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Decolonizing Global Mental Health: The Psychiatrization of the Majority World
Decolonizing Global Mental Health is a book that maps a strange irony. The World Health Organization (WHO) and the Movement for Global Mental Health are calling to ‘scale up’ access to psychological and psychiatric treatments globally, particularly within the global South. Simultaneously, in the global North, psychiatry and its often chemical treatments are coming under increased criticism (from both those who take the medication and those in the position to prescribe it). The book argues that it is imperative to explore what counts as evidence within Global Mental Health, and seeks to de-familiarize current ‘Western’ conceptions of psychology and psychiatry using postcolonial theory. It leads us to wonder whether we should call for equality in global access to psychiatry, whether everyone should have the right to a psychotropic citizenship and whether mental health can, or should, be global. As such, it is ideal reading for undergraduate and postgraduate students, as well as researchers in the fields of critical psychology and psychiatry, social and health psychology, cultural studies, public health and social work.
192 pages, Paperback
First published September 16, 2013
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August 2, 2019
"The most potent weapon in the hands of the oppressor is the mind of the oppressed."- Steve Biko (p. 69)
This book calls itself a "provocation" (p. 12) and for many, it will be just that.
"There can be no mental health without our expertise. We are the knowers and yet we remain the untapped resource in mental health care. We are the experts. We want to be listened to and to fully participate in our life decisions."
- Pan-African Network of Users and Survivors of Psychiatry, Cape Town Declaration, 2011 (p. 143)
"Society is much more comfortable dealing with poverty as a mental health problem rather than a social issue." (p. 47)
While this book does not reference specifically by name the social or medical models of disability, this book is very much operating from the framework of the social model of disability, and strongly promotes a "nothing about us, without us," self-advocate-led structure for determining the ways a community responds to distress. Mills positions the Global Mental Health Movement (GMHM) within the medical model of disability, and responds to it using the social model (p. 19, 27).
Notably, the author challenges the idea of labeling something as "mental illness" or "symptoms" to begin with and instead refers to distress - a move that centers the experience of the client, often referred to here as a survivor to reference the negative and traumatic experiences people can have in the psychiatric / global mental healthcare system.
Here, the Global Mental Health movement is criticized for failing to collaborate with local communities to coordinate research priorities (p. 4), and for the manner in which mental health interventions can be "violence with a 'civilizing mission'" (p. 106), a violence that violates human rights under the justification of being 'treatment' (p. 5), with characteristics such as noncompliance, using non-Western healing practices, violence, self injury, or simply a diagnosis itself used as justification for why treatment is necessary. Additionally, she points out the ways that the "trope of irrationality and dangerousness, as well as that of the child-like, were key mobilizations" of colonialism (p. 96).
"Throughout the world people with disabilities are subjected to mistreatment due to neglect and lack of care, but to compound this, for many, the 'pain and suffering is a direct consequence of treatment practices whose states purpose is to provide treatment, care, or protection.' Here, '[r]ather than being recognized as torture or other cruel, inhuman, or degrading treatment or punishment, these are compounded by remaining invisible or being justified' often as 'essential' treatment. Many investigative reports into mental health care worldwide evoke a strange intertwining between treatment and torture, often marked by the impunity enabled under the guise of 'treatment.'" (p.87)
"Why is self-harm constructed as an act of violence while [direct / unmodified] ECT [without anesthesia] is constructed as 'treatment', despite some of the injuries it causes? (p. 90)
"Not only are those with a label of 'mental illness' assumed to lack insight, but fear of the 'procedure is treated as an irrational symptom of mental illness,'" (p.94)
"...The evocation of the 'poor country', and that of the 'violent', 'suicidal', and 'treatment unresponsive' individual, work alongside each other to change our normative recognition of violence, and to legitimize and sanction violence in the name of 'treatment' (p. 93) - even when these treatments would be considered "legal battery and child abuse" if taken "outside of this psychiatric 'state of exception' (p. 99).
Psychiatric medications and research is questioned throughout the book (p. 97). Readers may be taken aback, until they become familiar with the work in books like "The Emperor's New Drugs" and "Mad in America." Readers unfamiliar with this work should know that China Mills' allegations are backed up by solid information, controversial as it may be.
