We can’t ‘copy-paste’ mental health support across the globe

In January 2021, I had the pleasure of writing the following essay for Semi-Colon – a digital publication concerned with facilitating conversations about mental health with a spirit of curiosity rather than reluctance. The article is available here: https://www.semi-colon.com/articles/we-cant-copy-paste-mental-health-support-across-globe.

Over the last couple of decades, the field of Global Mental Health (GMH) has emerged as an area of study, practice, and research to address inequities in providing mental health support across the world. Historically, low- and middle-income countries (as classified by the World Bank’s assessment of their economies) have struggled to establish and maintain the types of mental health services typically seen in high-income countries. This gave rise to concerns that the considerable burden caused by mental disorders [1] would go unchecked in low- and middle-income countries, which in turn prompted coordinated action aimed at building consensus about how best to respond.

In recent years, there has also been growing recognition of the important role that GMH can play in advancing progress in how people with a lived experience of mental health struggles in high-income countries (such as the US and the UK) can be better supported – particularly those who are marginalised and underserved by existing services. This is more befitting of the ‘Global’ ambition and scope that GMH ascribes to – rather than being restricted to certain parts of the world, it can have important impacts across the world. As such, ‘GMH’ is best understood as a diverse range of activities characterised by collaboration with local stakeholders to generate innovative, pragmatic, and context-sensitive approaches related to mental health and wellbeing in settings where resources are limited.

A myriad of initiatives (ranging from training community members to deliver forms of talking therapy, to reforming archaic mental health legislation) falls under the GMH ‘umbrella’. Furthermore, a plethora of various actors contribute to GMH work, including people with lived experience of mental health difficulties, traditional healers, health professionals, government ministries, policymakers, researchers, non-governmental organisations, and international agencies (for example, the World Health Organization). As agendas, expertise, and ideas about the best ways forward can differ hugely, one may naturally wonder how coordination and consensus are established?

To answer this question, it is vitally important to understand how knowledge relating to mental health and well-being is shared, and how decisions about what knowledge is deemed credible are made. After all, what is considered a fact of life to people living in a particular part of the world, can seem like an absolute fantasy to those living elsewhere. It is important to recognise that there can be marked discrepancies in the power that different stakeholders have to shape the agenda for GMH. Care needs to be taken not to undermine the legitimacy and credibility of the knowledge and ideas that stakeholders bring when different worldviews meet because this can prove hugely detrimental to fruitful collaboration.

There is growing recognition amongst those involved in GMH of the risk of what has been referred to as epistemic injustice [2] – put simply, this is the risk of people incorrectly believing that ‘the way I understand things is the way that other people ought to understand things’. When working in cultural contexts that are different from our own, we need to hold our assumptions lightly, enter into dialogue and discussion with local partners, and be open to the shared learning that can happen in those spaces. 

It’s ultimately about respectful partnership, mutual learning, and pragmatic innovation to see what works on the ground. We need to ensure that we tailor support to the cultural context rather than copy-paste what has been shown to work in a different cultural context.

Research evidence confirms that forms of support that have historically been viewed as bona fide treatments from a Western perspective (e.g. psychotherapies such as Cognitive Behavioural Therapy) can be helpful, provided these are adequately adapted for the cultural context in low- and middle-income countries. However, research has also indicated that existing forms of support in low- and middle-income countries (such as traditional healing practices) can have positive impacts on minor to moderate mental health difficulties in these settings [3]. Key questions to consider in evaluating the merits of different forms of support include: does it seem relevant and appropriate to the community, are people willing to access the support, does it uphold and protect people’s human rights, does it show evidence of bringing about benefit for people, is there adequate resource to sustain the support, are there community members who can be trained to deliver the intervention in a cost-effective way?

Some ‘home-grown’ interventions developed in the low- and middle-income countries have shown promise in supporting local populations’ mental health and well-being. For example, in Zimbabwe, the ‘Friendship Bench’ [4] was developed as a form of support where community members were trained to deliver a problem-solving intervention during meetings on benches placed in local clinics’ grounds. This has shown to be effective in treating symptoms of depression and anxiety. Similarly, in post-genocide Rwanda (where up to 1,000,000 people were killed in 1994), an approach called ‘sociotherapy’ or ‘Mvura Nkuvure‘ (heal me, I heal you) in the local Kinyarwanda language, has been developed and used extensively to reduce distress and facilitate community healing.

My colleagues and I at the University of Liverpool have been working in partnership with Community-Based Sociotherapy Rwanda [5] and researchers from the University of Rwanda (Kigala, Rwanda) and Makerere University (Kampala, Uganda) to explore adapting sociotherapy for the large number of Congolese refugees living in Rwanda and Uganda as part of the COSTAR project. Sociotherapy is delivered by two facilitators who are drawn from the local community and offered training. The intervention is delivered over 15 weekly sessions to groups of between 10 and 15 people and focuses on six phases of work: safety, trust, care, respect, new life directions, and memory. As a community-based approach, we hope that sociotherapy will help address the collective difficulties and shared sources of stress that affect refugees [6]. 

It is hugely important to recognise the enormous role that low- and middle-income countries play in generating knowledge relating to GMH. Too often in recent history, people living and working in the low- and middle-income countries have been narrowly viewed as recipients of knowledge. In particular, there are opportunities for stakeholders living in high-income countries to learn from the pragmatism and pluralism used in low- and middle-income countries. We must explore opportunities to promote more equitable knowledge flows that can improve mental health systems in high-income countries that fail to adequately meet people’s needs, particularly for underserved populations such as Black, Asian and Minority Ethnic groups.

As GMH moves forward, it will be helpful to clarify its vision and ambition. As highlighted previously, a goal of GMH at its outset was to reduce inequities in the availability of services to address mental health difficulties across the globe. However, we must look beyond that to determine what the primary purpose of these mental health services actually is. If you ask mental health professionals, many will say it’s to reduce the symptoms of mental health problems. On the other hand, politicians may wish to minimise the economic impact that mental health difficulties have on their nation’s economy. But if you were to ask a person who has experienced mental health difficulties, and who may be enduring a poor quality of life even after their symptoms are alleviated, their perspective may be different again. 

In recent years, there have been concerted efforts to consult with those who have a lived experience of mental health difficulties (a.k.a ‘expert by experience’) to ensure that their voices are heard in GMH initiatives [7]. This has coincided with a greater focus on important outcomes such as well-being and quality of life, which relate more to a person’s ability to flourish and live a life that has vitality and meaning. Indeed, perhaps an enduring legacy of GMH can be its ability to refine processes and procedures that empower people and communities across the world to clearly articulate what living well and feeling fulfilled means to them.

So, to conclude, when considering mental health support across the globe it’s better to make less haste with ‘copy-paste’, and instead, work collaboratively with local stakeholders to coproduce what will work best in that particular place.

1. https://www.mentalhealth.org.uk/statistics/mental-health-statistics-uk-and-worldwide
2. The term ‘epistemic injustice’ was coined by Miranda Fricker in her book Epistemic Injustice: Power and the Ethics of Knowing that was published by Oxford University Press in 2007.
3. https://pubmed.ncbi.nlm.nih.gov/26851329/
4. https://www.bbc.com/future/article/20181015-how-one-bench-and-a-team-of-grandmothers-can-beat-depression
5. https://cbsrwanda.org/
6. https://www.liverpool.ac.uk/costar/
7. The UPSIDES Project provides an example of efforts being made to involve experts by experience in efforts to build capacity for the provision of mental health support https://www.upsides.org/project/

Clinical Psychology… and the global village

Authors: Ross G. White, Nargis Islam and Rosco Kasujja

The year 1961 heralded a number of key events. In January of that year, John Fitzgerald Kennedy became the 35^th President of the United States or America. Three months later, Yuri Gagarin became the first man in space. That year also saw the publication of a book by Carl Rogers (the American psychologist and founder of humanistic psychology) entitled ‘On Becoming a Person: A Therapist’s View of Psychotherapy’. This book did much to support the development of person-centred forms of support that continue to influence how various forms of psychotherapy and counselling are delivered today. But 1961 is also notable for a development that has profoundly shaped the design and delivery of psychiatric practice across the globe – it was the year that the World Psychiatric Association (WPA) was formally founded. In the 58 years that have passed, the WPA has grown significantly. Described as ‘psychiatry’s global association’ the WPA now represents 140 psychiatric societies in 120 countries serving more than 250,000 psychiatrists (http://www.wpanet.org/about-wpa). The remit of the organization includes the development of ethical guidelines and the publication of position statements on a range of issues relevant to the psychiatric profession. The WPA’s journal, World Psychiatry, is the number one ranked journal in the field of psychiatry.

 

Importantly, the WPA also provides important learning and educational opportunities for psychiatrists. A recent example of this is the endorsement that the WPA provided to the recent (February 2019) publication of an edited volume entitled Global Mental Health and Psychotherapy: Adapting Psychotherapy for Low- and Middle-Income Countries. Global Mental Health, as an area of study, research and practice that aims to promote equitable access to mental health services across the world, is clearly a key interest for the WPA. The focus of this particular volume resonates strongly with an academic paper published in 2014 that was written by two prominent psychiatrists Vikram Patel (Harvard University, USA) and Chris Fairburn (University of Oxford, UK) entitled The Global Dissemination of Psychological Treatments: A Road Map for Research and Practice. Psychiatrists, and the WPA as an international network of psychiatrists, are clearly committed to playing an important role in enhancing the availability of treatments for mental health problems in highly populated, but chronically under-resourced parts of the world.

 

By virtue of their training and expertise, Clinical Psychologists have made, and will continue to make, a vital contribution to the efforts aimed at addressing inequities in health and social care provision. Clinical Psychologists across the globe assess people, formulate cases and deliver interventions to individuals and groups across the life span. Clinical Psychologists work using various treatment models (e.g. CBT, ACT, IPT, Psychodynamic Psychotherapy), and therefore have expertise in a multiplicity of these models. Many Clinical Psychologists are trained to work systemically to address contextual factors that impact on people’s wellbeing at different levels of influence including personal, interpersonal, organizational and societal levels. Clinical Psychologists conduct impactful research that benefits a wide range of populations. As a result of their rich skillset, Clinical Psychologists act effectively in consultancy and supervisory roles. The ability that Clinical Psychologists have to work in multidisciplinary teams augurs well for members of the profession to collaborate effectively with experts in social science, anthropology and psychiatry – all of whom will have important role to play in understanding and supporting mental health and wellbeing across a diverse range of settings.

 

Although Clinical Psychology training programmes exist across the globe and there are numerous national associations, there is no World Association of Clinical Psychologists. It is reasonable to assume that like their Psychiatry colleagues, Clinical Psychologists would benefit from the formation of such an international network. In the absence of such a network, fruitful and productive collaborations have manged to flourish between Clinical Psychologists in different parts of the world. For example, Graham Powell and colleagues from the UK collaborated closely with colleagues in Bangladesh to support the establishment of the Bangladesh Clinical Psychology Society (http://bcps.org.bd/?page_id=279), the Umoza Trust (established by Clinical Psychologists who graduated from the University of Lancaster programme) has facilitated placement opportunities for trainee placements in Malawi (http://www.umozatrust.org/), and Hamish McLeod (University of Glasgow) and colleagues in Scotland have been working with Cesar Hakim (The Guidance and Training Centre for Child and Family, Bethlehem) to establishing the first applied child psychology training programme in Palestine (http://www.gtc.ps/index.php/en/therapeutic-services/getting-help/item/32-new-poster). A further example is provided by the Butabika-East London Link (https://www.butabikaeastlondon.com) which has facilitated opportunities for mutual learning for Clinical Psychologists and other mental health professionals working in Uganda and the UK. However, these collaborations have relied on the considerable commitment and endeavour of those involved, and unfortunately without a co-ordinated global initiative, opportunities for shared learning across these ventures been limited at best, non-existent at worst. Furthermore, without such a global network, Clinical Psychologists lack supportive structures and a professional ‘voice’ for practice and research issues that transcend geographic, cultural and linguistic boundaries and exceed the scope and remit of national bodies.

