Breaking Down Power Structures in Global Mental Health: A Call for Reciprocity

In a pioneering article published in the magazine Social psychiatry and psychiatric epidemiologya global team of researchers and practitioners calls for a new paradigm in global mental health (GMH) based on the concept of “reciprocity”.

This collaborative team, led by Drte Bemme of Kings College London, spanning 24 countries and comprising 39 collaborators, seeks to transform the understanding and practice of GMH, advocating for a shift from a deficit view to a strength-based perspective.

The project, driven by the desire for ‘reciprocity’ – the equal exchange of knowledge, goes one step beyond conventional evidence-based academic research. The goal is to highlight the fact that invaluable indigenous practices, overshadowed by Western medicine, have a significant role to play in the global mental health (GMH) domain.

In a telling admission, a recent editorial in the esteemed Psychiatry lancet the magazine acknowledged some missteps in the current GMH approach. The editors candidly wrote:

In this context, the concept of “differential treatment” is raised. The gap symbolizes the difference between those in need of mental health care and those in receipt of it. An unfortunate fallout of the current scenario is a new treatment gap, where only “medical professionals” are deemed qualified enough to provide care. As a result, people with specialist knowledge of their culture’s healthcare practices are marginalized, while Western medicine takes center stage. Psychologists in wealthy Western nations are beginning to understand the negative impact of this form of colonization on GMH.

The concept of ‘reciprocity’ underlines the importance of mutual relationships and egalitarianism in the creation of knowledge. According to the researchers, the method aims to promote sustainable relationships, encourage conceptual innovation and explore ways to match epistemic power, that is, the power in knowledge creation and propagation.

A notable concern raised in this research is the disproportionate concentration of funding, convening and publishing power in Global North institutions, which can often lead to a one-way transfer of knowledge. In an attempt to decolonize GMH, the researchers propose the concept of mutual learning, emphasizing that the processes and outcomes of knowledge production are inextricably intertwined.

The article demonstrates that a shift to the mutual learning process, while challenging, can yield significant benefits. By creating a slower, iterative process focused on building trust and responding to the needs of all collaborators, the researchers were able to develop a social paradigm with a four-fold invitation to GMH:

1. Transitioning from a deficit to a strength-based view of community mental health.
2. Prioritize local and experiential knowledge in scaling processes.
3. Direct funding to community organizations.
4. It critically challenges concepts such as trauma and resilience from the lens of lived experiences in Southern communities.

Despite the promise offered by mutuality, the authors caution that in GMH’s current institutional arrangements, mutuality remains elusive. They argue that addressing existing structural constraints is key to preventing symbolic use of the concept and ensuring its effective application. The research team emphasizes the lessons learned from their experience, hoping to provide insights crucial to achieving partial success in learning from each other.

Researchers from Kings College London and University College London have started a project called ‘Together to Transform’ (T2T). The project sought to facilitate knowledge exchange among scholars from 25 countries, involving 39 participants in a diverse range of nations, including Afghanistan, Australia, Bangladesh, Canada, Colombia, Ecuador, Ghana, India, Israel, Kenya, Lebanon, Malawi, Mexico, Mozambique, New Zealand, Palestine, Pakistan, Peru, Sierra Leone, South Africa, Spain, Syria, the United Kingdom, the United States and Zimbabwe.

Each learning pod provided unique insights. For example, the Community mental health systems pod rejected the deficit model commonly found in GMH research and espoused a strength-based approach to community mental health care. Drawing on experiential knowledge and data from Ghana, Palestine, South Africa and India, the group highlighted the role of informal care systems such as traditional healers and family support networks.

THE Scaling pod emphasized that replicating evidence-based models in different contexts requires more than fidelity: it requires trust, organizational values, flexibility, and meaningful collaboration with communities. The pod argued for an understanding of scaling that goes beyond a one-size-fits-all approach, recognizing the importance of local contexts and relationships.

THE Lived experience, resilience and trauma pod challenged current notions of trauma, emphasizing the need for participatory approaches that focus on lived experiences, local idioms, and socio-political ecologies. They stressed the need for a shift in understanding, away from distinctly Western notions of trauma and resilience.

THE Capacity building and funding pod identified the disconnect between the funding landscape at GMH, largely driven by processes and priorities set by funders in the Global North, and local realities at the community level. They called for fairer partnerships between funders and community organizations.

The mutual learning process generated a wide range of outputs, including conference panels, online events, podcasts, policy notes, essays of lived experiences, and an interactive website, thereby meeting the needs and incentives of diverse contributors and audiences.

However, the researchers do not hesitate to discuss the limitations and flaws of their methodology. They point out that the very fact that this project was led by London-based researchers underscores disparities in research funding, potentially making T2T look like an extension of colonialism. Furthermore, the process of selecting participants was also biased: the researchers themselves invited participants, who were chosen only from established research networks. The language barrier has posed another problem, silencing non-native English speakers especially when it comes to specialized terminology.

Another significant constraint was the challenge of sharing power. While many participants appreciated the open, shared, or leaderless style of facilitation, the reality was that power dynamics were simply masked rather than erased. The organizers found themselves bearing more responsibilities than initially anticipated, indicating that power sharing is best achieved with significant administrative support.

Another challenge was the delay in compensating practitioners due to university bureaucratic processes, which strained the principle of mutuality and affected relationships. The fee not only recognizes the value of contributions, but also encourages engagement, particularly for those for whom such activities were not part of their usual job.

Digital infrastructure also posed challenges, such as connectivity costs and unequal attendance patterns, due to different environments and working hours. Furthermore, King’s College London’s policy of not listing collaborators without formal and financial commitments limited the visibility of collaborations.

While this project inevitably reproduced some power dynamics that the project intended to challenge, the ultimate goal was to shift existing institutional power towards power-sharing practices and promote dialogue across three common epistemic divides:

1. Between academics from primarily quantitative disciplines and those from qualitative or theoretically driven disciplines.
2. Between academics and professionals at the community level.
3. Between collaborators located in the northern and southern hemispheres.

The damaging impact of colonization on psychological health is already known. The novelty of this research lies in its successful sharing of intercultural information. While it has had its share of logistical hurdles tainting the integrity of the project, T2T remains a significant step forward in promoting knowledge exchange.

Despite the challenges they faced, the ‘Together to Transform’ project provided invaluable insights into the complexity of achieving reciprocity in a global collaboration, revealing the need to address structural inequalities and epistemic inequities in academia. It demonstrated that building meaningful collaborations that seek to address and transform power imbalances in the realm of global mental health research is challenging but essential. The project’s iterative learning process underscored the potential of such initiatives to foster new ways of working together across academic, geographical and disciplinary divides.

It serves as a reminder that power imbalances can and should be challenged, and that more inclusive and diverse epistemic spaces and processes can be created to foster meaningful change in the mental health landscape.

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Bemme, D., Roberts, T., Ae-Ngibise, KA, Gumbonzvanda, N., Joag, K., Kagee, A., Machisa, M., van der Westhuizen, C., van Rensburg, A., Willan, S., Wuerth, M., Aoun, M., Jain, S., Lund, C., Mathias, K., Read, U., Taylor Salisbury, T., & Burg ess, RA (2023). Reciprocity as a method: Fostering a social paradigm for global mental health through mutual learning. Social psychiatry and psychiatric epidemiology. (Connection)