The author illustrates how the Global Mental Health Movement advises access to anti-depressant medications to treat impoverished farmers who have been economically harmed by neoliberal political and agricultural reforms and driven to suicide (p. 11, 36, 38-39), even though these medications may increase impairment (e.g. cognitive deficits, motor tics, headaches, dementia, brain atrophy, tardive dyskinesia, mania/hypomania) (p.22-23). She also looks at the economic incentives involved in opening up the global south as an untapped market for psychiatric medications, pointing out how psychiatrists have had their weddings and funerals paid for by pharmaceutical companies (p. 70).
Mills also spends a fair amount of time examining what she calls the "recruitment process" of creating "psychiatric citizens," including both an examination of the marketing techniques employed in the west and the street-side assessments and screening done by Western professionals in countries such as India.
"...the training of lay people to administer psychiatric diagnostic checklists is key to recruiting psychiatric subjects seems to resonate with the colonial imaginary of developing 'a class of interpreters between us and the millions whom we govern - a class of person Indian in blood and colour, but English in tastes, in opinions, in morals, and in intellect." (p. 65)
Concepts
1. Western ideas of mental health serve to export western ideas of personhood. (p.6)
2. Psychiatry is an agent of colonization/globalization and also lays the ground for other colonizations. (p 6, 30)
3. The GMHM is widening the boundaries of abnormality and medicalizing/pathologizing behavior (p. 20, 29)
4. Portraying distress as being caused by brain distress depoliticizes distress - this serves specific political and economic interests, namely the pharmaceutical industry (p. 30-31, 132, 137) and silences voices of political change (p. 42). Distress, or psychiatric symptoms of mental illness, can be personally and politically meaningful - the GMHM neglects this knowledge (p. 38). Defining these experiences as being outside the realm of human norms means people with these experiences may not be considered worthy of human rights protections (p. 98-99).
5. The GMHM assumes their understanding of biology is universal while culture is local (p. 33)
6. Worldwide, many outpatient mental health clinics are basically drug dispensaries (p. 45).
7. People with schizophrenia in the West have less favorable outcomes than those in the global south (p. 53). "A pluralism of approaches to distress may account for the better outcomes for people with a schizophrenia label in the so-called 'developing' countries of the WHO studies (p. 123). Psychiatric stigma is almost absent in communities where 'mental illness' is understood as spirit possession (p. 100).
8. "Portraying all socially unacceptable behavior as 'mental illness'" (p. 65) and "labeling people as 'irrational' and 'incompetent' due to 'mental illness'" (p. 100-101) actually increase stigma, exclusion, and even witch hunting by distancing those who experience distress as biologically different (p. 150)
9. "'Invisible disabilities' are 'made invisible by the structure and assumptions of normalcy.'" (p. 118)
10. "...non-Western people can give properly informed consent only if the terms in which they are being represented, which here means candidature for psychiatric caseness, are not alien or irrelevant to their interpretations of the world. ... the globalization of psychiatry also occludes local idioms of distress. (p. 130)
11. "...[c]hoices must be available in the community and this includes the choice not to use western medical 'solutions'". Safeguarding rights and providing effective services requires the provision of "non-medical sanctuary and support without drug treatment for a person during, and following a crisis, where consent to medical treatment is not given" (p. 140). Furthermore, "interventions should be 'home-grown' within local contexts and not solely imported from the global north" (p. 146).
