We can't 'copy-paste' mental health support across the globe

Over the last couple of decades, the field of Global Mental Health (GMH) has emerged as an area of study, practice, and research to address inequities in providing mental health support across the world. Historically, low- and middle-income countries (as classified by the World Bank's assessment of their economies) have struggled to establish and maintain the types of mental health services typically seen in high-income countries. This gave rise to concerns that the considerable burden caused by mental disorders [1] would go unchecked in low- and middle-income countries, which in turn prompted coordinated action aimed at building consensus about how best to respond.

In recent years, there has also been growing recognition of the important role that GMH can play in advancing progress in how people with a lived experience of mental health struggles in high-income countries (such as the US and the UK) can be better supported – particularly those who are marginalised and underserved by existing services. This is more befitting of the 'Global' ambition and scope that GMH ascribes to – rather than being restricted to certain parts of the world, it can have important impacts across the world. As such, 'GMH' is best understood as a diverse range of activities characterised by collaboration with local stakeholders to generate innovative, pragmatic, and context-sensitive approaches related to mental health and wellbeing in settings where resources are limited.

A myriad of initiatives (ranging from training community members to deliver forms of talking therapy, to reforming archaic mental health legislation) falls under the GMH ‘umbrella'. Furthermore, a plethora of various actors contribute to GMH work, including people with lived experience of mental health difficulties, traditional healers, health professionals, government ministries, policymakers, researchers, non-governmental organisations, and international agencies (for example, the World Health Organization). As agendas, expertise, and ideas about the best ways forward can differ hugely, one may naturally wonder how coordination and consensus are established?

To answer this question, it is vitally important to understand how knowledge relating to mental health and well-being is shared, and how decisions about what knowledge is deemed credible are made. After all, what is considered a fact of life to people living in a particular part of the world, can seem like an absolute fantasy to those living elsewhere. It is important to recognise that there can be marked discrepancies in the power that different stakeholders have to shape the agenda for GMH. Care needs to be taken not to undermine the legitimacy and credibility of the knowledge and ideas that stakeholders bring when different worldviews meet because this can prove hugely detrimental to fruitful collaboration.

There is growing recognition amongst those involved in GMH of the risk of what has been referred to as epistemic injustice [2] – put simply, this is the risk of people incorrectly believing that 'the way I understand things is the way that other people ought to understand things'. When working in cultural contexts that are different from our own, we need to hold our assumptions lightly, enter into dialogue and discussion with local partners, and be open to the shared learning that can happen in those spaces. 

It's ultimately about respectful partnership, mutual learning, and pragmatic innovation to see what works on the ground. We need to ensure that we tailor support to the cultural context rather than copy-paste what has been shown to work in a different cultural context.

There is growing evidence confirming that forms of support that have historically been viewed as bona fide treatments from a Western perspective (e.g. psychotherapies such as Cognitive Behavioural Therapy) can be helpful, provided these are adequately adapted for the cultural context in low- and middle-income countries. However, research has also indicated that existing forms of support in low- and middle-income countries (such as traditional healing practices) can have positive impacts on minor to moderate mental health difficulties in these settings [3]. Key questions to consider in evaluating the merits of different forms of support include: does it seem relevant and appropriate to the community, are people willing to access the support, does it uphold and protect people’s human rights, does it show evidence of bringing about benefit for people, is there adequate resource to sustain the support, are there community members who can be trained to deliver the intervention in a cost-effective way?

Some 'home-grown' interventions developed in the low- and middle-income countries have shown promise in supporting local populations' mental health and well-being. For example, in Zimbabwe, the 'Friendship Bench' [4] was developed as a form of support where community members were trained to deliver a problem-solving intervention during meetings on benches placed in local clinics' grounds. This has shown to be effective in treating symptoms of depression and anxiety. Similarly, in post-genocide Rwanda (where up to 1,000,000 people were killed in 1994), an approach called 'sociotherapy' or 'Mvura Nkuvure' (heal me, I heal you) in the local Kinyarwanda language, has been developed and used extensively to reduce distress and facilitate community healing.

My colleagues and I at the University of Liverpool have been working in partnership with Community-Based Sociotherapy Rwanda [5] and researchers from the University of Rwanda (Kigala, Rwanda) and Makerere University (Kampala, Uganda) to explore adapting sociotherapy for the large number of Congolese refugees living in Rwanda and Uganda as part of the COSTAR project. Sociotherapy is delivered by two facilitators who are drawn from the local community and offered training. The intervention is delivered over 15 weekly sessions to groups of between 10 and 15 people and focuses on six phases of work: safety, trust, care, respect, new life directions, and memory. As a community-based approach, we hope that sociotherapy will help address the collective difficulties and shared sources of stress that affect refugees [6]. 

It is hugely important to recognise the enormous role that low- and middle-income countries play in generating knowledge relating to GMH. Too often in recent history, people living and working in the low- and middle-income countries have been narrowly viewed as recipients of knowledge. In particular, there are opportunities for stakeholders living in high-income countries to learn from the pragmatism and pluralism used in low- and middle-income countries. We must explore opportunities to promote more equitable knowledge flows that can improve mental health systems in high-income countries that fail to adequately meet people's needs, particularly for underserved populations such as Black, Asian and Minority Ethnic groups.

As GMH moves forward, it will be helpful to clarify its vision and ambition. As highlighted previously, a goal of GMH at its outset was to reduce inequities in the availability of services to address mental health difficulties across the globe. However, we must look beyond that to determine what the primary purpose of these mental health services actually is. If you ask mental health professionals, many will say it's to reduce the symptoms of mental health problems. On the other hand, politicians may wish to minimise the economic impact that mental health difficulties have on their nation's economy. But if you were to ask a person who has experienced mental health difficulties, and who may be enduring a poor quality of life even after their symptoms are alleviated, their perspective may be different again. 

In recent years, there have been concerted efforts to consult with those who have a lived experience of mental health difficulties (a.k.a 'expert by experience') to ensure that their voices are heard in GMH initiatives [7]. This has coincided with a greater focus on important outcomes such as well-being and quality of life, which relate more to a person's ability to flourish and live a life that has vitality and meaning. Indeed, perhaps an enduring legacy of GMH can be its ability to refine processes and procedures that empower people and communities across the world to clearly articulate what living well and feeling fulfilled means to them.

So, to conclude, when considering mental health support across the globe it's better to make less haste with 'copy-paste', and instead, work collaboratively with local stakeholders to coproduce what will work best in that particular place.