Blog post contributed by Akriti Mehta
More than ten years after the publication of a series of articles published in the Lancetthat heralded in the age of global mental health, a report of The Lancet Commission on global mental health and sustainable developmentwas released at the Global Ministerial Mental Health Summitin London. It seeks to reframe mental health and place global mental health within the broader framework of the Sustainable Development Goalssuggesting future paths.
It is commendable that the leaders of the Movement for Global Mental Health, many of whom have authored this report, acknowledge the importance of social determinants of mental health. The continued opposition to long-term institutionalisation is welcome. Furthermore, the focus on a life course approach is promising. Most importantly, the report stresses the need to move beyond just ‘treatment gaps’ and to recognise the importance of Sustainable Development Goals.
It is important to bear in mind that the marriage between global mental health and sustainable development that this Commission proposes will lead to an increase in the already considerable financial resources allotted to the activities of global mental health. Where and how these resources are used will impact the lives of people for decades to come, especially in the global south. The stakes are high, and this makes it pertinent to critically engage with the Commission report, its agenda, and proposed activities. Detailed responses to the report will certainly follow in the next few months, and hopefully this will allow us all to carefully examine the impact of this Commission. As a start, this blog post will focus on three broad points—the framing of mental health, human rights, and the position of persons with psychosocial disabilities in the report.
How it frames mental health?
The field of global mental health and this Commission are based on the assumptions that experiences that differ from what is deemed ‘normal’ fall within the remit of health and medical frameworks. It follows that the causes of those differences are then located within the individual and ‘treated’ as such. Despite acknowledging the importance of a persons’ environment and life situation and mentions of the concept of ‘social suffering’, the slight shifts in language and concepts do not match up with this depoliticised and individualised understanding of mental health. This lends itself to a report that is peppered with contradictions and limitations which are sometimes acknowledged but often remain unaddressed.
Time and time again, in this report, text about the importance of social factors in relation to distress is followed by the medicalisation of that distress and the claim that it should be ‘treated’ through evidence-based health interventions. When discussing the impact of marginalisations on mental health, the arguments in the report do not move beyond the individual and fail to acknowledge the socio-political structures that perpetuate these oppressions.This is apparent not only from the content of the report but also the authors, majority of whom remain embedded in medical sciences, public health, and psychiatry.
At the very least, the authors should acknowledge that their understanding of mental health is just that – their understanding rooted in psy- disciplines with little input from persons from other highly relevant fields such as sociologists, gender studies academics, political theorists, legal scholars, development study researchers, mad scholars, post-colonial academics, critical race theorists, etc.
How it frames human rights?
‘Mental health is a fundamental human right’ – the report repeats this refrain. This right to mental health is conflated with the right to mental healthcare. What the Movement for Global Mental Health continues to omit is any examination on what counts as ‘care’. While the report speaks of the CRPD at several places, it refuses to meaningfully engage with it and does not open or allow debate on how a system can reconcile situations where two fundamental rights seem to be at odds. There is an unsaid or unwritten suffix to its insistence that ‘mental health is a fundamental human right’: It is ‘and that this right trumps all other human rights’. Global mental health benevolently seeks to provide this one particular right (the right to mental healthcare) at the expense of all other human rights.
As an example of its narrow framing of the CRPD, it says – “There is an urgent need for greater dialogue between advocates of the CRPD and people working on the ground in LMIC, to articulate systems of review based on evidence-based principles of competency” (p20). The implications of this sentence are of grave concern: First, it implies that the two groups of people (those who support CRPD and those who are working on the ground) are separate and mutually exclusive. While this is true of some CRPD advocates, its staunchest advocates (and the organisations they lead) are more aware of the realities of working in local contexts than most global mental health researchers. Second, it goes on to propose the solution which is ‘systems of review’, examples of which are all based on a system of guardianship. It does not consider solutions, many of which are supported by evidence, which may be outside of what global mental health consider appropriate.
Where it places users/survivors/persons with psychosocial disabilities?
The report points to what it calls the ‘fourth shift’, one “exemplified by the expression nothing about us without us” (p5). It makes much of the fact that “prominent individuals have disclosed their personal accounts of living with mental disorders” (p7) but prominent individuals have done this for decades just not in the format familiar to global mental health advocates. It recognises the importance of users and survivors, people with psychosocial disabilities and those with lived experience, but limits their engagement to individual acts. There is no mention of collective action, peer support, activism, advocacy, knowledge production, interventions around inclusive communities and sustainable livelihood that is the focus of several user-led organisations and DPOs in the global south. Without acknowledging this long-standing and continuing work, it frames the narrative around service users and their importance as if it were a novel approach.
Perhaps what we need is a fifth shift wherein the Movement for Global Mental Health engages with, listens to, and takes cue from the persons with psychosocial disabilities in the global south who challenge the mainstream, who are deemed less compliant, painted as ‘trouble-makers’. It is time to pay heed to what we say, for it is for our supposed benefit that global mental health claims to work.
This Commission was convened to reframe the conceptualisation of mental health. While it does reframe (or rephrase) old thinking about mental health, it fails to re-think old frameworks under which global mental health operates. To restate what has been said elsewhere in relation to this Commission , critique is not the same as dismissal and it is my sincere hope that the critical responses to it will be listened to, taken as seriously as we do this report, and that we are able to forge a future course that is more inclusive than this Lancet Commission.
Positioning of the author: I have experienced mental health services in India for over a decade. This experience of being categorised, ‘treated’, and how my small acts of defiance were received by professional, professors, and society as well as the work of others taught me to critically re-examine what ‘madness’ means. I am currently living in London working on a research project (www.eurikha.org) exploring knowledge production by users, survivors, and persons with psychosocial disability. I studied global mental health, learned to speak its languages, became familiar with the arguments for and against it, and write this blog from a somewhat uncomfortable position of someone who is broadly critical of the field but also feels that we must engage with it, in order to change it.