Questions this book asks:
Who decides what constitutes irrationality? (p.3)
Who decides what counts as "evidence"? (p. 4, 126)
What are the ethical implications of "fixing" people? (p. 126)
How can we conceptualize distress and disability without pathology and stigmatizing language (p. 126)
How should we respond politically to socioeconomic causes of distress? (p. 126)
How can we trace the intertwining of psychic and socio-political distress and resistance? (p. 126)
Is a medical framework the best way to frame distress and disability? (p. 126)
Notable Terminology / Vocabulary / People / Events
psychiatric imperialism / medial imperialism (p.6, 67)
Bhaba's description of colonial discourse (p. 9)
'white knowledge' (p. 14)
Etic vs Emic approach (p. 24)
language used to discuss distress & mental illness (p. 28)
bio-psycho-social model (p. 32-33)
noncompliance (p. 46)
Emil Kraepelin, the "father of schizophrenia" (p. 52)
Disorder as a means of escape from normative standards (p. 55)
Framing survivor "beliefs" vs. expert "knowledge" about treatment (p. 57)
Controversy over the schizophrenia diagnosis (p. 62)
blurred lines between mental health education and medical marketing (p. 69)
identity trauma caused by being labeled mentally ill in a language not your own (p. 73-75)
involuntary institutionalization (p. 78)
power issues in diagnosis (p. 79)
'social patients' whose problems are acknowledged as being caused by society (p. 88)
the discourse of protection from dangerous/violent climates (p. 89, 102)
infantilization of the global south (p. 96-97)
forced medication / chemical restraint (p. 103)
Convention on the Rights of Persons with Disabilities (p. 104)
Camouflaging (p. 112-118)
Fanon and the psychiatry of liberation (p. 136)
Global critical disability studies (p. 138)
colonial control of dissent to colonialism (p. 142-143)
Delirio de fome ('hunger madness') - "in drought-wrecked villages of 1960s Brazil, hunger became so normalized that it was no longer a sign of nutritional deprivation but instead a mental pathology to be managed by tranquilizers and sleeping pills imported from the US." (p. 41)
uljhan nuanced local term in a Hindi dialect that regards unfulfilled economic ambitions (p. 46)
The Erwadi Tragedy (Tamil Nadu, 2001) 26 people labeled with mental illness were chained up and died when a fire broke out in a religious healing hutment (p. 77)
Organizations
The Hearing Voices Network (p. 16)
Bapu Trust
MindFreedom International (p. 94)
Campaign to Abolish Psychiatric Diagnostic Systems such as ISD and DSM (CAPSID) (p. 129)
Campaign for the Abolition of the Schizophrenia Label (CASL) (p. 129)
World Network of Users and Survivors of Psychiatry (WNUSP) (p. 139)
Pan-African Network of Users and Survivors of Psychiatry (PANUSP) (p. 139, 143)
Soteria Network (p. 144)
Open Dialogue (p. 144)
The Icarus Project (p. 144)
The Philadelphia Project (p. 144)
Schizophrenia Awareness Association (p. 148)
When the great lord passes, the wise peasant bows deeply and silently farts.
- Ethiopian proverb (p. 108)
This book calls itself a "provocation" (p. 12) and for many, it will be just that.
"There can be no mental health without our expertise. We are the knowers and yet we remain the untapped resource in mental health care. We are the experts. We want to be listened to and to fully participate in our life decisions."
- Pan-African Network of Users and Survivors of Psychiatry, Cape Town Declaration, 2011 (p. 143)
"Society is much more comfortable dealing with poverty as a mental health problem rather than a social issue." (p. 47)
While this book does not reference specifically by name the social or medical models of disability, this book is very much operating from the framework of the social model of disability, and strongly promotes a "nothing about us, without us," self-advocate-led structure for determining the ways a community responds to distress. Mills positions the Global Mental Health Movement (GMHM) within the medical model of disability, and responds to it using the social model (p. 19, 27).
Notably, the author challenges the idea of labeling something as "mental illness" or "symptoms" to begin with and instead refers to distress - a move that centers the experience of the client, often referred to here as a survivor to reference the negative and traumatic experiences people can have in the psychiatric / global mental healthcare system.
Here, the Global Mental Health movement is criticized for failing to collaborate with local communities to coordinate research priorities (p. 4), and for the manner in which mental health interventions can be "violence with a 'civilizing mission'" (p. 106), a violence that violates human rights under the justification of being 'treatment' (p. 5), with characteristics such as noncompliance, using non-Western healing practices, violence, self injury, or simply a diagnosis itself used as justification for why treatment is necessary. Additionally, she points out the ways that the "trope of irrationality and dangerousness, as well as that of the child-like, were key mobilizations" of colonialism (p. 96).
