Interviews from the frontline: global mental health

Dr Ross White is Reader in Clinical Psychology at the Institute of Psychology, Health and Society, University of Liverpool. He investigates the role that socio-cultural factors play in the manifestation of mental health difficulties, and explores how psychological interventions can be adapted to accommodate cultural beliefs and practices. He is a co-investigator on the Arts and Humanities Research Council funded project ‘Researching multilingually at the borders of language, the body, law and the state’, and co-editor of The Palgrave Handbook of Sociocultural Perspectives in Global Mental Health. He is also a co-investigator in a research project being completed with the WHO and UNHCR investigating the efficacy of psychological interventions in the context and/or aftermath of humanitarian crises. He is a former Director of the MSc Global Mental Health programme at the University of Glasgow.

Psychiatry – the study and treatment of mental disorders – first developed as a specialty in the early 19th Century. As specialists began to travel further afield, questions arose regarding the universality of psychiatric diagnoses. The first worldwide-scale epidemiological studies of schizophrenia were spearheaded by the WHO in the 1960s, and over the course of the 20th Century, transcultural psychiatry found its place amongst psychiatrists and anthropologists working transnationally.

Mental health disorders have long been under-prioritised on the global health agenda. The WHO put out a call to action by launching the Mental Health Gap programme (mhGAP) in 2008; contemporaneously, The Lancet commissioned its first series on Global Mental Health in 2007, and its second in 2011.

We speak to Dr. Ross White, who works at the intersection of these issues. He is Co-Editor of The Palgrave Handbook of Sociocultural Perspectives in Global Mental Health; published earlier this year, the book comprehensively compiles contemporary research – from diagnostic classifications and psychopharmaceuticals, to the medicalisation and globalisation of mental health illness, to modern case-studies from Africa, Latin America, the Caribbean, Australasia, South and Southeast Asia.

Why is retaining a global perspective important to our understanding of mental health?

Over time, certain models for understanding mental health difficulties have risen to the fore in the West. For example, the ‘biopsychosocial model’ provides scope for understanding the dynamic way in which psychological, social and biological factors can interact to give rise to mental health problems.

However, this model may not be as familiar or meaningful to people in other parts of the world. Over 80% of the global population live in low- and middle-income countries, where commonly held explanations for mental health problems can vary markedly from the West. Furthermore, services (as recognised in the West) tend to be largely absent, under-resourced and/or understaffed in these settings.

Global Mental Health (GMH) as an area of practice, research and study provides a meeting space for diverse disciplines such as psychology, psychiatry, sociology, and anthropology to engage constructively with each other. In being concerned with inequities in mental health provision across the globe, GMH provides important opportunities to work collaboratively with local stakeholders to generate innovative, pragmatic, and culturally sensitive approaches to boosting mental health and wellbeing.

GMH also has much to offer mental health services in high-income countries where there is a need to critically reflect on the potential limitations of hegemonic positions, and to do more to support the needs of underserved populations e.g. minority ethnic groups.

What were the challenges in drawing together the perspectives contained within the handbook? 

As well as wishing to include the perspectives of psychologists, psychiatrists, and allied health professionals, we wanted to include perspectives from the fields of humanities e.g. history, geography, philosophy and anthropology. This is consistent with a recognition that understanding about distress has evolved according to time, place, societal influences and epistemic perspectives – so the humanities are central to GMH. To date, however, these disciplines have not been well represented in GMH texts. We are grateful that so many contributors were willing to be involved.

We made a concerted effort to involve people from the Global South and people with a lived experience of mental health problems. Thankfully the majority of the people we asked were able to commit to making a contribution. However, there were inevitably exceptions to this – circumstances prevented some of those who were keen to be involved from doing so.

The category fallacy is “the reification of one culture’s diagnostic categories and their projection onto patients in another culture, where those categories lack coherence and their validity has not been established.” – Kleinman, 1988.

What were some of the greatest insights, or take-home messages, for you throughout this process? 

A key point that we hope is conveyed in the handbook is that GMH is not a monolithic, homogenous enterprise. It encompasses a diverse range of activities relating to the development, evaluation, and implementation of interventions, assessments, policies and legislative measures relating to mental health and wellbeing. As such, GMH should not be seen as the globalisation of particular kinds of services; rather, it provides opportunities to critically reflect on the merits and demerits of different kinds of services.

The importance of recognising the biases that can be intrinsic to disciplinary training, and adopting a sensitivity to the local cultural and linguistic contexts, are also emphasised as central considerations for GMH endeavours. Taking heed of these considerations will help to reduce potential power imbalances, maximise the relevance of the work and ensure optimal engagement from local stakeholders who are expertly placed to highlight issues that need to be prioritised.

What first drew you to this field of research?

I have always been fascinated by the way in which understanding about mental health is shaped by societal attitudes, cultural beliefs and cultural practices. The way in which social theorists, such as Michel Foucault, highlighted the political and social justice ramifications of how definitions of mental health/illness are deployed made an indelible impression on me during my training as a Clinical Psychologist at the University of Glasgow. Prior to that, when I studied undergraduate psychology at Queen’s University of Belfast, I had completed two modules in Anthropology and this really whetted my appetite for learning more about the contribution that diverse disciplinary fields can make to understanding mental health.

As a qualified Clinical Psychologist wishing to develop a clinical-academic career, I was keen to engage in international mental health work. This led me to take up opportunities to collaborate with academic partners and NGOs in sub-Saharan Africa. I subsequently established the MSc Global Mental Health programme at the University of Glasgow.

GMH has provided me with invaluable opportunities to broaden my understanding of determinants of mental health, and to develop enriching collaborations with people from diverse countries and disciplinary backgrounds. It’s been a fascinating journey, and we hope that the handbook goes some way to helping others who are progressing GMH-related journeys of their own.

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