Paper short abstract:

Current debates surrounding global mental health are noteworthy for what they neglect to take into account, i.e., the lived experience of mental illness, including psychopharmacology. I argue for an approach that can specify substantive domains of relevance in terms of “extraordinary conditions.”

Paper long abstract:

Mental health slogans are increasingly part of global health campaigns. Within the Global Mental Health Movement, "No health without mental health," serves as a battle cry for practitioners, researchers, and advocates. Rival camps take different tacks concerning that status of psychiatric knowledge and practices. I identify a curious concordance in the thinking of proponents of brain activity mapping, on the one hand, and critics of the global mental health movement, on the other. Current debates are particularly noteworthy for what they neglect to take into account, that is, the lived experience of persons afflicted by mental illness as well as their kin. This is of specific relevance in relation to psychopharmaceutical and psychosocial interventions. After sketching contemporary lines of thinking regarding global mental health, I suggest an anthropological approach in terms of what I am calling "extraordinary conditions." I argue that this approach can contribute to the goal of specifying substantive domains of knowledge and experience that are of critical relevance for the field of global mental health. In particular, these concern the ability to formulate the meaning of the extraordinary, the circumstances of precarity, and the ubiquity of struggle in the domains of experience and treatment of mental illness. I argue that this formulation is vital not only for the field of medical/psychiatric anthropology but is also indispensable for the nascent field global mental health.

Paper short abstract:

The paper explores practices of decision-making in India in response to experiences of a social crisis resulting from mental illness

Paper long abstract:

Changes in a person's behavior due to mental problems are often experienced by his or her family and friends as a crisis in social relationships. In the plural medical environment in India, people may draw on an array of ritual and psychiatric institutions of healing and care to alleviate suffering and solve the crisis. In the wake of economic liberalization in India, mental health care emerged as a major discursive concern of the state and NGOs. How do selves and families afflicted with emotional distress or severe mental disorder navigate the various therapeutic possibilities of seeking care? While anthropologists have explored health seeking behavior from various angles, the question of how and if patients and their families exercise choice is rarely considered. This paper explores networks of human and non-human agencies involved in social decision-making processes related to diverse institutional practices of mental health care.

Paper short abstract:

This paper explores some of the ambiguities between globalized and global health discourses on addiction.

Paper long abstract:

Since the seminal volume, Global Mental Heath (Oxford 1995), Global Health has accepted behavioral-based pathologies as significant contributors to excess morbidity and mortality rates in those areas of the world where it has worked. Amongst the most elusive of these behaviors to both confidently track (and in which to intelligently intervene) has been drug use and abuse. On the one hand, some countries most impacted by the classic killers in Global Health, such as Tanzania, now has recognized significant rates of indigenous IV drug-use that would have been seen as impossibly exotic only fifteen years ago. At the same time, since effective interventions into addiction in the global North have nowhere near the consensus as other psychiatric interventions, it has not been especially clear what to do about such use, despite the obvious implications for, say, HIV spread that IV drug-use poses. On the other hand, the discourse of drugs in the Global North has been globalized for decades, with consumers (never mind law enforcement agencies) knowing that local use is connected to primary producers as far afield as Afghanistan, South-East Asia, and South America and embedded in international production-distribution-consumption systems of almost breath-taking flexibility and complexity. Nonetheless, neither the use of illegal drugs nor off-label use of legal pharmaceuticals (which has also grown substantially worldwide during this same period) are typically discussed within the same frame. This piece reflects on these contradictions and offers some (tentative) ideas of how we might examine addiction as a truly global phenomenon.

Paper short abstract:

Any dialogue between global mental health and psychiatric anthropology will stall as long as "culture" is defined without psychopharmaceuticals

Paper long abstract:

Global Mental Health (as a set of public health interventions supported by the World Health Organization) and psychiatric anthropology (as ethnographies of psychiatric practices) seem to converge on the foundational role of "culture." Both would maintain that mental health needs to be assessed in culture-sensitive ways. They both assume that culture provides patients with an interpretive framework that shapes the experiences of mental distress as much as the expression of distress. They both agree that culture provides different thresholds of tolerance, and that what is pathological in one cultural setting could be seen as normal in another. At times, they even agree that biopsychiatric interventions are not necessarily the best treatments available, and that being embedded in a traditional cultural way of being can be positive for mental health. However, as I will argue here, this convergence works only as long as a truncated notion of "culture" is used. The moment that, for example, material artefacts are made part of the culture concept, the convergence seems to break down. The anthropology of psychopharmaceuticals, which has emerged over the past decade, seems to be especially troubling for classic culturalist approaches in both GMH and psychiatric anthropology. In this paper, I will show why the inclusion--or exclusion--of psychopharmaceuticals into approaches to psychiatry as practice is the key test for any proper dialogue between GMH and psychiatric anthropology.

