A new review, published in the journal Critical Public Health, investigates the claims made in the 2018 Lancet Commission on Global Mental Health and Sustainable Development report. The critical review points to inconsistencies in the report’s purported rhetoric and its prescriptions for addressing mental distress worldwide. The review was led by Lisa Cosgrove, from the University of Massachusetts Boston, and China Mills, from the City University of London.
The researchers demonstrate the discrepancies between the initial claims of the report and its subsequent focus. The report begins by suggesting a public health approach for the movement for global mental health (GMH) and discusses the role of social determinants in underlying psychological distress. However, the report eventually betrays this approach by continuing to rely on conceptualizations of ‘mental disorder’ based on the Western biomedical model.
The reviewers also point out that the report proposes mental health interventions that are not rooted in local cultures or informed by service-users and instead recreates a “Global North” driving the “Global South” dynamic. These reductive understandings of mental health, the authors contend, carry on the colonial legacy of an imperialist past.
“From a critical public health perspective, it is important to challenge the rhetoric of ‘scaling up’ so that the GMH movement does not inadvertently recreate mental health systems and practices that allow for discrimination and human rights abuses,” they write.
In response to the call from the Lancet global mental health group to close the ‘treatment gap,’ many activists, service-users, and indigenous experts have cautioned against interventions that neglect the concerns and experiences of people in other cultures. Researchers have also critiqued the GMH movement for exporting a simplified understanding of mental health with an intra-individual focus.
The Lancet report was released in 2018 alongside a GMH Ministerial Summit hosted by the UK government. In response, service users and activists wrote a letter protesting the lack of attention to human rights violations that occur in psychiatric practice within Global North. One of the authors of the review, China Mills, has in the past criticized the GMH movement’s intentions in general, and this summit in particular, and have pointed to the UK government’s hypocrisy in posturing itself as a leader in world public health while cutting welfare benefits in its own nation.
Service-users and activists from countries like India, where measures to scale up such interventions are in full swing, have similarly commented that the GMH movement is failing to address problems of social violence and structural discrimination. The UN Sustainable Development Goals recently included mental health as one of its priorities, and the Lancet report comes on the heels of this development. Still, researchers have noted that simply scaling up mental health services, as they currently exist in the West, may impede the UN Sustainable Development Goals.
The authors of this review point to these concerns, among others. They write that despite the lip service to structural issues like gender violence and poverty, the proposed intervention models in the report remain clinical and individualized. The Western disease model, which guides the diagnostic criteria and eventual treatment of mental distress, focuses on peoples’ right to treatment denies service users’ a role in determining what constitutes treatment.
The review points out this failure of inclusion. Of the 28 people who authored the Lancet report, only one identified as a service-user. This raises concerns regarding how representative these goals are for the people they are supposed to help. The writers also reveal how the report co-opts the work of Pan African Network of People with Psychosocial Disabilities’ Cape Town Declaration, which has been critical of the GMH movement, to assuage their critics.
The review also breaks with the report in its framing of individual disorders as economically burdensome. This understanding of mental health is preoccupied with issues of human productivity. Presenting these problems as economic issues leave nations vulnerable to exploitation by pharmaceutical companies.
The writers question the quality of the epidemiological data used by the proponents of the GMH movement to qualify their interventions. They caution the readers that such misleading data could divert already scarce resources from other pressing public health problems.
They also take issue with the assertion in the report that psychiatric diagnosis would reduce stigma, pointing to research that shows the opposite to be true. On the contrary, context-sensitive and psychosocial models of mental distress are linked to empathy from others and lower rates of stigma, while biomedical explanations exacerbate social distancing.
The authors of the review suggest a set of solutions to many of these problems. They advise the GMH movement to move beyond a neoliberal human capital approach that interiorizes social distress. In its place, they suggest a critical global health and political economy approach, which prioritizes societal determinants of health like housing and human rights protections.
Further, the authors note, the movement must look for better epidemiological data that does not only consider mental health in economic terms but instead includes the voices of local communities, psychosocial disability advocates, and other stakeholders most affected by these policies. This involves developing a nuanced understanding that can discern when intervention is beneficial versus when it is harmful and uses service user experience to guide what useful intervention means.
The authors claim that it is essential to pay attention to local forms of knowledge and to put an end to coercive practices in mental healthcare, as it threatens autonomy and contributes to medical imperialism. The narrative against coercion in treatment has gained momentum as a new review just classified these practices as anti-therapeutic, ineffective, unethical, and a violation of human rights. Instead of ‘scaling up,’ the authors write that ‘scaling across’ “emphasizes the importance of the right to define one’s own experience, and of developing policies and practices that enhance the well-being of everyone.”
They further state that the GMH movement needs to reconceptualize how they understand and address the problem of stigma, which must be recognized at a socio-political level rather than a reductionist interpersonal one. All these measures are necessary to ensure that, despite the benevolent intentions of the GMH movement, it does not end up marginalizing the people who are at the receiving end of this knowledge and these interventions.
The authors conclude by calling for a paradigm shift where help and intervention are not only understood in biomedical terms but instead take into account on the global burden of obstacles approach suggested by the United Nations Special Rapporteur, Dainius Pūras:
“As psychosocial disability advocates, the UN Rapporteur, transcultural psychiatrists, and others have long emphasized, rather than conceptualize poverty, violence, or gender equality as predictive variables or risk factors for mental disorders, we need to see the crisis in mental health as a crisis of obstacles.”
This critical review touches upon many of the concerns that cultural anthropologists, critical psychologists, service users, and disability advocates have put forward. The Western disease model and a pharmacological approach often conflict with other cultures’ focus on social aspects of despair. Efforts to export Western approaches to mental health at this magnitude are especially worrisome, given that the value of such interventions is under scrutiny even in the Global North.
Cosgrove, L., Mills, C., Karter, J.M., Karter, Mehta, A., & Kalathil, J. (2019). A critical review of the Lancet Commission on global mental health and sustainable development: Time for a paradigm change. Critical Public Health. Published Online First: 18 September 2019. DOI: 10.1080/09581596.2019.1667488 (Link)