On World Health Day this year, Mr. Dainius Puras, the UN Special Rapporteur on Health, made a statement that depression is the consequence of a failure of the social justice system worldwide and that it should not be compensated by psychiatric drugs, noting the importance of reviving social systems and social justice once again. He followed this up with an even more radical report1, noting that “forgotten issues beget forgotten people,” remembering the planet’s colonial, imperialist, war-ridden past, and writing thus:
“For decades, mental health services have been governed by a reductionist biomedical paradigm that has contributed to the exclusion, neglect, coercion and abuse of people with intellectual, cognitive and psychosocial disabilities, persons with autism and those who deviate from prevailing cultural, social and political norms. Notably, the political abuse of psychiatry remains an issue of serious concern. While mental health services are starved of resources, any scaled-up investment must be shaped by the experiences of the past to ensure that history does not repeat itself.”
Mr. Puras counts the dominance of the medical model as one among the three main obstacles of the “global burden of obstacles” to full inclusion of persons with mental health problems and psychosocial disabilities. He cites “power asymmetries” between psychiatrists and users and the biased use of the medical evidence base as the other two indomitable global obstacles for inclusion. This is an unexpected and great addition to several documents from the offices of the UN already in use, such as the report last year from the Office of the High Commissioner of Human Rights on “Mental Health and Human Rights,” broadcasting the urgency of psychiatric harm and injury from the highest possible policy levels.
Mad in America has educated and advocated against the harm and injury caused by psychiatry over the years. A recent article by Pat Bracken, Philip Thomas and other psychiatrists in the British Journal of Psychiatry bespeaks of the great churning within psychiatry2. The number of allies to the global movement of people who survived psychiatry or who identify as persons with disabilities is growing phenomenally, supported, in the global south, by the collective voices of the cross disability movement.
It is in light of this growing certainty of the long term-disability and harm caused by psychiatry, and the crying need to bring new policies for ‘alternatives,’ that I present a few reflections of INTAR India 2016, an international conference which facilitated “Trans-Cultural Dialogues about Mental Health, Extreme States and Alternatives for Recovery.” INTAR India 2016 was hosted by the Bapu Trust for Research on Mind & Discourse in partnership with the International Disability Alliance (IDA), and supported by the Open Society Foundation, Mariwala Health Initiative, Fund for Global Human Rights and CBM-Australia. This conference brought a global north platform on ‘alternatives’ for ‘recovery’ to the global south for the first time, and showcased an amazing array of programs and people working on principles of inclusion and reclaiming communities.
It was a landmark event, with a gathering of users and survivors of psychiatry and persons who self-identified as people with psychosocial disabilities in the global south, supported by all other stakeholder groups. There were six plenaries and 20 plenary speakers, over 50 workshop speakers, and over 150 participants from over 40 countries (videos and interviews can be found here). A highlight of the conference was the studied presence of a number of officers from the United Nations, including the World Health Organization (WHO), Convention on the Rights of Persons with Disabilities (CRPD) committee members, and the presence of the international cross disability movement through the IDA, the largest global network of world and regional disabled people’s organizations.
Here, I have organized my reflections around the ‘transcultural dialogue’ part of INTAR India 2016, and what were some of the issues surrounding culture, psychiatry, social movements and dialogue. My reflections therefore capture more of the differences leading to dialogue than what bound us together.
At the outset, let me say more generally that it was largely the Asian movement of persons with psychosocial disabilities, going by the name TCI-Asia (“Transforming Communities for Inclusion-Asia”), that saw INTAR India 2016 as an event on ‘Inclusion.’ It was not only about ‘alternatives’ for supporting people in ‘extreme states or in crisis,’ though there was that, too. The global south is much more centrally engaged and embedded within the cross disability movement than the global north, and within the milieu of transformations inspired by the CRPD. Countries have not only ratified the CRPD, but cross disability movements have mobilized us into their movement to understand us better and to include us in their political and advocacy actions. For us, the object of the conference was to learn ‘how to practice inclusion,’ which is a question about life, and not just to learn non-medical alternatives, which is still about treatment.
