Paper short abstract:

This ethnographic case study draws on 20 hours of observations and participant interviews (n=24) to highlight the role of counsellors in delivering social interventions for mental health in primary care settings.

Paper long abstract:

Increasing attention has been placed on the importance of addressing 'big' determinants of common mental disorders, such as poverty, gender inequality - within treatment spaces. However, the current battery of mental health interventions available in the Global South - home to the greatest burden of CMD- prioritise socio-relational dynamics of distress, leaving the long-wave stressors created by social adversity largely unmediated. Much work is needed to identify routes to providing patients and communities opportunities to respond to the full gamut of social conditions that shape poor mental health outcomes.

Is it possible for mental health interventions delivered in primary care settings to be sites for tackling structural determinants of mental health? Our research provides an ethnographic case study of clinic in Klerksdorp, South Africa, where group problem solving therapy sessions modified to promote collective action in response to social determinants of depression were delivered with some success.

Analysis of interview and observational data highlights a series of communicative and practical strategies that enable shifts in psychological and normative framings in patients lives that serve as bridges to wider change in the lives of service users. It also highlights the pivotal role of the counsellor as 'change agent' in enabling the successful delivery of this modified group therapy. Implications for future 'socially informed' interventions delivered in primary care in LMIC settings are discussed.

Paper short abstract:

This research investigated two questions through an ethnographic case study of a community mental health programme in Kathmandu: 1) What are components of a 'thick' social approach to mental health in Nepal?; 2) How does such an approach impact on people with mental health problems?

Paper long abstract:

Mental health in Nepal has long been neglected at policy and practice levels. Formal services almost exclusively emphasize biomedical interventions with limited attention to social dimensions and interventions.

The current research investigated two questions: 1) What are components of a 'thick' social approach to mental health in Nepal?; 2) How does such an approach impact on people with mental health problems?

The paper develops an ethnographic case study of one community mental health programme, Chhahari Nepal for Mental Health (a second case study is currently in development). This involved analysis of programme documentation, case notes, participant observation of programme activities and interviews (n=17) with clients and their family members and programme staff.

A 'thick' social approach is characterized by a process of relationship building between workers and clients that draws on 'deep' knowledge of context and family dynamics. Interventions emphasize a 'slow' approach to build trust and engagement both with clients, family members and wider social and medical systems. A holistic approach emphasizing values of 'care', 'respect' and the complementarity of social and biomedical interventions was crucial to positive mental health outcomes for clients. This holistic working permitted a humanizing of mental health problems, better quality of life for clients and caregivers, increased acceptability of mental health care, and improved medication management.

This research is set within wider global mental health debates about the nature and hierarchies of 'evidence'. Our case study approach suggests the value of evidencing 'practice experience' to better understand the 'mechanisms' that enable mental health outcomes.

Paper short abstract:

An ethnographic account of people living with severe mental illness and negotiating their experiences of suffering within three distinct mental healthcare structures in India. The socio-culture ineptness of 'recovery' would be discussed vis-à-vis narratives of contextually-situated expectations.

Paper long abstract:

The traditional biomedical models of severe mental illness (SMI) and clinical recovery dictate mental healthcare practices and situate the responsibility of health and wellbeing within the individual. The newer mental healthcare policies guided by the Global Mental Health movement are also focusing on individualistic notions of personal recovery and human rights. However, this emphasis on personal transformation and agency does not necessarily align with the social, political, and cultural realities of India. An ethnographic study was undertaken at three distinct sites of mental healthcare - a halfway home, a private psychiatric hospital, and a community outreach centre- to understand the meaning-making processes around SMI. Analysis of semi-structured interviews, observations, field notes, and secondary material brought forth discourses of suffering situated in the complex socio-political hierarchies. Culturally-specific idioms of distress and subjective understandings of people living with SMI are consistently disregarded as they fail to align with the goals of the existing mental healthcare system. Thus, suffering in SMI was found to be further accentuated by an imposed 'quest for recovery'. This compels one to question the meaningfulness of such clinical engagements. The paper further problematizes the concept of recovery in the Indian context and explores alternative discourses through first-person narratives of people living with SMI.

