Global Mental Health Di Nicola Plovd

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Lectio Magistralis

Global Mental Health

Collaborative Care and Transdisciplinary Work in Community Mental Health

Vincenzo Di Nicola, MD, PhD

Medical University of Plovdiv

Dept of Psychiatry and Medical Psychology

Wednesday, 28 June 2017

9:30 – 11:00 am

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Lectio Magistralis

Global Mental Health

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Lectio Magistralis

Global Mental Health

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Vincenzo Di Nicola

MPhil, MD, PhD, FRCPC, DFAPA

vincenzodinicola@gmail.com

Full Professor of Psychiatry, University of Montreal Founder & Co-director, Psychiatry and Humanities Course, UdeM

Chief, Child & Adolescent Psychiatry,

Montreal University Mental Health Institute, UdeM President, American Psychiatric Association,

Quebec & Eastern Canada District Branch

Co-founder & Past Chair, APA Global Mental Health Caucus

Member, APA Council on International Psychiatry

Founding President, Canadian Association of Social Psychiatry

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Conficts of Interest

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Acknowledgements

Prof. Dr. Valentin Akabaliev Prof. Dr. Drozdstoj

Stoyanov

Dept. of Psychiatry and Medical Psychology

Medical University of Plovdiv

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Topics

Global Mental Health

International Aspects of Mental

Health

Collaborative Care

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Educational Objectives

At the conclusion of this session, the participant will be able to:

Defne and describe the Global Mental Health Movement

Connect the GMH Movement to international aspects of mental health

Understand the value of Collaborative Care and Transdisciplinary work

Appreciate community mental health as an ideal setting for GMH, collaborative care, and

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Part I:

Defning Global Mental

Health

Arthur Kleinman argues for a rebalancing

of academic psychiatry, citing global

mental health (GMH) as an emerging

priority

“Global health is now squarely on the

agenda of students, researchers and

funders.”

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Educational Objectives

Defne and describe the Global Mental

Health Movement

Connect the GMH Movement to

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The Roots of the

Global Mental Health

Movement

International psychiatry

(A Jablensky, N Sartorius)

Comparative psychiatry

(E Kraepelin, HBM

Murphy)

Psychiatric epidemiology

(M Rutter)

Public health

(M Marmot)

Social psychiatry

(F Redlich, A Leighton)

Cultural psychiatry

(RH Prince, A Kleinman)

Social determinants of health

(M Marmot, ACE

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Training and Projects in

Global Mental Health

Training in psychology

(McGill

University; Institute of Psychiatry, U London)

Child psychiatric epidemiology

(M Rutter)

Medicine

(McMaster U)

Ontario Child Health Study (DR Oford)

Paediatrics & Psychiatry

(McGill U)

Comparative psychiatry

(HBM Murphy)

Social psychiatry

(A Leighton)

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Training and Projects in

Global Mental Health

Epidemiological Research

Children’s Food & Mood Study (U London/U Ottawa) Quebec Children’s Mental Survey (U Montréal)

Syntheses

Cultural Family Therapy (1985-)

Transcultural Child Psychiatry (1991-)

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Training and Projects in

Global Mental Health

Community Child Psychiatry

Adolescent Day Programme (U Ottawa)

Community Child Mental Health Clinic (U Montreal)

Shared Care, Collaborative Care

Consultation-Liaison (Queen’s, U Montreal)

Transdisciplinary Collaboration

Research, Teaching, Clinic, Policy

Global Projects

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Global Mental Health

Pioneers

Vikram Patel

Eliot Sorel

Samuel Okpaku

Gabriel Ivbijaro

Critics

China Mills

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Global Mental Health & Psychiatry

Caucus

American Psychiatric Association

Caucus Co-Founders (2013)

Eliot Sorel

Vincenzo Di Nicola

Appointed President

Milton Wainberg (2014-15)

Elected Presidents

Eliot Sorel (2015-16)

Vincenzo Di Nicola (2016-17)

Khurshid R. Khurshid (2017-18)

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Global Mental Health

GMH is “an area of study, research

and practice that places a priority on

improving mental health and

achieving equity in mental health for

all people worldwide.”

– Vikram Patel & Martin Prince.

Global mental health: a new global

health feld comes of age.

JAMA

,

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“No Health Without Mental

Health”

“Mental health awareness needs to be

integrated into all aspects

of health

and social policy, health-system

planning, and delivery of primary and

secondary general health care.”

