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MAGic2015: Anthropology and Global Health: interrogating theory, policy and practice

Mental health and anthropology: local challenges to 'Global Mental Health'
Location JUB-G31
Date and Start Time 10 September, 2015 at 11:00
Sessions 3


  • Sumeet Jain (University of Edinburgh) email
  • Sushrut Jadhav (University College London) email
  • Claudia Lang (Ludwig-Maximilians-University, Munich) email

Mail All Convenors

Discussant David Mosse (SOAS) - tbc

Short Abstract

The 'global mental health' (GMH) agenda aims to improve access to mental health services in the 'global south'. Critics question the cross-cultural validity of the GMH 'evidence' base and the agenda's top-down nature. This panel considers the emergence of 'local mental health' alternatives to 'GMH'.

Long Abstract

The 'global mental health' (GMH) agenda has emerged as the major driver of north-south knowledge transfer in mental health. GMH aims to improve access to mental health services in the 'global south' and reduce inequalities in care. Two tenets underlie GMH: generation of scientific evidence and human rights discourse. Policy influence derives from assembling 'evidence' for mental health interventions and situating GMH within global health and development priorities. Medical anthropologists and cultural psychiatrists have questioned the cross-cultural applicability of the GMH 'evidence' base and the GMH agenda's top-down nature. They argue such interventions promote medicalization of distress and edit local voices, particularities and healing practices.

Medical anthropologists and culturally sensitive clinicians have argued for a bottom-up, radical approach: 'local mental health' (LMH). LMH studies of distress and well-being, mental health and healing practices, and flows of technologies and expertise challenge the basis of global interventions. This approach is thus well placed to critically consider relationships between locally rooted alternatives and GMH. This panel focusses on the emergence of conceptual, policy and programmatic 'local mental health' alternatives to 'global mental health'. The panel will address questions such as: What alternatives to GMH have been effectively applied? How are LMH ideas appropriated and re-shaped by GMH practice & reverse? How might local conceptions of distress, well-being and healing be incorporated into mental health policy and practice? How are psychiatric nosologies constructed, appropriated, translated and resisted? How could voices and concerns of socially excluded groups shape mental health policy and practice?

This panel is closed to new paper proposals.


Madness in India: Society, State and mental health care

Authors: Sanjeev Jain (National Institute of Mental Health and Neurosciences)  email
Alok Sarin (Sitaram Bhartia Institute of Science and Research)  email

Short Abstract

An understanding of contemporary social factors, the history of development of health services, and the engagement with the people it serves, is necessary to inform the discourse on mental health policy planning. Adequate attention does not seem to have been paid to these factors in the discussions and plans regarding mental health care in India

Long Abstract

The development of mental health services India, shows a marked focus on biomedical model, and relatively less attention to social determinants of mental health. Social factors have not been adequately incorporated into ideas about mental health. Adapting bio-medical models to diverse social settings, may be one reason for the disparate, and often, chaotic service delivery.

We try to incorporate a historical perspective on the trajectories that mental health care and service delivery have undergone, in India, starting from the mental hospital system created during the colonial period, to the WHO influenced positions in the post-Independence period, and the paradigm shifts that have accompanied this. The emphasis on mental hospitals in 19th century, and on de-centralized community care in the 20th century, in India, both mirrored developments in Europe and North America. Their utility in the south Asian context was often questioned, but the tension between developing care systems that were compatible with global standards, as well as locally relevant, persists. Psychiatric services in societies undergoing rapid social and economic transition often have to make uneasy compromises between the need and provisioning for care, human rights issues, as well as ensuring that health care remains inclusive and accessible to all segments.

The on-going debates about the nature of the models, whether they should be specialist driven, public or private, whether they should be based in the primary health system, how ‘local’ and how ‘global’ they should be, are some of the ideas that we would like to explore in this presentation.

Towards a diversified evidence base for global mental health: cultural adaptation of community mental health interventions in Pune, India

Authors: Sumeet Jain (University of Edinburgh)  email
Bhargavi Davar (Bapu Trust for Research on Mind & Discourse)  email

Short Abstract

An inclusive global mental health ‘evidence-base’ must consider how programmes adapt interventions to local context. This paper examines the processes through which the Seher community mental health programme (Pune, India) has innovated to adapt interventions to the cultural context of local communities.

