Structural Conditions of the Mind: Global Contexts, Concerns, and Solutions for Global Mental Health from Medical Anthropology

Review by Megan B. Hinrichsen
April 16, 2018

Global mental health: anthropological perspectives

by Brandon A. Kohrt and Emily Mendenhall, eds.
Published 2015

Left Coast Press

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Global Mental Health: Anthropological Perspectives, a collection of ethnographic chapters edited by Brandon A. Kohrt and Emily Mendenhall, is well situated at the intersection of medical anthropology and global health. The discipline of global health recognizes that health issues, including those related to mental health, transcend national boundaries and require global attention. Further, global health prioritizes achieving equity in health for people worldwide. Although global mental health draws upon on a range of disciplines, the field of anthropology takes “pride of place” (8). Although it is uncertain that anthropology has truly carved out the most prominent or important position among the other fields in global mental health, the collection of chapters contained in Global Mental Health surely indicate that anthropology should emphasize its utility in both recognizing and alleviating suffering worldwide.

 Global Mental Health is a robust and vibrant collection that expresses theoretical and ethnographic insights of current research and demonstrates important methodological approaches in practice among anthropologists in the growing field of global mental health. The volume is expertly organized and contextualized beginning with Vikram Patel’s astute foreword. Patel’s foreword introduces the volume’s main objectives, including the anthropological pursuit of understanding mental illness in its context, implementing evidence-based and locally-relevant interventions for mental illness, and ultimately relieving suffering.  This volume pays particular attention to the role of contextual factors in global mental health, especially the structural influences on mental health. Recognizing the importance of the context of mental health disorders and social suffering, however, is not the end of this volume’s contributions. The authors also emphasize the growing need for prevention and treatment within these contexts. Global Mental Health is grounded in ethnography, highlighting the experiences of people around the world who suffer from various forms of mental illnesses as well as the experiences of family members and other caretakers.

 The volume opens with introductory chapters by editors Korht, Mendenhall, and Peter J. Brown on anthropological perspectives on mental health, historical background on medical anthropology’s role in global mental health, and anthropological methods in global mental health research. Kohrt, Mendenhall, and Brown’s writing guides this volume as they introduce and analyze the chapters in each section and conclude with a forthright call for future directions of anthropological engagement in global mental health. The contributions of Kohrt, Mendehall, and Brown are some of the volume’s strongest. It is specifically remarkable that the conclusion does not consist of a synthesis of the major themes covered in the preceding chapters. Instead, the authors of the conclusion extend beyond the boundaries of this volume and make suggestions for future research and the future role of anthropology in global mental health in recognition that there is still much work to be done to better understand and improve mental health around the world.  

The three interrelated sections of this volume outline some of the key challenges in global mental health. The first section, comprised of six chapters, covers the social and structural roots of mental illness around the world. The second section speaks to differential access to care and treatment approaches across cultural and economic (high and low resource) settings in six chapters. The final section, with its five chapters, involves the global mental health workforce and the idea of task-sharing. Global Mental Health frames all of this content calling attention to the significance of anthropology in developing more efficient methods of improving mental health across many populations and contexts.

Mental health is relatively understudied in anthropology and other disciplines related to global health as it is commonly considered to be part of “traditional notions about a ‘hierarchy of needs’ [that imply] that mental health should only be addressed after infectious disease, maternal and child health, and basic living standards” (27). Considering mental health a luxury is one common misconception that this volume intends to overturn. Others involve the cultural tropes of people being “poor but happy” and insisting that mental illness is a disease of “civilization” (27). Poverty is correlated with poor mental health worldwide. Stressful living situations associated with poverty, the social determinants of health, are addressed in Part I. The authors are careful, however, not to essentialize poverty. Writing about water insecurity in highland Bolivia, Amber Wutich et al. note the unfortunate tendency that “any study that connects resource insecurity to mental illness runs a very real risk of contributing to the ‘medicalization of poverty’” (66). Focusing on treating the symptoms of poverty rather than the structural roots of the problem does not change anything. However, Wutich et al. convincingly argue that all mental health policies should begin with ensuring that everyone has access to the basic necessities of life. Other insights in this section involve how people experiencing distress worldwide navigate these negative experiences in their considerations of their own pasts, presents, and futures. This section includes Nadia El-Shaarawi’s recognition that mental health struggles from Ali, an Iraqi refugee, has more to do with “the disruption of life trajectory and the uncertainty of his future” than his signs and symptoms (81). Daniel Mains’s chapter on young men and khat chewing in Ethiopia also addresses the alterity of the future and its implication for mental health. Eileen Anderson-Fye explores the “inconceivable choices between enduring an awful present for a better imagined future” made by young women in Belize (113). Other chapters explore “idioms of distress” (30) like “thinking too much” in Ethiopia, Nicaragua, and Haiti.