– Martin Prince, Vikram Patel, Shekhar

Saxena, et al. No health without mental

health.

The Lancet, 370,

No. 9590, 8

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Global Mental Health

Taking into account

cultural diferences

and

country-specifc conditions

, GMH deals with:

the epidemiology of mental disorders in

diferent countries

their treatment options

mental health education

political and fnancial aspects

the structure of mental health care systems

human resources in mental health

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Global Mental Health

Key contemporary studies:

Global Burden of Diseases Report (Murray &

Lopez, 1996)

Social Determinants of Health (WHO, 2003)

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Global Mental Health

GMH defned by Samuel Okpaku by fve

criteria:

Universal and transnational criterion –

universal or transnational aspect (not local)

Public health criterion –

population basis

Stakeholders criterion –

international in

composition, educational, scientifc,

governmental & nongovernmental

Problem ownership criterion –

local ownership

of problem by recipients

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Global Mental Health

A step forward?

Data gathering and policymaking

versus

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Envelopes

Relational, social, cultural

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Relational contexts

Attachment and belonging

Lived experience

versus

Disembodied biostatistics

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Part II:

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Defning Family Studies

La terapia familiare è il punto di partenza per lo studio di unità sociali sempre più ampie

.

Family therapy is the starting point

for the study of ever wider social

units

.

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A Stranger

in the

Family:

Culture, Families, and Therapy

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Di Nicola, V. (2004).

Famiglie sulla soglia. Città invisibili, identità invisibili. In: Andolf, M. (ed.),

Famiglie immigrate e

psicoterapia transculturale.

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Transcultural Issues in Child Psychiatry

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Letters to a

Young

Therapist:

Relational Practices for the Coming Community

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Applications

In a world with huge global fows of

migrants and refugees instigated by

confict, disasters, or economic and

social reasons,

Cultural Family

Therapy

ofers clinical tools to

understand and treat families

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Part III:

Where are Children,

Families

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21

st

Century Global Mental

Health

Eliot Sorel’s volume, 21st Century Global Mental

Health (2012) has 5 sections, 16 chapters, 400 pp.

This collection does take children and families and to some extent culture into consideration.

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21

st

Century Global Mental

Health

Overview of the contents from a child, adolescent and family perspective:

Section 2: Determinants of Health and Mental Health

Family, psychosocial, and cultural determinants of health (my chapter, Di Nicola, 2012)

Section 3: Health and Mental Health of Populations

child mental health

global disasters mentions child friendly spaces

Section 4: Evaluating and Strengthening Health and Mental Health Systems

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21

st

Century Global Mental

Health

Index:

attachment – 2 mentions child mental health – 19 mentions

childhood, as a social construct

childhood conduct disorder, as a risk factor

•_{children, as special populations} •_{family intervention}

•_{family therapy – 5 mentions}

•_{relational approach relational disorders}

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Essentials of Global Mental

Health

• _{Samuel Okpaku’s (2014),}

_Essentials

of Global Mental Health

, has 8

sections, 44 chapters, 465 pp.

• _{Both children and family relationships}

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Essentials of Global Mental

Health

Overview of the contents:

•Section 4: Special Populations

– poverty and perinatal morbidity

– materal mental health

– children’s services

– child abuse

– child soldiers

– adolescent alcohol and substance abuse

•Section 5: Gender and Equality

– In spite of the section name, all chapters are about women’s mental health, none address men’s issues or LGBT issues, nor the problems facing single-parent and LGBT families and adoption

•Section 6: Human Resources and Capacity Building

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Essentials of Global Mental

Health

Index:

•_{attachment disorders}

•_{family members, family structure, family systems}

practice, family-level approaches to treatment

•_{marital violence} •_marriage

•_{relational perspective on women’s mental health} •_{Relationships}

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Global Mental Health:

Principles & Practice

• _{In the volume edited by Vikram Patel and}

associates (2014), Global Mental Health: Principles and Practice, there are 20 chapters, 512 pp.

• _{Just two of them address child and adolescent} mental health and women’s mental health.

• _{Its strength is in articulating principles including} epidemiology, culture and mental health, social

determinants of health, and health promotion. Key chapters on practice address stigma and

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Global Mental Health:

Principles & Practice

• _{On balance, this volume is stronger on principles}

than as a guidebook for practice in GMH.

