Book review:Decolonizing Global Mental Health: The Psychiatrization of the Majority World.by China MillsPublished by Routledge, London and New York. 2014178 pp.ISBN 978-1-84872-160-9 Softback – £24.99ISBN 978-1-84872-159-3 Hardback – £80.00
We are all familiar with the plague of pathologisation that has gripped the world over the last quarter of a century. Just about every nook and cranny of human experience has been redefined, commodified and re-branded, usually in the interests of the pharmaceutical industry. Teenagers and young adults are no longer shy, but suffering from avoidant personality disorder and thus in need of drugs, therapy, or both. The mood changes that have affected women during the course of the menstrual cycle for countless millennia have been transformed into premenstrual dysphoric disorder. We are no longer allowed to grieve for more than a few weeks without being diagnosed with major depressive disorder. The rise in diagnosis of ADHD in children and mild neurocognitive disorder has taken this trend to the limits of the human life cycle. Indeed, it is rapidly becoming clear that, for most of us in high income (HI) countries, not having a psychiatric diagnosis is a sign of abnormality. At the same time we should not be surprised to discover that this creeping ‘psychiatrisation’ is highly contagious, and is afflicting low and middle income countries (LAMIC). One of the main agents responsible for this is the Movement for Global Mental Health (MGMH).
This movement has set out a lofty agenda devoted to easing the suffering of people living in LAMI countries. Its objective is to ensure that people living in these countries have access to the best and most effective modern psychiatric drugs and therapies. In pursuing these objectives it assumes that to do so is a neutral project beyond political concerns. China Mills’s book Decolonizing Global Mental Health challenges this view. It locates Global Mental Health firmly within contemporary and historic global political and economic contexts. It does so in a variety of ways, for example by comparing the assumptions that underpin the movement with those of British Colonialism, particularly in India. She turns to several post-colonial writers, including Franz Fanon, Edward Said and Homi Bhabha. She examines articles written by those who are closely associated with the MGMH, and draws on her own experiences and field notes in which she interviewed survivors and service users in non-governmental organisations (NGOs) in India. She skillfully weaves these different strands together to produce a richly-textured book that moves effortlessly from past to present, and from India and Africa to Europe, and in doing so unpicks the tacit assumptions upon which the MGMH is built.
But what’s wrong with this movement, you may ask? Surely it’s a good thing that experts in higher income countries (HIC) should express concern about the mental health and well-being of those living in low and middle income countries (LAMIC), and try to do something about it. This raises the question what is to be done about it. The premise from which MGMH sets out is that conditions like depression and schizophrenia are biological disorders that are no different from HIV-AIDS or epilepsy, and people living in low- and middle-income countries have just as much right to access effective drug treatments for mental disorders as people in HIC. Setting to one side for the moment the evidence that drug treatments for psychiatric conditions are nowhere near as effective as is claimed, and the growing evidence that they are harmful, this is an appeal to the moral high ground based in an appeal to social justice.
This appeal is reinforced by the use of powerful and emotive images in the literature produced by MGMH, for example that of a naked child chained to a tree. The movement argues on rational and moral grounds that this is an unacceptable way to treat people afflicted by mental disorders. There are more humane forms of help. This makes it difficult to challenge and question the movement’s position. Beneficence is after all done for the best of intentions. Instead, China Mills asks what is the difference between the physical beatings given to mad people at a dargah (a Sufi shrine) or in Temple healing and ECT? Both may be experienced as violence. But because ECT has a ‘rational’ scientific explanation this is seen as different. It is justifiable. Seen in this light, global mental health is a civilising mission or at least that is how it sees itself. It is no different from the colonial work of Christian missionaries of an earlier era.
China Mills exposes the movement’s hidden political dimensions, revealing how a biomedical model of distress serves covert political agendas. In chapter two she draws attention to the increased incidence of depression and suicide in Indian farmers. The MGMH has responded to this vigorously via NGOs who buy antidepressants at reduced prices from pharmaceutical companies, followed by the offer of ‘free medication for life’. The problem here is that it locates the causes of depression in the brains of individual farmers. To see depression in this way is to disregard the political and economic contexts that the farmers struggle against. It ignores the consequences of global political and economic factors that have pushed down the price of cotton, making traditional farming methods uneconomic and unsustainable. Political problems demand political solutions, such as a collective response that would draw farmers together in solidarity to confront the external sources of their problems and to find ways around it. Treating individuals with drugs makes it much less likely that farmers will come together to challenge the status quo. It shifts the moral burden away from demands for cheaper products and higher profits in HIC, and instead sees depression as nothing more than a consequence of biology.
