static dichotomies and the disciplinary boundaries in discussing the complex issues emerging within the field of GMH as worldly encounters. Ultimately, we expect to highlight the ways in which anthropologists can contribute to creating new forms of engagement across disciplines and cultures to provide appropriate mental health care worldwide.

Paper short abstract:

This paper provides an institutional ethnographic analysis of how mental health is experienced as a “human right” through contemporary international relations, and dominant economic indicators of health and development.

Paper long abstract:

Global justice and human rights language, of which there are a number of competing interests, is increasingly present in mental health practice internationally. What happens at the intersection of the discourse and mental health/development practice legitimizes some notions of rights, and obscures others. In this paper, I explicate, through an institutional ethnography, how diverse "human rights" expressions arise in academic, political and international development sectors and how these expressions of "rights" are experienced in the field of mental health research and practice.

Through a particular site of research and knowledge making for mental health and development, I examine the discourses in action, on the ground, and trace the connections between local mental health work and the global "right to mental health" discourse. In the relations of local NGO, national research programs and official aid strategy we can see how the "right to mental health" is brought into action through economic indicators of health and development "results" and internationally coordinated poverty reduction strategy.

This paper provides an analysis of how existing rights discourses and practices are enabling, helpful, limiting and, at times, harmful to actual mental health and development. With these findings as a basis for discussion, I further unravel the more generalizable challenges for scholars of "the human right to health", and dilemmas for programmatic and social change for policy makers, funding program officers and health workers intent upon realizing everyday mental health and development goals.

Paper short abstract:

Ethnographic findings of Malaysian psychiatric inpatients and staff indicates that modernisation of services draws on international models but fits uneasily with a colonial ‘asylum’ approach set in the context of socio-political ethnic tension. This carries resonance for post-colonial societies.

Paper long abstract:

This paper draws on extensive ethnographic data of the experiences and perceptions of psychiatric in-patients and staff in institutional psychiatric settings in East Malaysia. Mental health provision in Malaysia offers interesting paradoxes with a slow progress towards revising anachronistic mental health legislation. The country has attempted to modernise its services by drawing on international models. However, the political and ideological value bases of Westernised models do not fit Malaysian values and norms. This is significant owing to Malaysia's colonial history where asylum services were developed to care for the colonial mad and migrant workforces from China and the Indian subcontinent following in its wake. The close association between anthropology, medicine and Imperialism also generated a fascination with the indigenous ethnic groups in the region. Today the reminders of Victorian psychiatric care are recognisable in Malaysian psychiatric daily practices, carrying resonance for other post-colonial societies. This socio-cultural-historical thread forms a narrative by which to trace other anomalies and contradictions played out in the system. Malaysian doctors have historically been trained overseas, unlike psychiatric medical assistants/nurses. Thus a disjuncture is found between the 'new' approaches introduced and customary practices. The highly religious context of Malaysia and rich traditional healing practices form another disjuncture in terms of secular, biomedical approaches that hold few cultural reference points for many of the ethnically diverse patients and staff. Additionally, diagnosed psychiatric morbidity and prevalence carry implications for ethnic groups, particularly in a modern Malaysia witnessing a growing Islamic resurgence and escalating ethnic tensions.

Paper short abstract:

After the Pol Pot era, in the early 1990s, Cambodia reinstituted a Western-style mental health system. Thus, since then, ‘global mental health’ policies have affected the transition of the local concept of mental illness and help-seeking behaviours in Cambodia. This impact is the focus of this paper.

