Breaking Down Power Structures in Global Mental Health: A Call for Mutuality

Multinational research team advocates for mutuality and challenges existing power hierarchies in Global Mental Health.

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In a pioneering article published in the journal Social Psychiatry and Psychiatric Epidemiology, a global team of researchers and practitioners calls for a new paradigm in Global Mental Health (GMH) based on the concept of ‘mutuality’.

This collaborative team, led by Dörte Bemme of King’s College London, spanning 24 countries and comprising 39 collaborators, seeks to transform the understanding and practice of GMH, advocating for a shift from a deficit view to a strength-based perspective.

The project, driven by a desire for “mutuality” – the equal exchange of knowledge, takes a step beyond conventional academic, evidence-based research. The aim is to underline the fact that invaluable indigenous practices, overshadowed by Western medicine, have a significant role to play in the domain of global mental health (GMH).

In a significant admission, a recent editorial in the esteemed Lancet Psychiatry journal recognized certain missteps in the current GMH approach. The editors candidly wrote:

“Without sufficient forethought, global mental health may become a globalized iteration of psychiatry’s potential to reinforce existing power structures and hierarchies.” In place of the current model, they advocated a fresh approach to knowledge creation. Their vision revolves around acknowledging “that expertise comes from individuals and communities in specific social, cultural, and economic environments, rather than the world being a ‘blank slate’ as the rhetoric of the ‘treatment gap’ had suggested.”

The concept of the “treatment gap” is raised in this context. The gap symbolizes the difference between those in need of mental healthcare and those who receive it. An unfortunate fallout of the current scenario is a newly formed treatment gap – one where only “medical professionals” are deemed qualified enough to deliver care. As a result, individuals with specialized knowledge of their own culture’s health care practices get marginalized, while Western medicine takes center stage. Psychologists from affluent Western nations are beginning to understand the negative impact of this form of colonization on GMH.

The concept of ‘mutuality’ underscores the importance of reciprocal relationships and egalitarianism in knowledge creation. According to the researchers, the method aims to foster sustainable relationships, encourage conceptual innovation, and explore ways to equalize epistemic power, i.e., power in the creation and propagation of knowledge.

A noteworthy concern raised in this research is the disproportionate concentration of funding, convening, and publishing power in institutions from the global North, which can often lead to unidirectional knowledge transfer. In a bid to decolonize GMH, the researchers propose the concept of mutual learning, emphasizing that knowledge production’s processes and outcomes are inextricably intertwined.

The article demonstrates that a shift towards the mutual learning process, while challenging, can yield significant benefits. By creating a slower, iterative process focused on building trust and being responsive to all collaborators’ needs, the researchers were able to develop a social paradigm with a fourfold call for GMH:

  1. Transition from a deficit to a strength-based view of community mental health.
  2. Prioritize local and experiential knowledge in scaling processes.
  3. Direct funding to community organizations.
  4. Critically challenge concepts like trauma and resilience from the lens of lived experiences in communities from the global South.

Despite the promise that mutuality offers, the authors caution that in the current institutional arrangements of GMH, mutuality remains elusive. They argue that addressing existing structural constraints is vital to prevent the tokenistic use of the concept and ensure its effective application. The research team emphasizes the lessons they have learned from their experience, hoping to provide crucial insights into achieving partial success at mutual learning.

The researchers from King’s College London and University College London initiated a project named “Together to Transform” (T2T). The project sought to facilitate knowledge exchange among scholars from 25 countries, involving 39 participants across a diverse set of nations, including Afghanistan, Australia, Bangladesh, Canada, Colombia, Ecuador, Ghana, India, Israel, Kenya, Lebanon, Malawi, Mexico, Mozambique, New Zealand, Palestine, Pakistan, Peru, Sierra Leone, South Africa, Spain, Syria, the UK, the US, and Zimbabwe.

Each learning pod delivered unique insights. For example, the Community Mental Health Systems pod rejected the deficit model commonly found in GMH research and espoused a strength-based approach to community mental health care. Drawing on experiential knowledge and data from Ghana, Palestine, South Africa, and India, the group highlighted the role of informal care systems like traditional healers and family support networks.