This is a book that has long been needed, and I found chapter seven to be the most powerful. She draws together themes from the earlier chapters in an attempt to answer the question; is it possible to ‘decolonize’ global mental health. She attaches particular importance to Fanon’s work and his attempts to work out how a critical psychiatry could be liberatory and anti-colonial. She concludes that it is possible but only if psychiatry engages fully with the socio-political and economic factors out of which distress and madness emerge, and how these factors oppress and subjugate all people, but especially those living in LAMICs. This is why for psychiatry to restrict itself to scientific models of distress is to fail utterly to engage with the political dimensions of madness. In this view critical psychiatry in practice has to be directed primarily at engaging with the implications of oppressive contexts upon people’s well-being. The failure of a psychiatry dominated by scientific models to engage with the social, political and economic contexts that give meaning to distress is a moral failure. When we buy a t-shirt for $6.97 from Wallmart we engage with a global system that exploits the weak and voiceless. China Mills’ view of critical psychiatry, a view greatly influenced by Franz Fanon, is that its practice must primarily be directed at tackling the oppressive contexts that have a negative impact on people’s well-being. This is a view I wholeheartedly support, and I strongly recommend her excellent book.
I think I have seen MGMH stuff,
“There are an estimated 20,000 people with severe mental illness shackled in their homes by their families.
An estimated 19 million people suffer from mental illness in Indonesia, yet because of a lack of services and basic public awareness, most people don’t get treatment.”
“Mental health problems range from severe conditions like schizophrenia to more common disorders such as depression and anxiety, all of which can lead to suicide if left untreated. ”
See how the pharmaceutical industry or “NAMI Indonesia” points to the estimated 20,000 people shackled in their homes by their families and uses that to declare the 19,000,000 people need treatment cause they are a “suicide risk” ?
20,000 turns into 19 million needing drugs, unbelievable.
As if the United States does any better, look at this:
Inside The USA’s Largest Mental Institution
“Walking into the “high observation” area, patients stare out through the glass walls of their cells, many nearly naked.
“They just don’t want to get dressed,” explains Deputy William Hong.
Across the way, about a dozen inmates are engaged in a “socialization” exercise. Some participants are chained to benches — “for civilian workers’ safety,” as Hong explains it. Others sit listlessly at tables, in long draping ponchos that deputies refer to as “suicide gowns.”
“They can’t rip it,” explains Hong. Clothes can prove dangerous tools to a depressed or paranoid inmate.
“They’ve tried to flush it down — clog the toilet, flood the area. Or they’ve tried to harm themselves,” he says. ”
I would rather by chained to a palm tree in Indonesia by my family then be in a plexi glass box or chained to a bench inside Americas largest torture chamber called “help”.
Thanks for your comments, which are right on the mark. As you imply, we have no right to criticise the way people in LAMI countries are treated when they experience madness and distress, when the care on offer in HI countries is so appalling.
Yes this is true. First world countries like Finland are turning out 80% full Recovery rates for ‘Schizophrenia’ through social methods and other European countries want the same – they are not interested in the scrap heaping of limited children.
This was meant to go under the tobacco industry comment, sorry. Fiachra
Thanks for this…nice to see Franz Fanon getting an outing as well…
Reading this review reminded me of a News Night segment screen not that long ago… a Muslim woman was swaddled in towels and was being read the Koran by an Imam…as a response to her mental distress…
Interestingly this approach to her distress was presented as problematic for UK mental health professionals and obviously shocking for “right thinking” civilized News Night viewers…
What they didn’t show was how western mental health professionals would prefer her to have been treated, instead of being read to out of the book of her own religion…obviously what you are supposed to do is get five or six men to hold her down, strip off her clothes and inject her with mind altering drugs….so modern…so so terribly modern…so terribly nice and civilized…
Agree fully. ‘Non-Western’ responses to illness and distress are so often portrayed as ‘primitive’ or barbaric, when the history of. Psychiatric treatments in the West, as Jo Moncrieff and Bob Whitaker and other have shown is just as, if not more barbaric.
China fights back,
Prosecutors have been eyeing pharma (and other industries) for violations of the Foreign Corrupt Practices Act (FCPA), and several drugmakers have paid millions of dollars to settle corruption probes. Though Glaxo is based in Britain, its shares are listed in the U.S., making it vulnerable to FCPA prosecution.
And now, Glaxo is a natural target. According to Chinese authorities, Glaxo’s employees funneled almost $490 million in bribes to scores of doctors, all in an effort to meet aggressive sales-growth targets. Because doctors are civil servants in China–technically, “government officials”–kickbacks to physicians could easily run afoul of the FCPA.
Read more: http://www.fiercepharma.com/story/glaxosmithklines-china-probe-triggers-us-bribery-investigation/2013-09-09
It’s all a dirty game to make billions drugging the world.
Many thanks for drawing this to my attention. I wasn’t aware of this. Indeed, the way pharma is pushing psychiatric drugs in LAMI countries is reminiscent of the way the tobacco industry has targeted these same countries as the ‘rich’ countries have restricted advertising for tobacco products, introduced public smoking bans, and made sales to young people illegal. It stinks.