Paper long abstract:

This paper describes how 'global mental health' movement and policies have affected local mental health conditions in Cambodia. I collected official Ministry of Health documents related to Cambodia's mental health plans from the 1990s till the 2010s. In addition, I carried out my fieldwork in the clinical setting at the department of psychiatry, Khmer-Soviet Friendship Hospital, in Phnom Penh, Cambodia for a year, ending in September 2011 . The history of Cambodian psychiatry can be traced to the French colonial era, when French institutional psychiatry was gradually introduced into French colonial Cambodia from around 1900. Then Takhmau Psychiatric Hospital was established in 1940, but it was totally destroyed during the Pol Pot era (1975-1979) due to the repression of intellectuals and the killing of most of the medical staff. However, after the Pol Pot era, in the early 1990s, Cambodia re-established a Western-style mental health system with the support of the international community and implemented an educational programme to train psychiatrists. Yet some care has continued to be provided by traditional healers, like Kruu Khmer, monks, village elders or mediums, and traditional medicine remains widely popular among the local population. In this paper, I especially focus on the transition of the concept of mental illness and help-seeking behaviours in Cambodia after the reinstitution of the Western-style mental health system in the 1990s.

Paper short abstract:

Critiques of the global expansion of psychiatry are informed by studies of curtailment of patient freedom typical in colonial contexts or totalitarian regimes and the depoliticisation through medicalisation of the wider social forces and inequalities embodied in the mentally ill. In this ethnographic biography of the indigenous Tongan Psychiatrist, Dr Mapa Puloka, I examine the key influences and negotiations during the decade that established the mandate for a Tongan psychiatry that faced little resistance from the Tongan population and successfully increased patient admissions

Paper long abstract:

Critiques of the global expansion of psychiatry are informed by studies of curtailment of patient freedom typical in colonial contexts or totalitarian regimes and the depoliticisation through medicalisation of the wider social forces and inequalities embodied in the mentally ill.

In this ethnographic biography of the indigenous Tongan Psychiatrist, Dr Mapa Puloka, I examine the key influences and negotiations during the decade that established the mandate for a Tongan psychiatry that faced little resistance from the Tongan population and successfully increased patient admissions. This article offers a rare case study of a successful collaboration with traditional healers and a historical and epistemological contextualisation of his attempt to shift the locus of causality for mental illness from exteriorized 'evil spirits' to interiorized notions of brain disease through hybrid translations of psychiatric terms and diagnoses, key media and grassroots interventions, and regional collaborations. His success suggests a valuable point of confluence between histories of medicine, cross-cultural and transcultural psychiatry and medical anthropology of critical interest to a growing global mental health movement. In the non-colonial context of the constitutional monarchy of Tonga, the political inferences and implications of Psychiatric knowledge reflected and supported the changes in identity that underscored the movement towards greater democracy

Paper short abstract:

I consider the new ethical dilemmas and fields of intervention opened up for medical humanitarianism by the growing authority and prominence of Global Mental Health discourses. In particular, I explore the debates sparked by the implementation of a pilot psychiatry program at a small clinic serving poor and war-wounded patients in rural Sierra Leone.

Paper long abstract:

In this paper, I consider the new ethical dilemmas and fields of intervention opened up for medical humanitarianism by the growing authority and prominence of Global Mental Health (GMH) discourses. The paper examines the social dynamics of collaboration between a university global health program and an American-funded NGO that runs a clinic and community health programs for the poor and war-wounded in rural Sierra Leone. In particular, I explore the debates, discomforts, and relational fractures triggered by the implementation of a pilot "community psychiatry" program--inspired in part by a reading of Vikram Patel's "Where There Is No Psychiatrist"--intended to diagnose and medicate psychosis in a handful of local patients living in poverty. The controversies sparked by the program throw into relief the often sharply divergent moral and epistemological grounds that motivate the engagement and collaborative styles of the actors involved, and highlight the ways in which the notion of "humanitarian emergency" may be mobilized to legitimate troubling forms of experimentality in contexts of limited public health infrastructure and accountability. Attempts to implement the GMH agenda raise difficult questions about how to reconcile careful consideration of local cultural contexts and structural constraints with the urgent tone of calls to mitigate treatable suffering even in the absence of trained mental health professionals. Above all, such charged negotiations underline the high stakes for target communities, who are more often considered and addressed through abstract moral categories than in their complex and ambiguous humanity.

