What if…we decolonized mental health services?
Around 75 per cent of those who take their own lives are in low and middle-income countries. The WHO’s response to this alarming fact has been to promise a rapid scale-up of access to anti-depressants and anti-psychotics. The problem with this solution, Rachel Aviv suggests in Strangers to Ourselves, is that modern psychiatry was ‘not designed to address the kinds of ailments that arise from being marginalized or oppressed for generations’. Further, the promotion of pharmaceuticals over local or alternative therapies encourages those suffering ‘to look into themselves as if they were the cause of social ills’.
So strong has this approach been that even the former head of the American Psychiatric Association, Loren Mosher resigned in 1998, citing how psychiatry had ‘been almost completely bought out by the drug companies’ and that the profession no longer sought ‘to understand whole persons in their social contexts’.
The language of the US Diagnostic and Statistical Manual of Mental Disorders (DSM) has been exported to the Global South since its inception, but the WHO’s Global Mental Health Movement (MGMH) put things into turbo-drive as it sought to ‘weed out irrational and inappropriate’ local therapies.
Writing about the rapid growth of suicides amongst indebted Indian farmers, China Mills writes: ‘While farmers write suicide notes to the government telling of an unliveable life due to agricultural reforms, MGMH calls for increased access amongst farmers to anti-depressants’.
People in distress have long been caught between a rock and a hard place. Upending a system that effectively relies on profit-driven over-medicalization and psychiatric incarceration would be no easy task, and access to decent mental health support can be difficult to impossible. The use of solitary confinement, electroconvulsive therapy (without anaesthesia) and caged beds has been found in places including Ghana, India and the Czech Republic. The World Network of Users and Survivors of Psychiatry is one example of a campaign working to strengthen the international Convention on the Rights of Persons with Disabilities (CRPD) on the basis that ‘pain inflicted in the name of treatment may violate international law’.
The scope of a radical overhaul would need to extend well beyond Asia and Africa and into the Global North where the scientific model has no answer for distress fuelled by oppression such as racism. Notably, for non-white people, the risk of psychosis increases the whiter the community they live in is.1
As Aviv argues, a new mental health system must attempt to describe sufferers’ mental life on their own terms, not through ‘a checklist of behavioural symptoms’ found in the DSM. But there are signs of change. In the US, inspired by the remote ambulance service spearheaded by the Black Panther Party, the Anti Police-Terror Squad ‘Mental Health First’ works to dispatch first responders to Black people in a mental health crisis and promote de-escalation over violent policing.
Organizations such as the Centre for Mental Health Advocacy at Bapu Trust, India, are working with people in distress to access multiple bases of knowledge. ‘Counselors at Bapu Trust helped families find explanations – or multiple explanations – that resonated with their own experiences of illness,’ Aviv explains, ‘rather than using language that seemed to have been designed for a different model of the self.’ According to Mills, this work requires agitating for ‘patients who wished to seek out support from traditional healing centres, [that] were forcibly removed by local State governments and re-diverted to psychiatric hospitals for medicalization.’ There are also glimmers of answers when it comes to treatment for intergenerational trauma. While treating survivors of the genocide by the Khmer Rouge in Cambodia, Gardner Health Services in California found that instead of a weekly appointment with a shrink, centering the belief systems of suffers was far more effective than the jargon-filled, sanitized language of Cognitive Behavioural Therapy. In Trieste, Italy, mental healthcare has been transformed to include doctors without uniforms, communal lunches, access to nature, culture and patient assemblies. The city has sought to redefine the role of the physician and reduce stigma, with mixed results.
While politics cannot be blamed for all forms of distress, and many people find relief from appropriate medication, curiosity about individual patients’ needs and stories of suffering need to be at the heart of mental health support. We need an abundance of options – creative and local therapies – over deference to confinement and medicalization.
1 T M Luhrmann, ‘Social Defeat...’, Culture, Medicine, and Psychiatry, Vol 31, No 2, May 2007.