Title: Where Is the Family in Global Mental Health? Presenter: Vincenzo Di Nicola, M.D., Ph.D. Learning Objectives: Audience participants will be able to: (1) Articulate why a central role for families is needed for the effectiveness of clinical and research programs in Global Mental Health (GMH); (2) Describe how health categories that focus solely on individuals can obscure awareness of relational, social, and cultural processes that contribute to health and illness. Abstract: 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 define 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 significant of human relationships based on the family and community, GMH risks creating another disembodied field divorced from our lived experience as communal and relational beings. References Di Nicola, Vincenzo. A Stranger in the Family: Culture, Families, and Therapy. New York & London: W.W. Norton, 1997. Di Nicola, Vincenzo. Letters to a Young Therapist: Relational Practices for the Coming Community. New York & Dresden: Atropos Press, 2011. Di Nicola, Vincenzo. 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. Bio Sketch Vincenzo Di Nicola, MPhil, MD, PhD, is a Child and Adolescent Psychiatrist who uses family, social and cultural perspectives to investigate children and families in disadvantaged contexts, both at home and abroad. He works with migrant children and families and the impacts of trauma. Di Nicola is the author of “A Stranger in the Family: Culture, Families, and Therapy” (1997), “Letters to a Young Therapist” (2011), and a forthcoming selection of his writing, “On the Threshold: Children, Families, and Culture Change,” edited and introduced by Armando Favazza, MD, MPH. Di Nicola is Chair of the APA Global Mental Health Caucus and Full Professor of Psychiatry at the University of Montreal.

1. SSPC Opening Plenary
Global Mental Health
and the Family

2. SSPC Opening Plenary
Global Mental Health
and the Family
Moderator: James Griffith
Society for the Study of
Psychiatry & Culture
Annual Meeting – Princeton, NJ, USA
Thursday, April 27th, 2017
9:00 – 11:00 am

3. SSPC Opening Plenary
Global Mental Health
and the Family
Moderator: James Griffith
Presenters:
Vincenzo Di Nicola
Suzan Song
James Griffith

4. Conflicts of Interest
The presenters have no financial conflicts of
interest to declare

5. Plenary Structure
Vincenzo Di Nicola:
Where is the Family in Global Mental Health?
Suzan Song:
War-Affected Youth: A Family-Centered,
Intergenerational Approach to Recovery
James Griffith:
Grappling with Ambivalence About Families
in Global Mental Health
20 mins presentations + 10 mins questions
30 mins general discussion

6. SSPC Opening Plenary
Global Mental Health
and the Family
Moderator: James Griffith
“Where is the Family in Global
Mental Health?”
Vincenzo Di Nicola

8. Vincenzo Di Nicola, MD, PhD
vincenzodinicola@gmail.com
Professor of Psychiatry, University of Montreal
Chief, Child & Adolescent Psychiatry,
Montreal University Mental Health Institute
APA Quebec DB Representative & President-Elect
Chair, APA Global Mental Health Caucus
Founding President, Canadian Association of
Social Psychiatry

10. Educational Objectives
At the conclusion of the presentation,
audience participants will be able to:
(1) Articulate why a central role for families is
needed for the effectiveness of clinical and
research programs in Global Mental Health
(GMH)

11. Educational Objectives
At the conclusion of the presentation,
audience participants will be able to:
(2) Describe how health categories that focus
solely on individuals can obscure awareness of
relational, social, and cultural processes that
contribute to health and illness.

12. Part I:
Defining 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)

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

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

15. 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 field
comes of age. JAMA, May 19, 2010, 303(19):
1976-77.

16. “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.

17. Global Mental Health
Taking into account cultural differences and
country-specific conditions, GMH deals with:
the epidemiology of mental disorders in different
countries
their treatment options
mental health education
political and financial aspects
the structure of mental health care systems
human resources in mental health
human rights issues, among others

18. 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)

19. Global Mental Health
GMH defined by Samuel Okpaku by five criteria:
Universal and transnational criterion – universal or
transnational aspect (not local)
Public health criterion – population basis
Stakeholders criterion – international in composition,
educational, scientific, governmental and
nongovernmental
Problem ownership criterion – local ownership of
problem by recipients
Team criterion – multi-disciplinary
and multi-party

20. Global Mental Health
A step forward?
Data gathering and policymaking versus
clinical concerns and meaningful engagement

21. Envelopes
Relational, social, cultural
Categories versus contexts

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

23. Part II:
Defining Family Studies

24. Defining 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

25. With an individual approach, something’s missing …

26. Cultural Family Therapy
CFT weaves together family stories that
express their mental and relational
predicaments and conceptual tools for
conducting clinical work

27. Cultural Family Therapy
• CFT is an ongoing update of our notions of
“family” and “therapy,” on one hand, and of
“culture” and “psychiatry,” on the other

28. Without cultural understanding,
we build walls instead
of bridges …

29. Applications
• In a world with huge global flows of migrants
and refugees instigated by conflict, disasters,
or economic and social reasons, CFT offers
clinical tools to understand and treat families
experiencing severe stress due to rapid and
massive culture change

31. Part III:
Where is the Family in GMH?

34. 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 into
consideration.
My wish is to maintain and increase this key sensibility.

35. 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

36. 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

38. 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)

39. Essentials of Global Mental Health
Overview of the contents:
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

40. 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
No mention of adolescents, youth, or couple and family therapy

42. Global Mental Health:
Principles & Practice
In the volume edited by Vikram Patel and his 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.

43. 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 affirmative and
embracing in its scope.

49. 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
different shapes under the influence of social and cultural determinants.
• While I read Watter’s book with interest, I was disappointed to find 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.

51. Decolonizing Global Mental Health
• China Mills’ (2013) 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.

52. 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.

53. Conclusion –
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.

54. Conclusion –
Family Critique
• 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.

55. • The work on attachment (which is theoretically important and
clinically fertile) and belonging (its counterpart in social and
cultural psychiatry, addressing aspects of affiliation, 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).

56. Categories vs
Relational, social, and cultural context
• 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 define mental health and illness
more fully, meaningfully, and realistically.

57. • 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 significant of human relationships based on the
family and community, GMH risks creating another
disembodied field divorced from our lived experience as
communal and relational beings.

58. Family
I see humanity as a family
that has hardly met.
– Theodore Zeldin
An Intimate History of Humanity

59. 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: Defining global mental health and
psychiatry. Global Mental Health & Psychiatry Newsletter,
January 2016, I (2): p. 11.

60. 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): 421-422.
• 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.
• Okpaku, Samuel O., ed., Essentials of Global Mental Health.
Cambridge, UK: Cambridge University Press, 2014.

61. Bibliography
• Patel, Vikram, Harry Minas, Alex Cohen, Martin J. Prince, eds.
Global Mental Health: Principles and Practice. Oxford, UK:
Oxford University Press, 2014.
• Patel, Vikram & Martin Prince. Global mental health: a new
global health field 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.

62. Acknowledgements
SSPC Planning Committee
Family Therapy Colleagues
• Dr. James Griffith
• Dr. Suzan Song
• Dr. Steven Wolin
GMH Colleagues
• Dr. Gabriel Ivbijaro
• Dr. Samuel Okpaku
• Dr. Eliot Sorel
Turku, Finland

63. Questions
&
Comments