Paper short abstract:

Based on ethnographic data from urban India, I examine how context influences the interpretations and use of the Mini Mental State Examination (MMSE), a popular screening instrument for dementia. I will focus on the interpretations and use of the Mini Mental State Examination (MMSE) by clinicians in Delhi when used to screen for dementia. My analysis is framed in two ways: object – the Mini Mental State Examination is understood by Indian clinicians; and praxis – how is the scale used. I demonstrate how the MMSE, while appearing to adhere to universal diagnostic principles, in practice validates time-efficient techniques rather than reliably screening for cognitive impairment.

Paper long abstract:

"Alzheimer's at a moderate stage," is a diagnosis that can have a lasting impact on individuals, families, and health systems. The power of such a diagnosis is based in a biomedical ontology wherein neuropsychological screening, clinical tests, and observable symptoms are assumed to be universally applicable. However screening and diagnostic tools are created and administered within specific political, cultural and clinical contexts that problematise their supposed universality. Based on ethnographic data from urban India, I examine how context influences the interpretations and use of the Mini Mental State Examination (MMSE), a popular screening instrument for dementia. My analysis draws on Bruno Latour's ideas of 'science in the making,' and is framed through object: how the MMSE is immutable and mobile with cognition presumed to be uniform across time and space; and praxis: how the MMSE's routine application reinforces local power structures rather than accurate screening of cognitive impairment. Subsequently there is a need to rethink how dementia screenings are undertaken accounting for cultural and structural variances as false-negative or even false-positive screening has implications for service delivery and quality of care.

Paper short abstract:

In this paper, I draw upon over two years of ethnographic fieldwork conducted in Egypt with one popular French-based transnational medical humanitarian organization. I analyze the bureaucratic and medical practices of this organization within their Cairo-based clinic and homeless children’s shelter. Drawing on interviews with homeless children and medical experts, the research reveals how new relations of care between humanitarian doctors and children are shaped by a psychiatric examination form—its creation, archiving and transnational circulation. As the object through which childhood trauma and mental illness is demonstrated and rendered legitimate for a global audience (Fassin and Rechtman 2009), I suggest this examination form both produces new categories of subjectivity in Egypt, such as the young psychiatric patient or ‘problem’ street child, and new figurations of potential political crisis, which street children are believed to embody.

Paper long abstract:

In this paper, I draw upon over two years of ethnographic fieldwork conducted in Egypt with one popular French-based transnational medical humanitarian organization. I analyze the bureaucratic and medical practices of this organization within their Cairo-based clinic and homeless children's shelter. Drawing on interviews with homeless children and medical experts, the research reveals how new relations of care between humanitarian doctors and children are shaped by a psychiatric examination form—its creation, archiving and transnational circulation. As the object through which childhood trauma and mental illness is demonstrated and rendered legitimate for a global audience (Fassin and Rechtman 2009), I suggest this examination form both produces new categories of subjectivity in Egypt, such as the young psychiatric patient or 'problem' street child, and new figurations of potential political crisis, which street children are believed to embody.

The implications of this research for the field of global mental health point to how a) child subjects in Cairo consume psychiatric care and come to understand their bodies and health through that care, and b) how global processes engage in local places in the contemporary Arab/Muslim Middle East through the daily work of trained, local humanitarian mental health experts.

Paper short abstract:

International campaigns promote psychotropic drugs to treat psychosis. However research with people with mental illness in Ghana revealed dissatisfaction with the effects of antipsychotics suggesting a need to develop interventions which are more responsive to the experiences of those who use them.

