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Challenging the globalisation of biomedical psychiatry
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For over 100 years biomedical psychiatry has dominated the way people throughout the western world understand their sadness and distress, despite the lack of empirical evidence that distress has a biological basis. Now, the interests of the global pharmaceutical industry and trans-national professional elites such as the World Health Organisation and the World Psychiatric Association are extending these biomedical accounts across the globe. This paper briefly describes biomedical psychiatry and its origins before considering how this project is closely aligned to the interests of the pharmaceutical industry. It ends with a call for a new agenda in mental health, driven by the concerns and interests of ordinary people in local communities, and an outline of recent developments in Britain and elsewhere that illustrate this challenge to the biomedical hegemony.
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... The mhGAP initiative and the broader global mental health (GMH) movement 9 10 have been engaged in a debate about the appropriateness of globalising standardised mental healthcare across cultures and contexts. [11][12][13] Critiques of GMH include concerns about: (1) inadequate identification and integration of local modes of expression of distress and related healing practices; (2) risks of medicalisation or psychiatrisation of everyday forms of distress and (3) broader ethical concerns about the imposition of biomedical frameworks. [14][15][16] Despite efforts to acknowledge culture and context in recent mhGAP materials, critics have argued that in practice mhGAP implementation tends to prioritise a biomedical approach to the relative exclusion of alternative, locally grounded, approaches to care. ...
... 14 17 18 These and other critiques have spurred discussion of alternative approaches to GMH emphasising greater engagement with social and cultural context. 13 14 16 Notwithstanding these conceptual critiques and practical challenges, the mhGAP programme continues to be implemented in varied settings. The programme has been used to train a range of groups including primary healthcare staff, physicians, schoolteachers and others, and the diagnostic algorithms have been adopted by healthcare workers and traditional healers in countries in Africa, Asia and South America. ...
... One of the major risks of neglecting locally meaningful cultural idioms and social systems that frame the experience of distress and wellness, and expectations for care, is that effective local processes of healing, coping and recovery may be missed or discounted. [12][13][14] Delivering interventions in context involves engaging the formal, traditional and informal healthcare systems, which may have their own pathways to care and diagnostic and treatment practices, including culturally grounded interventions as well as culturally adopted and adapted interventions. 59 Inadequate attention to culture can create situations in which individuals in need of support are unable or reluctant to access services. ...
In 2002, WHO launched the Mental Health Gap Action
Programme (mhGAP) as a strategy to help member states
scale up services to address the growing burden of
mental, neurological and substance use disorders globally,
especially in countries with limited resources. Since then,
the mhGAP program has been widely implemented but
also criticised for insufficient attention to cultural and
social context and ethical issues. To address this issue and
help overcome related barriers to scale-up,
we outline a
framework of questions exploring key cultural and ethical
dimensions of mhGAP planning, adaptation, training, and
implementation. This framework is meant to guide mhGAP
activity taking place around the world. Our approach is
informed by recent research on cultural formulation and
adaptation, and aligned with key components of the WHO
implementation research guide (Peters, D. H., Tran, N. T.,
& Adam, T. (2013). Implementation research in health:
a practical guide. Implementation research in health:
a practical guide.). The framework covers three broad
domains: (1) Concepts of wellness and illness—how to
examine cultural norms, knowledge, values and attitudes
in relation to the “culture of the mhGAP”; (2) Systems
of care—identifying formal and informal systems of
care in the cultural context of practice.; and (3) Ethical
space: examining issues related to power dynamics,
communication, and decision-making.
Systematic
consideration of these issues can guide integration of
cultural knowledge, structural competence, and ethics in
implementation efforts.
... En último extremo, sólo desarrollando una democracia más real, menos formal, más al alcance de amplias capas de la población (y, precisamente, de las más necesitadas), puede lograrse una atención integral a las psicosis, tanto en los países postindustriales como en los países en vías de desarrollo. Con Appadurai defendemos que la "democracia profunda", el sentirse miembro activo de una comunidad integrada, la democracia a partir de los "núcleos vivenciales naturales" de la población, es una dimensión indispensable para el desarrollo de programas de salud verdaderamente alternativos 2-7 , como ya hace años demostraron los estudiosos de las enfermedades cardiovasculares y mentales a partir de los estudios de Rosetto y Whitehall [50][51][52][53][54] . Pero ello implica un cambio copernicano en nuestra perspectiva teórica, epistemológica y cultural. ...
... Implica una apuesta decidida por una psicopatología alejada de las vías tradicionales y de la psiquiatría "biocomercial". Una nueva psicopatología que no esté en contra de los modelos biológicos de la misma, tales como la "nueva neuropsiquiatría", ni con los modelos teóricamente fundamentados de psicopatología (basados en el apego, la mentalización, los "sistemas emocionales", la psicopatología ecológica y evolucionista...), pero que prime, por encima de todo, la psicopatología derivada de los problemas cotidianos y reales de la población y la psicopatología basada en la relación [54][55][56][57][58][59][60] . ...