 

So, what might a World Association of Clinical Psychologists offer? Well, potential benefits could include: the creation of a hub for sharing examples of good practice, promoting standardization in  training and improving global mobility of Clinical Psychologists, enhancing equitable exchanges of knowledge from practitioners in the Global South to those in the Global North and vice versa, the production of international guidelines relating to Clinical Psychologists’ areas of expertise (e.g. the formulation of clinical cases, the delivery and supervision of psychological therapies), and improved public understanding about the profession of Clinical Psychology and an associated reduction in stigma associated with mental health care that this might bring. Furthermore, an International network could facilitate dialogue between Clinical Psychologists about how best to adapt working practices for local cultural and service-delivery contexts. At this time of unprecedented global mobility, professional support and advice for those who work across different countries tends to be very limited. Having an international professional network could address such gaps – thus ensuring a safer and more ethical model of best practice. A global professional network for Clinical Psychologists would also provide much needed representation and support to Clinical Psychologists working in countries where national associations are being blocked, or not being granted formal recognition by governments.

 

Creating a global network for Clinical Psychologists will also present challenges and potential pitfalls that will require careful consideration and negotiation. There will be a need to reflect on the potential impact that dynamics of power and privilege can have on collaborative initiatives. A failure to recognise and mitigate against power dynamics may hamper equitable exchanges of knowledge between those working in different parts of the world. There have been concerns expressed that international collaborations relating to mental health can be akin to neo-colonial ventures or medical imperialism^1,2,3. Engagement in international working therefore requires not only an ethical framework to ensure that activities cause no harm, but also a commitment to authentically recognise the range of indigenous psychologies, expertise and skills that can be evident in different cultural contexts, and be open to the possibilities that exist for models of health and social care to evolve to accommodate these⁴.

 

Professional groupings, such as the Association of Clinical Psychology UK (ACP-UK), are well placed to play an active role in building the foundations of something akin to a World Association of Clinical Psychologists. It’s time to recognise the important contribution that Clinical Psychology can play in enhancing the mental health and wellbeing of people across the globe, and to appreciate the key role that an international network can play in giving the profession of Clinical Psychology an active voice in key debates and initiatives. If there is a willingness for this to happen, technology can help to facilitate innovative ways of establishing and maintaining global connectivity. At this time when there is so much to be preoccupied by with regard to domestic concerns, it is vitally important that Clinical Psychologists look outward to the opportunities that international collaboration can bring. By invoking a modicum of the sense of hope and endeavour that imbued key events in 1961, Clinical Psychologists can perhaps make some history of their own.

 

References

 

1. Fernando, S. (2010). Mental health, race and culture (3rd ed.). Basingstoke: Palgrave Macmillan.

 

2. Watters, E. (2010). Crazy like us: The globalization of the Western mind. London: Constable and Robinson.

 

3. Mills, C. (2014). Decolonizing Global Mental Health: The Psychiatrization of the Majority World. Routledge, London

 

4. White, R., Jain, S., & Giurgi-Oncu, C. (2014). Counterflows for mental well-being: What high-income countries can learn from Low and middle-income countries. International Review of Psychiatry, 26(5), 602-606.

 

Biographies of the Authors

 

Dr. Ross White is a Reader of Clinical Psychology at the University of Liverpool. He was lead-editor of The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health. He has active research collaborations with the World Health Organization and United Nations High Commissioner for Refugees focusing on evaluating psychosocial interventions for refugees in the UK, EU and sub-Saharan Africa.

 

Dr. Nargis Islam is a Clinical Psychologist based in Oxford, where she has worked in the NHS and on Clinical and Counselling Psychology training programmes. She has active clinical, training and research collaborations with NGO’s working in the Rohingya camps in Bangladesh, and with educational and clinical organisations in both UK and Bangladesh.

 

Dr. Rosco Kasujja is the Head of Department, Mental Health & Community Psychology at Makerere University School of Psychology in Kampala, Uganda. He is currently the President of the Uganda Clinical Psychology Association. He has active Clinical Collaborations with NGOs in Uganda offering clinical supervision and training in the area of trauma.

Global Mental Health: Origins and Key Debates

Abstract: Understanding about aberrant behaviours has varied across time, geography and culture. In recent decades, Global Mental Health has emerged as an area of research, study and practice that is concerned with promoting equitable access to mental health services in low-resource settings. This article reflects on the emergence and development of Global Mental Health activity. The article discusses a number of contentious debates relating to Global Mental Health. Specific issues discussed include: the legitimacy given to particular forms of evidence, the primacy given to local vs. global influences, and decisions about what constitutes ‘treatment’ for emotional distress.  Rather than being a monolithic enterprise, Global Mental Health is presented as a heterogeneous range of practice and research-based activities that defy easy categorisation. In particular, the innovative work that is being undertaking under the auspices of Global Mental Health to develop/evaluate psychosocial interventions, and to utilise creative/innovative ways to overcome a lack of highly trained specialists in low resource settings, offer promise for improving the lives of many people across the world.

This is an abridged and updated version of the following chapter: ‘White, R. G., Orr, D. M., Read, U. M., & Jain, S. (2017). Situating Global Mental Health: Sociocultural Perspectives. In The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health (pp. 1-27). Palgrave Macmillan UK’ reproduced with permission of Palgrave Macmillan: https://link.springer.com/book/10.1057/978-1-137-39510-8 

Introduction

Contemporary discourses about ‘mental disorders’ owe much to the emergence of ‘Psychiatry’ as a field of medicine. The early development of psychiatry centered on the contribution of (almost exclusively male and white) protagonists based in Europe (e.g. Freud, Bleuler, Jung). As such, psychiatric theory and practice were strongly influenced by European societal attitudes and sensibilities. However, as psychiatrists began to travel to other parts of the world, interest grew in the potential applications that psychiatry might have in different cultural settings. An example of this came in 1904 when the German Psychiatrist Emile Kraepelin visited Java to determine whether the diagnosis of ‘dementia praecox’ (a fore-runner of what was to become the diagnosis of schizophrenia) existed there. In 1925, Kraepelin compared the presentation of Native American, African American and Latin American people in psychiatric institutions in the US, Mexico and Cuba (Jilek, 1995).

Questions regarding the incidence of mental disorders in different societies and the universality of psychiatric diagnoses have continued since Kraepelin’s work in the early 20th Century CE. Large-scale international comparative epidemiological studies only began during the 1960s with the World Health Organization (WHO) sponsored epidemiological studies of schizophrenia (Lovell, 2014). To this day, many countries lack nationally representative epidemiological data for mental disorders (Baxter et al., 2013). The provision of psychiatric treatment as a part of state-sponsored health care systems has also emerged unevenly, with the bulk of investment, and innovations in forms of intervention and organization, taking place in high-income countries (as classified by the World Bank). When health care systems were introduced by colonial governments in the 19th and 20th Centuries CE, mental health was a very low priority compared to public health and the control of infectious diseases (Njenga, 2002).

Despite the limited global reach of epidemiological studies and priority given to mental health, a growing field of enquiry and practice emerged in the post-colonial period, which came to be termed ‘transcultural psychiatry’. Though this was and remains a diverse field, two notable aspects were the interests that certain anthropologists had in cultural influences on mental disorders and societal responses, and the emergence of psychiatrists originating from the Global South who were trained in Europe and were attempting to apply psychiatric diagnoses to local populations. This confluence of anthropologists and psychiatrists, some of whom had been trained in both disciplines, was strengthened after the 1950s by the beginning of large-scale migration from the former colonies to countries of Europe and North America and the growing numbers of service users from diverse cultures in psychiatric services. Academic departments and courses in transcultural psychiatry began to be established, notably at McGill in Canada and Harvard in the US, and academic journals such as Transcultural Psychiatry began publication. In 1995, some of the most influential anthropologists in transcultural psychiatry based at Harvard University, including Arthur Kleinman, published a book entitled World Mental Health: Problems and Priorities in Low-Income Countries (Desjarlais et al., 1995). This volume set out the concerns regarding human rights, lack of treatment and rising incidence of mental disorders in terms that in many ways set the agenda for what was later to be termed ‘Global Mental Health’. Six years later the World Health Organization brought renewed attention to mental health by making it the topic of their annual ‘World Health Report’ for the first time in its history (WHO, 2001).

The term ‘Global Mental Health’ (GMH) was first coined in 2001 by the then US Surgeon General, David Satcher. Reflecting on the publication of the 2001 World Health Report (WHO, 2001) and a year-long campaign by the World Health Organization (WHO) on mental health, Satcher proposed that the United States should bring mental health onto the global health agenda by ‘taking a leadership role that emphasizes partnership, mutual respect, and a shared vision of improving the lives of people who have mental illness and improving the mental health system for everyone’ (2001, p.1697). GMH was given additional visibility through the launch of the Movement for Global Mental Health (MGMH). The MGMH traces its origins back to the consortium of experts that constituted The Lancet Group for Global Mental Health (2007; 2011), and who published two series of papers to highlight the need for action to build capacity for mental health services in low- and middle-income countries. The MGMH now has a membership of around 200 institutions and 10,000 individuals (http://www.globalmentalhealth.org/about). The MGMH was a partner in The Lancet Commission for Global Mental Health and Sustainable Development (Patel et al., 2018) which was launched On World Mental Health Day, 10^th October 2018. The launch of the commission coincided with a Global Ministerial Mental Health Summit in London, UK (https://globalmhsummit.com/home). The central message conveyed by the commission, and indeed the principal focus of the summit, was that mental health and wellbeing are fundamental to the achieving sustainable development goals (UN, 2015).

This article briefly summarises some key debates concerning GMH: including contention about the legitimacy given to particular forms of evidence, the primacy given to local vs. global influences, and assumptions regarding what constitutes ‘treatment’ for emotional distress.

Standardisation and Evidence-based Medicine

Since its emergence, GMH has been the target of a vocal critique, most prominently concerning a perceived dominance of biomedical approaches. Critics have suggested that GMH is a neo-colonial, medical imperialist approach that serves to expand markets for psychotropic medication (Summerfield, 2012; Mills, 2014). Refuting such accusations, Patel (2014) points out that the bulk of interventions evaluated in GMH research have focused on psychosocial interventions. Furthermore, Patel (2014, p.786) states that it would be ‘unethical to withhold what biomedicine has to offer, simply because it was ‘invented somewhere else’.’ Bemme and D’Souza (2014) have contended that the globalization of particular forms of intervention has not been a principal concern of GMH. Instead, they suggest that a central feature of GMH has been the dissemination and utilization of particular epistemologies and research methodologies for evaluating interventions across the globe. The emergence of the Evidence-Based Medicine (EBM) paradigm (see Guyatt et al., 1995), and the hierarchical approach to research evidence that it espouses, has had a significant impact on shaping standardized procedures for evaluating health interventions.

