APA Symposium Global Issues in Mental

GMH & Psychiatry Symposium

Global Issues in
Mental Health

GMH & Psychiatry Symposium

Global Issues in Mental Health
Co-Chairs: Vincenzo Di Nicola
Fernando Lolas

American Psychiatric Association
Annual Meeting – San Diego, CA, USA
Wednesday, May 24th, 2017
2:00 – 5:00 pm

GMH & Psychiatry Symposium

Global Issues in Mental Health
Co-Chairs: Vincenzo Di Nicola
Fernando Lolas

Primary Care & School Mental Health,
Ethics & Culture, and
Migrant & Refugee Mental Health

Conflicts of Interest
The presenters have no fnancial
conficts of interest to declare

Symposlum Overvlew
Co-ichalrs: Vincenzo Di Nicola & Fernando Lolas: Opening remarks –
5 mins
Presenters: 20 mins presentations + 5 mins questions
1. Gabrlel Ivbljaro:
Realizing the Vision for GMH through Primary Care Transformation
2. Fernando Lolas:
The Ethics of Cultural Sensitivity and GMH
3. Vlnicenzo Dl Nlicola:
Borders and Belonging: Global Migrants and Mental Health
4. Davld M. Ndetel:

Experiences of School Mental Health in Rural and Urban Settings in
Kenya 
5. Aleema Zakers and Nadla Daly:
Perspectives of International Fellows and Residents
Dlsicussant: Gabrlel Ivbljaro – 20 mins
General dlsicusslon – 30 mins

Aicknowledgements
Council on International
Psychiatry
Dr. Bernardo Ng
Global Mental Health &
Psychiatry Caucus
Dr. Fernando Lolas
Dr. Gabriel Ivbijaro
Dr. David M. Ndetei
Dr. Aleema Zakers
Dr. Nadia Daly
Turku, Finland

Eduicatlonal Objeictlves
At the conclusion of this session, the participant will be able to:
Appreciate global initiatives in primary mental health to deal
with health disparities, complexity and co-morbidity 
Understand the ethical dimensions of cultural competence,
ethical sustainability and culture-fair guidelines in global
mental health 
Evaluate a pilot study for implementing child mental health
care in diferent school settings in Kenya 
Identify the global mental health needs of migrants and
refugees in the light of changing defnitions of borders and
belonging 
Acknowledge and accommodate the perspectives of
psychiatrists-in-training in global mental health theory and
practice 

Toplics
Global Mental Health
(Global, Political and Social Issues)
Internatlonal Aspeicts of Mental

Health
(International Collaborations) 

Short Symposlum
Abstraict
This symposium by the
Global Mental Health (GMH) Caucus
addresses key developments in the GMH movement, integrating
social determinants of health, primary care, school mental health,
bio-ethics and cultural psychiatry, and emerging themes in
medicine and the humanities on migrants, refugees and borders.
Presentations by senior physicians address: (1) global initiatives in
primary mental health to deal with health disparities, complexity
and co-morbidity; (2) ethical dimensions of cultural sensitivity,
ethical sustainability and culture-fair guidelines; (3) a pilot study for
school mental health in several school settings in Kenya; and (4)
needs of migrants and refugees in the light of changing defnitions
of borders and belonging.
An international fellows and a resident provide the perspectives of
psychiatrists-in-training on GMH. A pioneer in GMH will be a

discussant before opening a dialogue with the audience on these
critical, cutting-edge issues in the global delivery of mental health
care. 

Gabrlel Ivbljaro
1. Reallzlng the Vlslon for GMH through
Prlmary
Care Transformatlon
Medical Director, The Wood Street Medical Centre,
London, UK
President, World Federation for Mental Health
(WFMH)
Chair, The World Dignity Project
Professor, NOVA University, Lisbon Portugal 
The Arerosue of Iyede Kingdom  

Gabrlel Ivbljaro
1. Reallzlng the Vlslon for GMH through
Prlmary
Care Transformatlon

Global initiatives on mental health outcomes aim to
improve on current projections for global mortality
and burden of disease by 2030.
People with severe mental disorder die 10-20 years
earlier.
Primary care transformation can narrow the scienceto-service gap in GMH. Primary care data is reviewed.
GMH policies are part of care in their own right rather
than tools to implement care. 

Fernando Lolas
2. The Ethlics of Cultural Sensltlvlty and GMH
Professor of Psychiatry and Director, Interdisciplinary
Center for Bioethics, University of Chile
Member of the Chilean Academy of Language
Corresponding Member of the Royal Spanish Academy
Honorary Member of the Chilean Academy of Medicine
Doctor Honoris Causa by fve Latin American universities
Member, Editorial boards of World Psychiatry (ofcial
journal of the WPA), Transcultural Psychiatry & other
journals

Director, Acta Bioethica

Fernando Lolas
2. The Ethlics of Cultural Sensltlvlty and GMH
Global violence, mass migration and climate change
make refection on GMH imperative.
Yet ethics is local, determined by culture and custom.
Developing cultural sensitivity is a challenge.
“Ethical sustainability” of policies demands strong
forms of social empathy and pragmatic approaches.
This ofers fresh insights on the global dimension of
health, a hermeneutical understanding of culture and
an emphasis on new social and intellectual practices.
This new conception of health permits a coherent
formulation of “culture-fair” GMH.