La atención integral a las psicosis, el objetivo de la colección 3P, es, sin embargo, piedra
de toque dentro del capítulo de la atención a la salud mental y del Movimiento por la Salud Mental Global, del que nos habla en este libro Benedetto Saraceno. Y no sólo es piedra de toque en nuestro campo profesional, sino que, a nuestro entender, se trata de un elemento clave para medir la integración y democracia real reinantes en una sociedad: de hecho, la reciente historia de la humanidad es buena muestra de cómo pueden coincidir en un mismo siglo intentos de exterminio de las diferencias (y el exterminio de los pacientes con psicosis ) con los intentos comunitarios y técnicos más profundamente democráticos y comunitaristas Empero, esa perspectiva del tema más “global”, ideológica o “política”, había figurado en nuestra colección en escasas ocasiones, lo cual podría ser una importante carencia: como venimos postulando ininterrumpidamente desde 1978, la atención integral a la psicosis necesita de cambios no sólo teóricos y organizativas, sino también políticos y culturales. Por todo ello (y por muchas otras razones que no es el caso de resumir aquí), desde al menos 1978 mantenemos ese principio de que la atención a las psicosis es uno de los mejores indicadores
de la democracia real de una sociedad.
... En último extremo, sólo desarrollando una democracia más real, menos formal, más al alcance de amplias capas de la población (y, precisamente, de las más necesitadas), puede lograrse una atención integral a las psicosis, tanto en los países postindustriales como en los países en vías de desarrollo. Con Appadurai defendemos que la "democracia profunda", el sentirse miembro activo de una comunidad integrada, la democracia a partir de los "núcleos vivenciales naturales" de la población, es una dimensión indispensable para el desarrollo de programas de salud verdaderamente alternativos 2-7 , como ya hace años demostraron los estudiosos de las enfermedades cardiovasculares y mentales a partir de los estudios de Rosetto y Whitehall [50][51][52][53][54] . Pero ello implica un cambio copernicano en nuestra perspectiva teórica, epistemológica y cultural. ...
... Implica una apuesta decidida por una psicopatología alejada de las vías tradicionales y de la psiquiatría "biocomercial". Una nueva psicopatología que no esté en contra de los modelos biológicos de la misma, tales como la "nueva neuropsiquiatría", ni con los modelos teóricamente fundamentados de psicopatología (basados en el apego, la mentalización, los "sistemas emocionales", la psicopatología ecológica y evolucionista...), pero que prime, por encima de todo, la psicopatología derivada de los problemas cotidianos y reales de la población y la psicopatología basada en la relación [54][55][56][57][58][59][60] . ...
"...resulta especialmente valioso para nuestra colección publicar en ella el último libro
de Benedetto Saraceno, Director de Salud Mental y Abuso de Sustancias de la Organización Mundial de la Salud (OMS) entre los años 1999 y 2010. Nadie mejor que él para proporcionar una perspectiva de la salud mental en el siglo XXI que tenga en cuenta, por un lado, las políticas de la OMS y las países y agrupaciones que están empeñados en el cambio y, por otro, la conexión entre políticas globales (nacionales, supranacionales y de la OMS) y políticas y experiencias locales en decenas de países. Todos los usuarios, familiares, clínicos o investigadores del ámbito de las psicosis deberían tener una idea de qué se está haciendo a nivel global (vale decir “en el globo”, a nivel mundial) sobre el tema. ¿Quién mejor que el propio Benedetto Saraceno, para proporcionar esa “visión bifocal”, tanto por su experiencia político-institucional como por sus dotes didácticas e ideológicas?"
... Another aspect refers to the celebration of madness, which means that madness is not reduced to suffering and is not a disease; it is a way of being that deserves to be recognized and validated in society along with the defence of the right to be mad in the public space, a challenge to society as a whole for greater recognition of madness and the defence of rights in the field of mental health. In this sense, the Mad Pride movement in Chile not only differs from other countries in the region, but also establishes a distance from the tradition of user organisations at a global level that receive funding from the pharmaceutical industry to constitute themselves as pressure groups for governments in order to obtain more health benefits (Thomas et al., 2005;Lehmann, 2009, pp. 34-35). ...
