AN INTERVIEW ON GLOBAL MENTAL HEALTH IN DEBATE AND RESEARCH

Dr Hanna Kienzler is Senior Lecturer in the Department of Global Health & Social Medicine at King’s College University, London. She is also an Associate Researcher at the Douglas Mental Health University Institute in Montreal, Canada. Dr Kienzler shares her experiences in both debate and research in Global Mental Health.


 

How did you first become interested in global mental health?

My interest in global mental health first developed through my work on trauma and local expressions of distress in different parts of the world. What I found fascinating was that the debates that shaped the beginning of the movement around global mental health had great similarities been those that had taken place with regards to trauma and Post-Traumatic Stress Disorder (PTSD) in the 1990s. At the time, scholars and interventionists had set out to validate PTSD as a universal and cross-culturally valid psychopathological response to traumatic distress, which, they believed, could be diagnosed using standardised instruments and ameliorated, even cured, by Western approaches to psychiatric treatment.

On the other end of the spectrum, scholars like Derek Summerfield famously argued that Western-style approaches to diagnosis and treatment only made sense in particular contexts and moral frameworks and, accordingly, become problematic in contexts where individuals and groups framed their distress in different, possibly non-compatible, ways.

This harsh debate led, over time, to compromise – researchers strived to incorporate both viewpoints by paying attention to expressions that appeared similar to PTSD as well as to local idioms of distress, which required local forms of healing and caring. Similar to the relativists, such scholars emphasised the importance of looking beyond trauma to understand its relation to other everyday stressors such as poverty, social exclusion, and various forms of social discrimination, all of which impact on people’s health and wellbeing. Miller and Rasmussen’s work on “War exposure, daily stressors, and mental health in conflict and post-conflict settings” was an important milestone in pushing the trauma narrative beyond itself.

So, how is this relevant to global mental health? At the beginning of the 21st Century, calls for contributions were made to what seemed to be a new field. It appeared that universal assumptions about mental health, their expressions, and approaches for treatment, were being reconstructed with a human rights perspective. The famous Lancet series, published in 2007, predicted that mental disorders would become the leading cause of the global disease burden in 2020. The WHO Mental Health Gap Action Program (mhGAP) pushed the cause for mental health further by aiming to scale-up services for mental, neurological and substance use disorders, particularly in low- and middle-income countries. At this moment, several scholars who used to be critical of the PTSD concept stepped forward highlighting, once again, that mental disorders are shaped by sociocultural contexts, beliefs, and values. Treatments claimed (but often insufficiently proven) to work in Western settings might have no traction elsewhere where suffering is deeply connected to inequities and extreme poverty.

Treating the causes of the causes with psychiatric medication seemed inappropriate and, to many, appeared to carry post-colonial connotations. Once again, debates became heated in publications and meetings. I attended one such meeting – a closed-door event to allow different fractions to voice their positions openly – at McGill University, and thus engaged in the discourse myself, with the guidance and support of my mentor and friend Duncan Pedersen. We started attending conferences and published together taking our own positions vis-à-vis the debate.

What remained striking and curious to me were the parallels to the earlier debates around trauma and PTSD. I think we have now entered a phase where opponents are attempting to soften their stances by combining universalism with relativism into some form of a dialogue. The new treatment modalities seem to reflect that psychosocial approaches appear – in theory – to outweigh medical ones. Doerte Bemme at McGill has conducted absolutely fascinating research in this area from an anthropological perspective and is revealing, through her ethnographic work, surprising findings related to what actually happens when theories and ideals are put into practice.

How are you involved with this topic currently?

I have decided to pull out of the debates, but try to remain involved at their margins. Instead of arguing for or against something, I went back to solid research investigating how global standards travel and change their shape or even content as they move from one locality to another. Indirectly, I am thus able to show that whatever is claimed to be “the gold standard” based on scientific evidence is actually not what ends up being implemented on the ground. Therefore, claims around validity and effectiveness need to be re-thought and replaced by a closer look at actual practices undertaken as well as their consequent outcomes.

For example, in the context of Kosovo and the occupied Palestinian territory, I have conducted research on new models of mental healthcare emerging at the intersection of global health agendas and mental health aid. More recently, I have been taking a critical look at Article 19 of the Convention on the Rights of Persons with Disabilities (CRPD) called “Living independently and being included in the community”. This research forms part of a larger Wellcome Trust funded project called “Mental Health and Justice” (PI on the project is Gareth Owen). With a team of researchers including Rita Giacaman, Ursula Read, Genevra Richardson, and Sridhar Venkatapuram, I use ethnography combined with legal and philosophical analysis to explore the diverse meanings, barriers and resources of what it means for persons with mental health problems to live in their respective communities, particularly in Palestine, Ghana and the UK. The research is participatory as we invite people with mental health problems  to collect, interpret and publish findings together with us as co-researchers.

So, rather than criticising a document like the CRPD for its universalistic tendencies, we want to understand how “community”, “support”, and “independence” are conceptualised in different sociocultural contexts, legal documents and normative philosophical debates, and how such conceptualisations affect the lives of people with mental health problems and their families. Through this work we will, in one way or another, contribute to global mental health discourses, especially due to our focus on barriers, resources, and rights. However, as I said, the goal is not to debunk universal arguments or to strengthen relativistic ones. Instead, we want to work with and hear from people with mental health problems to understand their lives and the change they would want to see. How this could fit with international standards is another and, of course, important question that we try to unpack carefully.