"Throughout the world people with disabilities are subjected to mistreatment due to neglect and lack of care, but to compound this, for many, the 'pain and suffering is a direct consequence of treatment practices whose states purpose is to provide treatment, care, or protection.' Here, '[r]ather than being recognized as torture or other cruel, inhuman, or degrading treatment or punishment, these are compounded by remaining invisible or being justified' often as 'essential' treatment. Many investigative reports into mental health care worldwide evoke a strange intertwining between treatment and torture, often marked by the impunity enabled under the guise of 'treatment.'" (p.87)
"Why is self-harm constructed as an act of violence while [direct / unmodified] ECT [without anesthesia] is constructed as 'treatment', despite some of the injuries it causes? (p. 90)
"Not only are those with a label of 'mental illness' assumed to lack insight, but fear of the 'procedure is treated as an irrational symptom of mental illness,'" (p.94)
"...The evocation of the 'poor country', and that of the 'violent', 'suicidal', and 'treatment unresponsive' individual, work alongside each other to change our normative recognition of violence, and to legitimize and sanction violence in the name of 'treatment' (p. 93) - even when these treatments would be considered "legal battery and child abuse" if taken "outside of this psychiatric 'state of exception' (p. 99).
Psychiatric medications and research is questioned throughout the book (p. 97). Readers may be taken aback, until they become familiar with the work in books like "The Emperor's New Drugs" and "Mad in America." Readers unfamiliar with this work should know that China Mills' allegations are backed up by solid information, controversial as it may be.
The author illustrates how the Global Mental Health Movement advises access to anti-depressant medications to treat impoverished farmers who have been economically harmed by neoliberal political and agricultural reforms and driven to suicide (p. 11, 36, 38-39), even though these medications may increase impairment (e.g. cognitive deficits, motor tics, headaches, dementia, brain atrophy, tardive dyskinesia, mania/hypomania) (p.22-23). She also looks at the economic incentives involved in opening up the global south as an untapped market for psychiatric medications, pointing out how psychiatrists have had their weddings and funerals paid for by pharmaceutical companies (p. 70).
Mills also spends a fair amount of time examining what she calls the "recruitment process" of creating "psychiatric citizens," including both an examination of the marketing techniques employed in the west and the street-side assessments and screening done by Western professionals in countries such as India.
"...the training of lay people to administer psychiatric diagnostic checklists is key to recruiting psychiatric subjects seems to resonate with the colonial imaginary of developing 'a class of interpreters between us and the millions whom we govern - a class of person Indian in blood and colour, but English in tastes, in opinions, in morals, and in intellect." (p. 65)
Concepts
1. Western ideas of mental health serve to export western ideas of personhood. (p.6)
2. Psychiatry is an agent of colonization/globalization and also lays the ground for other colonizations. (p 6, 30)
3. The GMHM is widening the boundaries of abnormality and medicalizing/pathologizing behavior (p. 20, 29)
4. Portraying distress as being caused by brain distress depoliticizes distress - this serves specific political and economic interests, namely the pharmaceutical industry (p. 30-31, 132, 137) and silences voices of political change (p. 42). Distress, or psychiatric symptoms of mental illness, can be personally and politically meaningful - the GMHM neglects this knowledge (p. 38). Defining these experiences as being outside the realm of human norms means people with these experiences may not be considered worthy of human rights protections (p. 98-99).
5. The GMHM assumes their understanding of biology is universal while culture is local (p. 33)
6. Worldwide, many outpatient mental health clinics are basically drug dispensaries (p. 45).
7. People with schizophrenia in the West have less favorable outcomes than those in the global south (p. 53). "A pluralism of approaches to distress may account for the better outcomes for people with a schizophrenia label in the so-called 'developing' countries of the WHO studies (p. 123). Psychiatric stigma is almost absent in communities where 'mental illness' is understood as spirit possession (p. 100).