Paper short abstract:

This paper will examine the role that anthropological understandings of human moral experience can play in understanding psychiatric distress.

Paper long abstract:

This paper will examine the role that anthropological understandings of human moral experience can play in understanding psychiatric distress. Moral anthropology has emerged recently as an important locus of debate, theory, and ethnographic research. This field's theoretical and ethnographic understanding of morality as cultural system, expressed in embodied existential experience, has direct and multi-faceted relevance for understanding psychiatric distress. The moral experience dimension of psychiatric distress runs through the illness experience: from its onset, through the ways illness experience transforms the relationship of sufferer and social surround, through the experience of treatment, recovery, cultural stigma and relapse. As part of this analysis, the paper will examine the way local moral worlds collide with the institutional values of globalized psychiatry. The paper will compare case material from the United States and Morocco. The case material demonstrates the use of person-centered ethnography as a specific method of clinical ethnography that can productively explore the dynamic interactions of moral experience and illness experience.

Paper short abstract:

This paper inquires into the idea of the Other as the subject of transcultural psychiatric intervention aimed at torturesurvivors living in Denmark. I elucidate the ambiguities underpinning therapeutic interventions, engaging with critical concepts such as empathy, suffering and other minds.

Paper long abstract:

This paper inquires into the idea of the Other when the Other is the subject of transcultural psychiatric intervention. Based on recent fieldwork in the field of transcultural psychiatry aimed at survivors of torture now living in Denmark my concern is to tease out ideas of the Other as someone in need of a particular, that is transcultural, rather than ordinary psychiatric intervention. What are the markers of the assumptions that therapists hold to be true, and different about the Other that is not like us. I thereby hope to get nearer to the assumptions about who the therapeutic Other can be said to be and what place such an Other takes up in the imagination of Danish therapists working in this field. The context for such an inquiry is a political climate in which the Danish state on the one hand thinks of itself as the empathic state per se and on the other hand tries actively to minimize the amount of refugees from primarily the Arab peninsular. Simultaneously Danish doctors, psychiatrists and psychologists have for many years spearheaded treatment and thinking about interventions to survivors of torture both in their current places of dwelling as well as in their countries of origin. I thereby hope to contribute to the field of Global Mental Health with a discussion of some of the political ambiguities underpinning therapeutic interventions to new citizens in Scandinavia whilst engaging with critical concepts such as empathy, otherness, suffering and other minds.

Paper short abstract:

Early psychosis is a new label for being mentally healthy and at the same time having a strong probability of developing psychosis.We explore the possibility for anthropologist to participate in the debates around this emerging liminal condition.

Paper long abstract:

Early psychosis is used today as a label for a condition of being mentally healthy and at the

same time having a strong probability of developing a severe mental illness. It represents a space of liminality or, as we call it, a "grey zone" between pathology and health, illness and non illness. We understand this grey zone of early psychosis as a constitutive third space which brings stability to dichotomies in contemporary psychiatric and social practices, while being itself fraught with practical uncertainties. This liminal condition seems a perfect place to bridge the clinical concearns of psychiatrists and the interpretative concearns of anthropologists.

This paper is based on ethnographic fieldwork in highly specialized psychiatry in France and Switzerland. It will explore the possibility for anthropologists to participate in debates between researchers, clinicains and patients in the debates around the enactment of this liminal condition.

Specifically, we explore the strength and weaknesses of the longstanding tradition of taking an "naive" or "idiotic" role during research compared to the affordances of explicitly engaging in full co-laboration with psychiatrists. The latter approach is more burdensome duing the inital steps of obtaining ethical approval and negotiaitons of the place of anthropology in the reseach project, moments when many projects fail already. The trust established during this phase may offer unique opportunities during later phases of reserach. Yet it also challenges the self-understanding and research ethics of the anthropologist.