Considering depression is the leading cause of disability worldwide, do you think our society considers it as enough of a priority?

My gut reaction, informed by academic literature and news reports, would be to answer the question with ‘no’. No, because we are failing persons with mental health problems and other disabilities overall. However, it is not just individuals who discriminate and push persons with mental health problems to the margins, it is also the education and employment sectors, the National Health Service, urban planning… Additionally, increasing inequities and, related to this, poverty rates, have shown to wreak detrimental effects on our mental health, highlighting that the root of mental illness can often be found in societal structures and values which, in turn, calls for socio-political and economic rather than only medical interventions.

When I look toward the contexts within which I work – contexts of war and post-war, I would say that great attention is paid to mental health problems like depression, anxiety and PTSD. However, there exists hardly any research into what it means for persons with severe mental disorders to live through political insecurity and violence and flight and refuge. Humanitarian agencies, now often well-trained in psychological first aid, have little, if nothing, to offer to persons with severe mental health problems – illnesses that are chronic and require long-term and uninterrupted medical and psychosocial treatment and care.

This is a huge research and intervention gap in contexts of armed conflict. To challenge this situation, I am working in partnership with academics at Birzeit University in Palestine to develop a research capacity within academic and non-academic mental health institutions both here in the UK and Palestine to generate locally relevant evidence for access and barriers to mental health and social services, and available treatment options and their effectiveness, and help to improve support structures and specialist services. This research forms part of a larger international RCUK funded project called Research for Health in Conflict, led by Richard Sullivan that focuses on key and neglected areas: the political economy of health in conflict and cancer and mental health research in war-affected regions.

So, in a roundabout way: our society does not consider depression enough of a priority because it does not consider mental health and its social, economic and political determinants a priority.

Do you think mental health should be tackled with a collective global approach, rather than a country by country? 

I believe that it is crucial to think and act globally. We are in this together. However, this should certainly not translate into developing one-size-fits-all approaches to mental health system development, diagnosis, treatment and care. Scientific evidence is sometimes misguidedly direct toward this. Yet, I believe that it is crucial to understand that it is often less scientific evidence that shapes mental health reforms and outcomes, but rather, large-scale politics.

To give you an example connected to my work in Palestine: following the Second Intifada, the WHO was invited to conduct a situational analysis of the local mental health situation and, based on the findings, work with the Palestinian Ministry of Health and other actors to reform the overtly institution-based mental health system into a community-based one. Since then, mental health has yet to be completely integrated into primary healthcare, provide adequate support in the community for persons with mental health problems and their families and implement a mental health law. This is despite the fact that WHO proposed to follow an evidence-based approach.

The reasons for slow progress are inherently political. While there is certainly a lack of political will on the ground, the global community is just as responsible. A striking example is when mental health system reform processes came to a grinding halt in 2006. Why? The international community withdrew all direct financial support following the election of Hamas, which was identified as a terrorist organisation with whom the donor countries refused to formally interact. Consequently, the construction of the Community Mental Health Centres was suspended and mental health policy remained unfinished. This, in turn, made it impossible for mental health professionals to provide community-based mental health care.

The situation changed again in 2007, when Mahmoud Abbas formed a government in the West Bank. As a result of this political shift, the WHO could apply for funding from the EU to underwrite the implementation of the mental health policy. Funding was provided in two phases (2008–2011 and 2011–2015) which was not sufficient to fully integrate mental health into primary healthcare. This process is ongoing: mental health system development has turned into a patchy project which neglects difficult conversations about unequal power relations between donors and recipients, and practices of exclusion in the context of the Israeli occupation.

I hope that this example makes clear that something like mental health is not separate from large-scale politics, and that a global perspective will need to confront historical and current political agendas and power relationships if meaningful change is to be achieved. In the meantime, I suppose we have to rely on small projects and lots of goodwill, besides, of course, good scientific evidence.

What do you think the future looks like for global mental health?

I am heartened to see the move to bring experts together, including researchers, health professionals, and policy makers from low- and middle-income countries, to think of innovative and locally relevant ways to reform mental health systems. While part of me wants to applaud these attempts, another part of me continues to feel uncomfortable. The discomfort relates to the fact that mental health protagonists appear to actively flatten power hierarchies by maintaining a fictive ideal of equality in the face of very real inequities in people’s lives and working conditions.

This ideal is somewhat fictive on another level as well in that it hides the fact that donors continue to be located in high-income contexts and, through the dispensation of money, shape the research and intervention agenda in unequal ways giving experts from resource poorer countries less of an opportunity to determine the focus of mental health research. Attempts to make low- and middle-income country researchers primary applicants on grants without providing them with real decision-making power further masks unequal relations. For global mental health to be successful, these unequal power dynamics have to be addressed head-on – catchphrases such as “evidence-based”, “best practice”, “sustainability”, and “accountability” will not get us very far if they are de-coupled from these conversations.

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