APA Symposium Global Issues in Mental

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GMH & Psychiatry Symposium

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GMH & Psychiatry Symposium

Global Issues in Mental Health

Co-Chairs: Vincenzo Di Nicola

Fernando Lolas

American Psychiatric Association

Annual Meeting – San Diego, CA, USA

Wednesday, May 24th, 2017

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GMH & Psychiatry Symposium

Global Issues in Mental Health

Co-Chairs: Vincenzo Di Nicola

Fernando Lolas

Primary Care & School Mental Health,

Ethics & Culture, and

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Conflicts of Interest

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Symposlum Overvlew

Co-ichalrs: Vincenzo Di Nicola & Fernando Lolas: Opening remarks – 5 mins

Presenters: 20 mins presentations + 5 mins questions 1. Gabrlel Ivbljaro:

Realizing the Vision for GMH through Primary Care Transformation 2. Fernando Lolas:

The Ethics of Cultural Sensitivity and GMH 3. Vlnicenzo Dl Nlicola:

Borders and Belonging: Global Migrants and Mental Health 4. Davld M. Ndetel:

Experiences of School Mental Health in Rural and Urban Settings in Kenya

5. Aleema Zakers and Nadla Daly:

Perspectives of International Fellows and Residents

Dlsicussant: Gabrlel Ivbljaro – 20 mins

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Aicknowledgements

Council on International

Psychiatry

Dr. Bernardo Ng

Global Mental Health &

Psychiatry Caucus

Dr. Fernando Lolas

Dr. Gabriel Ivbijaro

Dr. David M. Ndetei

Dr. Aleema Zakers

Dr. Nadia Daly

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Eduicatlonal Objeictlves

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

Appreciate global initiatives in primary mental health to deal with health disparities, complexity and co-morbidity

Understand the ethical dimensions of cultural competence, ethical sustainability and culture-fair guidelines in global mental health

Evaluate a pilot study for implementing child mental health care in diferent school settings in Kenya

Identify the global mental health needs of migrants and refugees in the light of changing defnitions of borders and belonging

Acknowledge and accommodate the perspectives of

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Toplics

Global Mental Health

(Global, Political and Social Issues)

Internatlonal Aspeicts of Mental

Health

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Short Symposlum

Abstraict

This symposium by the Global Mental Health (GMH) Caucus

addresses key developments in the GMH movement, integrating social determinants of health, primary care, school mental health, bio-ethics and cultural psychiatry, and emerging themes in

medicine and the humanities on migrants, refugees and borders. Presentations by senior physicians address: (1) global initiatives in primary mental health to deal with health disparities, complexity and co-morbidity; (2) ethical dimensions of cultural sensitivity,

ethical sustainability and culture-fair guidelines; (3) a pilot study for school mental health in several school settings in Kenya; and (4) needs of migrants and refugees in the light of changing defnitions of borders and belonging.

An international fellows and a resident provide the perspectives of psychiatrists-in-training on GMH. A pioneer in GMH will be a

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Gabrlel Ivbljaro

1. Reallzlng the Vlslon for GMH through

Prlmary

Care Transformatlon

Medical Director, The Wood Street Medical Centre, London, UK

President, World Federation for Mental Health (WFMH)

Chair, The World Dignity Project

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Gabrlel Ivbljaro

1. Reallzlng the Vlslon for GMH through Prlmary

Care Transformatlon

Global initiatives on mental health outcomes aim to improve on current projections for global mortality and burden of disease by 2030.

People with severe mental disorder die 10-20 years earlier.

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Fernando Lolas

2. The Ethlics of Cultural Sensltlvlty and GMH

Professor of Psychiatry and Director, Interdisciplinary Center for Bioethics, University of Chile

Member of the Chilean Academy of Language

Corresponding Member of the Royal Spanish Academy Honorary Member of the Chilean Academy of Medicine Doctor Honoris Causa by fve Latin American universities Member, Editorial boards of World Psychiatry (ofcial journal of the WPA), Transcultural Psychiatry & other journals

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Fernando Lolas

2. The Ethlics of Cultural Sensltlvlty and GMH

Global violence, mass migration and climate change make refection on GMH imperative.

Yet ethics is local, determined by culture and custom. Developing cultural sensitivity is a challenge.

