Contesting Global Mental Health - MHI

ISSUE NO. 6 OCTOBER

THE MARIWALA HEALTH INITIATIVE JOURNAL

Re-Vision

Contesting Global Mental Health

World Mental Health Day, Medicalised Mental Health Awareness, and Psychiatric Subjectivation

Authoritarian Neoliberal Regimes and Global Mental Health

Enough Politeness: Decolonising Mental Health in a Society Oblivious to Its Colonial Wounds

Work with Us, Not against Us

Context

Mental Health in the Time of Genocide

Reshaping Narratives: Reproductive Justice among Women in Kashmir

Mental Health and Marginalisation

Warriors Within: Decoding the Paradox of Strength and Vulnerability among the Naga Tribe

Redefining Queerscapes through Poetry

The Impact of AFSPA on the Mental Health of the Naga People

Engage

Collective Healing and Trauma-Informed Approaches for the Mental Health of Survivors of Trafficking

Assessing the Effectiveness of the Mental Health Equity Global Agenda for Low- and Middle-Income Countries 

Fostering Mental Healthcare in a Postcolonial Continent with Digital Medicine

Tackling Mental Health Inequalities for Roma Communities in the UK

Behind Bars

RE-VISION

01

Contesting Global Mental Health

Disrupting Knowledge and Power Systems

Raj, Saniya and Amalina

AUTHOR

Studio Ping Pong

illustrator

author’s bio

Raj, Saniya and Amalina

Raj Mariwala is Director, MHI.

Saniya is a sociologist, currently working as an Associate (Mitigation) at Project 39A NLU, Delhi. Through her research and writing work, she engages with discourses on law, nationalism and governance with a keen focus on climate politics and disability.

Amalina has an educational background in psychology and social science. She is currently a training associate at MHI, and is involved in the administration, impact assessment and research related to MHI’s various training programs on gender-sexuality and organisational diversity and equity. 

illustrator’s bio

Amreeta Banerjee

Alice A. Barwa completed her MA in Education from Dr. B.R. Ambedkar Univerity, Delhi (AUD), in 2022, and is from the Oraon Adivasi community, a native of Chhotanagpur Plateau, Chhattisgarh. She has been an advocate for Adivasi rights and voices as a member of an Adivasi youth collective @TheAdivasiPost, and has been an Adivasi youth representative at UN Climate Change Conference in Glasgow, Scotland, in 2021. Her research interests include education, culture, sociology, and linguistics.

Introduction

Global Mental Health (GMH) emerged in 2007 with a Lancet series that called for increased mental health services in low and middle-income countries (LMICs). The series was authored by academics and researchers affiliated with organisations such as the World Health Organisation (WHO), the World Bank, and universities, primarily in the Global North. 

A decade later, the Lancet Commission on Global Mental Health and Sustainable Development reviewed the field’s progress, emphasising the need to scale up services, address social determinants, and leverage digital technology. Most Commission members were Global North experts or academics, with only one user-survivor voice.

The 2018 Commission noted progress in closing treatment gaps in LMICs and doubling mental health support but also recommended expanding services, addressing social determinants, adopting digital tools, and developing public policies. 

These threats included the limited impact of clinical treatments and rising adverse social determinants. Notably, one of the identified threats was the critique of the dominant biomedical narrative and Western psychiatric framework. From the field’s inception in 2007 to the present in 2024, the same voices—affiliated with elite American and British universities, organisations, journals, and funders—continue to dominate, reflecting Eurocentric biomedical narratives. 

Post the COVID pandemic, there has been growing attention to mental, public, global, and planetary health. In this edition, we examine how GMH pillars have adapted to threats including global upheavals like viral infections, war, occupation, climate change or critiques of the dominant biomedical approach.

Critiques and Crises

The field of Global Mental Health (GMH) has gained prominence but also faced criticism. Critics such as China Mills and Bhargavi Davar (2016) pointed out its dominance by Global North expertise and methods.

“MGMH [The Movement for Global Mental Health] is increasingly functioning as a global space that shapes the contours of what can be said […] The Movement’s calls ‘to make mental health for all a reality’ serve to make mental health as a reality thinkable in certain ways that are dominated by ways of knowing and intervening upon distress which come from the global North.”

Additionally, anthropologists have critiqued the field for repeating colonial dynamics wherein practices and systems from Western contexts are pushed upon culturally unique countries and regions. 

A key critique is the field’s focus on ‘scalability’ and ‘treatment gaps’ in LMICs, equating distress with mental health disorders while overlooking the critical impact of socioeconomic inequalities.

