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.