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Conclusion

This part of the book provides an excellent forum for debate and bringing together what might become polarized views. There is a great deal at stake for the fledgling field of GMH. For too long, mental health has been sidelined from international health and development policy. In an attempt to right this trend, advocates of GMH have adopted many of the arguments of global health, choosing to focus on what is ‘global’: the global burden of disease (using international diagnostic classification systems), the costs of mental illness, the need for evidence-based approaches and the necessary quantification of costs and impact of scaling up mental healthcare (Lancet Global Mental Health Group 2007). In so doing advocates of GMH have opened themselves to the criticism that they are not aware of (or even do not care about) the realities of local cultural experiences of distress—that they are not aware of the need to adopt caution in scaling up evidence-based interventions when the evidence base is derived largely from high-income countries.

This criticism is important, and it needs to be taken on board, particularly as we attempt to build the evidence base in LMICs. However, to some extent the criticism is also, I believe, misplaced and even ironic. It is misplaced because many of the leaders in the field of GMH come from low- and middle- income countries where they are profoundly aware of the plurality in local cultural idioms of distress. Examples include Ricardo Araya, who led the development of collaborative primary care for depression in Chile (Araya et al. 2003); Atif Rahman, who developed the healthy thinking program, using ‘lady health workers’ to provide cognitive behavior therapy for perinatally depressed women in Pakistan (Rahman et al. 2008); and Vikram Patel who pioneered the delivery of primary care for common mental disorders in India (Patel et al. 2003).

The criticism of GMH as being insensitive to local culture is also ironic because several of the leaders in the field of GMH began their research careers by examining local cultural idioms of distress. For example, Vikram Patel’s initial ground-breaking research in Zimbabwe in 1996 focused on the reported experience of ‘kufungisisa’ (thinking too much) among primary care patients in Harare (Patel 1996). His work in this area led to his development of the Shona Symptom Checklist, a validated instrument whose items are based on local idioms of distress and which is now used routinely in primary care clinics in Harare to screen for the ‘Friendship Bench’ counseling intervention (Chibanda et al. 2011), an intervention which has benefitted thousands.

In short, notwithstanding the important criticisms of GMH, we may all have more in common than we think. And while it is important to have robust debate, it is also important to find common ground. There is a great deal at stake for the many millions of vulnerable and marginalized people living with mental health problems, particularly in low- and middle-income countries. Divisions in the field can dilute efforts to address their needs, both locally and globally.

Acknowledgments I am grateful to Erica Breuer for her comments on an earlier draft of this commentary.

 
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