Long Abstract

Critics argue that the emphasis within global mental health (GMH) on standardized evidence-based 'packages of care' developed in Euro-American contexts supplants local innovations and capacities. A more inclusive GMH 'evidence-base' must consider how programmes in the 'global south' adapt interventions to local context. The aim of this paper is to examine the processes through which the Seher community mental health programme (Pune, India) has innovated to adapt interventions to the cultural context of low-income communities. Between 2004 and 2014, the programme shifted orientation from mental health services to building the capacities of communities to address mental health issues. We argue that the successful cultural adaptation of Seher interventions was premised on shifts in programme design and organizational culture. Programme design encompassed cultural ways of expressing psychosocial distress and illness and enabled support for a range of differentiated roles including mental health experts, formal grassroots workers and community volunteers, thus reducing dependence on 'experts'. Organizational culture was re-oriented to allow changes in programme content based on feedback from grassroots workers and communities. The Seher experiences suggest the importance of a dialogical flow of knowledge, competencies and skills between 'communities' and 'experts' as central to building a culturally inclusive GMH evidence base.

Screening for Dementia: Fluidity and the Mini Mental State Examination in India

Author: Bianca Brijnath (Monash University)  email

Short Abstract

Using the concept of ‘fluidity’ from Science and Technology Studies, this paper analyses the cultural and contextual fluidity of the Mini Mental State Examination (MMSE) in screening for dementia in urban India.

Long Abstract

The Mini Mental State Examination (MMSE) is a popular screening instrument for dementia. Drawing on ethnographic data from India, three vignettes are presented to examine how the MMSE is operationalised by interviewers and respondents. Using the concept of 'fluidity' from Science and Technology Studies, it will be demonstrated that the MMSE is fluid and changes according to individual norms, institutional resources, and cultural settings. In some environments, the scores are discounted in order to count; in others, the scale is perceived as an invitation to talk; and finally, the MMSE can also operate as an entry-point to seek treatment for other psychological concerns. It will be argued that while within a GMH agenda, the so-called rigour and reliability of the MMSE is compromised, as a fluid object, the scale can become a contextually and culturally relevant tool that allows for extra-screening 'talk.' It is this talk that gives health professionals clues about cognition and impairment thus allowing them to make more evidence-informed decisions about treatment and management pathways.

The WHO Paradox and Mental Health Hybridity in Kerala, India

Author: Murphy Halliburton (Queens College, CUNY)  email

Short Abstract

This paper will examine the paradoxical relationship between research and policy on mental health at the WHO, and present a study of mental health programs in Kerala, India including a center that combines biomedical and ayurvedic treatments and a WHO program to expand the use of psychiatry.

Long Abstract

This paper will first examine a paradoxical relationship between research and policy on mental health at the World Health Organization (WHO). WHO research has found better mental health outcomes in India than any other place they have studied, and yet WHO programs try to "save" India from its mental health problems through psychiatric interventions, rather than learning what India is doing right. Despite India showing a better outcome in recovery from schizophrenia and related disorders than any country that has been studied, developed or developing, a variety of mental health specialists have declared that India has a "90% gap" between mental health needs and available treatment. This paper will examine the development of this paradox, and how discourses about the 90% gap are used. It will then consider the variety of local practices that may have contributed to India's success in recovery and present a case study of mental health programs in the state of Kerala, India, including a center that combines ayurvedic and biomedical mental health treatments and a WHO-sponsored program that is expanding the use of biomedical psychiatry in Kerala communities. This paper is based on fieldwork conducted in 2014 on recovery from schizophrenia in Kerala and includes an examination of the eclectic and hybrid practices of the state's numerous psychosocial rehabilitation centers. It will suggest what the WHO could learn from Kerala's experience treating psychopathology and how the WHO might productively work with rather than supplant the region's rich array of healing practices.

(Re-)Invented Ayurvedic psychiatry and Local Mental Health in Kerala

Author: Claudia Lang (Ludwig-Maximilians-University, Munich)  email

Short Abstract

The aim of this paper is to explore how the creation of Ayurvedic psychiatry engages GMH discourse in which mainstream psychiatry is hegemonic. This could contribute not only to a greater availability and accessibility but also to a greater diversity in the field of mental healthcare in Kerala.