8. "Portraying all socially unacceptable behavior as 'mental illness'" (p. 65) and "labeling people as 'irrational' and 'incompetent' due to 'mental illness'" (p. 100-101) actually increase stigma, exclusion, and even witch hunting by distancing those who experience distress as biologically different (p. 150)
9. "'Invisible disabilities' are 'made invisible by the structure and assumptions of normalcy.'" (p. 118)
10. "...non-Western people can give properly informed consent only if the terms in which they are being represented, which here means candidature for psychiatric caseness, are not alien or irrelevant to their interpretations of the world. ... the globalization of psychiatry also occludes local idioms of distress. (p. 130)
11. "...[c]hoices must be available in the community and this includes the choice not to use western medical 'solutions'". Safeguarding rights and providing effective services requires the provision of "non-medical sanctuary and support without drug treatment for a person during, and following a crisis, where consent to medical treatment is not given" (p. 140). Furthermore, "interventions should be 'home-grown' within local contexts and not solely imported from the global north" (p. 146).
Questions this book asks:
Who decides what constitutes irrationality? (p.3)
Who decides what counts as "evidence"? (p. 4, 126)
What are the ethical implications of "fixing" people? (p. 126)
How can we conceptualize distress and disability without pathology and stigmatizing language (p. 126)
How should we respond politically to socioeconomic causes of distress? (p. 126)
How can we trace the intertwining of psychic and socio-political distress and resistance? (p. 126)
Is a medical framework the best way to frame distress and disability? (p. 126)
Notable Terminology / Vocabulary / People / Events
psychiatric imperialism / medial imperialism (p.6, 67)
Bhaba's description of colonial discourse (p. 9)
'white knowledge' (p. 14)
Etic vs Emic approach (p. 24)
language used to discuss distress & mental illness (p. 28)
bio-psycho-social model (p. 32-33)
noncompliance (p. 46)
Emil Kraepelin, the "father of schizophrenia" (p. 52)
Disorder as a means of escape from normative standards (p. 55)
Framing survivor "beliefs" vs. expert "knowledge" about treatment (p. 57)
Controversy over the schizophrenia diagnosis (p. 62)
blurred lines between mental health education and medical marketing (p. 69)
identity trauma caused by being labeled mentally ill in a language not your own (p. 73-75)
involuntary institutionalization (p. 78)
power issues in diagnosis (p. 79)
'social patients' whose problems are acknowledged as being caused by society (p. 88)
the discourse of protection from dangerous/violent climates (p. 89, 102)
infantilization of the global south (p. 96-97)
forced medication / chemical restraint (p. 103)
Convention on the Rights of Persons with Disabilities (p. 104)
Camouflaging (p. 112-118)
Fanon and the psychiatry of liberation (p. 136)
Global critical disability studies (p. 138)
colonial control of dissent to colonialism (p. 142-143)
Delirio de fome ('hunger madness') - "in drought-wrecked villages of 1960s Brazil, hunger became so normalized that it was no longer a sign of nutritional deprivation but instead a mental pathology to be managed by tranquilizers and sleeping pills imported from the US." (p. 41)
uljhan nuanced local term in a Hindi dialect that regards unfulfilled economic ambitions (p. 46)
The Erwadi Tragedy (Tamil Nadu, 2001) 26 people labeled with mental illness were chained up and died when a fire broke out in a religious healing hutment (p. 77)
Organizations
The Hearing Voices Network (p. 16)
Bapu Trust
MindFreedom International (p. 94)
Campaign to Abolish Psychiatric Diagnostic Systems such as ISD and DSM (CAPSID) (p. 129)
Campaign for the Abolition of the Schizophrenia Label (CASL) (p. 129)
World Network of Users and Survivors of Psychiatry (WNUSP) (p. 139)
Pan-African Network of Users and Survivors of Psychiatry (PANUSP) (p. 139, 143)
Soteria Network (p. 144)
Open Dialogue (p. 144)
The Icarus Project (p. 144)
The Philadelphia Project (p. 144)
Schizophrenia Awareness Association (p. 148)
When the great lord passes, the wise peasant bows deeply and silently farts.
- Ethiopian proverb (p. 108)
May 20, 2021
I had mixed feelings about this.
Mills explores the increasing colonization of global concepts of mental health - the west imposing its psychiatric notions of mental illness/wellness onto the global south. She also, as part of her research (the book is based on her dissertation), did ethnographic research in India which she uses as a case study to demonstrate the way India and its people are colonized by (but also resist) psychiatrization.