Reclaiming communities: Experiences of ‘community’ are different worldwide. In Asian tracts, large networks of human settlements exist that are connected in their experience by various socioeconomic, cultural and other deprivations. High-income Asian countries (Korea, China) are more individualistic and less dependent on their neighbourhoods, social capital and kinship relationships. In this, they are more like the global north. In INTAR, shared experiences of the marginalized black communities of urban users and survivors from the UK, led by Jayasree Kalathil, connected very well with those of the poorer Asian folks, who identified more as ‘people with disabilities.’ We also resonated strongly with the works of Kwame McKenzie — who mobilized the notion of ‘social capital’ as a support resource, working with black communities in the UK — and Chris Hansen, who shared her practice of Intentional Peer Support, which seems to be a global need.
For some groups in the global north, ‘community’ meant a peer community of people who have gone through the experience, whereas in the Asian countries, ‘community’ meant more and more spirals of people sharing experiences of different kinds, but particularly familial, social, economic and cultural groups. A sense of ‘naturalized communities’ existed in Asian country experience, needing negotiation and education on the value of democratic inclusion through concepts such as ‘circle of care’ and ‘community confrontation’ (as broadcast in the Seher program of the Bapu Trust). This was different from the north country experience, where efforts were focused on how to reinvent and reclaim communities through programs like family constellations, family conferencing, Open Dialogue and Trialogue. It is not unusual, in the global south, to count leaves, herbs, resins, effusions and various other non-human, even transcendental energies shared generously by plants, trees and other life forms as ‘community,’ as described by Michael Winkelmann. The Asian support systems created by NGOs were also populated with body-based and arts-based support measures, moving beyond thought, logic, reason and cognition into the realm of imagination, intuition and sensory experiences.
Dependence on the state: In the global south, governments barely, if ever, invest in mental health care/inclusion, leaving the practice of it to families and communities, their strengths and limitations and their local contexts and connotations. The exasperation and disappointment of having governments frame and fund everything was evident in presentations by Mary O’Hagan, Peter Stastny, and others, where grassroots movements — for example peer support — have been co-opted through institutionalized mechanisms of the state and state funding. Withdrawing funding, likewise, led to betrayal, anguish and insecurities over survival, both of peer leaders, as well as support organizations, as found in the UK and the USA. Whereas the real time challenges of being a guidance body to dismissive or recalcitrant national member states, particularly of the global south, was evident in the expectations laid out by the WHO in their key messaging for de-institutionalization. The Commonwealth nations have a plethora of colonial-type mental asylums, built and maintained today with the same colonial mindset and barely reformed legislations. State regulation is meagre, leading to a ‘trade in lunacy’ by private business houses abetting violence, abuse, corruption and fraudulent practices. There was a collective call to de-institutionalization, however, unless strongly north country led, it is difficult to imagine de-colonizing the sector in the global south.
Globalizing medical treatments: Bob Whitaker laid out the paradox of what’s happening with respect to globalizing medical treatments, between the north-south exchanges. The north invented the treatments, packaged and exported it, and now it is doing better in the global south. An exchange with Vikram Patel of the movement for global mental health suggested that the vision for the inclusion of persons with psychosocial disabilities may be global. However, despite everyone’s best intentions, it seemed that the river of psychopharmacy was making its own pathway through the global south, with no stops anywhere within policy or practice. INTAR India 2016 became very important for the global south against this rising tide of psychopharmaceuticals and overmedicalization of people’s psychosocial distress and disabilities.
The WHO, in a renewed effort at reform, has recently released their full basket of “CRPD compliant” training materials. Does this mean we don’t have to advocate for inclusion anymore? Of course not. The training materials continue to talk about quality rights that must be established in ‘inpatient services,’ even though the text contradictorily accents ‘de-institutionalization’ everywhere. In India, the WHO’s “Quality Rights” trainings are being used to make better mental asylums. There is much work to do, including dialogue with the WHO.
For more on the subject of inclusion and the CRPD, watch our short film, On Inclusion:
- A/HRC/35/21, “Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. Human Rights Council, 28th March, 2017. ↩
- Pat Bracken, et. al. (2012). “Psychiatry beyond the current paradigm”. British Journal of Psychiatry, 201:430-434. ↩