Thomas et al. (2007) have cautioned against the assumption that human behaviours and problems are amenable to investigation using the same positivist methods that are applied in the natural sciences. In a similar vein, EBM has also been criticized for disregarding the social nature of science and obscuring subjective elements of the human interactions that occur in the context of medicine (Goldenberg, 2006). Greenhalgh et al. (2014) identified a number of limitations in the EBM paradigm as currently practiced, including a susceptibility to bias in trials, a failure to take account of multi-morbidity, and a tendency to promote over-reliance on ‘algorithmic rules’ over reasoning and judgment. Furthermore, other commentators have suggested that ‘gold standard’ EBM methodologies may lack sufficient sophistication for understanding cross-cultural nuances in how emotional distress can be understood and addressed in different contexts (Summerfield, 2008; Kirmayer & Pedersen, 2014).

Kirmayer and Swartz (2013) highlighted the need for the GMH agenda to embrace a ‘pluralistic view of knowledge’, which can be integrated into empirical paradigms guiding GMH-related research. More recently, the notion of mental health interventions as ‘complex’ interventions interacting with context to influence outcomes has led to a challenge to the gold standard of randomized controlled studies (Moore et al., 2015). Researchers have called for new methods of evaluation including the use of qualitative methodologies such as ethnography to observe such interactions and unintended effects (Kirmayer & Pedersen, 2014). These approaches have been embraced in several studies of community-based mental health interventions in low-income settings across the globe (de Silva et al., 2015). The development of GMH has helped to build an appreciation that the experience of emotional distress is embedded within the particularities of social and moral worlds, and calls for methods of investigation and evaluation which are sensitive to ‘locally relevant evidence’ and take account of contextually situated experience (Kienzler and Locke, 2017).

The ‘Global vs. Local’ Distinction

The dichotomy that has been drawn between forms of support that reflect ‘local’ (i.e. specific to particular contexts) beliefs and practices, as opposed to ‘global’ (i.e. standardized/universalist) approaches, has been keenly debated in GMH-related discourses. Some have argued that global initiatives for mental health pose a threat to indigenous or local practices (Mills, 2014; Fernando, 2014). Patel (2014) has warned against the idealization of indigenous (i.e. local) practices, which can include inhumane treatments and practices. Miller (2014) has also argued that a person living in a LMIC ‘deserves better than being urged to stay in (his/)her niche in some great cabinet of ethnopsychiatric curiosities’ (p.134). Bauman (1998) highlighted the way in which what is considered to be ‘local’ has become organic and porous, as new and ever-evolving associations are formed with ‘global’ processes. Bemme and D’Souza (2014) pointed to the relevance of the anthropologist Anna Tsing’s (2005) concept of ‘friction’ for exploring the connections between the ‘local’ and ‘global’ in the context of GMH. Friction captures how the supposedly smooth flows of ‘universal’ ideas, concepts and policies across the globe are, in reality, slowed down or dragged back on particular terrains; yet at the same time, movement only occurs in the first place through the friction that results from gaining purchase on a particular ground. Thus, the global and the local may hinder each other and/or propel each other forward, but they are never locked into the kind of zero-sum rivalry with which they are so often portrayed. Tsing’s approach emphasises the ongoing co-production of culture in the encounter between universal and particular in ‘zones of awkward engagement’ (Tsing 2005, p.4, xi); rather than being opposites, the two are mutually altered in unforeseen ways by this process. The dynamic interaction between ‘local’ and ‘global’ has been captured by the hybrid concept referred to as ‘glocalization’ (Robertson, 1994), which recognizes the process of syncretization that occurs between local and more global influences. From this perspective, ‘doing’ GMH would cease to be a debate between the relative merits of adopting universal categories or preserving a pre-existing set of local categories, and would become a question of what further possibilities might emerge from the meeting between the two. So, whilst facilitating opportunities to recognise the importance of ‘local’ context, GMH research, practice and study also needs to be mindful of the way in which local experience is influenced by wider social, political and economic forces, and the contribution that structural factors (including poverty, war and violence, migration and displacement) make to mental health.

The ‘Treatment Gap’ and Community-based Interventions

Borrowing language from Global Health (GH), The Lancet Series on Global Mental Health (2007; 2011) and the mhGAP Action Programme (WHO, 2008) and mhGAP Intervention Guide (WHO, 2010; 2016) draw on the notion of the need to fill the ‘treatment gap’ (i.e. the gap between what the numbers of people assumed to be suffering from mental illness and the numbers receiving treatment). As is the case for burdensome physical health conditions (such as HIV/AIDS and malaria), the urgency for ‘scaling-up’ services for mental health difficulties has in part been justified on the basis of the moral obligation to act (Patel, Saraceno & Kleinman, 2006; Kleinman, 2009).  Indeed, the MGMH has been engaged in concerted efforts to mobilize stakeholders and lobby for policy change to address the ‘treatment gap’. Vikram Patel has stated that there is a need ‘to shock governments into action’ and that language should be employed strategically for this purpose (Bemme & D’Souza, 2012; para. 24). For example, it is suggested that the ‘treatment gap’ for mental health difficulties is as high as 85% in low-income countries (Demyttenaere et al., 2004), and that urgent action needs to be taken to bridge it. However, the aforementioned concerns about the poor quality of epidemiological data relating to mental disorders in LMIC (see Baxter et al., 2013) will have important implications for the accuracy of estimates of the ‘treatment gap’.

Critics have argued that the concept of the ‘treatment gap’ has privileged particular forms of treatment whilst simultaneously failing to recognize the important contribution that other forms of support and healing may bring to people living across the globe (Bartlett et al. 2014; Fernando, 2014). In particular, allopathic forms of intervention have assumed high levels of credibility and legitimacy in the Global North and elsewhere. The term ‘allopathy’ was first introduced by German physician Samuel Hahnemann (1755-1843) when he conjoined the Greek words ‘allos’ (opposite) and ‘pathos’ (suffering). It is defined as the treatment of disease by ‘conventional’ means (i.e. with drugs having effects opposite to the symptoms). Commentators have expressed concerns that employing rhetorical language of the ‘treatment gap’ may well shock governments into taking action, but this action may not be inclusive of the pluralistic forms of support available (White & Sashidharan, 2014a,b). Researchers have suggested that pluralism and a multiplicity of treatment options might bring potential benefits for engagement and outcome for individuals experiencing mental health difficulties in LMIC (Orr and Bindi, 2017). Jansen et al. (2015) pointed out that the concept of the ‘treatment gap’ has advocated a particularly individualistic approach to scaling-up services for mental health in LMIC. Similarly, Kohrt & Griffith (2015) have highlighted the need for practitioners to work across therapeutic levels (including family, community, and wider contexts) according to ecological systems theory. Fernando (2012) suggested that the burden of mental health problems experienced collectively by communities is likely to be greater than the sum of the burden on the individual members of that community, especially in the context of ‘collective traumas’ (see Audergon, 2004; Somasundaram, 2007; 2010). Bemme and D’Souza (2014) observed that GMH initiatives have narrowly conceptualized ‘community’ as a method of service delivery. Specifically, community care is proposed as more cost-effective option (Das & Rao, 2012).

Moving forward, there is a need to explore how the concept of ‘community’ can be promoted as a means of harnessing collective strengths and resources to promote mental wellbeing (Jansen et al., 2015). In particular, community-based psychosocial interventions may offer promise for alleviating the burden of emotional distress. Psychosocial interventions are based on an appreciation that aspects of a person’s surrounding social environment can combine with psychological factors to impact on their physical and mental health. The Mental Health and Psychosocial Support Network (MHPSS Network – https://mphss.net) provides examples of innovative approaches for addressing psychological and social determinants of mental health. It is important that community-based approaches are cognisant of concerns that community action and volunteering in GH and GMH initiatives may take advantage of community workers by relying heavily on their often unpaid and demanding work (Maes, 2015; Kalofonos 2015). This has implications for both the sustainability and quality of care provided, particularly where there is inadequate investment in ongoing training and supervision.

Conclusion

Over the last 18 years, GMH has evolved from its embryonic roots to establish itself as a field of study, debate and action, which is now latticed by diverse disciplinary, cultural and personal perspectives. Whilst the development of GMH has attracted contention and controversy, this contention has tended to be based around narrow and restrictive interpretations of GMH. Rather than being a monolithic endeavour, GMH needs to be understood as a heterogeneous endeavour incorporating a diverse range of activities. Moving forward it will be important to recognise the important opportunities that GMH provides to work collaboratively with local stakeholders to generate innovate, pragmatic, and culturally sensitive approaches to addressing mental health and wellbeing in low resource settings.

 

Biographical Notes About Authors

Dr Ross White is an Associate Professor of Clinical Psychology at the University of Liverpool. His research collaborations with the World Health Organization and United Nations High Commissioner for Refugees focuses on evaluating psychosocial interventions for refugees in the UK, EU and sub-Saharan Africa. Dr David M. R. Orr is a Senior Lecturer in the Department of Social Work, Wellbeing and Social Care at the University of Sussex. His research projects have focused on adult safeguarding and self-neglect, global mental health, and representations of dementia in contemporary films and fiction. Dr Ursula M. Read is an anthropologist and research fellow based in Global Health and Social Medicine at King’s College London. Her research utilises ethnographic methods to explore the experiences of people with severe mental illness and their families in Ghana. Dr Sumeet Jain is a Senior Lecturer in the School of Social and Political Sciences at the University of Edinburgh. His research draws on inter-disciplinary knowledge and mixed methods to unpack the notion of a ‘global’ mental health, and attempts to inform development of services that account for local experiences and understandings of psychological distress.

 

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ACTing For Refugee and Asylum Seeker Mental Health

Around 4 years ago, the World Health Organization were keen to develop a self-help intervention for their suite of low-intensity psychological interventions that are intended to be of use in low-resource settings and/or humanitarian contexts:

Click to access WHO-%20Volunteering%20and%20Internships-%20Brochure.pdf

They consulted with a number of people about the possibility of using Acceptance and Commitment Therapy (ACT) to inform the new intervention. This included discussions with those using ACT in low resource settings: including myself and other members of ‘commit and act’ (http://commitandact.com)… and ACT was selected as the intervention model of choice.

Russ Harris (https://www.actmindfully.com.au/about-russ/), along with other people from the ACBS (https://contextualscience.org/acbs), did a fantastic job of developing the Self-Help Plus (SH+) intervention. A five-session guided self-help intervention (utilizing audio recordings and an illustrated work-book) that is delivered in group-format. The approach is intended to be readily adaptable for different cultural and linguistic contexts. The group-based nature of the intervention means that it is highly scalable. In particular, it is hoped that SH+ will be helpful for refugees and asylum seekers who experience considerable levels of distress as a consequence of events in their country of origin, the circumstances of their migration and/or persisting uncertainty and stress in their host country.

The WHO need to complete two fully powered randomized controlled trials indicating that an intervention is efficacious before they make it available through their web-portals.