Socioeconomic and sociopolitical factors like war, occupation, poverty, rising unemployment, and gender-based violence cause natural reactions of distress, which GMH often pathologises (depression, for instance), offering medical solutions for complex, non-medical problems.

Additionally, nuance is often lacking in ‘expert’-led discourse on GMH; while raising awareness and improving access to mental health services is important, the reasons for access barriers—such as travel distance to find a practitioner or a lack of cultural and structural competency in training—are rarely explored, often leading to pathologisation and harm to users.

The GMH field appears disengaged from unfolding global crises. The Gaza genocide has persisted for nearly a year, claiming thousands of Palestinian lives yet leading mental health bodies and journals have issued statements supporting Israel or focusing on the war in Ukraine. Sub-Saharan Africa’s 49 countries, with borders drawn during 18th and 19th-century colonisation, face ethnic tensions, and resource disputes, leading to conflict and humanitarian crises. Colonial extractivism and climate change exacerbate instability, with 35 conflicts in 18 countries displacing nearly 39 million people. The mental health implications for affected communities impacted by international development dynamics are rarely discussed.

The GMH field often frames distress as symptoms of psychological disorders that can be treated using Western methods like talk therapy and psychiatry while overlooking the effects of intersecting power systems such as capitalism, patriarchy, authoritarianism and colonialism. Despite the ongoing critique, the field still emphasises a “unidirectional” flow of resources and attention from affluent, Western countries to address mental health in LMICs in the Global South.

LMIC Poster Child

Global Mental Health views the world through national units, assuming each nation has a homogenous culture and is either powerful or powerless based on its location in the Global North or South. This approach oversimplifies the complexity of Global South communities, ignores internal power dynamics, and overlooks diverse mental health needs, and the impact of neoliberal policies.

GMH fails to account for the complexity of the ‘Global South’ and its material realities, which are shaped by power dynamics beyond the Global North-South binary. Even within this framework, GMH often overlooks the ongoing impact of neoliberal dynamics and focuses instead on the perceived lack of service delivery from Western mental health systems to the ‘underdeveloped’ world. GMH then consequently and often unknowingly conceptualises Global South as an unresponded (singular) customer of the modern healthcare service. This leads to failures in understanding the varied mental health needs of diverse communities in LMICs, their domestic-regional geopolitics, and the layers of embedded power systems.

Consider India within the North-South binary: while classified as a ‘Global South’ country, it is home to some of the world’s wealthiest individuals and a political elite, with a complex economy driven by neoliberal desires and demands. The mental health needs of Indians differ from the West and cannot be singularly defined by a ‘Global South’ perspective. As this volume’s essays will demonstrate, mental distress and access to mental health in India are shaped by caste, class, religion, and gendered identities.

‘Indian’ perspectives of GMH are largely dominated by upper caste academics and professionals, neglecting the social determinants affecting the majority- deprived of adequate housing, sanitation, food security, dignity and healthcare, and are vulnerable to climate disasters and forced migration.

Their mental health needs require structural and social reorganisation within India, not just the upscaling of modern psychiatric medicine.

GMH’s call to incorporate ‘Indigenous’ knowledge systems is well-intentioned but overlooks the complex politics of indigeneity. In India, ‘indigenous’ can refer to tribal, Adivasi communities or be used to promote divisive insider-outsider narratives, fuelling communal conflict whereby Muslims and Christians are not seen as fully worthy of citizenship. Labelling Hindu culture as ‘Indigenous’ reinforces the Brahmanical caste order and shields it from the ‘modern’ critique., Marginalised castes, religions, and ethnicities face both material and psychological oppression within a socio-economic structure shaped by India’s global position and social fabric. Thus, no single “Indian” perspective or knowledge system can adequately capture the country’s diverse mental health needs.

The North-South divide acknowledges a colonial history, positioning the South as less powerful. This framing, however, overlooks the South’s own colonial ambitions and oppressive systems. India’s treatment of the North East and Kashmir, including militarisation, profit-driven projects, and the suppression of local voices, has caused a severe mental health crisis over decades.

For GMH to effectively address mental health in LMICs, it must critically examine and move beyond these binary divisions. Critiques of mental health service delivery, framed by the West-East or North-South divide, often end up reinforcing the very dominant perspectives they aim to challenge.

Experts by Experience

There has been a gradual shift to decentre biomedical expertise and prevent the harms of psychiatry in Eurocentric discourse. In GMH, this is reflected in the 2018 Lancet Commission, which included one user-survivor voice, and the formation of the Global Mental Health Peer Network (GMHPN) the same year.

