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Should global mental-health initiatives focus on inequality, violence?

Addressing persistent problems of violence, hunger and poverty will likely do more good than a focus on 'global mental health.'

In his always-interesting MindHacks blog, British psychologist Vaughan Bell wrote Monday about one of the hottest topics among his professional colleagues: the relatively new and controversial field of global mental health.

Efforts are under way to make mental health a world priority. That’s a worthwhile and noble goal, but what does it mean to promote mental health?

There’s still a lot of argument, Bell points out, “about whether ‘global mental health’ is just a means of exporting Western ideas and diagnoses in a sort of 21st century globalisation of the mind.”

Many mental-health experts, especially those in Latin America, says Bell, believe that instead of focusing on Western psychological disorders, “we should be instead focusing on inequality and violence to improve mental health.” This approach, he adds, has its roots in liberation psychology, which was founded in the 1970s by the El Salvadorian Jesuit priest and social psychologist Ignacio Martin-Baro (who was tragically assassinated on the campus of Central American University in November 1989 during his country’s civil war).

Martin-Baro believed, says Bell,

that there is no such thing as an apolitical act in mental health, and, indeed, in health care in general.

For example, the West’s understanding of the victims of war, torture and displacement in terms of [post-traumatic stress disorder] and other diagnostic labels is largely due to the experience of treating refugees who have fled these horrible situations.

In this context, PTSD makes sense in the West because it has the implicit assumption that the person is now safe (after all, it’s post-traumatic stress disorder) and that the experiences and reactions described in the diagnosis are, therefore, inappropriate.

However, if you live in a war zone, intrusive thoughts, feeling on edge and avoiding reminders of danger could be considered quite a reasonable reaction to the constant experience of death and violence.

When you meet people who do live in war zones, who would clearly meet the criteria for PTSD, they rarely complain about their mental state. They’re usually more concerned about the actual dangers.

They’re concerned about torture, not intrusive thoughts about being tortured — the threat of rape, not rape-related anxiety.

So, the hard question becomes: are we really helping by sending professionals and training locals to recognise and treat people with, for example, PTSD?

And this is where Martín-Baró drew his inspiration from. The way we understand and treat mental health problems, he argued, is always political. There is no absolute neutrality in how we understand distress and those that think so are usually just blind to their own biases.

So, the hard question becomes: are we really helping by sending professionals and training locals to recognize and treat people with, for example, PTSD?

But that question is often ignored or dismissed as the mental-health community seeks to satisfy its own interests, says Bell.

Big Pharma pushes theories as adverts for its medication. Western mental health professionals can see themselves as healers of people who don’t necessarily need healing.

Researchers see an untapped gold mine of data and local scientists see a way out of what seems like a limiting and unglamorous academic life distant from the shining lights of Northern Hemisphere High Science.

So when we talk about ‘mental health literacy’ are we talking education or propaganda? It’s not an easy question to answer or,  for many, to even think about.

Poor moms, anxiety and poverty

As I read Bell’s description of liberation psychology and the debate currently under way among proponents and critics of global mental-health initiatives, I thought of a study released last week about poor mothers and anxiety disorder.

It was a study conducted right here in the United States.

Researchers at Rutgers University analyzed data collected from almost 5,000 participants in an ongoing study of single-parent families in the United States. They found that poor mothers (those, for example, who received free food or had trouble paying their utilities or had to move in with others) were much more likely to be diagnosed as having generalized anxiety disorder (GAD) than mothers with greater financial resources. But they also found no evidence that this anxiety was the result of  some “internal malfunction.”

The women’s anxiety instead had a very real — and understandable — external cause: poverty.

“This is an important distinction to make because interventions are predicated on ways in which problems are conceptualized,” wrote the study’s authors. “Our findings suggest that anxiety in poor mothers is usually not psychiatric, but a reaction to severe environmental deficits.”

What the women need, therefore, is not treatment for a mental disorder, but financial aid and services that will help lift them out of poverty.

You’ll find Bell’s full article on his MindHacks website. The Rutgers study was published in the journal Child and Adolescent Social Work, but is, unfortunately, behind a paywall.

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