I can't fault Mills's writing too much because it's pretty on-par for academic writing - perhaps a bit more accessible than most. Still, it's overwhelmingly dense. Sometimes she sites three or four theorists in a short paragraph without really explaining those theories. The text is also peppered much too liberally with long quotations with little exploration of what those mean for her argument. I would have liked if she picked a smaller number of theoretical frameworks and explored them more in depth in the context of her critique of global mental health.
Another thing that didn't quite work for me was the way Mills applies strategic universalism. Towards the end of the book, Mills suggests that a critique of "global mental health" that attempts to replace psy-discourse with something else can risk reproducing a universalizing of the local into the global. I found this ironic as at times Mills could be said to do the same thing. Her ethnographic work on psychiatrization in India is excellent, but she often reads that analysis alongside examples from other very different cultural contexts in the global south to prove her point. A sustained, culturally grounded analysis in the Indian context may have been more effective.
Another criticism I have of this book is one I'd leverage at Mad studies in general. I say this as a (former) Mad studies scholar, and would leverage this criticism at my own dissertation work as well. Criticisms of the biomedical model are important; however, I feel that sometimes Mad studies scholars are speaking beyond what they really know one way or another about the biomedical model. It is one thing to speak from lived experience, or offer philosophical critiques; it is another thing to speak about (and dismiss) biological knowledge that few Mad studies scholars, I think, have a firm grasp on, as Mad studies tends to be rooted in the social sciences and humanities rather than the biological sciences.
I remember when I was a PhD student I met an Engineer and he asked me what right had I to say anything about mental health, and shouldn't I leave this for the doctors and scientists? What did I know about the brain? I had a lot to say about mental health and I think that the 'mental health' realm needs the social sciences and humanities. And even more so the perspectives of people with lived experience like myself. That said, he had a point in that I'm no neurologist. Mad studies scholars cite over and over again a small handful of dissident psychiatrists (e.g. Breggin) and journalists (e.g., Whitaker) to dispute biological models of mental illness - Mills does this too in her introduction. It forms the backbone of her takedown of the medical model as taken up in global mental health. To be clear, I am no big fan of the medical model, but I am also a lover of science. There are some valid (that is, not purely ideological) criticisms of Breggin and Whitaker's work that I have yet to see taken up meaningfully in Mad studies. I would like to see less reliance on these usual suspects in Mad studies, as they are cherry picked and never, as far as I have seen, accompanied by a sustained scientific debate. Using these dissidents' arguments about the medical model involves (for most of us) speaking well beyond our scope of knowledge.
I'd rather we focus on what we're good at. A realm where Mad studies scholars excel is discourse analysis. Despite the density of her writing, Mills is no exception. There's some pretty brilliant analysis in here, using a postcolonial approach to analyze the way that psychiatric discourse is taken up in the global south, and India in particular (e.g. "Mental illness" as a barrier to progress (a white western idea of progress); psychiatrization creating new forms of personhood/citizenship (or non-personhood) that did not exist prior to colonization; psychiatrization introducing new forms of community surveillance/new visual economies - for example how 'beggars' are now understood as mentally ill and the public encouraged to watch them for 'symptoms'; the creation of the global south as an untapped pharmaceutical market by pharmaceutical companies) Mills astutely shows the ways diagnostic and psychopharmaceutical technologies create mental health/illness as new realities that did not previously exist in the Indian cultural discourse. Her analysis of how psychiatry functions as a state of exception to determine what forms of violence are 'acceptable' (to 'heal'; as part of 'civilizing' missions) is also very sharp.
There's a lot here to admire, and this book comes early in her career; this start is promising. Despite some of my criticisms of this work (and Mad studies as a discipline) it is nice to see more work weaving together post-colonial and Mad theories and analysis.
Mills explores the increasing colonization of global concepts of mental health - the west imposing its psychiatric notions of mental illness/wellness onto the global south. She also, as part of her research (the book is based on her dissertation), did ethnographic research in India which she uses as a case study to demonstrate the way India and its people are colonized by (but also resist) psychiatrization.