In Northern Uganda, SH+ has been evaluated for reducing distress in female South Sudanese refugees. This work was led by Dr Wietse Tol. We published the results of the feasibility study in World Psychiatry:

https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20537

Two additional papers (one reporting on the adaptation of the intervention into Juba Arabic for South Sudanese refugees; and the other being a protocol for the fully powered RCT) are pending publication in an upcoming issue of the journal Global Mental Health. The definitive trial completed in December 2017. We recruited over 600 female South Sudanese refugees. The paper reporting the results of the trial is in preparation. Additional funding has been secured to adapt and evaluate SH+ for male refugees in Northern Uganda.

In addition, a large grant from the EU (€3,000,000) has been secured via the HORIZON2020 scheme to conduct two simultaneous RCTs evaluating SH+ for refugees in 1) five EU countries (Italy, Germany, Austria, Finland, UK) and 2) Turkey. This project is called Refugee Emergency: DEFining and Implementing Novel Evidence-based psychosocial interventions (RE-DEFINE) (Project ID: 779255) and is being led by Prof Corrado Barbui. The project webpage is in its final stage of development and will be available to view imminently. In this trial SH+ is being evaluated as a preventative approach for stopping the development of mental disorders in refugees and asylum seekers. The project started in January 2018, and we will be commencing recruitment in the coming weeks. I am leading a recruitment site in Glasgow, UK (ably assisted by Mariana Popa @MScherbatsky11).

The WHO has been crucial to supporting this work. Particular credit must go to Mark van Ommeren, Ken Carswell, Felicity Brown (now with War Child), Teresa Au and Jennifer Hall.

It was great to present on ‘ACTing for Refugees and Asylum Seekers’ at the ACBS Polska conference in Poznan, Poland that took place in May 2018 – #acbsPL

It is still relatively early days, but it is great to have witnessed how SH+, and the research endeavors relating to the evaluation of SH+, has grown in recent years. The RE-DEFINE project is due to complete in December 2020.

If you are interested to read more about the challenges and opportunities that cross-cultural work relating to mental health can bring, please check-out the interview I did for The Psychologist:

https://thepsychologist.bps.org.uk/volume-31/june-2018/there-are-key-nutrients-can-support-people-experiencing-mental-health

And if you are interested in the important role that Contextual Behavioural Science can play in the field of ‘Global Mental Health’, please check out the following article:

https://www.sciencedirect.com/science/article/pii/S2212144717300583

Global Mental Health: A category benefiting from its contesting?

On the 5^th and 6^th June Kings Health Partnership in conjunction with King’s College London hosted a conference entitled: ‘Global Mental Health and Psychosocial Support’ (http://www.kcl.ac.uk/ioppn/news/events/2017/June/Global-mental-health-and-psychosocial-support.aspx) that was held at the KCL Waterloo campus. The conference was well attended with over 300 clinicians, researchers and students present. True to the focus of the conference there was also a good range of overseas speakers from countries such as Libya, Palestine, Zimbabwe, Uganda, and Sierra Leone.

I was invited to speak about work that I have been involved with relating to the adaptability of Acceptance and Commitment Therapy in sub-Saharan Africa. My presentation was part of the ‘Interventions in Global Mental Health’ session on the first day. Other sessions at the conference focused on themes such as ‘Reverse Innovation & Mutual Learning’, ‘Models of Partnership’, ‘Working with Trauma and in Conflict Situations’, ‘Helping the Helpers’, ‘Insights from the Field: NGO work’, ‘The Ethics and Politics of Global Mental Health’, ‘Training and Sustainability’, ‘Working with International and National Policy’ and ‘Acceleration and Scaling Up’. It was a very rich 2 days with a lot of thought-provoking material presented. In particular the panel discussions that were sprinkled liberally through the programme facilitated interesting discussion and, sometimes frank, exchanges of views. The organisers (Elaine Hunter, Alison Beck and Tope Ademosu) deserve great credit for ensuring diverse perspectives on GMH were presented.

This blog entry is intended to summarise some of the key points for reflection that arose for me across the two days. Readers who are active on Twitter may also wish to check out #KHPGMH2017 which captures the thoughts of others who attended.

 

Should we be doing global mental health at all?

GMH as an area of study, research and practice is principally concerned with addressing inequities in mental health provision across the globe. The lack of infrastructure (as recognized by high-income countries) for managing mental health problems in low- and middle-income countries (LMIC) has meant that a great deal of GMH attention thus far has fallen on LMIC. But this has led to accusations that GMH is founded on skewed, ethnocentric assumptions about what mental health services should be and that GMH is a Trojan horse that seeks to globalize psychiatric systems of care. However, these accusations have in turn been criticized as reductive misrepresentations of diverse approaches that are increasingly sensitive to the needs and views of local stakeholders. For those interested to read more about the development of GMH and related debates, the introductory chapter to The Palgrave Handbook of Socio-cultural Perspectives of Global Mental Health which is entitled ‘Situating Global Mental Health: Socio-cultural Perspectives’ may be of interest.

It was clear that many of the presentations, my own included, focused on the adaptation and/or scaling-up of psychosocial/psychological interventions that had been developed in high-income countries that were now being countries. This may be attributable to the fact that a wealth of psychological interventions have been manualised in high-income countries, and the evidence-base for these interventions has largely been established in high-income countries. Inevitably the content of these interventions has been influenced by the way in which people living in high-income countries experience, conceptualize and articulate their experiences. The suggestion is that these processes vary according to the local cultural and linguistic context, which gives rise to diverse ‘ethnopsychologies’. Unsurprisingly, an issue that arose at the conference was the extent to which it is appropriate to ‘export’ psychological interventions from HIC to LMIC, and whether it is appropriate for people from HIC to even work in LMIC. The possibility remains that there are approaches that originate in LMIC that may be effective for addressing distress that people experience there. In particular, approaches that are different from the allopathic approaches of the West, which from a Western perspective are some-what dismissively referred to as ‘alternative’ or ‘complementary forms’ of support (e.g. traditional healing, or faith healing) may represent affordable, acceptable, culturally appropriate, and effective strategies for managing distress.

Unfortunately, presentations focusing on indigenous forms of (psychosocial) support were sadly lacking from the conference schedule. This was disappointing given the findings of the review conducted by Nortje et al. (2016) that synthesized findings from 32 studies (conducted in 20 different countries) that investigated the efficacy of traditional healers for addressing mental disorders. The review concluded that traditional healers ‘might help to relieve distress and improve mild symptoms in common mental disorders such as depression and anxiety’ (Nortje et al., 2016, P154). There is increasing recognition of the importance of working with alternative/complementary practitioners as they represent a group of stakeholders that people in LMIC have engaged with for generations to address distress. Collaborations of this type must reflect on the merits and demerits of each other’s respective approaches whilst guarding against of the risk of ethnocentric subjugation of ways of knowing and practicing that are unfamiliar to them. Navigating these challenging metaphorical waters will be tricky. However, adhering to a rights-based approach that prioritizes opportunities for enhanced citizenship of people will be helpful.

Angela Byrne and her reflections on why she is no longer doing international work

 

A number of presenters at the conference (particularly some of those in ‘The Ethics and Politics of Global Mental Health’ session) were of the opinion that GMH as an endeavor was a potentially flawed project due to the inherent skewing towards Western perspectives. Angela Byrne’s presentation bore the forthright title ‘Why I chose to stop working internationally’. Angela expressed with great honestly and authenticity her concerns about the risk of harm being wrought by, albeit well intentioned, people intervening in cultural contexts that they are unfamiliar with. She highlighted the risk that the potential to ‘the silence of local people’ in supposed collaborative international partnerships bears testament to these issues. In highlighting a range of cultural and linguistic barriers to doing international mental health related work, Angela noted that if you cannot speak the language(s) of the place where you are going to be working, then you are a drain on their resources. Angela’s presentation highlighted the importance of people paying close attention to their reasons for engaging in international work and the costs, as well as the benefits, of this involvement. Practitioners will need to be mindful of the implicit, as well as more explicit, assumptions and biases that they bring to this work. In particular, it will be important to be vigilant to the positions of power that can emerge when identifying closely with professional and disciplinary knowledge. All forms of professional training have blind-spots, which may become particularly exposed when applied in different contexts. The lack of flexibility that professionals adopt has been referred to as the ‘tyranny of experts’ by William Easterly. Local stakeholders can also contribute to these power dynamics by adopting an attitude of resistance to interventions, or indeed by taking an overly deferential position to international experts [i.e. Kristen Edquist (2008) highlighted the risk that international agencies might constitute ‘mental health assemblages’ that could serve to globalize pathologies]. Where possible, it will be vital to make explicit the assumptions that are inherent to the theoretical models that are informing international work. Discussing these assumptions with a diverse range of relevant stakeholders should be a key feature of the preparation for the work.

 

The harm of doing vs. the harm of not doing

Whilst acknowledging the need for cultural sensitivity, and caution with regard to the power dynamics in how knowledge is brokered, I would counter that people should not exclude themselves from international mental health related work on the basis that they not from the local cultural and linguistic context in which the work is taking place. This could amount to what I would term ‘ethnopsychological acquiescence’, where people prefer not to act or intervene on the basis that they do not know enough about how distress is experienced, conceptualized and articulated in that context. I agree that there is a need to progress with care, but by working in partnership with local stakeholders and adopting paradigm humility (where we hold our world view and associated assumptions about paradigm lightly) opportunities for fruitful, enriching and productive collaborations exist. The nature of the work itself is a central consideration, but equally the attitude that people bring to this work is key. In being mindful of the risk of doing no harm, we must also be aware of the limiting impact that inaction may have on efforts to improve mental wellbeing across the globe.

 

The Politics of Identity

Over the course of the two days the politics of identity, and the privilege that particular identities can imbibe, was a theme that emerged in a number of presentations and associated discussions. Nimisha Patel in her talk entitled ‘The mantra of do no harm: International healthcare responses to refugee people and human rights violations’ spoke passionately about the need to acknowledge the long-shadow that ‘whiteness’ casts over international mental health work, and how power is disproportionately distributed in this work. She argued, persuasively, for the need to prioritise a human-rights based approach that tackles the social injustices that underlie the distress that people experience across the world, and for people to eschew the inclination to be a bystander to injustices being committed.

As a white male, aspects of Nimisha’s presentation made for uncomfortable but important listening. It provided an opportunity to acknowledge how the ‘privileges’ that come with being white, male and born in a HIC have afforded me with particular opportunities to learn about mental health in international contexts. My circumstances also provided me, but not others (particularly my LMIC-based collaborators), with the opportunity to attend this particular conference. Nimisha’s points were very well made. She speaks with great grace and wisdom. But in recognising the power imbalances that various forms of privilege can bring (and endeavouring to address injustices associated with this), we need to be aware of the importance of avoiding stereotyping in all its forms. Efforts aimed at promoting the rights of disenfranchised groups  (e.g. minority groups, those living in low resource settings, and those experiencing mental health difficulties) should not denigrate the humanity of other groups. My upbringing in Northern Ireland brought into sharp focus the importance of reconciling injustices and transforming conflict, but it has also made me very wary of discourses that can serve to ‘other’ groups of people.

