Politics and mental health

In response to my positioning of both cross-cultural psychiatry and the user/survivor movement as alternatives to dominant mental health discourses, Cohen importantly points out that, although such resistance to psychiatric knowledge has both spread and increased, it should be acknowledged that:

[W]ith the proliferation in categories of mental illness and the further infiltration of the psychiatric discourse into everyday life, the hegemony of psychiatric knowledge is probably more powerful and pervasive currently than at any previous point in the profession’s history.

(2016, p. 303)

Elaborating on an argument perhaps only alluded to in my article, Cohen at several points makes clear the connection between the hierarchical systems of knowledge that underpin modern mental health services and “the social and economic priorities of neoliberal capitalism” (p. 302). He thus exhorts us, as critical mental health scholars, to concentrate less on “assessing the slim chances of psychiatrists giving up their power to oppress user/survivors and rather … on further analyzing the structural determinants that allow such hegemonic forms of expert discourse to exist and continue to expand in Western society” (p. 302).

In a short section of my article, I briefly described the Mental Health Gap Action Programme (mhGAP; World Health Organization, 2010) Intervention Guide (Swerdfager, 2016), something Patel, Boyce, Collins, Saxena, and Horton have argued, “should become the standard approach for all countries and health sectors; irrational and inappropriate interventions should be discouraged and weeded out” (2011, p. 1442). In the preamble to this document, Director General of the World Health Organization Margaret Chan makes the case for addressing mental health on a global scale:

Taking action makes good economic sense. Mental, neurological and substance use disorders interfere in substantial ways, with the ability of children to learn and the ability of adults to function in families, at work, and in society at large.

(Chan, 2010, p. iii)

Armed with tools such as the mhGAP Intervention Guide, the idea goes, local mental health practitioners can more efficiently address the great economic burden that global mental health experts contend mental illness puts on “society at large.”

Indeed, it is not hard to riffle through the global mental health literature and find myriad such examples of explicitly neoliberal language and logic being employed to justify the relevance and spread of this ostensibly global field. The name of the field’s flagship program itself—the mhGAP—refers to a treatment gap between those who need mental health services and those who have access to them; something which can reach up to 75% to 90% (Patel, 2012, p. 7) in “low-income and middle-income countries where the gaps are largest” (Patel et al., 2011, p. 1441). Everywhere the emphasis is placed on the economics of mental illness, the burden of its existence, and the efficiencies to be had in promptly addressing it.

Of course generally left unposed are questions of whether or not the economic system that so demands productive efficiency is not itself partially causing these problems. It is ignorant to pretend that the spread of global mental health policy has occurred in a vacuum, and indeed the political economies of mental health bear further research and investigation.

This leads to Jain’s discussion of a growing body of “interdisciplinary work [that] has potential to advance a more transparent understanding of the ‘operation’ of global mental health whilst shifting the very basis of this ‘operation” (Jain, 2016). Jain’s presentation of the contested history of cross-cultural psychiatry offers an example of such work, certainly adding depth to my own presentation of that discipline as largely resistant to orthodoxy. The point illustrated here is that there is nothing inherent to cross-cultural psychiatry that makes it naturally prioritize user/survivor experiences any more than mainstream mental health services; that, in fact, this discipline may produce nothing more than alternative sources of expertise, and attendant personal prestige for ‘local’ academics who might otherwise be ignored by their Euro-American counterparts. Returning to Cohen’s point, if both cross-cultural and mainstream psychiatry are fully accepting of the logics of neoliberal capitalism then it is unlikely that one will truly...