I can't fault Mills's writing too much because it's pretty on-par for academic writing - perhaps a bit more accessible than most. Still, it's overwhelmingly dense. Sometimes she sites three or four theorists in a short paragraph without really explaining those theories. The text is also peppered much too liberally with long quotations with little exploration of what those mean for her argument. I would have liked if she picked a smaller number of theoretical frameworks and explored them more in depth in the context of her critique of global mental health.
Another thing that didn't quite work for me was the way Mills applies strategic universalism. Towards the end of the book, Mills suggests that a critique of "global mental health" that attempts to replace psy-discourse with something else can risk reproducing a universalizing of the local into the global. I found this ironic as at times Mills could be said to do the same thing. Her ethnographic work on psychiatrization in India is excellent, but she often reads that analysis alongside examples from other very different cultural contexts in the global south to prove her point. A sustained, culturally grounded analysis in the Indian context may have been more effective.
Another criticism I have of this book is one I'd leverage at Mad studies in general. I say this as a (former) Mad studies scholar, and would leverage this criticism at my own dissertation work as well. Criticisms of the biomedical model are important; however, I feel that sometimes Mad studies scholars are speaking beyond what they really know one way or another about the biomedical model. It is one thing to speak from lived experience, or offer philosophical critiques; it is another thing to speak about (and dismiss) biological knowledge that few Mad studies scholars, I think, have a firm grasp on, as Mad studies tends to be rooted in the social sciences and humanities rather than the biological sciences.
I remember when I was a PhD student I met an Engineer and he asked me what right had I to say anything about mental health, and shouldn't I leave this for the doctors and scientists? What did I know about the brain? I had a lot to say about mental health and I think that the 'mental health' realm needs the social sciences and humanities. And even more so the perspectives of people with lived experience like myself. That said, he had a point in that I'm no neurologist. Mad studies scholars cite over and over again a small handful of dissident psychiatrists (e.g. Breggin) and journalists (e.g., Whitaker) to dispute biological models of mental illness - Mills does this too in her introduction. It forms the backbone of her takedown of the medical model as taken up in global mental health. To be clear, I am no big fan of the medical model, but I am also a lover of science. There are some valid (that is, not purely ideological) criticisms of Breggin and Whitaker's work that I have yet to see taken up meaningfully in Mad studies. I would like to see less reliance on these usual suspects in Mad studies, as they are cherry picked and never, as far as I have seen, accompanied by a sustained scientific debate. Using these dissidents' arguments about the medical model involves (for most of us) speaking well beyond our scope of knowledge.
I'd rather we focus on what we're good at. A realm where Mad studies scholars excel is discourse analysis. Despite the density of her writing, Mills is no exception. There's some pretty brilliant analysis in here, using a postcolonial approach to analyze the way that psychiatric discourse is taken up in the global south, and India in particular (e.g. "Mental illness" as a barrier to progress (a white western idea of progress); psychiatrization creating new forms of personhood/citizenship (or non-personhood) that did not exist prior to colonization; psychiatrization introducing new forms of community surveillance/new visual economies - for example how 'beggars' are now understood as mentally ill and the public encouraged to watch them for 'symptoms'; the creation of the global south as an untapped pharmaceutical market by pharmaceutical companies) Mills astutely shows the ways diagnostic and psychopharmaceutical technologies create mental health/illness as new realities that did not previously exist in the Indian cultural discourse. Her analysis of how psychiatry functions as a state of exception to determine what forms of violence are 'acceptable' (to 'heal'; as part of 'civilizing' missions) is also very sharp.
There's a lot here to admire, and this book comes early in her career; this start is promising. Despite some of my criticisms of this work (and Mad studies as a discipline) it is nice to see more work weaving together post-colonial and Mad theories and analysis.
September 27, 2017
I gave this 2 stars *only* because I couldn't even force myself to finish the first chapter, so I can't conscionably justify the dreaded 1 star. The book presents some valid points on a macro level but fails to present them in a professional, academic manner. For example, Dr. Mills' take on the relationship between Big Pharma and psychiatric meds seemed promising, but proved to be an outdated and incomplete presentation of the current state of biopsychological research (ft. erroneous in-text citations whaaat? #editing). The intro was oddly formatted and contained an excess of personal information that, while sometimes interesting (a label that does not apply to: "here are some extraneous & literary asides highlighting my interactions with mosquitoes and trains in India so you know I'm a REAL global health professional"), would have been best kept in an author's note. I'm really disappointed because I was sooo psyched (pun intended) to read this.