I addressed issues relating to GMH and identity politics in the final panel discussion of the conference when I spoke about how these discussions had impacted on me. Whilst being aware of the crucial importance of acknowledging injustices that have been perpetrated against particular groups of people, and the need to respect diversity, I also feel that it is vitally important we acknowledge the common humanity that is shared across different identities. These issues were discussed in the aftermath of the last U.S. election with some commentators reflecting on the need for what has been termed ‘post-identity liberalism’ i.e. a move towards acknowledging diversity, whilst embracing commonality and promoting solidarity. I think it is fair to assume that the vast majority of people who were present at the conference share a commitment to making a positive impact on the lives of people experiencing distress across the globe – a common cause that people can work together to advance. I think the organisers of the conference deserve enormous credit for trying to create a space for different diverse discourses to be shared, but moving forward the challenge for GMH will be to ensure that marginalised voices (many of which were not represented at the conference) are also heard, and that this can make a meaningful contribution to shaping the sense of shared humanity and solidarity it can engender.

 

‘Flows’ of Knowledge

In acknowledgement of the need to improve mental health services in HIC, interest is growing in how insights from GMH can help to promote innovation and improved effectiveness of mental health services in HIC. This is a topic that colleagues and I have reflected on in recent papers that we have published e.g. the editorial in the British Journal of Psychiatry by Sashidhrana et al. (2014) entitled ‘Global Mental Health in High-income Countries’ (http://bjp.rcpsych.org/content/209/1/3). Despite the hard work and commitment of various stakeholders, if a school report was to be issued about mental health services in HICs it would read ‘Could do better’. Martha Nussbaum (2011) has previously commented that ‘All nations are ‘developing’…All are failing at the aim of ensuring dignity & opportunity for each person’. This is exemplified, by the fact that there are large proportions of the population in the UK who are underserved by mental health services. Angela Byrne’s presentation included a quote that debunked the myth (perpetuated by policy makers and services) that these populations are ‘hard to reach,’ – it stated ‘we are not hard to reach, we’re just easy to ignore’. It may be that mental health services in the UK could be more inclusive of diverse explanatory models of mental health difficulties, and work more closely with stakeholders who are knowledgeable about these explanatory models (e.g. religious leaders, practitioners of Chinese Traditional Medicine etc.) to deliver forms of intervention that are acceptable to greater proportions of our populations can engage with. It will be important for there to be an open and equitable exchanging of knowledge between different stakeholders to avoid what Miranda Fricker (2009) has referred to as ‘epistemic injustices’ i.e. when people are wronged in their capacity to be knowers.

Lord Nigel Crisp providing his key-note address.

Consistent with this idea of HIC learning from LMIC, the conference had a dedicated stream called ‘reverse innovation’. This has been referred elsewhere as ‘reverse engineering’. Angela Byrne, a clinical psychologist who has experience of international work, stated at the conference that the use of the word ‘Reverse’ takes for granted that there is a normative direction of innovation and that this may be problematic. Similarly, Lord Nigel Crisp in his key-note speech indicated that he does not like the term and the condescending connotations that it conjures. In my writing about GMH, I along with my colleagues have introduced the term ‘counterflows for global mental wellbeing’ (White et al., 2014) to specifically capture the way in which for too long people living in LMIC have been regarded as recipients of knowledge rather than generators of knowledge about mental health, and that there is a need for people in HIC to be receptive to potentially helpful knowledge that runs counter to the prevailing direction of knowledge (i.e. from HIC to LMIC).

 

Treatment and Prevention

During his key-note speech, Vikram Patel reflected on the tensions that exists between focusing resource on ‘treating’ mental health difficulties vs. investing in preventive approaches aimed at addressing the social determinants that contribute to mental health problems. He suggested that claims that all resources should be directed to preventative strategies, is like saying TB should be controlled simply by ending poverty. Equally, however, he could have observed that focusing on ‘treatments’ without adequately addressing the social contexts in which people live their lives (and the associated poverty, marginalization and disempowerment that large proportions of the global population experience) would be akin to treating someone for cholera without addressing the source of the infection. One of the slides used by a presenter in their PowerPoint presentation captured this sentiment by including a quote from the WHO European Office that stated that ‘Modern societies actively market unhealthy lifestyles’. Careful attention needs to be paid to striking a balance between investing in treatment and prevention programmes.

 

The Ethics of Diagnosis

The key-note by Vikram Patel was also cause for reflection on the ethical ‘elephant in the room’ that has loomed large in debates relating to the merits and demerits of GMH initiatives. This relates to the concerns have been expressed by people such as Derek Summerfield, China Mills (who both presented at the conference) and myself, about the use of psychiatric diagnosis in LMIC when concerns have been raised about the validity and reliability of these systems in HIC. Indeed, concerted efforts are being made by clinicians and academics in the UK to propose alternative frameworks to diagnosis (e.g. the Power-Threat-Meaning framework: http://www.isps2017uk.org/beyond-diagnosis-meaningful-patterns-emotional-distress-power-threat-meaning-framework-and). Patrick Hughes who presented in his capacity as a WHO consultant for the mhGAP programme remarked that there is considerable pressure to make diagnoses in international mental health work that he has undertaken because this fits into the recording systems that international agencies use. Vikram Patel noted that in spite of concerns about concerns about the validity of psychiatric diagnoses (that can mean that some researchers decide not to share diagnoses with research participants recruited in LMIC), there are also imperatives for using diagnostic categories in research settings as this ‘gets papers published’. There is an urgent need for the scientific community to engage in dialogue about this unsatisfactory and potentially harmful approach. Perhaps this is an issue that the upcoming Third Series on Global Mental Health commissioned by The Lancet will address. It is too important an issue not to be focused on.

I would like to express my deep gratitude to Dr Nargis Islam (Clinical Psychologist) who also attended the conference, and who provided helpful comments and suggestions about the content of this blog entry.

 

The final panel of the conference chaired by Prof Martin Prince

References

Edquist, K. (2008). Globalizing pathologies: mental health assemblage and spreading diagnoses of eating disorders. International Political Sociology, 2(4), 375-391.

Fricker, M. (2009) Epistemic Injustice: Ethics and the power of knowing, Oxford, Oxford University Press.

Nortje, G., Oladeji, B., Gureje, O., & Seedat, S. (2016). Effectiveness of traditional healers in treating mental disorders: a systematic review. The Lancet Psychiatry, 3(2), 154-170.

Nussbaum, M. C. (2011). Creating Capabilities: The Human Development Approach. Harvard University Press: US.

Sashidharan, S.P., White, R.G., Mezzina, R., Jansen, S., Gishoma, D. (2016). Global Mental Health in High Income Countries (Editorial). British Journal of Psychiatry, 209, 3-5.

White, R.G., Jain, S., and Giurgi-Oncu, C. (2014) Counterflows for mental well-being: What high-income countries can learn from Low and middle-income countries. International Review of Psychiatry, 26, 602-606

White, R.G., Jain, S., Orr, D., & Read, S. (Editors) (2017) The Palgrave Handbook of Global Mental Health: Socio-cultural Perspectives. Palgrave-Macmillan. https://link.springer.com/book/10.1057%2F978-1-137-39510-8

 

 

 

 

 

Lusoga reflections on the solace that songs can bring

This afternoon (Tuesday 9th May 2017) we concluded the interviews that we were conducting to explore how processes of overcoming difficulties in Uganda are captured in some of the languages spoken in the country. Happily, Dr Cornelius Gulere (the Lusoga language expert based at Makerere University) responded to my request for a meeting. He is involved in the Intellectualization of African Language Initiative (IALI: http://ialiuganda.org), which has the strap line: ‘To efficiently transform our local languages into languages of science to be used for scientific discourse’. As part of this initiative, Dr Gulere has recently been invited to participate in meetings which aim to promote ‘Science Centred Mother Tongue Development’.

Rosco and Dr Gulere at Makerere University

The interview occurred under the shade of a tree a short distance from Makerere University Guest House. The interview questions were put to Dr Gulere in English. He responded in Lusoga before taking the time to translate a summary of the information that he had shared in English. In response to a question about the stories that people share in the Lusoga language about overcoming difficulties, Dr Gulere emphasized the important role that proverbs and riddles play in the Lusoga language. He also reflected on the tragic loss of his father at a comparatively young age, and the songs that provided comfort to him at that time. He stated that religious verses and hymns make an important contribution to the language that is shared between Basoga people at challenging times. Examples of Lusoga language phrases that cite God’s central role in overcoming difficulties include ‘Katonda aidha kukukuuma’ (God will keep you) and ‘Atyo bwasazeewo’ (That’s how God has decided). Dr Gulere observed that there is growing pressure to overcome particular life challenges within circumscribed periods of time. Whereas, in years gone by, bereavements would have traditionally been marked by 40 days of mourning, the churches are now less keen to endorse this – emphasizing instead that God will tend to the dead person’s soul rather than the behavior of those who remain alive.

Dr Gulere indicated that when he gets upset he sings a doxology (i.e. a brief hymn) to himself for comfort and solace. He observed that expressions used by the Basoga tend to be short, one-word utterances. He opined that rather than get preoccupied about the nature of the difficulties, the Basoga have a tendency to employ these utterances in conjunction with sympathetic non-verbal gestures, before shifting the locus of the communication to factors apparently extraneous to the distressing event e.g. focusing on aspects of the ecology – the trees, the birds, the animals.

In terms of insights about Basoga cultural beliefs, we learned how seeing a woman upon leaving the house has traditionally been regarded as a bad omen. Dr Gulere however shared that he now adopts an attitude of welcoming this potential omen as an opportunity to confront and overcome any challenges that might come his way. Dr Gulere commented that the closest Lusoga word for ‘resilience’ (Okukukaalukana) was difficult to translate directly into English – the word used was described as ‘deep, persistence, endurance, struggling, coming back, overcoming’. After sharing one of his own fantastic poems, he also directed us towards the music of singer/song-writer Racheal Magoola and the Afrigo Band. He stated that their song ‘Obangaina’ provides an example of Basoga language renderings of overcoming difficulties. A video of the song can be viewed by clicking the link below:

https://www.youtube.com/watch?v=BOqEBm7oCPs

At the end of the interview, Dr Gulere and I got into conversation about the Makerere University campus. He mentioned how the hill on which Makerere University is situated used to be a heavily forested area that was populated with numerous impala (i.e. a medium sized form of antelope) and monkeys. Historically Kampala was known as the city of 7 hills. When the British first arrived they called the area on which Kampala now stands as the ‘Hills of the Kampala’. This corresponds to the Luganda phrase ‘Akasozi ke’Empala’: “Kasozi” meaning “hill”, “ke” meaning “of”, and “empala” the plural of “impala”. In Luganda, the words “ka’mpala” mean “that is of the impala” (European settlers added the ‘i’ to ‘mpala’ because they struggled to pronounce the nosal ‘mp’ – the word ‘mpala’ means to run fast and wild). Over time one word “Kampala” was adopted as the name for the city.

Kampala ranks number one across the globe as the capital city that reports the highest number of lightning strikes. True to form, this evening a storm blow into Kampala, the winds picked up, and the deluge commenced. It was an awe-inspiring moment to bear witness to the force of the rain and the drama of the thunder and lightning that accompanied it.

