Politics and mental health

Thomas Swerdfager

Philosophy, Psychiatry, & Psychology, Volume 23, Number 3/4, September/December

2016, pp. 309-311 (Article)

Published by Johns Hopkins University Press

DOI: https://doi.org/10.1353/ppp.2016.0036

For additional information about this article

https://muse.jhu.edu/article/648245

Access provided at 7 Jan 2020 04:40 GMT from University of Waterloo

 Politics and Mental
Health
I
n response to my positioning of both cross-
cultural psychiatry and the user/survivor move-
ment as alternatives to dominant mental health
discourses, Cohen importantly points out that,
although such resistance to psychiatric knowl-
edge has both spread and increased, it should be
acknowledged that:
[W]ith the proliferation in categories of mental
illness and the further infiltration of the psychiat-
ric discourse into everyday life, the hegemony of
psychiatric knowledge is probably more powerful
and pervasive currently than at any previous point
in the profession’s history. (2016, p. 303)
Elaborating on an argument perhaps only alluded
to in my article, Cohen at several points makes
clear the connection between the hierarchical sys-
tems of knowledge that underpin modern mental
health services and “the social and economic pri-
orities of neoliberal capitalism” (p. 302). He thus
exhorts us, as critical mental health scholars, to
concentrate less on “assessing the slim chances of
psychiatrists giving up their power to oppress user/
survivors and rather … on further analyzing the
structural determinants that allow such hegemonic
forms of expert discourse to exist and continue to
expand in Western society” (p. 302).
In a short section of my article, I briefly de-
scribed the Mental Health Gap Action Programme
(mhGAP; World Health Organization, 2010) In-
tervention Guide (Swerdfager, 2016), something
Patel, Boyce, Collins, Saxena, and Horton have
argued, “should become the standard approach
© 2017 by The Johns Hopkins University Press
Thomas Swerdfager
for all countries and health sectors; irrational and
inappropriate interventions should be discouraged
and weeded out” (2011, p. 1442). In the preamble
to this document, Director General of the World
Health Organization Margaret Chan makes the
case for addressing mental health on a global scale:
Taking action makes good economic sense.
Mental, neurological and substance use disorders
interfere in substantial ways, with the ability of
children to learn and the ability of adults to func-
tion in families, at work, and in society at large.
(Chan, 2010, p. iii)
Armed with tools such as the mhGAP Interven-
tion Guide, the idea goes, local mental health
practitioners can more efficiently address the great
economic burden that global mental health experts
contend mental illness puts on “society at large.”
Indeed, it is not hard to riffle through the global
mental health literature and find myriad such ex-
amples of explicitly neoliberal language and logic
being employed to justify the relevance and spread
of this ostensibly global field. The name of the
field’s flagship program itself—the mhGAP—refers
to a treatment gap between those who need mental
health services and those who have access to them;
something which can reach up to 75% to 90%
(Patel, 2012, p. 7) in “low-income and middle-
income countries where the gaps are largest” (Patel
et al., 2011, p. 1441). Everywhere the emphasis
is placed on the economics of mental illness, the
burden of its existence, and the efficiencies to be
had in promptly addressing it.
310 ■ PPP / Vol. 23, No. 3–4 / September–December 2016
Of course generally left unposed are questions
of whether or not the economic system that so
demands productive efficiency is not itself partially
causing these problems. It is ignorant to pretend
that the spread of global mental health policy has
occurred in a vacuum, and indeed the political
economies of mental health bear further research
and investigation.
This leads to Jain’s discussion of a growing
body of “interdisciplinary work [that] has poten-
tial to advance a more transparent understanding
of the ‘operation’ of global mental health whilst
shifting the very basis of this ‘operation” (Jain,
2016). Jain’s presentation of the contested history
of cross-cultural psychiatry offers an example of
such work, certainly adding depth to my own pre-
sentation of that discipline as largely resistant to
orthodoxy. The point illustrated here is that there
is nothing inherent to cross-cultural psychiatry
that makes it naturally prioritize user/survivor
experiences any more than mainstream mental
health services; that, in fact, this discipline may
produce nothing more than alternative sources
of expertise, and attendant personal prestige for
‘local’ academics who might otherwise be ignored
by their Euro-American counterparts. Returning
to Cohen’s point, if both cross-cultural and main-
stream psychiatry are fully accepting of the logics
of neoliberal capitalism then it is unlikely that
one will truly offer much resistance to the other.
A shared focus on improving diagnosis and treat-
ment statistics at the expense of developing contex-
tualized understandings of user experiences does,
as Jain and I seem to agree, mean that subjugation
of these latter discourses will continue to occur.
Tying Jain and Cohen’s commentaries together, it is
essential to realize that this subjugation is and will
always be about more than questions of epistemol-
ogy—scientific or ‘alternative’ or otherwise. These
are also questions of political philosophy, about
who is entitled to which rights and where we, as
a society, choose to allocate authority.
What I had hoped to contribute to this special
issue and these debates is an emphasis of these
political aspects of the user/survivor movement.
Situating the movement within a framework of
subjugating and resistant discourses and using
Foucault’s work to understand the relationships
between knowledge and political power helps
us in turn to understand how and why certain
types of ‘evidence’ are prioritized over others
and, hopefully, encourages us to move past bi-
nary understandings of rational versus irrational
knowledge. Discussing the politics of epistemol-
ogy—the ways in which some research methods
presuppose philosophies predicated on efficiency
as a virtue and ‘scaling-up’ as an endpoint—opens
space to understand resistant epistemologies not as
irrational or wrong but as political alternatives. If
instead these debates are seen from a sociopolitical
viewpoint, we might be better able to acknowledge
the legitimacy of all points of view and narratives
of experience, in the same way that we (hopefully)
strive to acknowledge the human dignity entitled
to all persons, regardless of social class or rank.
Author and activist Arundhati Roy writes that
to truly understand the scope and impact of the
spread of modern neoliberal capitalism “is to
situate yourself at the very edge of sanity, to of-
fer yourself up for ridicule” (2000/2014, p. 101).
This is a phrase that has personally resonated with
me, and with which I imagine many in the user/
survivor movement, and critical research more
broadly, might identify. She concludes:
What is happening to our world is almost too
colossal for human comprehension to contain.
But it is a terrible, terrible thing. To contemplate
its girth and circumference, to attempt to define
it, to try and fight it all at once, is impossible.
The only way to combat it is by fighting specific
wars in specific ways. (Roy, 2000/2014, p. 127)
I would argue that one of the most essential such
specific ways is, of course, to reclaim author-
ity over one’s experience and mental landscape,
wherever and whenever possible. If this involves
being situated at the edge of sanity, then perhaps
so be it; it does not mean, as user/survivor research
has indicated, being incapable of cogent thought
or recovery from distress. It instead only means
being subjected to a politically applied label, and
like any other political assertion, it offers myriad
opportunities for resistance.
 Swerdfager / Politics and Mental Health ■ 311

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