Dr. China Mills, researcher and author of the book “Decolonizing Global Mental Health: the Psychiatrization of the Majority World,” takes a critical approach toward recent attempts to globalize mental health diagnoses and treatments. By prioritizing Western psychiatric understandings of suffering, such movements disregard local knowledge and locate problems within individuals, she argues. As an effect, the focus is shifted from ameliorating harmful social policies and patterns, such as poverty, to treating individuals’ biochemistries.
Mills argues that this approach to global mental health, “obscures and naturalizes structural determinants of distress, disablement, and impoverishment; … and narrowly frames global populations as amenable to the increasingly globalized knowledge systems and practices of the psy-disciplines (psychiatry, psychology and psychotherapy) and psycho-pharmaceuticals.”
The recent inclusion of mental health priorities within UN development goals comes after criticisms that mental health has been excluded and overlooked as an impediment to development. Addressing mental health went from being an invisible development issue to one of pressing importance, explicitly outlined as urgent.
While Mills acknowledges the benefits of this inclusion in the UN’s Sustainable Development Goals (SDG), she also argues that a more nuanced examination of its drawbacks is necessary.
“The successful inclusion of mental health within the SDGs should be celebrated for bringing much-needed policy attention to mental health,” she writes. “However, it is important to take this opportunity to engage critically with both mental health and development so as not to reproduce the power inequalities and harmful practices each has been associated with at a global scale.”
In her paper, Mills outlines how mental health came to be at the forefront of development goals initiatives. She takes a nuanced approach to deconstructing their content (e.g., how suffering and solutions are predominantly described through psychiatric frameworks) as well as the harmful implications that may arise from these initiatives.
Within these globalizing movements, such as “The WHO’s Comprehensive Mental Health Action Plan 2013-2020,” “mental disorders” are framed as disabling to individual productivity and to national and international development. The argument made is that development initiatives ought to invest in mainstreaming mental health interventions and strategies on a global scale to reduce stigma and lessen the economic burden of mental disease.
Yet, what Mills points out is that these interventions and strategies have been derived from Western, psychiatric contexts. Namely, that suffering is understood as an “illness” or a “problem.” Little room is dedicated to exploring the limitations of Western conceptualizations and strategies, or the benefits to privileging local ones.
“The language/s available within a culture provide the conceptual tools with which to name, understand and act on experiences, and are thus central to discussions of what comes under the rubric of psychological or emotional well-being,” Mills explains. “Thus, how an experience is named, for example as ‘illness’ or as ‘distress’, has material effects on possibilities for action.”
“Many critics writing from the global South emphasize that the export of understandings of mental health (and associated models of service) from North to South damage the social fabric of local ecologies of care and support by discrediting and diverting resources away from localized, culturally valid forms of healing.”
One important consideration involves asking: Does using a medical explanation of suffering help to decrease stigma and thereby promote social support and healing? Mills highlights research demonstrating that this is not the case. Biological and brain-based explanations may actually increase the stigmatization of people experiencing distress compared to explanations that emphasize suffering caused by social circumstances or trauma.
While mental health is described in mostly medical terms within these initiatives, “development” is a word used throughout, that also contains various definitions, none of which are clearly defined throughout the campaigns. This is significant, argues Mills, because development goals have historically been criticized as promoting Western ideals too, such as the privileging of capitalism and neoliberal economics that seek to privatize resources and enable the perpetuation of neocolonial practices.
Mills makes a case that these critiques need to be considered before these initiatives begin hastily applying psychiatric frameworks on a global scale. She examines the conflation within these campaigns between neurological disorders, such as epilepsy and dementia, with so-called “mental disorders,” such as depression and anxiety; the claim that “mental illness” is chronic and debilitating, requiring life-long management; and, importantly, the underlying argument that depression, and other mental disorders, are threatening productivity and constituting a costly economic burden.
Additionally, Mills further examines the connections drawn between mental health and poverty.
“The positive association between poverty and mental health problems is ‘one of the most well-established in all of psychiatric epidemiology’ and key to making the case for the inclusion of mental health within the SDGs. Yet, despite this, there is little conclusive evidence about the nature, direction and mechanisms of the relationship between mental health and poverty, which is usually conceptualized as a vicious cycle.”
When SDGs and similar movements frame poverty as a risk factor to mental disease or as an outcome of mental disease, a deeper analysis that might urge systemic reforms is lost when the emphasis is placed on individual treatment for pathology. Mills illustrates this point:
“A central implication of this is that interventions tend to steer towards treating mental disorder to reduce poverty, rather than toward making the structural changes that would eradicate poverty.”
Alternatively, Mills suggests that we consider policies directed toward addressing income inequality, but also those acknowledging the various ways in which “living and working conditions disable people through the production of impairment (injuries, exhaustion, stress).”
Finally, she touches upon what she refers to as “the emerging market of ‘mental disorder,’” calling attention to criticism of the uncritical promotion of pharmaceutical interventions above others. This is particularly concerning when the global South has been identified as an “untapped and emergent” opportunity for promising pharmaceutical sales growth.
“The huge financial incentive to frame distress as ‘mental disorder’ treatable by medications, alongside the widely documented unethical practices of the pharmaceutical industry — including concealing adverse effects of drugs found in clinical trials and testing potentially harmful new products on people living in poverty — marks a central area of contention for calls to mainstream mental health within development and warrants further exploration.”
Overall, Mills’ work adds to ongoing conversation and debate surrounding the complexities involved in globalizing psychiatric frameworks. She summarizes:
“The article highlights the urgent need to foster a more nuanced understanding of the interplay between mental health and development, and shows how, at times, interventions in the two fields work together in producing reductionist, economistic, individualized and psychologized responses to poverty.”
“Now is the time for multiple stakeholders to engage in critical interdisciplinary debates about mental health and development, avoiding the often simplistic take up of one by the other.”
Mills, C. (2018). From ‘invisible problem’to global priority: the inclusion of mental health in the Sustainable Development Goals. Development and Change, 49(3), 843-866. (Link)