• _{In spite of the enthusiastic blurb from the editor}

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Crazy Like Us

• American journalist Ethan Watters’ Crazy Like Us: The Globalization of the American Psyche (2010) criticizes the notion of exporting US notions of health and illness around the world, posing a key critique with his his provocative and polemical title.

• I agree that all notions of health and wellbeing, illness and disease have a distinct human history and cultural geography. By this I

mean that these notions are not merely biological givens, evolving over time and taking diferent shapes under the infuence of social and cultural determinants.

• While I read Watter’s book with interest, I was disappointed to fnd no chapters on adolescents, children, youth, or families.

• The index has references to: “adolescents” (several mentions), “children” (numerous mentions), and “Children’s Impact Events Scale.”

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Decolonizing Global Mental

Health

• _{China Mills’ (2013) more scholarly critique,}

Decolonizing Global Mental Health: The

Psychiatrization of the Majority World, raises

similar problems by placing GMH itself in a global perspective, including the perspectives of critical political theory and post-colonialism.

• _{There are many mentions of radical critical}

thinkers in the social sciences, politics, and

colonialism, e.g., the Caribbean psychiatrist and revolutionary Frantz Fanon is amply discussed.

• _{Mills is especially critical of a key GMH notion of}

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Decolonizing Global Mental

Health

• _{Nonetheless, and again surprising for critiques}

that aim at more embracing and inclusive perspectives, there are no chapters on

adolescents, children and youth, or families.

• _{The index to this volume includes references to:}

“child-like” and “children, and ECT, and medication, colonialism.”

• _{There are no citations for adolescents, youth,}

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The Need for a Relational

Model

• In Eliot Sorel’s volume, 21st Century Global Mental

Health (2012), I examined the family, psychosocial, and cultural determinants of health (Di Nicola,

2012).

• These are critical and essential aspects that

demand study and inclusion in any comprehensive view of health.

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Family Critique of GMH

• _{Those of us who work with mental health issues}

from a family perspective believe that seeing individuals in isolation is limited and ignores, minimizes or discounts the importance of

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• _{The work on}_attachment_{(which is theoretically}

important and clinically fertile) and belonging (its counterpart in social and cultural psychiatry,

addressing aspects of afliation, identity, and social cohesion) demonstrates that relationships

in general are avenues for treatment from both a family therapy perspective and the social

determinants of health perspective (Di Nicola, 2012).

• _{This is the}_systems_or_{relational approach}_to

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Category vs context

(Relational, social, and cultural

contexts)

• _{From a family perspective, the Global Mental}

Health Movement appears as a regressive step to the usual Western health categories that focus on individuals as bearers of larger issues in the

family, community, society and culture.

• _{These larger envelopes are addressed in the}

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• _{These aspects of GMH may deepen the}

practitioners’ perception of public health and epidemiology and their international

organizations as being removed from clinical concerns and from their meaningful relational contexts.

• _{Without such notions as attachment and}

belonging, ignoring the most signifcant of human relationships based on the family and community, GMH risks creating another disembodied feld

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Part IV:

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– With over one billion global migrants, the 21st century has begun as the century of the migrant.

– Contentions over borders demand that our way of thinking about and dealing with migrants and borders be revised.

– This has implications for anthropology and geography, politics and philosophy, and not least for medicine and psychiatry.

– Psychiatry must redefne how we deal with migrants and refugees, their displacements and potential traumas and their place in the world.

– Implications for the theory and practice of psychiatry, for global mental health and for policy and service planning, as well as for therapeutics will be addressed.

Source: APA Symposium, San Diego, CA, USA, May 2017

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Theory of the Border

(2016)

Thomas Nail

• _{“The border is a process of social}

division”

• _{“Social motion is divided”}

• _{Coralled … territorial fences …}

politically expelled … juridically

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Theory of the Border

• _{The fence, the wall, the cell, the}

checkpoint, the frontier, the limit, the

march, the boundary …

• _{What they have in common is a}

_division

or

bifurcation

• _{The border is in between (}

_threshold,

limology

)

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The Figure of the Migrant

(2015)

Thomas Nail

• _{“The migrant is the political fgure of our time”}

• _{“At the turn of the twenty-frst century, there}

were more regional and international migrants

than ever before in recorded history. Today,

there are over 1 billion migrants and each

decade the global percentage of migrants and

refugees grows. Political theory has yet to take

this phenomenon seriously. My work argues

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The Figure of the Migrant

• “It requires a whole new theoretical starting

point that does not begin with stasis and the

state, but with the more primary social

movements

that constitute the state, as

well as the social alternatives that arise

from those same movements.”