The chapters in Part II focus on how treatment approaches and access to healthcare shape people’s experiences of mental health in both high and low-resource settings. This section, complementing the first, demonstrates that ethnographic methods can be useful in exploring how local idioms relate to standardized psychiatric categories. The authors in this section, including Bonnie N. Kaixer and Hunter Keys’ study of Haitians in the Dominican Republic and Jeffrey G. Snodgrass’s exploration of Hindu ways of framing mental illness and suffering contribute toward this goal. This section also explores differences in the treatment of mental illnesses and the tendency for some mental health systems to treat suffering more intensively. The ethnographic chapters highlighting this tendency include Jack R. Friedman’s chapter on the high prevalence of institutionalized psychiatric care in Romania and Emily Mendenhall’s chapter on the long-term, cyclical “costs” of medicalizing suffering by prescribing pharmaceuticals instead of psychotherapeutic treatments among impoverished populations in the United States (205). Sarah S. Willen, with Anne Kohler, ends this section by calling attention to the “culture of medicine” that seeks to universalize patients and make patients backgrounds and structural inequalities irrelevant (239). The treatment approaches in this section have a wide range and underscore the importance of questioning standardized psychiatric categories in local contexts, paying attention to how forms of treatment may impact mental health and suffering, and how clinicians themselves are socialized to interpret mental health and their relationships with their patients.

The final section, Part III, draws attention to the “treatment gap,” the general lack of recognition of mental illness as a pressing concern, and the shortage of mental health professionals worldwide (255). Availability of care is not the only issue; care must also be evidence-based, culturally appropriate, and do no harm. To address the gap in treatment and the many factors that can make mental healthcare inaccessible, inappropriate, or even detrimental, this section explores the concept of task-sharing with non-specialist providers of care. This section explains the current drive to employ local people who can help address the psychosocial origins of suffering. The narratives in this section point to the need to address structural issues like syndemics of poverty and disease in Kenneth Maes’ chapter. Others address the socioeconomic problems of obtaining basic needs among the community and its health workers alike, as shown in the narratives of community health workers in central Mozambique written by Ippolytos Kalofonos and Neely Myers’ chapter on peer helpers in the United States. Non-specialists can deliver mental healthcare to more people suffering from mental illness, however, the non-specialist caregivers themselves may be vulnerable to, or otherwise unable to address, wider structural conditions that impact their communities.

Global Mental Health ends with a powerful and deeply thoughtful message to its readers on not only on the limits of the volume at present but also the limitations facing anthropologists and their research. Global Mental Health attempts to be global in its focus and does represent a fair mix of populations. However, the vast majority of its authors are from North America, a problem facing anthropology as a whole. The editors recognize that most of the mental illnesses covered in the volume are common and more severe mental disorders, like schizophrenia, are absent. Their observation is that the focus on common mental disorders is reflective of the unequal focus within the discipline and not just within this one volume.

The editors and authors featured in Global Mental Health recognize the weaknesses not only of their current work but also the weaknesses within anthropology. The messages in this volume expand the conversation on mental health within medical anthropology and global mental health but the narratives of Juana, Ali, Habtamu, Laura, Mari, Arminda, and many other interlocutors shared in this volume need to be amplified. The editors call on anthropologists to “overcome disciplinary practices that have impeded their productive engagement” with global mental health (341). Anthropologists need not only describe the local context but venture into more applied work to alleviate suffering in those local contexts. Anthropologists should design, implement, and scale local solutions for mental health delivery.

The stories told and insights shared in these chapters are clear and engaging though thoroughly academic. Global Mental Health would be appropriate for academics, clinicians, graduate students, and advanced undergraduate students who want to expand their knowledge and question assumptions about mental health and critically evaluate the strengths and limitations of anthropology’s engagement with global mental health. 

Megan B. Hinrichsen, Assistant Professor of Anthropology at Monmouth College, is a medical anthropologist who has researched structural conditions affecting well-being in Quito, Ecuador. She earned her Ph.D. in medical anthropology from Southern Methodist University.

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