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When you are not the minority anymore in the global health community: has the time for mental health finally come?

By Sara Ardila-Gómez
on January 9, 2015

Mental health workers and activists have complained for many years about the marginal place of mental health on the public health agenda. Mental health has tended to be neglected among public health priorities and when included, it was more for rhetorical than factual reasons. But 2015 starts with two major surprises for mental health. First, in the post-2015 sustainable development (SDG) agenda, currently under negotiation, mental health (or more accurately mental illness and its burden) is mentioned within the suggested health objectives (“reduce the burden of non-communicable diseases, including mental illness”). Second, the World Bank titled its yearly World Development Report “Mind, Society and Behavior”, focusing on the “psychological” logic (or sometimes lack of logic) when taking decisions. The first feeling – although I don’t want to generalize obviously – for a mental health professional who has complained for so long is somewhat similar to the old joke of a “minority party” when it wins for the first time the elections and one of its members says, “finally here we are, and that makes us so happy, but… what are we going to do now?”.

Admittedly, being mentioned in these documents might be just part of being “politically correct” for the ones holding the pen, but we can nevertheless assume that some ground has been gained if there is a perceived need to mention something in documents like these – and in the case of the World Bank, it’s definitely more than just being politically correct.  In addition, let’s not forget, if we consider that mental health refers to the way in which human beings think, feel and behave, it is clear that achievement of a future SDG agenda requires taking into account mental health. As we all know, the current (dire) state of the planet has been human-caused (see all the talk of an “Anthropocene”). So “sustainable development” is the mantra now, for good reason. For this to materialize, we need to change urgently the way we humans think and the things we value in order to make our behavior and lifestyles more sustainable (and improve mental health), while knowing that probably the consequences of those changes won’t be (fully) seen or experienced by us. But they will be witnessed and lived by our children and future generations.

Being part of the “opposition” is obviously quite different from being part of the mainstream. How mental health workers and activists are going to play their cards in the Global Health arena, now that mental health is rising on the agenda, will be a major challenge. This is even more the case as there are many internal disputes in the mental health field (between different professions, between different theoretical traditions, between professionals and non-professionals). I remember for example a story a professor told us when a health team had to deal with an important “natural” disaster some years ago: in order to screen for health related problems, the team had decided to use a single screening tool, with a couple of questions for each area. Mental health specialists were unable to get to an agreement on a simple couple of questions and, because of that, mental health was kept out of the screening.

Going back to how 2015 started well for mental health, we need to be fair: this is not the first time that mental health has been mentioned as part of the global health agenda (some years ago, a World Health Report focused on mental health, for example, and there has also been increasing attention for non-communicable diseases in recent years, with mental health sometimes specifically being mentioned in its slipstream). Yet, it is probably the first time that mental health has been included in a broader development agenda, even if the SDG agenda still has to be finalized. Anyhow, it seems unlikely that the increasing focus on mental health will subside in the coming years. Given this momentum, some things need to be thought over, and I want to address just two of them here.

First, on the post-2015 development agenda, it is clear that mental suffering is huge in our world: economic crises, inequalities, war and “natural” disasters all correlate with mental conditions such as depression, suicide, anxiety and others. But to think about human suffering (caused by other human beings) in terms of mental illness is an oversimplification. Even when in the end it is an individual who cannot sleep, who doesn’t want to live anymore, and is in need of individual care, this doesn’t mean that the problem –and its solution- is just an individual one. I remember a conference about sexual abuse, where the lecturer presented a model of intervention whereby, even if the wounds caused by the traumatic event were addressed at the individual level, the last step of the treatment was the involvement of this person in social movements that fought against this very situation. This is, from my point of view, a change of perspective needed for all health professionals. Maybe it sounds utopian, but we need to include within our goals that the “patient” leaves the consultation room with tools for solving the health problem at the individual as well as at the collective level. Of course, this is not a new statement, but we need to keep arguing for this, and in this respect it might be useful to take an in-depth look at the latest World Bank Report and one of its key ideas: how ‘mental models’ (the ways in which we interpret the environment and give sense to our experiences) shape how we understand problems, and due to that, how we respond to them (for instance, as previously mentioned, one mental model of health workers would be that health solutions at the clinical level are just individual ones).

Second, more specifically zooming in on this World Bank Development Report, given my background as a psychologist, the change of perspective on the understanding of human decision-making, in comparison to the 1993 Report, is quite a surprise. For years psychologists have said that “rational” thinking is not the only way, and many times it has been said that it is not even the most important way in which human beings think and take decisions. In recent years, this has gone mainstream (see for example D Kahneman’s bestseller,  ‘Thinking, fast and slow’). So, it is no doubt also a step forward that the World Bank now takes this into account for policy making. Nevertheless, at the same time, I think we need to be cautious, and by this I mean that while perceived rationality has been used as a powerful tool and argument to impose policies in the past, other ways of understanding human behavior can also be used -and have been used/abused already in some cases – as powerful tools to manipulate.

So, I would say that 2015 challenges mental health workers and activists to introduce more complex ways of understanding and dealing with human suffering and its relationships with sustainable development, and make them comprehensible. No development can be sustainable if it causes suffering among a huge part of the world population and, at the same time, no sustainable development will be achieved without changing the “mental” component of health and life.

The time for mental health has come. It’s up to us to seize it now.

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