• _{“Instead of starting with a set of preexisting}

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The Figure of the Migrant

• Across disciplines – anthropology,

geography, philosophy, political science –

the migrant was treated as an

exception to

the rule

of existing theoretical frameworks

• The migrant is rather the

constitutive

condition of contemporary politics

• _{Migration is historically constant – sedentary}

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Implications for

Global Mental Health

The migrant is the global fgure of our time.

At once strange and familiar, close and distant,

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Implications

• _{For GMH and international psychiatry}

(theoretical)

• _{For policymaking and service}

planning

(administrative)

• _{For therapeutics}

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Implications

• _{For GMH and international psychiatry}

(theoretical)

• _{A new science of}

_limology

_and

kinopsychology

based on the

migrant

and the

sojourner

–

World burden of disease

–

Social determinants of health

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Implications

• _{For policymaking and service planning}

(administrative)

–

Who is a citizen?

–

Who has access to care?

–

_{Who is a migrant or refugee?}

–

Who defnes and controls the border?

–

_{What can}

_rights

_and

_dignity

_{mean in a world}

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Implications

• _{For therapeutics}

_(clinical)

• _{A new approach to therapy}

–

_{“Threshold people” (limology)}

–

_{Acculturation, identity (“evental}

psychiatry”)

• _{We live in a world of “intimate}

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Part V:

Collaborative Care,

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Educational Objectives

• _{Understand the value of Collaborative}

Care and Transdisciplinary work

• _{Appreciate community mental health as}

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“Intimate Strangers”

I see humanity as a family

that has hardly met.

–

Theodore Zeldin

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Bibliography

• Di Nicola, Vincenzo. A Stranger in the Family: Culture,

Families and Therapy. New York: W.W. Norton & Co., 1997.

• _{Di Nicola, V.}_{Letters to a Young Therapist: Relational}

Practices for the Coming Community. New York: Atropos Press, 2011.

• _{Di Nicola, V. Family, psychosocial, and cultural}

determinants of health. In: Sorel, Eliot, ed., 21st Century

Global Mental Health. Burlington, MA: Jones & Bartlett Learning, 2012, pp. 119-150.

• Di Nicola, V. Forum: Defning global mental health and psychiatry. Global Mental Health & Psychiatry Newsletter,

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Bibliography

• Joshi, Paramjit T. and Lisa Cullins, eds. Global Mental

Health Issue. Child and Adolescent Psychiatric Clinics

of North America. January 2016.

• Kleinman, Arthur. Editorial: Rebalancing academic

psychiatry: why it needs to happen – and soon.

British Journal of Psychiatry Dec 2012, 201 (6)

: 421-422.

• Marmot, Michael. The health gap: the challenge of an

unequal world. The Lancet, Vol 386, Issue 10011:

2442–44.

• Mills, China. Decolonizing Global Mental Health: The

Psychiatrization of the Majority World. East Sussex,

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Bibliography

• _{Okpaku, Samuel O., ed.,}_{Essentials of Global}

Mental Health. Cambridge, UK: Cambridge University Press, 2014.

• _{Nail, Thomas.}_{The Figure of the Migrant}_{. Stanford,} CA: Stanford University Press, 2015.

• _{Nail, Thomas.}_{Theory of the Border}_{. 2016. Oxford,} UK: Oxford University Press, 2016.

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Bibliography

• _{Patel, Vikram & Martin Prince. Global mental} health: a new global health feld comes of age.

JAMA, May 19, 2010, 303(19): 1976-77.

• _{Prince, Martin, Vikram Patel, Shekhar Saxena, et} al. No health without mental health, The Lancet, 370, No. 9590, 8 Sept 2007: 859-877.

• _{Sorel, Eliot, ed.,}₂₁st Century Global Mental Health.

Burlington, MA: Jones & Bartlett Learning, 2012.

• _{Watters, Ethan.}_{Crazy Like Us: The Globalization of}

the American Psyche. New York: Free Press, 2010.

• _{Williams, Raymond.}_{Keywords: A Vocabulary of}

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Acknowledgements

• _{Prof. Dr. Valentin Akabaliev} • _{Prof. Dr. Drozdstoj}

Stoyanov

Dept. of Psychiatry and Medical Psychology

Medical University of Plovdiv

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