An impala – key to the naming of Kampala

Cliodhna’s reflections:

This afternoon we met with Dr. Cornelius Gulere whose first language is Lusoga. We sat outside with the surrounding trees shading us from the afternoon sun. Similar to the themes of other interviews, Christianity and the influence of the church was an oft mentioned topic. Like Mr. Abiti Nelson, he described the function of traditional grieving songs in comforting the bereaved, and how the church encourages people to sing Christian hymns instead. Moreover the traditional means of grieving, whereby people would sleep over in the home of the deceased for 40 days, concluding with a communal feast has been replaced by the traditions of the church. Dr. Gulere described how this move away from tradition can mean that people may be left without a sense of comfort and company. However the syncretism of traditional practices and the newer influence of the church was evident in his claim that many go to church, not necessarily to pray but to perform more traditional rituals.

Dr. Gulere discussed the problem of childlessness, and how women experiencing this might perform a ritual of drinking the water that an older woman has poured and has flowed towards them. He also described rituals of naming babies, which were also a prominent point of discussion in the Baganda student group. For example if a birth comes soon after the death of a relative, the first choice of name is that of the deceased. In this way they remain present in some form which brings comfort to those who have lost someone.

The importance of song in everyday life was evident throughout our conversation with Dr. Gulere. He began to sing a number of times including one song that his mother used to sing to him as a child. However he said that she is now more interested in singing religious songs. He said that he loves to sing in the church choir even after a hectic week as it is a source of comfort for him. He described losing his father and the power of singing songs in that time and how when a person sings, tears can flow and you can feel ‘lower down’, a term he used a number of times to describe being calmed down. While he was grieving the loss of his father he would sing a particular hymn over and over again until the tears no longer came. Dr. Gulere also shared a poem with us that he had written in Lusoga.

Again I was struck by the willingness of the people we met to open up and share stories, songs, and even personal poems with us. The setting and content of this interview was a wonderful way to conclude our work in Kampala and I feel compelled to return and explore this diverse country more in the future.

Moments of contemplation at the shore of Lake Victoria as the trip to Uganda draws to an end

Acceptance and Commitment Therapy in a Ugandan Context: Exploring Values Guided Action

Today provided an opportunity to deliver an ‘Acceptance and Commitment Therapy’ (ACT) workshop in Kampala for a range of counsellors and psychologists. ACT is a third-wave psychological therapy that aims to help people to clarify their values and to engage in behaviours that are consistent with these values, as they hold doubts, fears and concerns that might arise lightly. Previous posts in this blog attest to the efforts I have made in conjunction with ‘commit and act’ (http://commitandact.com) to build capacity for ACT in Sierra Leone and Uganda. We have published research that has highlighted the feasibility of training non-specialist workers in delivering ACT in low resource settings (http://eprints.gla.ac.uk/117762/). A recent book chapter entitled ‘commit and act in Sierra Leone’ (http://link.springer.com/chapter/10.1057/978-1-137-39510-8_31), published in ‘The Palgrave Handbook of Socio-cultural Perspectives on Global Mental Health’ (http://link.springer.com/book/10.1057/978-1-137-39510-8), reports on the potential value that ACT might offer for building capacity for mental health in low resource settings.

 

In August 2014, I delivered the first ever ACT workshop in Uganda. In subsequent years, other trainers including Igor Krnetic and Joe Oliver have delivered workshops. Dr Rosco Kasujja has done a great job at keeping momentum going with the development of ACT in Uganda. It was great that Rosco was available to co-facilitate. It is always a joy to work with Rosco. Our styles of working complement each other and together we form what our friend and colleague Richard Fay refers to as the ‘Ros-collective’!

Rosco and myself – ‘The Ros-collective’

 

The workshop provided an opportunity to catch up with some people that I met during my visit to Kampala in 2014. In addition, I was also honored that colleagues based in Lira who had assisted with a research study we conducted there in 2015 had also made the long trip down to Kampala. This group included Fr Ponsiano who was so crucial to the completion of that research project. I had been very much looking forward to seeing him again.

 

There were a total of 30 attendees present at the workshop who spoke a total of 6 different mother tongue languages. In addition, to Luganda (N = 10), which has been highlighted in previous blog posts, individuals reported the following languages as their mother-tongues:

• Lango (N = 9) is spoken by 2.1 million people according to the 2014 census – who are concentrated in the Northern region of Uganda. Lango shares lexical similarity with the Acholi language that has also featured in recent blog entries.
• Runyankore-Rukiga (also known as Chiga; N = 7) is a Niger-Congo language spoken by 2.4 million people in Uganda.
• Ateso (N = 2) (also known as Teso) is a Nilo-Saharan language spoken by 2.4 million people across the country.
• Lumasaaba (also known as Masaaba; N = 1) is a Niger-Congo language spoken by 1.7 million people.
• Runyoro (also known as Nyoro; N = 1) is a Niger-Congo language spoken by 970,000 people in Uganda.

In advance of the workshop, the attendees had been invited to participate in a research survey that investigated how notions of overcoming difficulties are captured in their language, poems and songs. After completing the survey questions individually, members of the language groups were allowed to discuss their responses and then complete an additional response sheet relating to the consensus of the group regarding their responses.

 

The completion of the research activity proved to be a helpful ice-breaker for the workshop that followed. It served to ground the subsequent focus on therapeutic strategies aimed at ameliorating distress in the context of the languages that they use on a daily basis to conduct their work. This particular workshop focused on ‘Values Guided Action: An ACT Approach’. The workshop was intended to be experiential with attendees having the opportunity to apply the material to their own lives, so that they might be able to share the approaches with people they are supporting in a more authentic way. The attendees engaged well with the practices/exercises that were included. I was pleased with the level of interaction that the attendees had with me, and the insightful questions that they asked. I am very excited and optimistic about the opportunities that exist for ACT to be tailored to Ugandan cultural and linguistic contexts. I hope that the work that we are undertaking as part of the current research will help to inform this.

 

At the end of the one-day workshop, Fr Ponsiano provided warm words of appreciation to myself, Rosco and Cliodhna for organizing and delivering the workshop. Not for the first time, I was struck by the remarkable grace that Fr Ponsiano embodies. His poise, considerate manner, and eloquence as an orator, are plain for all to see. As he expressed his gratitude, I was able to be deeply present with the reasons why I do the work that I do – to share insights that I have learned, whilst benefitting greatly from the warmth, wisdom and sense of connection that others are kind enough to share with me. I am pleased to say that Fr Ponsiano is planning to commence a PhD in the coming months exploring conflict transformation in Uganda. He, more than most, is well placed to make an important contribution to this area of work.

 

The reflections of Cliodhna Cork (Research Assistant and MSc Global Mental Health graduate):

 

It was great to sit in on the ACT workshop, delivered by Ross and Roscoe. As I am not a qualified therapist, it was primarily useful for my own daily practices as well as being an education into using this form of therapy in varied settings. There were many insights from practicing therapists on using ACT to address trauma, particularly in Northern Uganda where entire communities have quite recently experienced deeply traumatic events. I was inspired by the huge sense of social responsibility among these therapists and students, and the lengths they go to in order to provide often voluntary services to those most in need of it. It was encouraging to see how a form of therapy primarily developed in the USA and Europe could be meaningfully and successfully used in a different context. This is due in part to ACT’s focus on a person’s values without enforcing predetermined goals or values onto them. Thus ACT can be easily adapted to each therapeutic relationship and context. That said however, while doing group work with other attendees I was struck by the realisation that despite all of our vastly different backgrounds, ages, and languages there seem to be some basic values that are almost universal: valuing family and social relationships came up time and time again, as well as living an ‘honest’ life.

I spoke to some psychology graduates and masters students who mentioned the lack of state funded jobs available to them. However, there seemed to be glimmers of hope, with one student saying that the state was slowly investing more in clinical psychology based jobs. Many engaged in voluntary work with NGOs or non-profit organisations both to get relevant experience and to give back to their communities. One example is Faces Up whose Facebook page can be found here: https://www.facebook.com/FacesUpUganda/ while some were even involved in founding their own non-profit organisations such as ‘Special Minds Initiative’ (https://www.facebook.com/SpecialMindsIni/) co-founded by Hillary Mutatiina.

 

I was grateful to have had the chance to meet Fr. Ponsiano, who Ross had spoken about with admiration during the Global Mental Health masters. It is clear that he is a man of great dignity and I wish him every success in his plans for the future.

Workshop attendees

The Acholi Quarter, Kampala District: The Precarity of Displaced Living

To follow up on the meeting with the Acholi Makerere Student Association yesterday, we travelled out of Kampala to visit residents of an Acholi village which was constituted when large numbers of conflict affected Acholi people were displaced from their land in Northern Uganda in the mid to late 1980s. The King of Buganda (Muwenda Mutebi II) gifted the land to be used by the Acholi people during the crisis.

The Acholi Quarters, Kampala District

The village is officially referred to as the ‘Acholi Quarters, Banda Zone 1, Banda Parish, Nakawa Division, Kampala District’, and it consists of 5000 people squeezed into a comparatively small patch of land that is boundaried by a railway line, a river and a road that leads to a Seven Day Adventist Church. This was clearly a very deprived area with basic amenities. The area has been described as a ‘slum’ and it is not uncommon for out-breaks of health conditions commonly associated with slums (e.g. Cholera outbreaks) to occur. Further details about the conditions in the Acholi Quarters are available here: https://www.ntnu.edu/documents/152037/0/2009+Fieldwork+Report+-+Acholi+Quarters%2C+Kampala.pdf/77f770ce-d0b2-4470-9d55-5cc8d3083cbf

 

We first met with a community elder who Rosco had liaised with in the weeks prior to our arrival in Uganda. The elder warmly welcomed us and then went to gather up community members for our meeting. John Steven Opio, our facilitator from yesterday’s meeting had kindly agreed to accompany us to this meeting and pose the questions to the group in Acholi, so that we could conduct the discussions entirely in Acholi – which was the mother tongue of all of the attendees.

Produce on sale

On arrival in the quarters we were escorted down an alley and into a single room building that serves as a meeting place for community members. We greeted each of the people that had kindly made time to meet with us. There were 24 people (15 women and 9 men) in attendance – the majority of whom were above 50 years of age. This served to counterbalance the comparatively younger aged Acholi people that we had spoken to the previous evening. The meeting lasted around 90 minutes.

The room of our meeting with community members from Acholi Quarters

Young children, curious as to why the adults had gathered together, poked their heads through the open doorway into the room – only to be shooed away by the adults. The energy again built throughout the duration of the meeting, culminating in the singing of songs and a number of people getting up to dance (click the link below to see the video below – reproduced with the kind consent of everyone present). There were broad smiles and enthusiastic cheering amongst those present – people were clearly enjoying themselves.

https://www.dropbox.com/s/xeid9in6jkwsiug/IMG_1404.MOV?dl=0

In terms of words that I was able to pick up, it seems that the Acholi words ‘kanyo’ or ‘ciro’ can be used to capture what in English is termed as ‘resilience’. At the end of the meeting I talked in English with a number of the people present. They were keen to highlight the difficult conditions in which they are living, and how important it is for the community to act collectively to support each other. A point that one man was keen to make was that if additional resource and support was to be made available to assist the Acholi people this should be spent in improving conditions in Acholi land in Northern Uganda, rather than in the Acholi Quarters in Kampala. There are concerns that the King wants his land back and that the rights of the Acholi people to remain on the site are far from secure. The Acholi people have endured high levels of precarity in recent times and there is no guarantee that this will be resolved any time soon.

