Global Mental Health Di Nicola Plovd

Lectio Magistralis

Global Mental Health
Collaborative Care and Transdisciplinary Work
in Community Mental Health

Vincenzo Di Nicola, MD, PhD
Medical University of Plovdiv
Dept of Psychiatry and Medical Psychology
Wednesday, 28 June 2017
9:30 – 11:00 am

Lectio Magistralis

Global Mental Health
Prof. Vincenzo Di Nicola, MD, PhD

Lectio Magistralis

Global Mental Health
Prof. Vincenzo Di Nicola, MD, PhD

Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, DFAPA
vincenzodinicola@gmail.com
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
President, American Psychiatric Association,
Quebec & Eastern
Canada District Branch
Co-founder & Past Chair, APA Global Mental Health
Caucus
Member, APA Council on International Psychiatry
Founding President, Canadian Association of Social
Psychiatry

Conficts of Interest

The presenter has no fnancial
conficts of interest to declare

Acknowledgements

Prof. Dr. Valentin Akabaliev
Prof. Dr. Drozdstoj
Stoyanov
Dept. of Psychiatry and
Medical Psychology
Medical University of Plovdiv

Turku, Finland

Topics

Global Mental Health
International Aspects of Mental
Health
Collaborative Care

Transdisciplinary Collaborations
Community Mental Health

Educational Objectives
At the conclusion of this session, the participant will
be able to:
Defne and describe the Global Mental Health
Movement
Connect the GMH Movement to international
aspects of mental health
Understand the value of Collaborative Care and
Transdisciplinary work
Appreciate community mental health as an ideal
setting for GMH, collaborative care, and
transdisciplinary work

Part I:
Defning 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.”
– Kleinman (2012, p. 421)

Educational Objectives
Defne and describe the Global Mental
Health Movement
Connect the GMH Movement to
international aspects of mental health

The Roots of the
Global Mental Health
International Movement
psychiatry (A Jablensky, N
Sartorius)

Comparative psychiatry (E Kraepelin, HBM
Murphy)

Psychiatric epidemiology (M Rutter)
Public health (M Marmot)
Social psychiatry (F Redlich, A Leighton)
Cultural psychiatry (RH Prince, A Kleinman)
Social determinants of health (M Marmot, ACE
Study)

Training and Projects in
Global Mental Health
Training in psychology

(McGill
University; Institute of Psychiatry, U London)
Child psychiatric epidemiology (M Rutter)

Medicine (McMaster U)
Ontario Child Health Study (DR Oford)

Paediatrics & Psychiatry (McGill U)
Comparative psychiatry (HBM Murphy)
Social psychiatry (A Leighton)
Cultural psychiatry (RH Prince)

Training and Projects in
Global Mental Health
Epidemiological Research
Children’s Food & Mood Study (U London/U Ottawa)
Quebec Children’s Mental Survey (U Montréal)

Syntheses
Cultural Family Therapy (1985-)
Transcultural Child Psychiatry (1991-)
Children & Families in Global Mental Health
(2015-)

Training and Projects in
Global Mental Health

Community Child Psychiatry
Adolescent Day Programme (U Ottawa)
Community Child Mental Health Clinic (U Montreal)

Shared Care, Collaborative Care
Consultation-Liaison (Queen’s, U Montreal)

Transdisciplinary Collaboration
Research, Teaching, Clinic, Policy

Global Projects
Teaching & consultations in Brazil
Mission Haïti

Global Mental Health
Pioneers
Vikram Patel
Eliot Sorel
Samuel Okpaku
Gabriel Ivbijaro

Critics
China Mills
Ethan Watters

Global Mental Health & Psychiatry
Caucus
American
Psychiatric
Caucus
Co-Founders
(2013) Association
Eliot Sorel
Vincenzo Di Nicola
Appointed President
Milton Wainberg (2014-15)
Elected Presidents
Eliot Sorel (2015-16)
Vincenzo Di Nicola (2016-17)
Khurshid R. Khurshid (2017-18)
More than 500 members in 3 years!

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,
May 19, 2010, 303(19): 1976-77.

“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
Sept 2007: 859-877.