None of these criminals in the USA ever do prison time, like in this case http://www.zyprexa-victims.com in China however things are different.
In 2007, China executed Zheng Xiaoyu, the former head of the country’s food and drug regulatory authority, after he was convicted of taking bribes to approve flawed medicine blamed for several deaths.
In America when the lawsuits roll in from the families of sick and dead patients, pharma simply uses a small portion of it’s windfall profits to settle out of court, admitting no guilt.
How many people went to jail for destroying the lives of children by pushing Risperdal on them off label ? ZERO of course.
Try that in China.
Way to go, China. But sorry to say, this may be what all the makers and prescribers of all the antipsychotics deserve.
Initially, since my only personal family history of possible “mental illness,” and it was not considered to be such by my family or doctors, was a grandmother who’d had a brief extremely adverse effect to Stelazine, and she’d been quickly taken off it. And she never had any other problems after being taken off it and lived happily to the age of 94.
When researching psychiatrists’ crimes against me, I’d originally thought my family alone had adverse reactions to neuroleptics. Since all my psychiatrists lied to me and my family claiming the worst possible adverse reaction of any of their drugs was “thirst” and no one ever suffered adverse effects to the drugs, that made me ungodly sick.
But now I know the antipsychotics are toxic drugs to all people, and I do now believe the unethical and unscrupulous manufacturers and prescribers of these toxic drugs do deserve a death penalty.
I pray for justice. And do believe those forcing antipsychotics upon others have reason to repent, and use their malpractice insurance for what it was intended. What if there actually is a God, and it’s not you, psychiatrists? Just a theory ….
What’s the difference between a psychiatrist and God?
God doesn’t think he’s a psychiatrist!
Sounds like a very interesting book, thank you for the recommendation, Dr. Thomas.
Anything that is “mental”, is by definition biological in nature, as there is no mind without a brain. All our thoughts and behaviours can be correlated with brain activity.
As you have highlighted Dr. Thomas, when using the term “mental illness”, many people forget about the problems in living with which a person’s “mental illness” is associated, and the focus turns to their brain, than on life situations. Psychiatric labels make this worse.
How many times have I not heard that someone committed suicide because of their “mental illness”. Sigh.
Hi Phil, great review. What gets me is how so many professionals with transcultural backgrounds seem to be party to this . Arthur Kleinman in the 1970s talked about the category fallacy, i.e. the very catergories we use to describe mental distress can not themselves be seen as culture free entities. If you take an example like protracted grief, it says much about how we should be in relation to loss as a society. I am sure at root is an economic equation which mearly looks at days off work. In cross cultural studies of course there is wide variation in responses to death. It seems sad to try and level all those out into one global response.
I’m not sure I should comment, since the earlier commenters did such a good job. I would emphasize, though, the importance of trying to get criminal prosecutions of some of these people. Unfortunately, when American drug executives push the drugs on people in less-developed countries, criminal prosecutions are not likely.
But a few prison terms would work wonders for the behavior of psychiatrists like Joseph Biederman.
Regarding “a naked child chained to a tree”, before they psychiatric-ally drug him instead of the chains ( pills = a kinder owner?) they might want to do physical tests like blood tests and a brain scan to see if he is physically ill, then test his sight , hearing and speech to see if communication is possible. Before assuming he is crazy because everyone says he is crazy.
Since it’s been known for decades that the antipsychotics CAUSE a “chemical lobotomy,” I’m a little confused about why the psychiatric community still thinks such “brain damaging” drugs are thought to be humane treatment of anyone.
Can any of the psychiatric professionals explain this to me?
And, just an FYI, two of the doctors who tried to kill me with willy nilly massive psychiatric drugging, because they wanted to cover up the abuse of my children and me by the ELCA religion and a prior “easily recognized iatrogenic artifact,” at an ELCA hospital, were natives of India.
My research indicates there’s a much lower incidence of “mental illness” in India, than the US, however. Why are the Indian doctors coming over to the US to harm and try to kill native, ethical and innocent, Americans for the unethical child abuse supporting religions and incompetent doctors? I think the Indian doctors should go back to their own country and pretend defaming and massively drugging people with antipsychotics is “appropriate medical care” instead.
But my understanding is the caste system in India wisely does not put doctors at the top. And so it is only in America that the Indian doctors may get away with force medicating people for belief in God, to cover up child abuse and prior medical mistakes, despite that actually being illegal in this county also.
I am so sorry for the atrocities that you experienced but abusive psych practices occur among doctors of all nationalities and aren’t limited to ones from India. And no, we don’t want people in other countries to suffer. No one should.
You are asking a great question about why brain disabling drugs are considered humane treatment. I hope you receive an answer.