Long Abstract

Mental healthcare in Kerala comprises not only mainstream psychiatry and various forms of religious healing but also Ayurvedic psychiatry. Although there have always been vaidyas who treated various forms of mental distress, the institutionalization of Ayurvedic psychiatry as an own discipline is a recent phenomenon. It is perceived to offer a less invasive, less debilitating alternative to mainstream psychiatry which is mainly criticized by patients and their families for its heavy side effects. The aim of this paper is to explore how the creation of this new branch of Ayurveda engages GMH discourse in which mainstream psychiatry is hegemonic. How are global psychiatric nosologies appropriated, translated and resisted in Ayurvedic psychiatry? How is scientific evidence construed? How do practitioners and students police and transgress boundaries to allopathy on the one hand and religious healing on the other? Moreover, how do practitioners engage and implement community psychiatry? What are the limitations?

The integration of Ayurvedic psychiatry as a culturally sensitive psychiatric theory and clinical services into local mental health schemes and policies might contribute, I argue, not only to a greater availability and accessibility of mental health experts in the state but also to a diversity of different forms of therapy, especially for common mental disorders, which would again improve outcomes for these disorders.

Strategies for assessing mental distress: Communication, idioms of distress, and local instrument development

Author: Bonnie Kaiser (Emory University)  email

Short Abstract

This paper explores how a local mental health agenda advances communication and measurement in mental health practice. Drawing on examples from Haiti, the paper describes development of culturally appropriate instruments and the identification of particularly local means of communicating distress.

Long Abstract

Of central concern to mental health practice is an understanding of how mental distress is experienced and communicated. Idioms of distress provide a powerful means of communicating distress in local worlds. This paper describes research in Haiti's Central Plateau to identify idioms of distress that represent cultural syndromes, with a focus on the idiom of distress reflechi twòp (thinking too much). This syndrome is characterized by troubled rumination at the intersection of sadness, severe mental disorder, suicide, and social and structural hardship. Recognizing and understanding "thinking too much" may facilitate culturally appropriate recognition, communication, and intervention to reduce long-term psychosocial suffering. Beyond improving clinical communication, idioms of distress reflect broader social ills. Reflechi twòp is explicitly linked to socioeconomic realities that shape life possibilities, suggesting that considerations of structural violence are central to understanding this idiom.

Complementary to questions of communication are questions of measurement. The development of culturally appropriate mental health assessment instruments is a central concern for much anthropology of mental health work. Simple translation of questionnaires can produce misleading and inaccurate conclusions. Multiple alternate approaches have been proposed, and this paper describes two approaches in rural Haiti. First, ethnographic data collection was employed to develop new instruments: the Kreyòl Distress Idioms and Kreyòl Function Assessment scales. In tandem, an established transcultural translation process was used to develop Haitian Kreyòl versions of the Beck Depression Inventory and Beck Anxiety Inventory. Without these efforts, screening would have captured a combination of atypical suffering, everyday phenomena, and potential psychotic symptoms.

"How I floated on gentle webs of being": African psychiatrists' stories about the mental health treatment gap on the continent

Author: Sara Cooper (London School of Hygiene and Tropical Medicine)  email

Short Abstract

This paper explores the stories 28 African psychiatrists told about the mental health 'treatment gap'. Despite the dominance of a biomedical paradigm, there were cracks in this master narrative which offer important alternative insights into mental health care provision in Africa.

Long Abstract

A key focus of the movement for 'global mental health' has been on highlighting the high levels of untreated mental illness in Africa and making proposals for reducing this 'gap'. This movement has been criticised for insufficiently attending to the epistemologies embedded in its recommendations, and inadequately considering the views of practitioners 'on the ground'. Employing a narrative-based approach, I accessed the practice-based stories about the 'gap' in treatment amongst 28 psychiatrists working at the rock-face of public mental health care provision in four African countries: South Africa, Uganda, Nigeria and Ethiopia. Dominant thinking amongst these psychiatrists was heavily informed by a medico-scientific paradigm, one which is based upon many questionable assumptions, binary oppositions and Eurocentric tendencies. There were, however, cracks within this master narrative, which crystalised in the stories that were told by three particular psychiatrists. Their narratives operated within an alternative paradigm, one which I argue is informed by the tradition of phenomenology, and particularly the ideas associated with French philosopher Merleau-Ponty. Focusing primarily on the ethical and hermeneutic aspects of their work, these three psychiatrists' stories revealed the complexities around understanding and responding to the hierarchies of values and socio-cultural systems that shape the nature of their patients' suffering and associated behaviours. Here the notion of uncertainty emerged as a key conceptual resource. This more marginalised way of knowing may offer important conceptual and practical insights into enhancing mental health care in Africa in ways very different from those created by current seats of power.