Paper long abstract:

Global campaigns to 'scale up' mental health services promote psychotropic medication as the first line of 'evidence-based' treatment for psychotic disorders. However, such campaigns pay insufficient attention to the experiences of those who take antipsychotics including unpleasant and dangerous side effects, limited perceived efficacy, and discontinuation of treatment. Whilst these responses are well-documented for users of mental health services in high-income settings, there has been very little research in low-income countries. This paper reports on ethnographic research in Ghana with people with long-standing mental illness and family members. Despite a perception among health workers that many families were ignorant of biomedical treatment for mental illness, most informants had used psychiatric services including antipsychotic drugs. However despite valued effects such as calming aggression or agitation and facilitating sleep, discontinuation of treatment was common in the long term due to feelings of weakness and prolonged drowsiness. Such experiences conflict with perceptions of health as strength and a desire for medicines to enhance strength and endurance, particularly when physical exertion is required for most farming and household chores. Furthermore, the failure of antipsychotics to bring about a lasting cure could paradoxically reinforce spiritual perceptions of mental illness since illnesses which recur despite medical treatment are suspected to have a spiritual cause. This paper concludes by arguing that mental health initiatives should attend more closely to the evidence of those who experience mental distress and its treatment and work with families to develop innovative interventions which are responsive to their needs.

Paper short abstract:

This ethnographic paper examines deployment of psychiatric diagnoses in rural northern India. I address two issues: 1) ‘use’ of psychiatric categories by professionals and lay people and 2) intersection between professional categories and local illness categories in clinical and community settings.

Paper long abstract:

In recent years, the 'global mental health' agenda has dominated academic and policy discussions of mental health in low income countries. One of the central 'technologies' of 'global mental health' interventions are diagnostic systems including the ICD and DSM. These are seen to provide a standardized and universal means of measuring psychiatric morbidity with consequent increase in 'access' to services. However, the perceived cultural invalidity of western diagnostic categories as applied in non-western settings forms the core of current critiques of GMH (Summerfield, 2008). This paper draws on ethnographic research from north India to examine deployment of international diagnostic systems in primary mental health care clinics. I address two issues: 1) the ways in which mental health professionals and patients & family members 'use' diagnostic systems for particular reasons and 2) the intersection between international diagnostic categories and local illness categories in clinical and community settings. The ethnographic data suggests a degree of fluidity on the ground, with both psychiatric diagnoses and local illness categories being defined both in relation and in opposition to each other. Usage of local and psychiatric categories is shaped by a range of factors including caste, gender and poverty. This fluidity has important implications for the operation of the community mental health service in this area, particularly issues of access and care which are central to the GMH agenda.

Paper short abstract:

This paper examines how Mozambican mental health caregivers negotiate competing global or transnational norms and emphasizes (from the fragile universalisms of Global Mental Health to the emphases of transnational NGOs) while also confronting the skepticism of many patients and families.

Paper long abstract:

In Mozambique, mental health and psychiatric services are few, frequently underfunded and understaffed. Ethnographic work has shown how local forms of healing are preferred and, often, more effective than psychological interventions based in Western or biomedical conceptions of mental illness and healing. Yet institutions of mental health care do exist - from the National Health Services' Mental Health Unit to forms of mental health care and counseling provided by transnational NGOs. In a context where a majority of health funding, even in the public system, is dependant on NGOs and donors, mental health providers work to "link" their efforts to transnational initiatives and global health infrastructures. As a result, caregivers recognize that a Global Mental Health agenda may offer new resources for care, even as they acknowledge how many patients understand their predicaments as material, financial, or social in origin rather than psychological or psychiatric.

This paper examines how caregivers negotiate competing global or transnational norms and emphasizes (from the fragile universalisms of Global Mental Health to the emphases of transnational NGOs) while also confronting the skepticism of many patients and families. Drawing on ethnographic interviews conducted with mental health providers in Maputo and Nampula, Mozambique, it highlights how psychologists and psychiatrists navigate this fraught institutional and epistemological landscape. It also draws on analyses of medical care in Africa more broadly to suggest that the universalisms deployed by mental health professionals are not unique to the Global Mental Health agenda but are also resonant with broader definitional and epistemological struggles.