July 17, 2025
This is not a light read, but it’s an important one. Mills brilliantly unpacks how the Global Mental Health movement, often framed as benevolent, can act as a form of psychiatric colonialism, exporting Western norms and erasing local knowledges of distress.
If you’re interested in critical psychology, decolonial thought, or questioning the “helping” narrative of global health interventions, this will challenge you. Some parts are dense and theory-heavy (and a bit chaotic), but the core argument is powerful: mental health isn’t neutral, and globalizing psychiatry isn’t the same as "healing minds".
If you’re interested in critical psychology, decolonial thought, or questioning the “helping” narrative of global health interventions, this will challenge you. Some parts are dense and theory-heavy (and a bit chaotic), but the core argument is powerful: mental health isn’t neutral, and globalizing psychiatry isn’t the same as "healing minds".
December 4, 2022
A friend actually had recommended me this book, and I don’t regret reading it. I learned a lot about how psychiatry really harms non white folks and how it’s important for people to consider the fact that medication is a construct, how we don’t all share the same cultures, and how it’s important that we respect the other people’s cultures, without inserting our own opinions that can and do cause harm.
September 9, 2024
2.5 - Really interesting points about psychiatric treatment and what defines mental illness in different cultural views, but this read like a thesis, so hard to follow. Definitely made me think about the agenda bigger countries try to push on the global south with the medicalization of mental health. Definitely more confused than when I started reading.
July 15, 2021
5* - it was amazing
I do not rate this 5* because I think its arguments are faultless and untouchable, but for the interest it sustained in me personally, the relevance to my direction of study, and the writers and concepts it has (re)introduced me to. For no reason at all, this took me an absolutely disproportionate amount of time to read compared to its length (e.g. I read every other book I've read so far this year, and then some more, in between starting and finishing it) and I read this for leisure, often in brief and unfocused intervals, so therefore will absolutely need to return to this in future with a fine-toothed comb to really pick apart what sticks out to me. Nevertheless, I often found myself nodding along and making connections that fit well with the literature I have touched on or engaged with during my studies.
What immediately comes to mind for my own personal further exploration - the concept of 'chemical imbalance', its origins and its usefulness; finding identity within diagnosis, and what is and isn't pathologising with regards to certain behaviours (e.g. when and where is diagnosis useful? and the creation of difference); the definition and role of the 'human rights approach' in directing attitudes towards mental heath (should or shouldn't it?), and its link to modern colonialism; readings of Fanon and psychopolitics; the necessity of a marriage between biological science studies and social sciences, to truly discuss or even create 'psychopolitics'; and the genuine place of 'psy-' disciplines within and alongside the political, which I believe the author does not answer (and I don't know how to either).
I do not rate this 5* because I think its arguments are faultless and untouchable, but for the interest it sustained in me personally, the relevance to my direction of study, and the writers and concepts it has (re)introduced me to. For no reason at all, this took me an absolutely disproportionate amount of time to read compared to its length (e.g. I read every other book I've read so far this year, and then some more, in between starting and finishing it) and I read this for leisure, often in brief and unfocused intervals, so therefore will absolutely need to return to this in future with a fine-toothed comb to really pick apart what sticks out to me. Nevertheless, I often found myself nodding along and making connections that fit well with the literature I have touched on or engaged with during my studies.
What immediately comes to mind for my own personal further exploration - the concept of 'chemical imbalance', its origins and its usefulness; finding identity within diagnosis, and what is and isn't pathologising with regards to certain behaviours (e.g. when and where is diagnosis useful? and the creation of difference); the definition and role of the 'human rights approach' in directing attitudes towards mental heath (should or shouldn't it?), and its link to modern colonialism; readings of Fanon and psychopolitics; the necessity of a marriage between biological science studies and social sciences, to truly discuss or even create 'psychopolitics'; and the genuine place of 'psy-' disciplines within and alongside the political, which I believe the author does not answer (and I don't know how to either).
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