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
human rights issues, among others

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,
2008) and mhGap Intervention Guide (WHO,
2010)

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 & nongovernmental
Problem ownership criterion – local ownership
of problem by recipients
Team criterion – multi-disciplinary & multiparty

Global Mental Health
A step forward?
Data gathering and policymaking
versus
Clinical concerns and meaningful
engagement

Envelopes
Relational, social, cultural
Categories versus contexts

Relational contexts
Attachment and belonging
Lived experience
versus
Disembodied biostatistics
(statistics without the “bio”)

Part II:
Defning Family Studies

Defning Family Studies
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.
– Mara Selvini Palazzoli

A Stranger
in the
Family:
Culture, Families,
and Therapy
(1997)

Di Nicola, V. (2004).
Famiglie sulla soglia. Città
invisibili, identità invisibili.
In: Andolf, M. (ed.),
Famiglie immigrate e
psicoterapia transculturale.
Milano, FrancoAngeli (pp.
34-57)

Transcultural Issues
in Child Psychiatry
(1997)

Letters to a
Young
Therapist:
Relational Practices for the
Coming Community
(2011)

With an individual approach, something’s missing …

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
experiencing severe stress due to
rapid and massive culture change

Part III:
Where are Children,
Families
and Culture in GMH?

21st Century Global Mental
Health
Eliot Sorel’s volume, 21st Century Global Mental
Health (2012) has 5 sections, 16 chapters, 400
pp.
This collection does take children and families and
to some extent culture into consideration.
My wish is to maintain and increase this key
sensibility.

21st Century Global Mental
Health
Overview of the contents
from a child, adolescent and
family perspective:
Section 2: Determinants of Health and Mental Health
Family, psychosocial, and cultural determinants of health
(my chapter, Di Nicola, 2012)

Section 3: Health and Mental Health of Populations
child mental health
global disasters mentions child friendly spaces

Section 4: Evaluating and Strengthening Health and
Mental Health Systems
integrating mental health into primary care mentions
depression and early childhood development

21st Century Global Mental
Health
Index:
attachment – 2 mentions child mental health – 19
mentions
childhood, as a social construct
childhood conduct disorder, as a risk factor
•children, as special populations
•family intervention
•family therapy – 5 mentions
•relational approach relational disorders
Note: No mention of adolescent, youth

Essentials of Global Mental
Health
• Samuel Okpaku’s (2014), Essentials
of Global Mental Health, has 8
sections, 44 chapters, 465 pp.
• Both children and family relationships
are addressed (with some gaps)

Essentials of Global Mental
Overview of the contents:
Health
•Section 4: Special Populations
–
–
–
–
–
–

poverty and perinatal morbidity
materal mental health
children’s services
child abuse
child soldiers
adolescent alcohol and substance abuse

•Section 5: Gender and Equality
– In spite of the section name, all chapters are about women’s mental
health, none address men’s issues or LGBT issues, nor the problems
facing single-parent and LGBT families and adoption

•Section 6: Human Resources and Capacity Building
– child mental services in Liberia

Essentials of Global Mental
Health
Index:
•attachment disorders
•family members, family structure, family systems
practice, family-level approaches to treatment
•marital violence
•marriage
•relational perspective on women’s mental health
•Relationships
Note: No mention of adolescents, youth, or couple
and family therapy

Global Mental Health:
Principles & Practice
• In the volume edited by Vikram Patel and
associates (2014), Global Mental Health: Principles
and Practice, there are 20 chapters, 512 pp.
• Just two of them address child and adolescent
mental health and women’s mental health.
• Its strength is in articulating principles including
epidemiology, culture and mental health, social
determinants of health, and health promotion. Key
chapters on practice address stigma and
promoting political commitment for mental health.

Global Mental Health:
Principles & Practice
• On balance, this volume is stronger on principles
than as a guidebook for practice in GMH.
• In spite of the enthusiastic blurb from the editor
of The Lancet, Global Mental Health is somewhat
less than “global” in its reach and something less
than afrmative and embracing in its scope.

Crazy Like Us
• American journalist Ethan Watters’ Crazy Like Us: The Globalization
of the American Psyche (2010) criticizes the notion of exporting US
notions of health and illness around the world, posing a key critique
with his his provocative and polemical title.
• I agree that all notions of health and wellbeing, illness and disease
have a distinct human history and cultural geography. By this I
mean that these notions are not merely biological givens, evolving
over time and taking diferent shapes under the infuence of social
and cultural determinants.
• While I read Watter’s book with interest, I was disappointed to fnd
no chapters on adolescents, children, youth, or families.
• The index has references to: “adolescents” (several mentions),
“children” (numerous mentions), and “Children’s Impact Events
Scale.”
• There is no mention of attachment, family, community, network, or
youth.

