Anda di halaman 1dari 7

Globalising mental health: a neo-liberal project

Sami Timimi

Sami Timimi is based at the Lincolnshire Partnership NHS Trust and University of Lincoln, Lincoln, UK.

Abstract Purpose The papers aim is to review how relevant the World Health Organisations Mental Health Gap Action Programme (mhGAP) initiative is to mental health care in non-Western societies. Design/methodology/approach The paper provides a review of the programme and its relevance to mental health care by drawing on available literature and evidence. Findings mhGAP promotes the idea that mental health problems exist as problems within individuals, that they represent a substantial, though largely hidden, proportion of the worlds overall disease burden, and that mental health services need scaling up across the globe to improve outcomes. However, mental health outcomes do not appear any better in those countries with the most developed services and the initiative does not seem to properly engage an evidence base that is at odds with the direction of travel the initiative recommends. Originality/value The paper explores these contradictions and argues that, whether intentional or not, mhGAP reects and is part of the global neo-liberal economic system and functions largely to expand the market for a particularly Western approach to understanding mental distress. Keywords Mental health, Mental illness, Psychiatry, Globalization, Neo-liberalism, Classication, Outcomes, Health services Paper type Literature review

The World Health Organisations (2010) Mental Health Gap Action Programme (mhGAP) initiative, uses a paradigm that holds fast to the idea that a fundamentally positivist technical and biomedical framework is the most appropriate starting point for promoting mental health care around the globe. This assumes a universalist and essentialist position in its understanding of and responses to the problems of personal distress, mental suffering and behavioural deviance. By universal I mean that the categories and assumptions that construct them are considered appropriate regardless of context (such as culture). This is a model imported from biomedicine, thus the category depression is assumed to describe an experience/condition that occurs in all societies, which at its core is the same thing. Thus, a blood pressure of 150/90 reects a similar physiology whether it is found in a middle class businessman in London or a rural farmer in Kashmir. In the same way at its core depression is then conceived as the same condition that can afict a middle class business in London or rural farmer in Kashmir. In this model culture can inuence the content (for example different beliefs about where to put the cut off for high blood pressure, or a greater emphasis on somatic symptoms to express low mood) but there is common form, meaning depression corresponds to same thing at its core whether it is the businessman in London expressing guilt and remorse or the rural farmer in Kashmir expressing chest pain and fatigue as the content. The essentialist position refers to the idea that the core syndrome will then have a similar course, prognosis and treatment response prole. In other words just as high blood pressure can lead to increase in likelihood of cerebrovascular accidents and will respond to the same groups of anti-hypertensive medication regardless of where you live and your cultural context, so will identifying depression mean that the person

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57

PAGE 154

ETHNICITY AND INEQUALITIES IN HEALTH AND SOCIAL CARE

VOL. 4 NO. 3 2012, pp. 154-160, Q Emerald Group Publishing Limited, ISSN 1757-0980 DOI 10.1108/17570981111249293

is at increased risk of prognostic events such as suicide and will respond to the same group of treatments (such as anti-depressants or Cognitive Behaviour Therapy). In addition to the mhGAP initiative assuming that current systems of understanding and classications are suitable for use across the globe, it also assumes that mental disorders represent a substantial, though largely hidden, proportion of the worlds overall disease burden, and that mental health services need scaling up to improve outcomes. These are all highly problematic notions that seem to have passed without any thorough debate or questioning of the possibility that each of these assumptions are valid and safe ones to make.