Cliodhna’s reflections:

Today’s interview took place a world away from the setting of Makerere University. We visited an Acholi village which was made up of precariously placed makeshift houses among ululating dusty red clay roads. We met with John Steven Opio again, our facilitator from the day before, who introduced us to the village elder and a large group of older residents. Without Steven the interviews would not have been possible and we were grateful for his translating and mediating skills. It was a wonderful experience to meet such a different demographic compared to previous groups and I look forward to hearing all of their stories and perspectives when the recordings are translated. Similar to the other interviews, it started off quite slowly and calmly but by the end there was dancing, singing, laughter, and children and teenagers looking in the windows and doors to see what all the fuss was about! Everyone seemed to really enjoy it, and again I got the sense that getting together and discussing things about a shared culture is simply a gratifying activity. However, we were aware of the huge difficulties facing the residents of this village where eviction and disease are commonplace and where there is no job security. They also expressed a desire to move back to Northern Uganda where they are originally from.

 

Walking back through the village after hearing these stories I was more aware of the ways that people were trying to make their lives work in such precarious conditions. There were various makeshift stalls or blankets set up along the roads selling vegetables, dried tilapia (a local staple fish) and white ants; young men had set up cinemas where they were charging a small price to see Hollywood films or live premier league football matches (the international recognised language of football!); and there were messages painted on the walls of small schools urging parents to educate their children. Today’s meeting showed me Ugandan life from another perspective, and was a lesson in the struggles facing displaced groups in this vastly ethnically and linguistically diverse country.

Using aspects of the landscape to linguistically capture the importance of cooperation: Reflections from the Lusoga and Acholi people

Today we returned to Makerere University to meet initially with the Basoga Society at the University. The Basoga Kingdom (one of five constitutional monarchies in present day Uganda) is located in the South east of Uganda between the Lake Victoria and Lake Kyoga. This land encompasses the districts of Jinja, Kamuli, and Iganga. The Basoga people speak the Lusoga language that is closely related to Luganda (both of which are Bhantu languages). There are 3 million speakers of the language according the 2014 census. There are a number of dialects of Lusoga and this can lead to contention relating to the correct pronunciation of words. The moto of the Basago people is: ‘Okwisania busoga n’amaani’ (literally: together Basoga is power/figuratively: unity is strength). This is similar to a Luganda proverb ‘Abayita ababiri bejjukanya’ which is literally translated as ‘Those who walk together remind each other’ (potentially reflecting risks to people that existed in rural ecologies), but is figuratively translated as ‘Unity is strength’. The emblem of the Basoga is provided below.

The emblem and motto of the Basoga people

In our group today there were six participants – five male and one female – all students at Makerere University. All of the attendees indicated that they spoke Luganda as well as Lusoga fluently. The dynamic of the group was markedly different from the Luganda group that we had with the day before. Whereas the group of Luganda trainee teachers were very focused and attentive, this group seemed to be a bit more playful. This was perhaps unsurprising – by virtue of their training, trainee teachers are well versed on how to engage in group based activities in an educational setting! The students were from a variety of different academic subject backgrounds. One of the group members had agreed to facilitate the discussion and to pose the questions for the other group members to answer. With Lusoga and Lugandan sharing some similarities, Rosco was also able to track the conversation and provide some co-facilitation. An issue that arose with Lusoga, but not with Luganda, related to the translation of the English word ‘phrases’ – English synonyms of the word had to be generated, which were then translated into Lusoga. As with previous sessions the intensity of the discussion tended to wax and wane at different points, but encouragingly everyone in the round contributed their thoughts. Some interesting Lusoga sayings that emerged through our discussions that resonate themes of resilience included ‘Esososisole bwelitata lituukakulyenyu’ (if a bird does not die it reaches the banana), and ‘Abasoga twulyofi nseete’ (Basogas we are like termites). The group explained that the latter metaphor captures the rapid progress that Basoga people can make through collaboration – one moment a termite hill is not there, and the next it is! The influence of ecology on linguistic metaphors was again evident in these sayings.

Termites and their hills – a feature of the landscape that capture the power of cooperation

The session with the members of the Basoga Society spurred me to look further into literature that has been published in the language that may be of relevance to our work. Dr Cornelius Wambi Gulere, an academic based at Makerere University, has written a number of books in Lusoga including : ‘911 Lusoga proverbs: Endheso mu Lusoga 911’ (https://www.academia.edu/1612549/911_Lusoga_proverbs_Endheso_mu_Lusoga_911). A dedication that Dr Gulere has made on a number of his publications (e.g. https://www.academia.edu/1381882/Lusoga_Stories_Ekidhuubo_kya_Girigooli_ekisembayo) reads: “Eri abaana abadhuuba okuguluka; aye nga maayabaidha kukuguka mu mbiro dh’amagezi” (To all the children to whom flying may be the yearning; but like the ostrich would excel in the race of wisdom). I have contacted Dr Gulere to check whether an English language translation of the text exists, and whether he would be available to meet with us in the coming days.

In the evening we had arranged to meet with the Acholi Makerere Student Association (AMSA: https://www.facebook.com/groups/152462336455/), which has about 40 members made up of the 120 Acholi students who attend Makerere University from a total student population of 35,000. The Acholi form a significant proportion of the Luo Nilotic ethnicity that predominates in the northern part of Uganda – they are consequently under-represented in the student numbers at Makerere University. The region where the majority of the Acholi people live is referred to as the ‘Acholi land’ and it spreads across the border between Northern Uganda and South Sudan – see the map below. The Acholi language is mutually intelligible with other languages spoken in Northern Uganda including Lango and Alur). Collectively, these western Nilotic Language are referred to Luo Languages. The 2014 census indicated that 1.5 million people in Uganda speak the Acholi language.

Acholi Land in Northern Uganda/Southern Sudan

It has been suggested that during the colonial era the Acholi were preferred by the British as soldiers and that this military ‘ethnocracy’ (i.e. a type of political regime in which the state apparatus is appropriated by a dominant ethnic group(s) to further its interests, power and resources) has contributed to a shaping of the Acholi ethnic identity over time. Further reflections on the Acholi identity are provided in the following article: http://www.tandfonline.com/doi/abs/10.1080/14725843.2015.1023255?scroll=top&needAccess=true&journalCode=cafi20. The Northern Region of Ugandan was heavily impacted by the conflict that occurred over 2 decades from the 1986 to 2006. This led to huge levels of displacement of the local population. It has been suggested that since the 1980’s the Acholi have experienced discrimination and exclusion from senior government offices. There continues to be marked inequality between the living standards in Northern Uganda compared with the remainder of the country.

The meeting took place a short distance from the Makerere University Guest House. The group had assembled in the relative cool of a grassy area between university buildings that doubled as an outdoor meeting space. The group had kindly agreed to set aside time during their routine meeting to talk with us. This was by far the largest group of people that we had met with – approximately 35 people. As the discussion evolved it became apparent that a subsection of the group were contributing to the discussions, whereas others were more reticent. It was agreed that we work with the sub-group of AMSA members, so that the others could progress with the other items on the agenda of their meeting. This meant that 10 people were left to interact with the Acholi speaking facilitator of the group (Mr John Stevens Opio).

The setting for our meeting with the Acholi Makerere Student Association

Hearing the Acholi language spoken by the students instantly brought me back to the time that I spent in Northern Uganda in April 2015. I was able to share pieces of the related Lango language that I had picked up during my time in Lira (see blog entries below relating to the work that we completed at that time). To my eyes and ears, the sharing of these basic pieces of language had a marked impact on the interactions that I had with the AMSA members. The fact that I had some, albeit small, knowledge of the Luo language seemed to facilitate a deeper sense of connection. As I listened intently to the discussions I was able to hear people make mention of linguistic descriptors of problems we had noted during our fieldwork in Lira e.g. ‘laro lobo’ (land wrangles – relating to disputes over the ownership of land that people had been displaced from). Clearly, the difficulties of the past continue to cast long shadows over the experience of the Acholi people. The discussions progressed well as the sun began to set – the encroaching darkness coinciding with the tapering of the discussions.

Prompted by a number of students approaching me to enquire about the possibility of studying in the UK, I addressed the larger group to provide some advice about applying for scholarships. Schemes like the Commonwealth Shared Scholarship Scheme (http://cscuk.dfid.gov.uk/apply/shared-scholarships/info-candidates/) although highly competitive can provide important opportunities for post-graduate study in the UK. My hope is that in spite of the current political climate, the UK will continue to invest in the development of young people in low income settings, and that the supported individual can cascade their knowledge and expertise to benefit individuals around them. Although, the first two days of the trip have been enriching, the energy levels have dipped as we adjust to the recent travel and the new surroundings. A good night sleep is required!

Cliodhna’s reflections:

“To start the day we met a small group of Basoga students at Makerere University. The sense of multilingualism was even more evident in this group because of the presence of three languages: Roscoe gave instructions in a mix of Lusoga and Luganda, while a member of the student group who was fluent in Basoga and English co-facilitated. Moreover there were discussions amongst the students about who spoke Lusoga ‘properly’ as well as talk about the fact that some members of the group did not seem to be aware of certain Lusoga rituals, songs, or phrases that were being discussed. These factors contributed to a greater sense of uncertainty within this group compared to the last student group. However it should be noted that the latter were part of a group that celebrates their culture so they may have been better versed in discussing the topic of the questions that we were asking.

Meeting with a large group of Acholi students in the evening at the very least taught us some lessons about conducting interviews in groups of over 30 people! After a couple of questions it was agreed that a smaller number of students would partake in the group interview while the rest carried on with their arranged meeting. The student who was helping to co-facilitate told us that the students were expressing their thoughts on the negative things affecting their lives at the moment. They were still eager to continue to talk as darkness crept up and it was clear that they have a lot of pressing concerns, in particular about their futures.

By the end of today I was more aware of the differences that had existed between all of the groups – and I presume that it will continue that way. However despite these differences, they have all had in common a sense of being invigorated or energised by the end of the interviews; perhaps because of talking amongst peers about cultural practices and symbols that they have in common, or from getting a chance to express their views on the negative issues affecting them.

Some of the difficulties of researching multilingually were also highlighted today- I noticed that if Ross asked a question in English everyone (naturally) answered in English and we, perhaps confusingly, had to explain that we wanted them to answer in their mother tongue. Moreover people seemed to have difficulty with the translation of the word ‘phrases’ which we didn’t anticipate, and to a lesser extent the phrase ‘everyday objects’. I pondered whether this had been translated as objects that we specifically use every day as opposed to ‘common’ objects present in our lives. It is clear to me that there are unanticipated obstacles in researching across a number of languages, often present in the smaller details.”

Exploring the language of wellbeing and distress in Uganda

It is great to be back in Uganda. I am here with Cliodhna Cork who is a colleague working at the University of Glasgow who is collaborating with me on an Arts and Humanities Research Council funded project that is exploring linguistic idioms of distress, resilience and wellbeing in different sites including Zimbabwe, Uganda, Ghana and Gaza. During the week-long trip to Uganda we will linking in again with Dr Rosco Kasujja from the Psychology Department at Makerere University. We have arranged to meet with people from different language speakers to learn more about idioms used in their language. Over forty of the languages indigenous to Uganda fall into three main families — Bantu, Nilotic, and Central Sudanic — with another two languages in the Kuliak family (see the graphic below for details of how the languages are distributed across the country).