Paper short abstract:

The paper uses the De Certau concepts of “strategy” and “tactics” to analyse how suffering people deal with the categories of mental problems and with those of spiritual troubles. From the point of view of the suffering they are tools in a tactical struggle to find their place in a social arena

Paper long abstract:

The paper is based on two different fieldworks carried on by the authors in Ethiopia and among the Ethiopian and Eritrean refugees belonging to Pentecostal churches in Rome. It aims to use the De Certau concepts of "strategy" and "tactics" to analyse how suffering people deal with the categories of mental problems, as they are conceived by biomedicine, and with those of spiritual troubles, as they are intended within the ORTHODOX CHURCH AND THE Pentecostal ones.

Both in Ethiopia and abroad, the experience of suffering could be labelled through the psychiatric categories or within a religious discourse.

The aim of the authors is not to counterpose the psychiatric discourse to religious ones. Rather they see both as speeches "strategically" built by those who have the power to designate the suffering as a problem, whether medical or religious.

The discourses and (self)-interpretations activate by the suffering people will be analysed as "tactical" behaviours in order to get what they consider is better to improve their situation.

If we focus on the experience of suffering people, then both the global health perspective and the religious ones can be seen in a different ways. If they are two different and competing discourses, from the point of view of the suffering people they are also tools in a tactical struggle to find their room and their place in a global social arena. It can shed a different light in the way of regarding global mental health from an anthropological point of view.

Paper short abstract:

This paper investigates the relationship between engagement in particular prayer practices and psychological wellbeing among members of a Catholic Charismatic intentional community in Rwanda.

Paper long abstract:

The impact of the 1994 Rwandan genocide and its aftermath on the mental health of both Tutsi and Hutu populations in Rwanda is considerable. Current reconstruction efforts by the state, however, do not provide the necessary institutional resources needed to address these growing mental health needs. Stepping into this gap are religious, and in particular charismatic and Pentecostal Christian communities and churches, who attempts to address adherents' mental health needs through various forms of religious healing and prayer. This paper investigates the relationship between engagement in particular prayer practices and psychological wellbeing among members of a Catholic Charismatic intentional community in Rwanda. Analysis is centered on identifying the different modalities in which God is encountered in the course of these practices, the affective articulation of these encounters, and how they translate into forms of social being-in-the-world, particularly in reference to adherents' psychological wellbeing. I draw on these materials to suggest that an appreciation for the manners in which religion and particular religious practices impact on psychological wellbeing and mental health, particularly in light of what some term the NGOization of religion, may serve to bridge the clinical concerns of global mental health and the interpretive concerns of psychiatric anthropology.

Paper short abstract:

Anthropology and psychiatry have a long relationship, and one of the places at which they overlap most significantly is in addressing religious phenomena in relation to mental health. This paper discusses how that relation is carried over into the developing field of global mental health.

Paper long abstract:

Anthropology and psychiatry have a long relationship, and one of the places at which they overlap most significantly is in addressing religious phenomena in relation to mental health. If anthropology leaves behind its concern with religious phenomena in order to participate in facilitate the global delivery of psychiatric services, and psychiatry is taken up with the urgency of its global clinical task to the detriment of its responsibility to understand and interpret mental illness, then the fruits of this relationship will be squandered. The treatment of religion in literature on global mental health can be taken as indicative of how the field treats the larger issue of meaning, and this in turn as indicative of the sensitivity of global mental health to the problems of experience and subjectivity. This paper discusses how the relation between anthropology and psychiatry is being reproduced and whether it is being enhanced by a global cross-cultural perspective in the developing field of global mental health.

Paper short abstract:

This paper analyzes the biopolitics of global mental health in terms of two categories: total nosology and total therapy. In this model human distress is managed less in terms of human needs than through a self-referential expert system.

Paper long abstract:

Global mental health (GMH) is a field that has emerged from the wave of new transnational agendas privileging knowledge based on supposed clinical and epidemiological evidence rather than gained from social "evidence" of suffering: that is, from subjective and local experiences and their uneven hybridization with the global metaculture to which GMH belongs. One of its frequent weaknesses is the treatment of human afflictions through a biopolitics organized in terms of two premises: total nosology and total therapy, which reproduce the forms and structures of total institutions in the wider space of a globalized world. Total nosology takes as its point of departure a definition of the patient self as a predetermined entity incompatible with the possibility of a subjective self formed through social action, including the professional cultures of mental health care. In this way, the damaged self is perceived as a psychopathological island, a stable and naturalized entity that responds to therapeutic interventions that are also stable and naturalized: total therapy. This model manages distress in terms of a self-referential expert system and its personified world of disorders and treatments more than in terms of human needs. Centered more on mental illness than on mental health, it is organized through treatment protocols rather than as the outcome of a clinical reflexivity that recognizes in affected persons knowledge born of experience, and is oriented more toward a politics of life than toward a politics for life.