Global Mental Health: The importance of contextual sensitivity and appropriate methodologies

Authors: Ross White (University of Glasgow)  email
Richard Fay (The University of Manchester)  email
Okalo Ponsiano (Center For Victim of Torture)  email
Rosco Kasujja (Makerere University)  email

Short Abstract

Drawing on research seeking to develop culturally appropriate psychosocial interventions for Lango-speaking people in Uganda, this paper problematizes the dichotomy drawn between ‘Global’ and ‘Local’ perspectives. Lango descriptions of distress highlight the complex reality that exists on the ground.

Long Abstract

The Universalist approach to addressing mental health difficulties across the globe has been critiqued for discounting the potential impact that the diverse beliefs and practices of people living in different cultural contexts have on people's experience of distress. Such critiques have suggested that scaling-up 'evidence-based' biomedical interventions may serve to undermine or extinguish local forms of support. Conversely, Conservationist arguments that adopt a dioramic and essentialised approach to 'culture' can be critiqued on the basis that syncretization occurs between and within cultures; the local is situated within the global and the global permeates the local. Whilst acknowledging the stark inequities in knowledge exchange that are evident between high-, middle- and low-income countries, this paper questions the extent to which these critiques capture the heterogeneous nature of Global Mental Health (GMH) initiatives. The paper draws on research conducted in Northern Uganda as part of an interdisciplinary project funded by the Arts and Humanities Research Council entitled: 'Researching Multilingually at the Borders of Language, the Body, Law and the State'. The paper explores Lango-language descriptions of problems experienced by people living in the Lira district of Uganda, and the local advice that is given to address these problems. The paper argues that GMH as an endeavour should not be constrained by either the Universalist or Conservationist approaches, but should instead promote the need for globally-minded practitioners who adopt context-sensitive perspectives in pursuit of appropriate methodologies for GMH. The importance of conducting interdisciplinary research into the languaging of distress is also highlighted.

The global mindset of development: the mental health-poverty nexus through a lens of psychiatrization

Author: China Mills (University of Sheffield)  email

Short Abstract

Some say that mental health is an obstacle to development goals because of the relationship between mental health and poverty. Here it is imagined that improving mental health will help to reduce poverty. However, this relationship may also be a sign of the psychiatrization of poverty.

Long Abstract

The concern that mental health is both absent within, and an obstacle to, development goals lies at the heart of current advocacy to mainstream mental health within the 2015 development agenda. This advocacy, driven by the Movement for Global Mental Health and the World Health Organization, hinges around the relationship between mental health and the economy, and specifically, the association between mental health and poverty.

While this relationship is often conceptualised as a vicious cycle, the focus tends to cluster in one direction - how improving mental health outcomes would improve economic outputs and reduce poverty. This means that the other half of the cycle - the mechanisms by which poverty eradication might improve mental health - remain under theorised. Hence social and economic transformation is imagined through individual transformation, thus allowing a discursive existence of social determinants of distress alongside largely individualised interventions. This paper will explore whether this, in part, can be understood as marking the psychiatrization of poverty - where the 'symptoms' of poverty are reconfigured (globally), by professionals and by the people who experience them, through psychological and psychiatric registers as 'symptoms' of mental disorders amenable to clinical, therapeutic and pharmaceutical intervention. Drawing upon fieldwork by the author in India, the tools and techniques of the global psychiatrization of poverty will be explored. Concern will be raised that this process may divert attention from; a) structural contributors to distress; b) the politics of psychiatric diagnosis; and c) the potentially detrimental effects of some development initiatives on (mental) wellbeing.

This panel is closed to new paper proposals.