Decolonizing Global Mental
• China Mills’ (2013)Health
more scholarly critique,
Decolonizing Global Mental Health: The
Psychiatrization of the Majority World, raises
similar problems by placing GMH itself in a global
perspective, including the perspectives of critical
political theory and post-colonialism.
• There are many mentions of radical critical
thinkers in the social sciences, politics, and
colonialism, e.g., the Caribbean psychiatrist and
revolutionary Frantz Fanon is amply discussed.
• Mills is especially critical of a key GMH notion of
“health gaps,” but that is a separate issue which I
have addressed elsewhere.

Decolonizing Global Mental
Health
• Nonetheless, and again surprising for critiques
that aim at more embracing and inclusive
perspectives, there are no chapters on
adolescents, children and youth, or families.
• The index to this volume includes references to:
“child-like” and “children, and ECT, and
medication, colonialism.”
• There are no citations for adolescents, youth,
families, marriage, attachment or relationships in
any form.

The Need for a Relational
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.
• We cannot have a truly global movement for mental
health without acknowledging the problems in our
current models of health and illness that shape our
models of health care delivery without including
local health cultures and healing traditions.

Family Critique of GMH

• 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
relationships as both resources for health and as
risk factors for illness.

• 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
health. Relational means seeing families as the
bearers of the cultures they come from and their
own unique cultures (Di Nicola, 1997, 2011).

Category vs context
(Relational, social, and cultural
contexts)
• 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
impersonal way of categories—e.g., child abuse,
substance abuse, violence, and treatment gaps—
rather than from the relational, social and cultural
perspectives that defne mental health and illness
more fully, meaningfully, and realistically.

• 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
divorced from our lived experience as communal
and relational beings.

Part IV:
Global Migrants, Borders
and Mental Health

Global Migrants, Borders
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.
– Implications for the theory and practice of psychiatry, for
global mental health and for policy and service planning, as
well as for therapeutics will be addressed. 
Source: APA Symposium, San Diego, CA, USA, May 2017

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
confned by identifcation documents
… detention centers … market, police,
security and informational borders

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)
• The border is in motion (kinopsychology)

•

The Figure of the Migrant
(2015)
“The migrant
is the political
fgure of our time”
Thomas
Nail

• “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
that doing so requires political theory to alter
its foundational presuppositions.”

The Figure of the Migrant
• “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
citizens, kinopolitics begins with the fows of
migrants and the ways they have circulated
or sedimented into citizens and states …”

The Figure of the Migrant
• 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
societies are the exception to this rule

Implications for
Global Mental Health
The migrant is the global fgure of our time.
At once strange and familiar, close and distant,
we are now a world of “intimate strangers.”

Implications
• For GMH and international psychiatry
(theoretical)
• For policymaking and service
planning (administrative)
• For therapeutics
(clinical)

Implications
• 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
– Treatment gaps

Implications
• 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
where the migrant, the border and the state
of exception are becoming the rule?

Implications
• For therapeutics

(clinical)

• A new approach to therapy
– “Threshold people” (limology)
– Acculturation, identity (“evental
psychiatry”)

• We live in a world of “intimate
strangers”

Miljo & Plovdiv

Part V:
Collaborative Care,
Community Health Care and
Working Across Disciplines

Educational Objectives
• Understand the value of Collaborative
Care and Transdisciplinary work
• Appreciate community mental health as
an ideal setting for GMH, collaborative
care, and transdisciplinary work

“Intimate Strangers”
I see humanity as a family
that has hardly met.
– Theodore Zeldin
An Intimate History of Humanity

Bibliography
• 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,
January 2016, I (2): p. 11.

Bibliography
• 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): 421422.
• Marmot, Michael. The health gap: the challenge of an
unequal world. The Lancet, Vol 386, Issue 10011:
2442–44.
• Mills, China. Decolonizing Global Mental Health: The
Psychiatrization of the Majority World. East Sussex,
UK & New York: Routledge, 2013.

Bibliography
• 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
Practice. Oxford, UK: Oxford University Press, 2014

Bibliography

• 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
Culture and Society. London: Croom Helm, 1976.

Acknowledgements

• Prof. Dr. Valentin Akabaliev
• Prof. Dr. Drozdstoj
Stoyanov
Dept. of Psychiatry and
Medical Psychology
Medical University of Plovdiv

Turku, Finland

Question
s
&
Commen
ts