Paper short abstract:

The notion of the 'credibility gap' has recently been invoked in Global Mental Health to explain why mental health specialists are not resorted to more frequently. This paper explores how well this concept applies within medically pluralist settings such as Peru, asking ‘What happens in the gap?’

Paper long abstract:

A recurring, indeed formulaic, device in the development of Global Mental Health (GMH) is the 'gap': the 'treatment gap,' gaps in research evidence, resource gaps between high- and low-income countries and populations, and more recently the 'credibility gap' (Patel 2014), postulated as the reason why many individuals and families do not seek help for mental disorders. Within the pragmatics of GMH, this device serves useful purposes; the identification of a 'gap' highlights an absence that invites filling. Yet this may be subtly misleading; for example, the 'treatment gap' is in fact - as a number of critics have pointed out - far from empty, only appearing as such because many, officially unacknowledged, forms of treatment are discounted.

Drawing on ethnographic fieldwork from highland Peru and relevant anthropological literature, this paper interrogates what is actually occurring in the space signaled by the notion of the credibility gap and related constructs within GMH. It explores the assumptions made about the reasoning, behaviors and affect of those whom GMH would serve, and where correspondences and mismatches seem to occur between social actors' perceptions of where the gaps lie. It is argued that the credibility gap potentially opens up space for more open and pluralist encounters within global mental health, yet may also act to delimit the boundaries within which these can occur. Equally, it is important to ask too what gaps other approaches and models might be harboring.

Patel, V. (2014) Rethinking mental health care: bridging the credibility gap, Intervention 12(S1): 15-20

Paper short abstract:

This paper delves into the fluid intertwining between psychiatric and indigenous medicine discourses and its effects on the trajectories of indigenous women who have experienced sexual violence (violent intergenerational incest) and are hospitalised at Bolivia’s National Psychiatric Hospital.

Paper long abstract:

Based on an ethnographic research, this paper focuses on the influence that ethnic, gender and class classification schemes have on the intertwining of psychiatric and indigenous discourses around the trajectories of indigenous and peasant women who have experienced sexual violence (specifically violent intergenerational incest) and are now hospitalised at the Chronic Unit of Bolivia's National Psychiatric Hospital. The definition of humanness is at the centre of such articulation, and is the locus that allows for the fluidity of exchanges between apparently distant worlds of meaning. Both in the communities of origin of the hospitalized women, and within the hospital, the production of the human is defined as the midpoint between poles of scarcity and excess of vital energies, as these are defined in each context. Giorgio Agamben's and Roberto Esposito's work concerning particular modes of defining humanness in different historical scenarios will be used to analyse, within psychiatric, judicial and community settings, what I describe as a continuum of forms of experiencing and delineating what to be human means. Humanness is never a definitive concept but is rather contested and adjusted in the intersection between collective practices and individual experiences within conflictive but interrelated contexts. Violence and power play a crucial role in determining the scope of any attempt to reproduce or change such definitions.

Paper short abstract:

The case study of the development of a local Tonga psychiatry, that drew on medical anthropology and transcultural psychiatry, provides a propitious case study to explore the biomedical imperialism vs cultural adaptation dialectic informing debate on Global Mental Health.

Paper long abstract:

The Global Mental Health (GMH) movement has revitalised questions of the translatability of psychiatric concepts and the challenges of community engagement in countries where knowledge of the biomedical basis for psychiatric diagnosis is limited or challenged by local cultural codes. In Tonga, the local psychiatrist Dr Puloka has successfully established a publically accessible psychiatry that has raised admission rates for serious mental illness and addressed some of the stigma attached to diagnosis. On the basis of historical analysis and ethnographic fieldwork with healers, doctors and patients since 1998, this paper offers an ethnographic contextualization of the development and reception of three key interventions during the 1990s that included collaboration with traditional healers and the formulation of hybrid terms. Dr Puloka's use of medical anthropological and transcultural psychiatry research, informed a community engaged brokerage between the implications of psychiatric nosologies and local needs. As such it reveals deficiencies in current polarised positions on the GMH project and offers suggestions to address current challenges of the Global Mental Health movement.