... Por el contrario, las dimensiones de sentido enfatizan el lugar de la locura como producción sociocultural. A su vez, el movimiento Orgullo Loco en Chile establece un distanciamiento con la tradición de organizaciones de usuarios(as) financiadas por la industria farmacéutica que se constituyen como grupos de presión hacia los gobiernos para obtener más prestaciones sanitarias(Thomas et al. 2005).En su conjunto, el ciclo de manifestaciones del Orgullo Loco en Chile ha promovido una concepción de la locura bajo los principios de la valoración de la diversidad y el reconocimiento de las diferencias, articulando con otras demandas de transformación social. En particular, la caracterización de la locura como identidad oprimida ha implicado la colaboración con otros actores colectivos en el campo de la discapacidad, las luchas feministas y el movimiento trans. ...
This article considers the cultural determination of Mental Health and the role conferred on language in the social construction of madness. From a historical perspective, the origin of organizations of “expatients and survivors” of psychiatry is examined together with the emergence of Mad Pride as a movement that challenges stigma, prejudice, discrimination and violence of sanism as a form of oppression. In this tradition, the use of the term Mad is redefined, a word that originally damaged, now reclaiming its meaning as part of human diversity; a condition of life that deserves to be recognized and celebrated in the public space. From a qualitative perspective and from an ethnographic approach, the symbolic productions of the Mad Pride marches held in Santiago between 2015 and 2018 are analyzed. Regarding the meanings of diversity, protest and carnival, the scope of this initiative is described in the field of political participation and citizen expression in contemporary Chile.
... The concerns raised in this research about medicalizing responses to trauma are in line with a current paradigm shift in the community based psy-professions to move away from diagnosis towards more socio-politically focused forms of assessment (Duncan, Sparks & Timimi, 2018;Johnstone & Boyle, 2018;Thomas et al, 2005,). It would appear that psychiatry, as a discipline, is also making some attempt to incorporate challenging new evidence from the field of traumatology (Valent, 2018). ...
This study considers whether the diagnosis Complex Post Traumatic Stress Disorder (C-PTSD) might replace Borderline Personality Disorder (BPD) as a less harmful alternative for women in forensic services. This paper investigates the perspectives of key informants with a high level of expertise in the fields of complex trauma and personality disorder. Semi-structured interviews were conducted with six participants and analysed using thematic analysis. Findings show contradictory perspectives and definitions for ‘personality’ and ‘trauma’. These understandings were mediated by the perceived levels of agency associated with each diagnosis as well as non-medicalised narratives of trauma. Informants’ preference for either a non-medicalised approach to trauma, C-PTSD or BPD depended on the associated levels of hopeless and the limitations of the forensic environment. C-PTSD was seen by some as reducing the victim-blaming phenomenon that can be generated and sustained by the application of a BPD diagnosis. Some participants raised concerns, however, that the diagnosis of C-PTSD implied a state of permanent victimhood. Furthermore, there were questions regarding women who do not identify as traumatised. Despite these concerns, it is concluded that the iatrogenic harm associated with a BPD diagnosis warrants a more ethical replacement.
This paper points to an underexplored relationship of reinforcement between processes of quantification and digitisation in the construction of mental health as amenable to technological intervention, in India. Increasingly, technology is used to collect mental health data, to diagnose mental health problems, and as a route of mental health intervention and clinical management. At the same time, mental health has become recognised as a new public health priority in India, and within national and global public health agendas. We explore two sites of the technological problematisation of mental health in India: a large-scale survey calculating prevalence, and a smartphone app to manage stress. We show how digital technology is deployed both to frame a ‘need’ for, and to implement, mental health interventions. We then trace the epistemologies and colonial histories of ‘psy’ technologies, which question assumptions of digital empowerment and of top-down ‘western’ imposition. Our findings show that in India such technologies work both to discipline and liberate users. The paper aims to encourage global debate inclusive of those positioned inside and outside of the ‘black box’ of mental health technology and data production, and to contribute to shaping a future research agenda that analyses quantification and digitisation as key drivers in global advocacy to make mental health count.
(Neuro)psychiatric diagnoses such as attention deficit hyperactivity disorder (ADHD) is a rapidly growing and globally increasing phenomenon, not least in different educational contexts such as in family and in school. Children and youths labelled as ADHD are challenging normative claims in terms of nurturing and education, whereas those labelled as ADHD are considered a (future) risk for society to handle. The dominant paradigm regarding ADHD is biomedical, where different levels of attention and activity-impulsivity are perceived as neurobiological dys/functions within the brain best managed by means of an individual diagnosis and instrumental pedagogy. The majority of those labelled as having ADHD encounter a dominant educational model in the form of what is referred to in this article as neurobehaviorism, which is based on onto-epistemological violence. As opposed to this act of violence against being—and against the psychiatrized subject—a less violent educational model is proposed, based on French philosopher Alain Badiou’s ontological examination of being and his concept of love as a truth procedure. In terms of the latter, the focus is on the potential of the encounter as a ‘Two scene of love’. Here, the encounter is a place where it is possible to create new truths and subjects, instead of taking the individual diagnosis as an axiom which only leads to individuals having fixed identities codified in a hierarchical order. This argument is drawn from the ‘mathematical’ formula 1 + 1 = ♥, which originates from an online forum for people who have come into contact with ADHD in one way or another.