Keywords: severe mental illness, recovery, India, socio-cultural context, alternative discourse

Paper short abstract:

The study explores Yoruba healers' mental healthcare. Ethnographic fieldwork shows that: Mental illness (MI)could be internal/external to the victim; having MI by default is possible;and treatment could be tangible or intangible. I conclude that MI and/or treatment is beyond victim's bodily symptoms

Paper long abstract:

Understanding different cultural stances on aetiology, diagnosis and preferred therapies for mental illness is germane to global mental health augmentation. This study explores Yoruba understanding of vectors and 'agents' of mental illness form the traditional healers' perspectives. My ethnographic fieldwork draws from popular and prominent traditional psychiatrist with years of practice in Abeokuta, southwest, Nigeria. Data reveal an array of 'predispositions' and approaches to mental illness and mental healthcare respectively. Among these is the concept of abisinwin (born to be mad) which indicates the possibility of having mental illness by default based on 'blood fusion' or born of a conception at a certain time in the Yoruba cosmic calendar. Other predispositions include natural factors such as accident and substance abuse, and preternatural factors such as curse and bewitchment. The vectors could be one or combination of the following: air, image, name, used materials, and dreams. The treatment can be internal or external to the victim through two major approaches: tangible and intangible. The tangible approach involves use of 'medication' while intangible could be either instructive or etutu. Each approach has different compositions and modes of usage but may be combined during treatment. Also, the recovery of an individual is not regarded as a proof of cure but an assurance that all relatives including the unborn generation are believed to be 'immune' against mental illness. This paper therefore concludes that mental illness exists beyond bodily symptoms and individual body among the Yoruba speaking people especially in the study location.

Paper short abstract:

Synthesising primary and secondary data from a rapidly urbanising district in Sri Lanka, we establish the gendered, cumulative, and transformative nature of surviving and deceased women's trajectories through self-harming experiences, culminating in a conceptual framework relevant beyond Sri Lanka.

Paper long abstract:

Women disproportionately experience self-directed violence (SDV), particularly those residing in South Asia and engaging in non-lethal behaviours, yet discourse remains informed by excessively male data. Limited research explores South Asian women's experiences to understand how, why and with what consequences they engage in SDV. Calls persist for targeted research on women of reproductive age to inform gender-sensitive prevention efforts. This paper contributes to theory building by developing an emic conceptual framework to understand women's pathways through SDV in urbanising Sri Lanka.

Applying an innovative psychosocial autopsy approach to gather primary and secondary data in 2016, we interviewed 17 surviving self-harming women and analysed narratives from 20 suicide inquest files of reproductive age women in Gampaha District using Interpretative Phenomenological Analysis.

Informed by living and suicided women's stories, seven interrelated, dynamic and cumulative dimensions formed a conceptual framework highlighting women's exposure to vulnerabilities particular to their socially constructed identity as inferior members of patriarchal societies. The ways in which women's gendered position limits their ability to manage impacts and access support, and the unsuitability of the language of impulsivity to describe women's SDV emerges. Women's selection of SDV in this context offers both transformative potential and unforeseen consequences.

Our framework presents women's SDV as one consequence of structural and interpersonal gender-based violence, enacted at all levels and over women's life courses. It is likely relevant in other contexts where traditional patriarchal structures persist. We advocate for a human rights-based approach to advance the prevention and postvention agenda for women's self-directed violence.

Paper short abstract:

This paper presents an ethnographic account of women's mental distress, or 'tension', as a register of rising economic inequality within and between households in the Gaddi tribal community of Kangra District in Himachal Pradesh, India.

Paper long abstract:

This paper presents an ethnographic account of women's mental distress, or 'tension', as a register of rising economic inequality within and between households in the Gaddi tribal community of Kangra District in Himachal Pradesh, India. This community has experienced a rapid change of labour regime from agro-pastoralism to participation in informal wage labour over the past century, rupturing not only the Gaddi mode of production, but also their distinctive pastoralist identity and associated moral cosmology. Rapid change has resulted in generational disparity in livelihood strategies, literacy, access to technology, expectations and age of marriage (Kapila 2003). This paper applies a feminist economic lens (Bear et al. 2015) to argue that ideals of Gaddi femininity and respectability are implicated in projects of upward social mobility. Taking the household as a micro-context of 'social' suffering, it traces how, as a result, new forms of mental distress are being experienced and expressed through the idiom of 'ghar ka tension'. It sees 'tension' as an emic term that allows women to register and resist increasing precarity within the household. This case highlights the importance of mental health interventions that take a life-course approach to recovery and an holistic approach to care - appreciating the dynamics of kinship, gender and economic inequality.

