A Bold Critique of Global Mental Health’s Expansion and Scalability

Challenging the 'scaling up' narrative, a multidisciplinary team confronts the overlooked value of local knowledge in global mental health interventions.

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In a bold commentary that pushes back against dominant perspectives in the field of Global Mental Health (GMH), a team of interdisciplinary researchers challenges the prevailing view of “scaling up” mental health interventions to address the “treatment gap.”

Their article, published in Transcultural Psychiatry, critically analyzes the goals, assumptions, and strategies underlying the GMH movement’s focus on expanding access to mental health care globally. The authors suggest that the very frameworks being employed may inadvertently devalue local knowledge, understandings, and solutions.

“The ‘scaling up’ advocated in certain circles of GMH is often more about “how can we treat people” rather than ‘how can systems support people to live a meaningful and socially included life.’ This is reflected in GMH’s focus on providing ‘services’ and ‘interventions’ as well as in the nature of these interventions—and a shift from the former perspective to the latter is necessary,” the authors write.
“This proposed reframing offers greater intersectionality in what shapes distress and how to address suffering, which invites a broader reconceptualization of mental health care as more than the absence of symptoms, but rather as dependent on complex systems involving wider social and structural determinants. Such a shift necessitates a reappraisal of the ‘values’ that are promoted by scaling up strategies. This requires recognizing and addressing the power disparity between those who decide what counts as ‘global’ and ‘local,’ and what is ‘scaled,’ how, and for whom.”

The article is the collaborative effort of an international and multidisciplinary team, including a blend of academic and lived experience perspectives. Among the authors are C. Bayetti, G. C. Khemka, P. Bakhshi, and J. F. Trani from Washington University in St. Louis. Bhargavi Davar represents both the Bapu Trust and Transforming Communities for Inclusion in India. Other contributors include P. Kothari of Iswar Sankalpa, M. Kumar of MHAT, and K. Mathias from Herbertpur Christian Hospital and the University of Canterbury in New Zealand. From the UK, W. Kwon and S. Jain hail from the University of Edinburgh, China Mills from City, University of London, and C. R. Montenegro from the University of Exeter.

Map of world made from different kinds of spices on wooden backgroundThe commentary is neatly divided into five sections. It begins with an overview of the current state of Global Mental Health (GMH). This is followed by a discussion on its prevailing scalability approach. The narrative then explores a reimagined vision of what “scaling up” could entail and concludes with a reflection on emerging research areas and the significant roles of international NGOs and other third-sector institutions.

GMH’s chief ambitions for 2023 include bridging the treatment gap, enhancing coverage access, and widening the service reach.

Illustrative of this scaling ambition is the World Health Organization’s ‘Mental Health Gap Action Program’ (mhGAP). Initiatives like the mhGAP are deeply anchored in the assumed universality of mental illness, disorder, and psychosocial disability. Notably, they hinge on third-party community health entities and organizations to facilitate mental health service provision.

This paradigm prompts reflection from the commentary’s authors. They pose:

“What is the nature of the content being scaled? How are processes—particularly regarding task-shifting/ sharing—being scaled, and under what politics of scale? GMH espouses and reproduces a view of mental health which, particularly in its early days, centres on individual pathology, often to the detriment of a wider view encompassing the well-being of individuals and communities. It defines mental disorders as universal phenomena, predicated on Western psychiatric models and nosology, with diagnoses matching distinct biomedical entities with clear biological aetiologies. This emphasis remains despite scholarly criticisms of its validity.”

Within the GMH arena, there’s a pronounced preference for evidence-based medicine (EBM), largely because EBM connects to the needs of prominent funding channels. Treatments that can be conveniently validated through EBM, such as pharmaceutical interventions and structured psychological therapies, are primarily chosen for “scaling up.” They overshadow more participatory, community-driven alternatives, which spotlight broader societal challenges impacting mental well-being, like climate change, social inclusion, poverty, and conflict.

The consequence?

“The result is that, where recognized, local and community knowledge is valued primarily for aiding implementation and acceptability of global solutions. Local actors are not empowered to question the motives, values, and worldviews inscribed within global mental health projects, or to deepen existing community competencies.”

The authors suggest that a fundamental shift is imperative for GMH. One that pivots from a singular focus on biomedical, quantifiable, and readily scalable interventions to adopt a more inclusive, intersectional stance. This transition warrants what the authors term a ‘reappraisal’ of core values and a concerted effort to foster a shared discourse between psychosocially disabled individuals and mental healthcare practitioners.

They maintain that this discourse is already active within certain third-sector organizations, notably in low- and middle-income countries like India. Here, a distinctive capacity for mental healthcare innovation and rights provisions to psychosocially disabled individuals is evident, exemplifying models that GMH has yet to fully embrace. This is feasible for grassroots organizations, given their foundation in community empowerment.

“Unfortunately, there is sparse literature investigating these participatory processes in localized mental health interventions.”

The commentary wraps with an appeal for more research, urging GMH experts to pinpoint the successful components of third-sector institutions, especially those flourishing in India.

“Innovative approaches to mental health care promoting holistic and people-centered care often rely on specific’ philosophies of care’ that demand particular soft skills to remain culturally grounded and to prioritize service users’ individual meanings, ownership and experiences.”

Arriving at a time when GMH faces scrutiny—even from institutions like the United Nations and the World Health Organization—this piece underscores pressing concerns. While GMH persists, its role in psychiatrizing the Global South, its evident leadership void, and its ongoing challenge of incorporating local knowledge persist as significant hurdles.

 

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Bayetti, C., Bakhshi, P., Davar, B., Khemka, G. C., Kothari, P., Kumar, M., … & Jain, S. (2023).        Critical reflections on the concept and impact of “scaling up” in Global Mental Health.            Transcultural Psychiatry60(3), 602-609. (Link)

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