This resource involves an attempt to rethink some of the fundamental assumptions of mental health work, showing how recent developments in philosophy and ethics can help to clarify some of the dilemmas and conflicts around different understandings of madness. Throughout, the authors examine the conflicting ways in which politicians, academics, and mental health professionals appear to understand madness, and contrast this with voices and experiences that are usually excluded - those of the people who use mental health services.
The ideas of critical psychiatry are influencing a growing number of psychiatrists in Britain and elsewhere. In this article we examine the origins and development of critical psychiatry over the past 25 years, through the work of philosophers such as Foucault and of critical social theorists such as Ingleby, Miller and Rose. We outline the important differences between critical psychiatry and anti- psychiatry. Finally, we examine the current status of critical psychiatry, and what is called postpsychiatry. We regard both as an attempt by practising psychiatrists to engage with service users' concerns about psychiatry, with government policies that stress democracy, citizenship and the importance of social and cultural contexts in health care, and with what might broadly be described as postmodernism.
Government policies are beginning to change the ethos of mental health care in Britain. The new commitment to tackling the links between poverty, unemployment, and mental illness has led to policies that focus on disadvantage and social exclusion.1 These emphasise the importance of contexts, values, and partnerships and are made explicit in the national service framework for mental health.2 The service framework raises an agenda that is potentially in conflict with biomedical psychiatry. In a nutshell, this government (and the society it represents) is asking for a very different kind of psychiatry and a new deal between health professionals and service users. These demands, as Muir Gray has recently observed, apply not only to psychiatry but also to medicine as a whole, as society's faith in science and technology, an important feature of the 20th century, has diminished.3
According to Muir Gray, “Postmodern health will not only have to retain, and improve, the achievements of the modern era, but also respond to the priorities of postmodern society, namely: concern about values as well as evidence; preoccupation with risk rather than benefits; the rise of the well informed patient.”3 Medicine is being cajoled into accepting this reality, but psychiatry faces the additional problem that its own modernist achievements are themselves contested. Consider this: although patients complain about waiting lists, professional attitudes, and poor communication, few would question the enterprise of medicine itself. By contrast, psychiatry has always been thus challenged. Indeed, the concept of mental illness has been described as a myth.4 It is hard to imagine the emergence of “antipaediatrics” or “critical anaesthetics” movements, yet antipsychiatry and critical psychiatry are well established and influential.5 One of the largest groups of British mental health service users is called Survivors Speak Out.
Psychiatry has reacted defensively …
This book is intended as a tool to help you learn from your patients and from your teachers. . . . We have written this book primarily for medical students and residents during the first several years of their training, although we anticipate that it may also be useful to individuals seeking psychiatric training from perspectives of other disciplines such as nursing or social work. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The nature of psychiatric care varies little among the capital cities of Southeast Asia. Differences that may exist are of degrees along a common dimension. Colonial forces from the past and contemporary diffusion of modern psychiatry have produced this remarkably uniform pattern of thought and treatment across divergent national and cultural boundaries. Our paper analyzes the homogenization of psychiatry in Southeast Asia in three ways. First, we examine international mental health education, consultation and collaboration as interlocking mechanisms for the transfer of psychiatric technology. Second, the indirect and undesirable consequences of the diffusion of psychiatric knowledge and practice are analyzed. Third, we pose recommendations for countering these unanticipated consequences through evaluation research, ethical guidelines, and educational and intervention practices that strengthen indigenous healing resources.
High up on the agenda of the World Trade Organisation (WTO) is the privatisation of education, health, welfare, social housing and transport. The WTO's aim is to extend the free market in the provision of traditional public services. Governments in Europe and the US link the expansion of trade in public services to economic success, and with the backing of powerful medico-pharmaceutical, insurance, and service corporations, the race is on to capture the share of gross domestic product that governments currently spend on public services. They will open domestic European services and domestic markets to global competition by government procurement agreements, dispute-settlement procedures, and the investment rules of global financial institutions. The UK has already set up the necessary mechanisms: the introduction of private-sector accounting rules to public services; the funding of public-sector investment via private-public partnerships or the private finance initiative; and the change to capitation funding streams, which allows the substitution of private for public funds and services. We explain the implications of these changes for European public-health-care systems and the threat they pose to universal coverage, solidarity through risk-pooling, equity, comprehensive care, and democratic accountability.