The Movement for Global Mental Health: Critical Views from South and Southeast Asia. Edited by William Sax and Claudia Lang, Amsterdam: Amsterdam University Press. 2021. pp. 336.
University of South Florida
This volume offers a thought-provoking critique of what the editors describe as the “Movement for Global Mental Health,” or the collective efforts of practitioners, scholars, and institutions to close an assumed “treatment gap” for people living with mental disorders primarily in low- and middle-income countries. The Movement for Global Mental Health (MGMH) became a dominant discourse and approach after a groundbreaking series of articles was published in The Lancet in 2007 calling for the scale-up of services to address mental disorders worldwide. But while editors William Sax and Claudia Lang explain that volume contributors are sympathetic to many of the aims of the MGMH, they nonetheless contend that the movement’s current agenda is based on several problematic assumptions. Most prominently, they argue that these assumptions include the universality of biomedical models and treatment methods, as well as a failure to deeply engage with Indigenous and alternative worldviews and therapies. While contributors offer crucial critiques of many facets of the MGMH—from an overemphasis on psychopharmaceutical treatment to an overreliance on biomedical models in conceptualizing a global “treatment gap”—the volume could engage more attentively with recent developments in the MGMH agenda and the diversity that exists within the ever-evolving movement.
The volume offers critical historical perspectives on the MGMH before delving into the movement’s current limitations and then exploring potential alternatives from a range of disciplinary perspectives. In the historical section, contributions from Stefan Ecks (anthropology), Annette Hornbacher (anthropology), and Anindya Das and Mohan Rao (psychiatry and public health) trace how the development of particular logics and attitudes that frame the MGMH have led to the movement’s perceived shortcomings.
Ecks focuses on questions related to foundational data, the relationship of economics to mental health, and the validity of the assumed “treatment gap” in the Global South. The “treatment gap” is generally described as the difference between the number of people estimated to need treatment for mental illness and the number of people actually receiving it. Ecks contends that much of the epidemiological data that underpins MGHM efforts remains disputed and that, while the movement purports to consider both “emic” and “etic” perspectives, “MGMH, in its current formulation, is an etic project” (44). While it may be true that MGMH efforts often privilege biomedical diagnostic categories, his claim that “local definitions of mental health (are) irrelevant for the MGMH project” does not reflect recent developments within the field, which I expand upon below. He does, however, raise the important points that causal links between economic wealth and mental health remain unclear and that discussions of the “treatment gap” in MGMH circles often fail to account for many forms of non-biomedical resources and services. Das and Rao make a solid argument that much MGMH literature has adopted too narrow a theoretical toolset and that concepts related to the social determinants of health should play a larger role in guiding global mental health efforts. Meanwhile, Hornbacher’s analysis of “schizophrenia” as a contested Western discourse, while fascinating, is perhaps less directly linked to the volume’s central themes, aside from highlighting the need to consider non-biomedical perspectives on mind, mental health, and treatment.
The volume’s second section, on current limitations, features contributions from Harish Naraindas (sociology) and Projit Bihari Mukharji (history and sociology of science). Naraindas describes his piece as a “foil” to the rest of the volume as he investigates treatments drawn from Ayurvedic and Buddhist/Hindu philosophies within the context of a German psychosomatic department. A justifiable question underpins his analysis: Why do MGMH efforts in low- and middle-income countries often aim to disengage “scientific” treatment methods from spirituality, while the opposite is true in Western settings? In unpacking recent attacks of so-called “mass psychogenic illness” that have affected groups such as schoolgirls and factory workers in India, Mukharji exposes flaws in using purely psychiatric models to understand disease causality and subjecthood. He argues that members of the medical establishment have failed to truly engage with the jinn-based frameworks that the afflicted and their families use to interpret their experiences. In addition, and quite critically, Mukharji emphasizes that jinn-possession frameworks challenge conceptions of individuality as the affected subject is a group whose bodies and minds are enmeshed in ways unintelligible to psychiatry.
The volume’s third section, “Alternatives,” is quite possibly the strongest, and it is where contributors get into the specifics of how the MGMH may revamp and reorient its current agenda. Murphy Halliburton delves into the question of why epidemiological data often shows better rates of recovery from severe mental illness in the “developing world” (and especially in India) than in the developed world. Drawing on Joel Robbins’ call to build an “anthropology of the good” (2013), he examines the role of family support and conceptions of love, or sneham, in cases of severe mental illness in India. While he admits that those he studies face many challenges and may not live an ideal or “happy” life necessarily, he contends that improved outcomes are tied to living a “valued or vital life” filled with supportive and loving relations (218). Coeditor Claudia Lang’s contribution to the volume uses a fine-grained analysis of Ayurvedic mental health therapy both to challenge the conception of the “treatment gap” and to demonstrate a case of truly meaningful integration of globalized psychiatry with Indigenous medical knowledge and practices. Finally, coeditor William Sax’s piece, based on decades of ethnographic work in Asia, Africa, and Europe, calls on the MGMH to seriously engage with the question of ritual, which has existed as a form of “global mental health” treatment throughout human history.
As mentioned, one weakness of the volume is the broad characterization of the current MGMH agenda. Since the publication of the 2007 Lancet series, several scholars and practitioners in the field have worked to address various concerns raised in the issue, often developing socio-culturally informed programs (Patel et al., 2018). For example, social scientists have created a “roadmap” for engagement with MGMH efforts (Kohrt et al., 2016) and calls to move away from biomedical categories are now widespread in the MGMH literature (Bemme and Kirmayer, 2020). In a recent column in Social Science and Medicine—Mental Health, Vikram Patel (2022), often considered one of the founders of the movement, stressed the need for more person-centered interventions in the MGMH that consider issues of identity and measurement of outcomes that go beyond clinical recovery.
Despite these shortcomings, The Movement for Global Mental Health remains a provocative and reflective addition to debates regarding the contours of the current and future MGMH agenda. Its careful and context-rich investigation of both the limits and possibilities for a more inclusive understanding of the MGMH will prove enlightening for both scholars and practitioners in related fields.
Bemme, D., and L. Kirmayer. 2020. “Global Mental Health: Interdisciplinary Challenges for a Field in Motion.” Transcultural Psychiatry 57 (1): 3–18.
Kohrt, B., E. Mendenhall, and P. Brown. 2016. “How Anthropology Theory and Methods Can Advance Global Mental Health.” Lancet Psychiatry 3 (5): 396–98.
Patel, V. 2022. “Scaling up Person-Centered Psychosocial Interventions: Global Mental Health’s Next Challenge.” Social Science and Medicine—Mental Health 2: 100072.
Patel, V., S. Saxena, C. Lund, G. Thornicroft, F. Baingana, P. Bolton, … J. Eaton. 2018. “The Lancet Commission on Global Mental Health and Sustainable Development.” The Lancet 392 (10157): 1553–98.
Robbins, J. “Beyond the Suffering Subject: Toward an Anthropology of the Good.” The Journal of the Royal Anthropological Institute 19 (3): 447–462.