Classication
In particular, the above assumptions rely on a belief that the classicatory systems we use to understanding and plan treatments for mental distress/behavioural deviance is reliable and valid across the globe. However, the systems we use such as Diagnostic Statistical Manual (DSM) and the International Classication of Diseases (ICD) have yet to demonstrate that they are reliable and valid in those countries with the most developed mental health services (Timimi, 2011b, c). In the developing world the classicatory system is even more problematic (Summereld, 2008). Unlike other areas of public health, mental health in those societies with the most developed services appears to be the poorest. In such societies epidemics of psychiatric diagnoses (e.g. ADHD, autism, depression, bipolar disorder) have only emerged and become popularised in recent years. Whilst there are complex political, social and cultural reasons for this, they are in part based on new categories and ideas about personhood, and the nature of distress. Once it comes to the non-Western context, these ideas are not only problematic they may prove counter-productive. For example, Skultans (2007) describes the process by which Latvia came to start using the diagnosis of depression. The process involved translation of ICD system into Latvian and a series of conferences organised by pharmaceutical companies to educate doctors about, amongst other things, depression. As doctors started to use the diagnosis, a radical departure from the older language of (largely somatic) distress notably the concept of nervi familiar to doctors and the general public took place, with increasing use of the concept of depression. The shift from concepts of nervi to that of depression switched the focus inward to the personal and away from a connection to the wider social and political realities that the concept of nervi embodied. The author comments that the narrative structure of these new accounts of distress indicates that people have internalised the values of capitalist enterprise culture, and the responsibility for personal failure that goes with it. There are many other similar examples. In India Jain and Jadhav (2009) observed how ofcial community mental health services operate in isolation from communities and their everyday realities. The focus on the narrow biomedical interpretations of patients experience (that mhGAP if successful will promote) means that community mental health collapses down to prescribing a pill, with the voices of patients and the general public, and the connection their experiences may have to social and political realities, going missing from the discourse.

Outcomes
Unlike the rest of medicine, no overall improvement in long-term prognosis for those diagnosed with a mental disorder has been demonstrated in Europe and North America over the past century. Some studies indicate the opposite, that compared to the pre-psychopharmacology period there are more patients who have developed chronic conditions such as chronic schizophrenia than in the past (Whitaker, 2010). In addition, there is copious evidence that shows that outcomes for major mental illnesses in the non industrialised world, is consistently better than in the industrialised world and particularly amongst populations who have not had access to drug based treatments (Hopper et al., 2007; Whitaker, 2010). One often cited reason for exporting Western model psychiatry to the rest of the world is the belief that societies in the developing world stigmatise those who have mental health problems. A review of the evidence however, shows that stigma maybe more of a problem

58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114

VOL. 4 NO. 3 2012 ETHNICITY AND INEQUALITIES IN HEALTH AND SOCIAL CARE PAGE 155

for Western societies whose institutions support the mainstream medical model view of mental distress and behavioural deviance. For example, Read et al. (2006) carried out a comprehensive review of the literature on stigma and schizophrenia to assess whether the medical model schizophrenia is an illness like any other approach helps reduce prejudice towards those with the diagnosis. They found an increase in biological causal beliefs across Western countries in recent years, but also that biological attributions for psychosis were overwhelmingly associated with negative public attitudes. Some anthropological evidence supports that lower problems with stigma in the developing world may be part of the reason for better outcomes there. For example, the anthropologist Juli McGruder studied families of those diagnosed with schizophrenia in Zanzibar. McGruder found that far from being stigmatizing, belief in spirit possession states served certain useful functions. It allowed a variety of socially accepted interventions and ministrations that kept the ill person bound to the family and kinship group. In addition, this way of viewing mental distress allowed the person a cleaner bill of health when the illness went into remission. An ill individual enjoying a time of relative mental health could, at least temporarily, retake his or her responsibilities in the kinship group. Since the illness was seen as the work of outside forces, it was understood as an afiction for the sufferer but not as an identity inscribed through unalterable internal factors such as his or her genes (Watters, 2009). It would seem then that the evidence available thus far suggests that there may be more to learn for mental health practice in the developed world from practice in the developing one than vice versa. So why would the current mhGAP initiative adopt what appears to be an approach that ies in the face of the evidence?