Paper short abstract:

This paper draws on ethnography of Peruvian peasant communities to discuss obstacles to community provision for severe mental disorders. Psychiatry must reckon with rival healers, ethnic divisions and resource-poor services, if it is to fill the 'treatment gap' between urban and rural mentally ill.

Paper long abstract:

In recent years, the 'global mental health' (GMH) movement has provided an impetus towards the scale-up of mental health care provision in developing countries, based on evidence-based practice. The tenets of the programme have not gone unchallenged, with criticisms of its tendencies towards medicalisation and question marks over its cross-cultural efficacy. Even some of GMH's harshest critics, however, have largely accepted the value of its input for disorders such as psychosis (Summerfield 2008). Yet even its proponents accept that the evidence base for the implementation of interventions with marginalised, rural populations is sparse.

This paper draws on ethnographic research in the peasant communities of a southern Peruvian province to discuss the possibilities and obstacles that confront efforts to extend the provision of services for severe mental disorders to this historically neglected population. Although psychiatric input is now available, it must compete with traditional healers and the evangelical churches for the loyalties of its patients, and deal with the legacy of historic tensions between health services and the largely indigenous residents. Patients often do not persist with it and it is by no means dominant. The GMH 'package of care' for psychosis relies heavily on the input of family, community figures and primary health workers for referral and monitoring; based on the Peruvian context, I explore how psychiatry will need to approach such social environments if it is to successfully fill the 'treatment gap' between the urban and rural mentally ill.

Paper short abstract:

This paper considers the different concepts of culture and inclusion that are increasingly shaping mental health policy and practice in the UK and Sri Lanka.

Paper long abstract:

This paper considers the different concepts of culture and inclusion that are increasingly shaping mental health policy and practice in the UK and Sri Lanka. Drawing from ethnographic research conducted in mental health policy and practice settings in both countries, the paper argues that 'culture' is similarly recognised in both contexts as being of fundamental importance for the provision of inclusive mental health services, although in very different ways. In the UK the legacy of social movements around race, gender, and disability and the legislation that sprang from them - in particular the Public Sector Equality Duties and 2010 Equality Act - has led to a drive to 'multiculturalise' mental health services. A crucial part of this is considered to be responding to the 'cultural differences and needs' of patients with 'diverse profiles' for the development of effective mental health interventions. In Sri Lanka, by contrast, 'cultural difference' is cited by many international and local NGOs, policy makers, and mental health practitioners as being the reason for the slow take-up of mental health services in the country. Because of 'culture,' it is often argued, Sri Lankan's don't recognise they are suffering from mental health problems and so go untreated. The paper concludes by arguing that these local variations in culture and inclusion concepts can be understood as forming part of broader processes of globalisation and localisation within which mental health systems in the UK are 'demedicalising' while in Sri Lanka they are 'medicalising.'

Paper short abstract:

Motivated Ethnography as a methodology to support case study exploring the realities of community mental health services within a rural South African Community in the era of Global mental health.

Paper long abstract:

The movement for global mental health's (Patel et al., 2011) continued efforts to scale up availability of mental health services has met with moderate successes. Investigations have pointed towards the value of task shifting, integrated services, and multi-disciplinary collaborations to support the mental health needs of underserved communities in many African contexts (Kasuma et al., 2011). However, there a need to evaluate how these very different approaches play out within the spaces demarcated by policy, material limitations, and symbolic and spatial complexities. Arguably, the realities through which policy and service delivery processes are lived are best viewed through ethnographic approaches (Lewis and Mosse, 2005) which remain underutilized within mental health research. This paper reports on findings from a case study of rural community mental health services in South Africa, which employed a motivated ethnographic approach (Duveen & Lloyd, 1993) in order to explore the lived realities of policy aligned with global movement recommendations for task shifting and multi-disciplinary integrated services for mental health at a district hospital. Findings indicate that the policy itself remains the primary barrier to effective service delivery, based on contingencies that are impossible to meet within the contexts of rural poverty stricken communities. Implications for future policy recommendations are discussed.