WASP Globalization Symposium- "Where Is the Child in Global Mental Health?" Vincenzo Di Nicola, MD, PhD 23rd WASP World Congress. Bucharest, Romania, Saturday, 26 October 2019, 10:45 – 11:45 am

1. WASP Globalization Symposium
Where Is the Child in
Global Mental Health?
Vincenzo Di Nicola, MD, PhD
23rd WASP World Congress
Bucharest, Romania
Saturday, 26 October 2019
10:45 – 11:45 am

2. Vincenzo Di Nicola, MD, PhD
vincenzodinicola@gmail.com
Professor of Psychiatry, University of Montreal &
The George Washington University
Chief, Child & Adolescent Psychiatry,
Montreal University Mental Health Institute
Founder & President, Canadian Association of
Social Psychiatry (CASP/ACPS)
Co-Founder & Past Chair, APA Global Mental
Health Caucus

4. 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)

5. 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)
Social determinants of health (Marmot) –
Adverse Childhood Events (ACE) Study

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

7. 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.

8. “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.

9. 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)

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

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

12. Part II:
Where Is the Child in GMH?

15. 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.

16. 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

17. 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

19. 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)

20. Essentials of Global Mental Health
Overview of the contents:
Section 4: Special Populations
poverty and perinatal morbidity
maternal mental health
children’s services
child abuse
child soldiers
adolescent alcohol and substance abuse
Section 6: Human Resources and Capacity Building
child mental services in Liberia

21. 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

23. 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.

26. 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.
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.

28. 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”

29. Decolonizing Global Mental Health
Nonetheless, and 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.

30. Unaccompanied Migrant Minors
A particular migrant subgroup that
requires attention is the unaccompanied
asylum-seeking minors (UASM)

31. Unaccompanied Migrant Minors
“Given the scale of migration amongst this
vulnerable subgroup, it is important that they
are not missed from screening and treatment
programs.”
Ref: Bempong, et al. (2019). Critical reflections, challenges and
solutions for migrant and refugee health. Public Health Reviews,
40(3).

32. Something’s missing …

33. 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.

34. Conclusion –
Child and Family Critique
Those of us who work with mental health issues from a child
and 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.

35. Categories vs
Relational, social, and cultural context
From a child and 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.

36. 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.

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

38. Bibliography
Bempong, N-E, et al. Critical reflections, challenges and
solutions for migrant and refugee health. Public Health
Reviews, 2019, 40(3).
Di Nicola, V. 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.

39. 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.

40. 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.

41. Acknowledgements
Symposium Co-Chairs
Dr. Roy Kallivayalil
Dr. Masafumo Mizuno
Fellow Panelists
Dr. Indira Sharma
Dr. Rama Rao Gogineni
Dr. Marianne Kastrup
Turku, Finland

42. Questions
&
Comments