The Scaling pod underscored that the replication of evidence-based models across diverse contexts requires more than fidelity—it calls for trust, organizational values, flexibility, and meaningful collaboration with communities. The pod argued for an understanding of scaling that goes beyond a one-size-fits-all approach, recognizing the importance of local contexts and relationships.

The Lived Experience, Resilience and Trauma pod challenged the current notions of trauma, emphasizing the need for participatory approaches that center on lived experiences, local idioms, and socio-political ecologies. They stressed the need for a shift in understanding, away from distinctly Western notions of trauma and resilience.

The Capacity Building and Funding pod identified the disconnect between the funding landscape in GMH, largely driven by processes and priorities set by funders in the global North, and local realities at the community level. They called for more equitable partnerships between funders and community organizations.

The mutual learning process generated a wide array of outputs, including conference panels, online events, podcasts, policy briefs, lived experience essays, and an interactive website, thus catering to the needs and incentives of different collaborators and audiences.

However, the researchers don’t shy away from discussing the limitations and flaws of their methodology. They underscore that the very fact that this project was spearheaded by London-based researchers underscores the disparities in research funding, potentially making T2T seem like an extension of colonialism. Further, the participant selection process was also skewed – the researchers themselves invited participants, who were chosen only from established research networks. The language barrier posed another problem, silencing non-native English speakers especially when dealing with specialized terminology.

Another significant constraint was the challenge of power sharing. While many participants appreciated the open, shared, or leaderless facilitation style, the reality was that power dynamics were merely masked rather than erased. The organizers found themselves holding more responsibilities than initially envisioned, indicating that power sharing is best achieved with significant administrative support.

Another challenge was the delay in compensating practitioners due to bureaucratic university processes, which strained the mutuality principle and affected relationships. Compensation not only acknowledges the value of contributions but also encourages engagement, particularly for those for whom such activities were not part of their usual work.

The digital infrastructure also posed challenges, such as connectivity costs and unequal attendance patterns, due to different working environments and schedules. In addition, King’s College London’s policy of not listing collaborators without formal and financial commitments limited the visibility of the collaborations.

While this project inevitably reproduced some power dynamics the project intended to challenge, the ultimate aim was to shift existing institutional power towards practices of power-sharing and foster dialogue across three common epistemic divides:

  1. Between academics from primarily quantitative disciplines and those from qualitative or theoretically driven disciplines.
  2. Between academics and community-level practitioners.
  3. Between collaborators located in the global North and South.

The damaging impact of colonization on psychological health is already well-known. The novelty of this research lies in its successful cross-cultural information sharing. While it had its share of logistical obstacles that tainted the project’s integrity, T2T remains a significant leap forward in promoting knowledge exchange.

Despite the challenges they faced, the “Together to Transform” project provided valuable insights into the complexity of achieving mutuality in a global collaboration, revealing the necessity to address structural inequities and epistemic injustices in academia. It showed that creating meaningful collaborations that seek to address and transform power imbalances in the realm of global mental health research is challenging yet essential. The project’s iterative learning process underscored the potential for such initiatives to foster new ways of working together across academic, geographical, and disciplinary divides.

It serves as a reminder that power imbalances can and must be challenged, and that more inclusive and diverse epistemic spaces and processes can be created to foster meaningful changes in the mental health landscape.

 

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Bemme, D., Roberts, T., Ae-Ngibise, K. A., Gumbonzvanda, N., Joag, K., Kagee, A., Machisa, M., van der Westhuizen, C., van Rensburg, A., Willan, S., Wuerth, M., Aoun, M., Jain, S., Lund, C., Mathias, K., Read, U., Taylor Salisbury, T., & Burgess, R. A. (2023). Mutuality as a method: Advancing a social paradigm for global mental health through mutual learning. Social Psychiatry and Psychiatric Epidemiology. (Link)

 

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