Our first appointment of the day was with Mr. Abiti Nelson, Conservator Ethnography, Department of Museums and Monuments, Uganda National Museum. We had some time to look around the museum, which provided a great opportunity to learn more about Uganda’s rich history and the country’s cultural diversity. Exhibits at the museum included items of cultural significance for the various ethnic groups in Uganda including head-dresses, clothes, tools for daily activities and implements for diagnosing, treating and preventing illness.

In the photograph below showing a section from the ‘Health’ display you can see a Buganda necklace under the ‘Prevention’ title. Rosco explained that this is placed around the neck of a premature baby to protect its health. The displays also included items of dress worn during ceremonies and traditional dances (see the photographs below).

Mr Nelson’s mother-tongue is Lugbara, which according to the 2014 census, is spoken by up to 1.1 million people in Uganda (https://www.ethnologue.com/country/ug/languages). He stated that he also speaks English (which he referred to at one point as ‘a political language’), and some Luganda, Swahili and Luo. Mr Nelson stated that a Lugbara word that is often spoken when people are happy is ‘awadifo’ which translates as ‘thank you’ – an expression of gratitude for fortuitous life circumstances. When asked about objects that Mr Nelson believed represented the capacity to overcome difficulties, he without hesitation responded with the Lugbara word ‘irece’ (known in other languages as calabash). The calabash is coincidentally the topic of the previous blog post. Mr Nelson has done conflict transformation work in Northern Uganda. He described the importance of the ‘Mato oput’ (forgiveness) traditional justice system of communal harmony, reconciliation and healing which was used by the Acholi people in Northern Uganda to support internally displaced people affected by the conflict between the Lord’s Resistance Army and the Ugandan People’s Defense Force. Mato-put involves the drinking of a bitter concoction contained in the calabash that has been made from roots. The consumption of the drink symbolizes the intention to shift the bitterness between two parties, and the perpetrator of the wrong-doing asks for forgiveness. In Lugbara, ‘Air’ has a prominent symbolic/metaphorical role in creating the correct circumstances for overcoming difficulties e.g. “Oli alari ma vu mi rua” (let good air blow). Eating together and sharing food also carries important significance for overcoming adversity – “Dri osuzu tualu” (put your hands together in one plate to eat food). “Suru ma e’yo” (meeting as a clan to discuss difficulties) was emphasized as an important platform for overcoming challenges.

It seems that a prominent story from Lugbara folklore relates to an arrow that was fired from a bow accidentally that fell to earth and killed someone. It is suggested that the misfortunes experienced by humans are a consequence of the blood being spilt by this arrow. Mr Nelson showed us a bow and arrow that the museum possesses and demonstrated how it can be fired. Historically, the misfortune an individual was experiencing could be assuaged by sacrificing a goat to satisfy the blood debt. The term “Ee ofezu dratia” is used to capture the on-going significance that this story of ‘the blood and arrow’ has for understanding adversity.

Mr Nelson shows us a bow and arrow from the museum collection.

Rituals referred to as ‘Lucou’ and ‘Mungusiza’ (which can be translated as ‘prayer’) were also highlighted as being important. Mr Nelson stated that the Lugbara word ‘opko’ is used to capture the concept of resilience. The discussion concluded with Mr Nelson highlighting the significance that traditional ‘funeral songs’ have historically served for assisting the Lugbara people to process their grief and move on. It seems that since the 1990s there has been a concerted effort from the churches to replace these traditional songs with hymns. There are concerns however that prohibiting the singing of these songs may have a detrimental effect on the grieving process.

It was great to return to Makerere University two years on from my last visit. Students busily made their way around the campus as the marabou storks circled in the sky above.

 

Cliodhna and Rosco at Makerere University

We had scheduled a meeting with Dr Mulumba M Bwanika, a Senior Lecturer in Humanities & Language Education, College of Education & External Studies, Makerere University, Kampala (http://cees.mak.ac.ug/users/dr-mulumba-m-bwanika). As we made our way to the office where the meeting was to take place a student crossed in front of me with the phrase “Be the salt and light in the world”. This is a paraphrasing of an extract from the Bible – Matthew 5:13-16. It served as a reminder of the important role that religion continues to play in Uganda and the comfort and guidance that people can derive from religious texts – whatever language these texts are written in. Rosco led this session and it was conducted in Luganda, which is the mother-tongue of both Rosco and Dr Mulumba. Dr Mulumba also speaks Swahili and English – he first started to learn English at the age of 5 years. Amongst the information that Dr Mulumba shared, there was mention of the ceremonial significance that the humble coffee bean can play in addressing conflict between parties – the coffee bean is broken in two and the two halves shared with the warring parties. He also stated that if in the past someone had narrowly escaped death (for example, whilst out hunting) then a hen or a cock would be killed as a substitute for the surviving human. As Cliodhna and I sat and listened to the exchange of Luganda between Rosco and Dr Mulumba, it was interesting to observe the non-verbal forms of communication; the use of hand gestures and facial expressions – it was clear that both were heavily engaged in the conversation and that they were enjoying the discussions. There were also opportunities to notice translingual occurrences i.e. the use of words that operate across different languages. Examples of such word usage that I noted during the conversation included words commonly used in English including – ‘structures’, ‘committees’, ‘months’, ‘process’ and ‘district’. In terms of important Luganda words, Mr Mulumba highlighted the following as being important for overcoming difficulties: ‘Okwerekereza’ (sacrifice), ‘Okukola ennyo’ (hardwork), ‘Okufaayo’ (commitment), and ‘Okubeera omugumu’ (be strong/courageous). A key phrase that Dr Mulumba thought captured the idea off overcoming difficulties that was translated for us was ‘Everything comes to an end’ (I was unable to note the Luganda rendering of this phrase), but we look forward to having audio recording of the interview transcribed and learning more.

After a great lunch at Makerere University Guest House (that included the Ugandan staple of matooke/plantains!), we met with a group of trainee teachers who were members of the Baganda Nkobazambogo group (that celebrates Bagandan culture; https://web.facebook.com/groups/bagandankobazambogo/)), which is a subset of the Makerere University Luganda Speakers Teacher Association (MALSTA). The 24 students (11 males and 13 females) all identified as being Muganda (the singular of Buganda) and listed Luganda as their first language. According to the 2014 census, Luganda (also referred to as Baganda or Ganda) is spoken by 5.6 million people as a first language with a further 1 million listing it as a 2^nd language (https://www.ethnologue.com/country/ug/languages). This session was facilitated by Rosco and Dr Mulumba and was conducted in Luganda. The trainee teachers engaged enthusiastically with the questions that were posed about phrases, objects, poems and songs that are used to help illustrate the process of overcoming difficulties in Luganda. Fortunately for us, the trainee teachers were not shy about contributing their ideas to the discussions. A number of them sang songs, which their classmates sang, clicked, clapped and tapped along to. During his ad hoc translation of the trainee teachers’ contributions, Dr Mulumba helpfully categorized the songs into 3 categories: secular, religious and folk stories.

It was clear from the discussions that ‘Bulombolombo’ (translated as ‘rituals’) make an important contribution to managing difficulties. Ritual and ceremony has been a key feature of life in Uganda throughout the centuries. The Buganda people had established a ‘traditional religion’ (the ‘Balubaale cult’) well before the arrival of other organized religions (such as Christianity or Islam) in the country (http://www.buganda.com/eddiini.htm). This religion identified ‘Katonda’ as the father of all Gods, and attributed power to ‘Guardians’ (including ‘Mukasa’ – the Guardian of the Lake) as well as lesser spirits (including departed ancestors and spirits that inhabited aspects of the environment). Various daily rituals were prescribed to keep these spirits at bay. The trainee teachers mentioned the importance of rituals such as ‘okusamira’ (which can be translated as ‘prayer’ – and is now used to refer to Christian church services and prayer) for overcoming difficult times. Another ritual that was discussed was ‘kwalula abaana’: an initiation ceremony that uses the umbilical cord of the child, which has been retained from birth for this purpose, where the child is seated on a mat along with other members of the father’s clan to receive their clan names (http://www.everyculture.com/wc/Tajikistan-to-Zimbabwe/Baganda.html). During this ceremony the child gathers with other members of the father’s clan to receive their clan names

A recurring theme throughout the meetings that we had today was the impact that bereavement can have on communities in Uganda. There was clear consensus that when expressing emotions that the mother-tongue was preferred. Some people explained that it provides a richer vocabulary for this than English does. For formal, business and official purposes, English language was indicated to be the language of choice. It seems that a range of narratives have helped to influence phrases, songs, poems and perspectives on overcoming difficulties in Uganda. It has been a fascinating start to the visit to Uganda and we look forward to meeting with further parties in the days to come.

A message about multilingualism displayed in the Education Department, Makerere University.

A fascinating day.

Each of my blog entries will be accompanied by a contribution from Cliodhna:

‘I will be complementing Ross’s posts with my own observations as a first time visitor to Uganda. Today was thus a particularly novel and fascinating experience for me, both in terms of arriving in this beautiful country for the first time, and in the richness of the interview content. Our first stop at the Uganda National Museum was a hugely informative start to the day providing me with a brief introduction to Uganda’s history. As Roscoe didn’t speak the language of our first interviewee, Ross asked the interview questions in English and Mr. Nelson answered in a mix of English and Lugbara. This worked well from our point of view as we heard sections of stories and useful information in English, but we also gathered valuable information in Lugbara on the dictaphone. Mr. Nelson had a wealth of stories of rituals, objects, songs, and phrases significant in his culture to tell us. As he is a curator of the museum he had objects in his office to show us as examples, this really added to the experience, particularly as he seemed to especially speak Lugbara when he was handling them- as he mentioned when he discussed how he uses English and Lugbara, Lugbara is for his cultural setting. We noted significant phrases that seemed to be repeated in relation to the questions we asked and asked him to write them down at the end with translations. Mentions of grief, the church, community, and family were prominent.

Our next interview with Dr. Mulumba was a very different interview to our first one. Conducted all in Luganda, Ross and I observed their body-language and gleaned some information from Roscoe’s short translations. This was a very different dynamic, but evidently a really informative and passionate conversation for the two men who had the opportunity to discuss their shared background and culture. We had an experience of a seemingly ‘untranslatable’ phrase that both couldn’t begin to translate despite being fluent in English. It was a phrase referring ritual of a bond between two people who agreed to protect each other, described as some sort of oath/agreement/contract but they agreed that those words did not suffice to explain the depth of this ritual.

After a quick but delicious lunch at the Makerere University Guesthouse we got back to the school of education to meet a group of undergraduate teaching students. When we came to the question about songs that signified overcoming distress Ross turned to me and said it would be great if we could ask them to sing one of these songs together, but sure enough without being prompted each person who spoke on this question sang the song and the group joined in. As Ross has mentioned I observed some English words interspersed through the Luganda discourses such as ‘feeling’, ‘expressing’, ‘business’, and ‘handshake’. I noted that I would have found it extremely difficult to answer these questions on my own culture or background and it was enlightening to see how even discussing songs, rituals, and phrases brought people together and created a sense of community and joy.

Overall a great and exciting first day and I anticipate a fruitful week ahead.’