Reecting the value system of the dominant culture


One important aspect of globalisation is the neo-colonial character of the way the world economy has become organised. This economic system has resulted in glaring inequalities between the economically developed and developing worlds. A more subtle impact of the neo-colonial nature of globalisation is the export of Western value systems to countries with value systems born out of different traditions. This can result in undermining the stability of some traditional beliefs and practices that may have served their communities well, at the same time as producing points of conict, antagonism and contradiction as the merits of different value systems clash (Ang, 1996). All too often these conicts are resolved in favour of the more powerful and inuential culture (i.e. that of the industrialized west). For example, the mental health model promoted by mhGAP focuses on the idea that mental health problems exist in individuals and expanding mental health services focussed on xing these problems at the level of the individual, is a desirable outcome. The idea of the individual as the locus of the self is a relatively recent Western invention and such a framework creates the psychological pre-conditions necessary for accepting the atomised social worlds that have been created. Yet, mental well-being seems closely connected to social and economic factors. Several international studies have concluded that more important than poverty per se is the degree of inequality. Thus, the greater the inequality (in economic and social resources) in any society, the poorer is the mental health of that society (Friedli, 2009; Pickett and Wilkinson, 2010). In this colonial model promoted by mhGAP, societies are viewed as becoming more literate about mental illness the more they adopt Western biomedical conceptions of diagnoses like depression, ADHD, and schizophrenia. Nested within this is a belief that modern, scientic approaches reveal the biological and psychological basis of psychic suffering and so provide a rational pathway to dispelling pre-scientic approaches that are often viewed as harmful superstitions. In the process of doing this, it is not only implied that those cultures that are slow to take up these ideas are therefore in some way backward, but also disease categories and ways of thinking about mental distress that were previously uncommon in many parts of the world are successfully exported. Thus, conditions like depression, post-traumatic stress disorder, and anorexia appear to be spreading across cultures, replacing indigenous ways of viewing and experiencing mental distress (Summereld, 2008; Watters, 2009). In addition to exporting these beliefs and values, Western drug companies see in such practice the potential to open up new and lucrative markets (Watters, 2009; Petryna et al., 2006).

115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171

PAGE 156 ETHNICITY AND INEQUALITIES IN HEALTH AND SOCIAL CARE VOL. 4 NO. 3 2012

It is no accident that forms of practice predicated on the assumption that mental distress is something that belongs to individuals emerged most prominently in those countries, that are the strongest advocates of the neo-liberal market system. Such societies are characterised by a consumer culture. As such the culture is driven by a social arrangement in which the buying and selling of goods and services is not only the predominant activity of everyday life, but is also an important arbiter of social organisation, signicance and control. Slater (1997, p. 101) has commented that today more of social life is produced in a thing-like form and this notion of a thing-like form ts well as a way of thinking about how diagnosis and professional practice in mental health often views mental distress and behavioural deviance. The resulting process, known as commodication, entails processes of abstraction that not only creates a thing, but, specically, a commoditised thing that can enter into the market. Thus, diagnostic categories relegate markers of individual differences to ones of lesser signicance and instead promote a more uniform and standardised type, which is easier to package, promote, and sell. As psychiatric diagnostic categories are built on a subjective basis and have as yet not been found to attach to any physical markers to support their existence as natural biologically congruent entities, they are ripe for exploitation as commodities. For example, childhood distress was once the remit of parents and families to deal with and in most parts of the world this remains the case. However, once this responsibility begins to migrate into being the remit of a professional class whose livelihood is based on an expertise in alleviating childhood distress and preventing behavioural deviance, and when this occurs in a free market context, then commodication is just around the corner. Once we have categorised states of emotional and behavioural deviance and these categories enter the market, they become the equivalent of brands. Each brand (such as ADHD, depression, autism, etc.) will develop a market including professionals (with expertise in the brand) and treatments (such as a particular medication or a particular form of therapy). Consumers (in this example) will be largely made of parents, who have come to be concerned that their child has a problem and that this problem is beyond their capability to resolve. However, it is not just parents, but layers of social pressures and cultural beliefs (in the shape of, for example, politicians, family practitioners, social workers, teachers, etc.) that play an important role directly as consumers for children under their authority or as consumer advocates encouraging parents to become consumers. These consumers now seek out a product (a diagnosis, an expert, a treatment) based on the information they receive (from advocates, media and a variety of marketing sources) in the hope that the product will offer a form of validation (of the struggles and anxieties being experiencing) and/or a sense of promise (having the product or brand such as a diagnosis will lead to an improvement in their life). Like all commodities the appeal is more at the emotional/desire level than the rational one (Timimi, 2011a). Once this system is set in motion we can predict a number of things will happen. Commodities tend to give only temporary experiences of satisfaction as markets must keep selling to keep the monetary ow going and so must keep convincing consumers that there is a better brand waiting for them. In other words, once an area of life has been subject to market commodication, we should predict that the market will grow in volume as new products and competitors enter the fray. Thus, the number of available psychiatric diagnostic categories has continued to expand, both in the ofcial manuals and in everyday practice. Not only do new categories emerge but so do new subcategories, number of professionals providing services, the number of professionals with specialisations and sub-specialisations, the number of treatment models (for example we have well over 400 systematised models of psychotherapy), and so on (Double, 2002). There is now a bewildering array of commodities out there for the distressed to try and access. Yet, unlike the rest of medicine where diagnostic categories have largely developed around an aetiological basis and where treatments have demonstrated sustained improvements in outcomes for patients, there is little encouraging news for long-term mental health outcomes and some potentially discouraging ones (Whitaker, 2010). Like any market there are periods of over-consumption resulting in cutbacks and a pruning off of some competitors. Likewise commodities can be subject to the changing whims of the producers and consumers as certain products go in and out of fashion (such as autism is the new ADHD). However, as a relatively young market the globalisation of this McDonalisation of mental health has only just started. The owners of these new products