Davld Ndetel and
3. Experlenices
of Sichool
Mental

Vlictorla
Mutlso
Health ln Rural and
Urban Settlngs ln Kenya 
Professor of Psychiatry, University of Nairobi
Founding Director of Africa Mental Health
Foundation
WPA Zone 14 representative
Chairman, African Division of the Royal College
of Psychiatrists

Davld Ndetel and
3. Experlenices of Sichool Mental Health ln
Vlictorla
Mutlso
Rural and
Urban Settlngs ln Kenya 
A pilot study to develop school mental health in
rural setting, urban and peri-urban settings in
Kenya demonstrates that it is possible to engage

key stakeholders, above all the children themselves.
The study concluded that life skills training is a
viable intervention that can be implemented in
Kenyan schools with minimal extra resources and is
therefore sustainable. 

Vlnicenzo Dl Nlicola
vincenzodinicola@gmail.com
4. Borders and Belonglng: Global Mlgrants & Mental
Health
Psychologist, psychiatrist & philosopher in Montreal
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
APA Quebec DB Representative & President
Co-founder & Past Chair, APA Global Mental Health Caucus
Member, Council on International Psychiatry
Founding President, Canadian Association of Social

Psychiatry
Professor Honoris Causa, FADOM, MG, Brazil

Vlnicenzo Dl Nlicola
4. Borders and Belonglng: Global
Mlgrants 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 are outlined. 

Aleema Zakers and Nadla
Daly
5. The Perspeictlve
of an APA
Internatlonal Fellow  and a Psyichlatry
Resldent

Dlsicussant:
Gabrlel Ivbljaro

Vlnicenzo Dl Nlicola
vincenzodinicola@gmail.com
4. Borders and Belonglng: Global Mlgrants & Mental
Health
Psychologist, psychiatrist & philosopher in Montreal
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
APA Quebec DB Representative & President
Co-founder & Past Chair, APA Global Mental Health Caucus
Member, Council on International Psychiatry
Founding President, Canadian Association of Social
Psychiatry
Professor Honoris Causa, FADOM, MG, Brazil

Eduicatlonal Objeictlves
At the conclusion of this session, the participant will
be able to:
Appreciate the impact of migrants and migrations
Understand the relevance of Global Mental
Health 
Re-evaluate culture and families in Global Mental
Health

Toplics
Global Mental Health
(Global, Political and Social Issues)
Internatlonal Aspeicts of Mental
Health
(International Collaborations) 

Keywords
Global Mental Health
Culture
Families
Migrants
Borders

Presentatlon Abstraict
In a time of increased fows of migrants and refugees around the
world, where there are over one billion migrants, we may say
that the 21st century has started as the century of the migrant.
In a world plagued with territorial wars and contentions over
borders, both our way of thinking about and dealing with
migrants and borders must 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
very 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 outlined in some detail.   

Keywords
Raymond Williams,
Keywords:
A Vocabulary of Culture and Society
(1976)
Culture, family, development are
among the most complex words in
European languages and countries

Part I:
Defnlng 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)

The Roots of the
Global Mental Health
International
psychiatry/WHO (Sartorius)
Movement
Comparative psychiatry (Kraepelin,
Murphy)
Psychiatric epidemiology (Rutter)
Public health (Marmot)
Social psychiatry (Redlich, Leighton)
Cultural psychiatry (Prince, Kleinman)
• Social determinants of health (Marmot)

Global Mental Health
Pioneers
•Vikram Patel
•Eliot Sorel
•Samuel Okpaku
•Gabriel Ivbijaro
Critics
•China Mills
•Ethan Watters

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 and nongovernmental
•Problem ownership criterion – local ownership of
problem by recipients
•Team criterion – multi-disciplinary
and multi-party

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:
Defnlng Famlly Studles

Defnlng Famlly Studles
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

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 Famllles and
Culture
ln GMH?

Conicluslon –
•

The Need for a Relatlonal
Model
In Eliot Sorel’s volume,
21 Century Global Mental
st

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.

Conicluslon –
Famlly Crltlque
• 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).

•

Categorles vs
Relatlonal, soiclal, and
icultural icontext
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:
Mlgrants and Borders

Without cultural
understanding,
we build walls instead
of bridges …

Je suis convaincu que vos eforts
contribuent à nous rapprocher du
temps où la psychiatrie sera, enfn,
humaine. – J.-P. Sartre

•

Theory of the Border
(2016)
“The border
is a process
of social
Thomas
Nail
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 Flgure of the
Mlgrant (2015)
“The migrantThomas
is the politicalNail
fgure of our time”

• “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 Flgure of the
Mlgrant
• “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 Flgure of the
Mlgrant
• 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

Impllicatlons
We live in a world of “intimate
strangers”
•For GMH and international psychiatry
(theoretical)
•For policymaking and service planning
(administrative)
•For therapeutics (clinical)

Impllicatlons
• 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

Impllicatlons
• 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?

Impllicatlons
• For therapeutics

(clinical)

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

• We live in a world of “intimate
strangers”

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

Blbllography
• 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.

Blbllography
• 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.

Blbllography
• 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

Blbllography
• 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.

Question
s
&
Commen
ts