Paper short abstract:

This research examined: 1) What are the types of skills and strategies community mental health workers (CWs for short) at Project Burans deploy with clients? 2) How do CWs conceptualize outcomes - both positive and negative? 3) How do CWs conceptualize the determinants of poor mental health?

Paper long abstract:

Community-based workers promote mental health in communities yet little attention has been given to the ways they operate and the strategies used (Chatterjee et al., 2014). For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery?

This research examined: 1) What are the types of skills and strategies community mental health workers (CWs for short) at Project Burans deploy with clients? 2) How do CWs conceptualize outcomes - both positive and negative? 3) How do CWs conceptualize the determinants of poor mental health?

We interviewed CWs (n=46) about clients who were randomly selected from those using a new 6-visit care-plan. Notes were typed down during the interviews and cross checked using the audio files. The notes were then coded by SJ and KM.

CWs displayed in-depth knowledge of the context of their client's lives and family dynamics and used this information to analyse possible factors that increased or decreased mental health for the client and their family members. CWs demonstrated a range of analysis and intervention skills building on contextual knowledge and personal critical reflection. The applied knowledge of the physical, social and family (ecological) contexts to undertake relevant and sometimes sophisticated analyses of the social determinants that shaped the mental health of clients. CWs used their in-depth knowledge of clients' mental health status, family dynamics and other contextual factors to adapt and implement micro-interventions in a bespoke way

Paper short abstract:

This paper is an ethnographic study of mental health interventions in a refugee settlement in Uganda.In this context, the integration of mental health services into primary care has led to an active disengagement of the humanitarian system with the socio-economic difficulties of their beneficiaries.

Paper long abstract:

This paper is an ethnographic study of mental health interventions in a refugee settlement in Uganda. Uganda currently hosts more than a million South Sudanese refugees fleeing a brutal and ongoing conflict. The emergency response to this crisis has recently included the integration of mental health services into primary care ones. This strategy, consistent with one of the main pillars of the movement for global mental health, is being piloted by the UNHCR in Ugandan refugee settlements, and is the focus of this study. Drawing on 6 months of in-depth ethnographic fieldwork in the refugee settlement of Palabek, northern Uganda,

this paper argues that mental health and psychosocial services in Palabek are largely incapable of addressing the widespread suffering and needs of their beneficiaries. This is due to two different reasons. Firstly, the heavy reliance of psychotropic medication leads to psychosocial dimensions of suffering to be overlooked, while "social interventions" are understood merely as efforts directed at ensuring compliance with the medication; on a similar note, the consequences of the side-effects of such medications on patients' social and economic environment are heavily overlooked. Secondly, the lack of thorough follow-ups leads to the concept of recovery being flattened down to continuous and virtually never-ending compliance with medication. In the context of Palabek refugee settlement, the prescription of psychotropic medication ultimately becomes a way for the humanitarian apparatus to actively disengage with the ongoing socio-economic difficulties that are in the best case precipitating, if not directly causing, the suffering of the refugees.

Paper short abstract:

Ethnographic research with community mental health workers in Ghana shows how globalised norms of clinical practice and audit render invisible forms of support enacted within relationships between clinicians and families which draw on socially embedded moral values and resist global replication.

Paper long abstract:

Critics of global mental health have often pointed to the dangers of biomedical reductionism and the pharmaceuticalisation of mental distress. In this paper I draw on long-term ethnographic fieldwork in Ghana to argue that, despite the prominence of psychotropic medication within clinical practice, the social is deeply embedded in interactions between community mental health practitioners, patients and caregivers. However it is rendered invisible since it is not accounted for within globalised formulations of the 'psychosocial' - often conceived as adaptable and portable technologies such as cash transfers, brief therapies and peer support - institutionalised social work, nor clinical audit. Nonetheless in Ghana the enactment of the social is an essential adjunct to clinical practice not only due to the need to work around the restrictions of resource scarcity, but to the social embeddedness of encounters between health workers, families and patients, particularly where these take place within family homes. Such encounters draw on a moral praxis of relatedness, social and religious values, philanthropy and obligation to address basic needs such as shelter, food, clothing and employment. Undocumented in clinical records and thus invisible within 'the clinic', they are rather shared informally through social media and local networks extending beyond the clinical. These forms of praxis resist global replication or standardisation, addressing social needs through small scale personalised support. They arise not only from the virtual absence of formal social services, but also enact longstanding practices of social redistribution which render life and care possible in the face of extreme poverty.