172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228

VOL. 4 NO. 3 2012 ETHNICITY AND INEQUALITIES IN HEALTH AND SOCIAL CARE PAGE 157

(largely institutional psychiatry and psychology based in the West and in partnership with the nancial and marketing prowess of the Pharmaceutical industry) are only just beginning the mass export and globalisation of this market and all the ideological implications this contains (Timimi, 2010, 2011a). Viewed through the prism of the political and economic context that drives what counts as knowledge, common sense and important values, the mhGAP initiative is part of a Western colonial project to export a set of values embedded in neo-liberal thinking, which will expand into new markets, increase prots and exploit social and human rights issues by turning them into personal ones that can be commodied.

Conclusion
Imposing Western medical model style psychiatry that mhGAP proposes on non-Western populations risks a number of things including: adoption of Western psychiatric notions of psychopathology to express mental distress, undermining of existing cultural strategies for dealing with distress, exploitation of social injustice, and the imposition of an individualistic approach that may marginalise family and community resources and divert attention from issues better framed in human rights terms. Before exporting current models around the world, more work is needed to ascertain the ways psychopathology is dened in various cultures (Hoagwood and Jensen, 1997), including cultural variations in symptom expression and phenomenology (Manson et al., 1997). Despite its acknowledgment of cultures role in psychopathology, the nosological systems that mhGAP relies on conceptualizes mental disorder as residing mainly in the individual. Such a nosological system itself emerged from an epistemology that is culturally constituted. Although emotive images of unacceptable practice in developing countries are often used, such as pictures of persons deprived of their liberty by being tied to a tree or whatnot, we should remember that mental health systems in the West have institutionalised deprivation of liberty through legal means and that mental hospitals often use restraint and rapid tranquilisation, sometimes with fatal consequences hardly evidence of a more humane system. Whatever part of conditions such as schizophrenia, depression or ADHD is biological (all behaviour ultimately derives from a biological substrate), how we construct meaning out of this is a cultural process. The lack of engagement with alternative perspectives from non-Western traditions reect a rather hidden form of institutionalized racism (or more accurately, institutionalized cultural hegemony) that has infected Western academic and political endeavours for several centuries. Not only does this present a real danger to the traditions and knowledge bases in existence in the non-Western world, but it also means that populations of the Western world are being denied the opportunity to benet from the positive effects that giving serious consideration to non-Western knowledge, values and practices may bring. The mhGAP initiative does have some indications of moving in a direction that acknowledges that mental health and social justice are intertwined, however, while it remains wedded to a biomedical paradigm, it will remain tied to a neo-liberal agenda.

Implications for treatment

Ascertain the ways psychopathology is dened in various cultures, including cultural variations in symptom expression and phenomenology, before exporting models to global contexts. Recognise that consent differs across cultures. Mental health systems in the west have institutionalised deprivation of liberty through legal means, with hospitals often using restraint and rapid tranquilisation, sometimes with fatal consequences. Engage alternative perspectives from non-Western traditions in mental health and models of illness. Incorporate existing cultural resiliencies to, and indigenous knowledge about, mental and emotional distress in Western-based models of treatment.