“Ethical sustainability” of policies demands strong forms of social empathy and pragmatic approaches. This ofers fresh insights on the global dimension of health, a hermeneutical understanding of culture and an emphasis on new social and intellectual practices. This new conception of health permits a coherent

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Davld Ndetel and

Vlictorla Mutlso

3. Experlenices of Sichool Mental

Health ln Rural and

Urban Settlngs ln Kenya

Professor of Psychiatry, University of Nairobi Founding Director of Africa Mental Health Foundation

WPA Zone 14 representative

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Davld Ndetel and

Vlictorla Mutlso

3. Experlenices of Sichool Mental Health ln

Rural and

Urban Settlngs ln Kenya

A pilot study to develop school mental health in rural setting, urban and peri-urban settings in

Kenya demonstrates that it is possible to engage

key stakeholders, above all the children themselves. The study concluded that life skills training is a

viable intervention that can be implemented in

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Vlnicenzo Dl Nlicola

vincenzodinicola@gmail.com

4. Borders and Belonglng: Global Mlgrants & Mental Health

Psychologist, psychiatrist & philosopher in Montreal 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

APA Quebec DB Representative & President

Co-founder & Past Chair, APA Global Mental Health Caucus Member, Council on International Psychiatry

Founding President, Canadian Association of Social Psychiatry

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Vlnicenzo Dl Nlicola

4. Borders and Belonglng: Global

Mlgrants and

Mental Health

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.

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Aleema Zakers and Nadla

Daly

5. The Perspeictlve of an APA

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Dlsicussant:

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Vlnicenzo Dl Nlicola

vincenzodinicola@gmail.com

4. Borders and Belonglng: Global Mlgrants & Mental Health

Psychologist, psychiatrist & philosopher in Montreal 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

APA Quebec DB Representative & President

Co-founder & Past Chair, APA Global Mental Health Caucus Member, Council on International Psychiatry

Founding President, Canadian Association of Social Psychiatry

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Eduicatlonal Objeictlves

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

Appreciate the impact of migrants and migrations

Understand the relevance of Global Mental Health

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Toplics

Global Mental Health

(Global, Political and Social Issues)

Internatlonal Aspeicts of Mental

Health

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Keywords

Global Mental Health

Culture

Families

Migrants

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Presentatlon Abstraict

In a time of increased fows of migrants and refugees around the world, where there are over one billion migrants, we may say that the 21st century has started as the century of the migrant.

In a world plagued with territorial wars and contentions over borders, both our way of thinking about and dealing with migrants and borders must 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 very place in the world.

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Keywords

Raymond Williams,

Keywords:

A Vocabulary of Culture and Society

(1976)

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Part I:

Defnlng 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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The Roots of the

Global Mental Health

Movement

International psychiatry/WHO (Sartorius)

Comparative psychiatry (Kraepelin,

Murphy)

Psychiatric epidemiology (Rutter)

Public health (Marmot)

Social psychiatry (Redlich, Leighton)

Cultural psychiatry (Prince, Kleinman)

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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

• _{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)}

• _{Mental Health Gap Action Program (WHO,}

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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 and nongovernmental

• _{Problem ownership criterion –}

_{local ownership of}

problem by recipients

• _{Team criterion –}

_{multi-disciplinary}

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Global Mental Health

• _{A step forward?}

• _{Data gathering and policymaking}

versus clinical concerns and

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Envelopes

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Relational contexts

• _{Attachment and belonging}

• _{Lived experience versus disembodied}

biostatistics (statistics without the

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Part II:

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Defnlng Famlly Studles

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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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 Famllles and

Culture

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Conicluslon –

The Need for a Relatlonal

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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Conicluslon –

Famlly Crltlque

• _{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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Categorles vs

Relatlonal, soiclal, and

icultural icontext

• _{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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Without cultural understanding,

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Je suis convaincu que vos eforts

contribuent à nous rapprocher du

temps où la psychiatrie sera, enfn,

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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 Flgure of the

Mlgrant

(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 Flgure of the

Mlgrant

• “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 Flgure of the

Mlgrant

• 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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Impllicatlons

We live in a world of “intimate

strangers”

• _{For GMH and international psychiatry}

(theoretical)

• _{For policymaking and service planning}

(administrative)

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Impllicatlons

• _{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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Impllicatlons

• _{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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Impllicatlons

• _{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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“Intlmate Strangers”

I see humanity as a family

that has hardly met.

–

Theodore Zeldin

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Blbllography

• 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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Blbllography

• 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.

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Blbllography

• _{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.

• _{Patel, Vikram, Harry Minas, Alex Cohen, Martin J.} Prince, eds. Global Mental Health: Principles and

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Blbllography

• _{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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