Grassroots movements led by survivors challenge the mental health system, exposing violence both within and beyond it. They aim to reshape the system from the ground up, not just prevent harm. Resistance to individualised biomedical discourse has long existed, as seen in  the Scottish Union of Mental Patients, the Insane Liberation Front in the 1970s, Asylum Magazine (1986), and the Aaina newsletter (2001). Similarly, Mad Pride, Mad Studies, and crip activism connect psychological distress to socio-political oppression and violence.

However, as the movement(s) are not homogenous, it is crucial to recognise who speaks from lived experience in GMH. Whether it is in clinical research, academia, services or as consultants for funders, the focus is on People with Lived Experience (PWLE) who may identify as ‘patients,’ ‘service users,’ or ‘experts by experience’. For instance, the Lancet Commission typically includes those who accept the medical model and advocate for reform within the system. Partnering with mental health professionals gives PWLE credibility and visibility, but risks co-opting their knowledge and political ideals of user-survivor movements, situating them within profit and efficiency paradigms. This perpetuates an individualised, decontextualised, cure-based, neo-liberal lens maintaining the power gap between medical experts and those with lived experience. 

Currently, lived experience in GMH is defined by diagnosis and engagement with formal mental health institutions. Is this truly representative of the majority world? What about those in countries with no services or significant treatment gaps? Can someone be considered a valid PWLE without access to a diagnosis? This notion of lived expertise is intrinsically tied to biomedical systems rooted in Global North socio-economic realities.

By narrowly focusing on carceral institutionalisation and asylum frameworks, GMH centres on discrimination within these systems, neglecting the broader social determinants of mental health. This limited scope overlooks areas where biomedical intervention isn’t central to the discrimination faced by those with psychosocial illness or distress.

By not including those surviving systemic discrimination embedded into health systems this perspective limits the term ‘lived experience’ to be used in the contexts of queerness, race, caste and other historical marginalisations. Especially, in the LMIC context, this means that PWLE often speak from privileged positions of caste, class, language and geography which affects their access to diagnosis, discourse and formal mental health services. 

This issue is also evident in the Global North, where only certain voices shaped by race, religion, ethnicity, and gender and sexuality, are valued. For instance, it took George Floyd’s murder for the American Psychiatric Association (APA) to finally recognise and apologise for its role in supporting structural racism affecting Black, Indigenous and People of Colour communities. Additionally, activist movements like neurodiversity face the same challenges as institutionalised approaches to lived experience, struggling with similar issues of representation and validation.

Disability and Decolonisation

The call to decolonise GMH has been made for over a decade but is only now gaining traction. To challenge GMH’s colonial roots, we must recognise that it perpetuates structural violence by upholding psychiatric definitions of normalcy and productivity, often serving neoliberal interests. This paradigm excludes and dehumanises populations based on their socio-political and economic realities.  Notably, prominent voices and funders of GMH remain silent on Congo and Gaza highlighting the dominance of Western knowledge and power hierarchies.

This must be examined intersectionally through Indigenous perspectives, mad studies, crip theory, and critical disability studies. However, the challenge arises when people’s movements are also implicated in this colonial framework.

Originating from autism advocacy, the neurodiversity movement initially missed crucial intersections like race, sexuality etc. Neurodivergence is often seen politically but lacks depth when limited to white, able-bodied perspectives, leading to advocacy efforts that reflect only a specific group. This narrow focus contributes to the disproportionate police violence and murder of Black youth and adults with mental illness in the United States.

When examining neurodiversity globally, we must ask how it manifests in historically marginalised communities and regions, and whether it includes systemic, biomedical, political, and relational factors.

In decolonising mental health, counter-narratives rooted in lived experiences challenge dominant paradigms, serving as both stories and critiques of what is currently seen as progressive approaches. Decolonisation is political, involving frameworks, accountability, and power structures. It requires recognising how colonisation has shaped bodies and minds, including the assumptions about them, and connecting this to experiences in colonial or postcolonial contexts. Failing to address how colonisation created and defined disability risks perpetuating colonial narratives in discussions about disability.

It is crucial to challenge the dominant decolonisation narrative by disabling it. This means recognising that the current framework fails to consider how both colonial narratives and Global South elites have impacted individual and collective bodies.

By centering the language of disability, GMH and other fields must acknowledge the ongoing colonisation of disabled bodies and colonial and postcolonial factors in shaping disability.

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