229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285

PAGE 158 ETHNICITY AND INEQUALITIES IN HEALTH AND SOCIAL CARE VOL. 4 NO. 3 2012

References
Ang, I. (1996), Living Room Wars, Routledge, London. Double, D. (2002), The limits of psychiatry, British Medical Journal, Vol. 324, pp. 900-4. Friedli, L. (2009), Mental Health, Resilience and Inequalities: How Individuals and Communities are Affected, World Health Organisation, Copenhagen. Hoagwood, K. and Jensen, P. (1997), Developmental psychopathology and the notion of culture, Applied Developmental Science, Vol. 1, pp. 108-12. Hopper, K., Harrison, G., Janka, A. and Sartorius, N. (Eds) (2007), Recovery from Schizophrenia: An International Perspective, Oxford University Press, Oxford. Jain, S. and Jadhav, S. (2009), Pills that swallow policy: clinical ethnography of a community mental health programme in India, Transcultural Psychiatry, Vol. 46, pp. 60-85. Manson, S.M., Bechtold, D.W., Novins, D.K. and Beals, J. (1997), Assessing psychopathology in American Indian and Alaska Native children and adolescents, Applied Developmental Science, Vol. 1, pp. 135-44. Petryna, A., Lakoff, A. and Kleinman, A. (Eds) (2006), Global Parmaceuticals: Ethics, Markets, Practices, Duke University Press, Durham. Pickett, K.E. and Wilkinson, R.G. (2010), Inequality: an underacknowledged source of mental illness and distress, British Journal of Psychiatry, Vol. 197, pp. 426-8. Read, J., Haslam, N., Sayce, L. and Davies, E. (2006), Prejudice and schizophrenia: a review of the mental illness is an illness like any other approach, Acta Psychiatrica Scandinavica, Vol. 114, pp. 303-18. Skultans, V. (2007), The appropriation of suffering: psychiatric practice in the post-soviet clinic, Theory, Culture & Society, Vol. 24, pp. 27-48. Slater, D. (1997), Consumer Culture and Modernity, Polity Press, Cambridge. Summereld, D. (2008), How scientically valid is the knowledge base of global mental health?, British Medical Journal, Vol. 336, pp. 992-4. Timimi, S. (2010), The McDonaldization of childhood; childrens mental health in neo-liberal market cultures, Transcultural Psychiatry, Vol. 47, pp. 686-706. Timimi, S. (2011a), Childrens mental health in the era of globalisation: neo-liberalism, commodication, McDonaldisation, and the new challenges they pose, Mental Health/Book 2, InTech, Open Access. Timimi, S. (2011b), No more psychiatric labels interview, Human Givens Magazine, Vol. 18 No. 3, pp. 24-8. Timimi, S. (2011c), No more psychiatric labels, Youngminds Magazine, August, p. 14. Watters, E. (2009), Crazy Like Us: The Globalization of the American Psych, The Free Press, New York, NY. Whitaker, R. (2010), Anatomy of an Epidemic, Crown, New York, NY. WHO (2010), mhGAP Intervention Guide, World Health Organisation, Geneva.

Corresponding author
Sami Timimi can be contacted at: stimimi@talk21.com

To purchase reprints of this article please e-mail: reprints@emeraldinsight.com Or visit our web site for further details: www.emeraldinsight.com/reprints

286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342

VOL. 4 NO. 3 2012 ETHNICITY AND INEQUALITIES IN HEALTH AND SOCIAL CARE PAGE 159

Author Queries
JOB NUMBER: 149668 JOURNAL: EIHSC

Dear Author Please address all the numbered queries on this page which are clearly identied on the proof for your convenience. Thank you for your cooperation
No Query

343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399

PAGE 160 ETHNICITY AND INEQUALITIES IN HEALTH AND SOCIAL CARE VOL. 4 NO. 3 2012

Anda mungkin juga menyukai