Issue 4 Academic Highlights: Mental Health
Updated: Sep 4, 2023
Race & Class. 2021
The government is pushing through a raft of legislation that both increases police powers for racialised surveillance and criminalisation of migrant populations. In this timely ethnographic piece, Bhatia maps out the mental health impacts of electronic monitoring (EM) on migrants. The methodology draws from a mixture of “participant observation at three refugee charity organisations, gathering and analysing case files and other documentary evidence, interviews with specialist practitioners and people seeking asylum”.
Bhatia begins with a blistering and convincing outline of the limitations and harms of EM. Intended by prison reformists as a means of decarceration and more ‘humane’ punishment, EM appears to fail on both fronts. Use of EM is greater in England and Wales than anywhere else in the world and “high use of imprisonment is linked with high use of EM”. Its “effectiveness in reducing re-offending is … minimal”, while the conceptualisation of EM as the softer option overlooks the impacts of long-term surveillance and state control that tend to double down along race and class lines. Furthermore, the EM industry is almost entirely privatised, with “lack of independent oversight”.
As Bhatia sets out, those seeking asylum deemed “at ‘high risk’ of harm, reoffending or absconding may be fitted with an ankle device and subjected to curfew”. EM of asylum seekers sits not within the jurisdiction of the criminal justice system, but rather the administrative arm of immigration system. Crucially, in its use of EM, in contrast to criminal justice, the immigration system places no clear time boundaries on how long EM will continue for. Although EM was put forward as an alternative to detention and other enforcement-based alternatives, it has instead formed part of a “widening … net of interventions”.
The author goes on to provide evidence demonstrating how non-enforcement based options - such as caseworker support - result in very low levels of absconding and non-compliance. Instead, as examples from the Immigration and Customs Enforcement in the US show through the rising use of GPS monitoring as part of EM, “tracking [goes] well beyond its original purpose and goal of stopping people from absconding and [instead] used as a ‘drag-net’ to trap and draw migrants into the criminal justice sphere”.
The central tenets of the article are very powerful. Bhatia begins by laying the foundations for EM as a form of racial surveillance, positioning surveillance as disciplinary tool, and weaving this into the context of slavery, colonialism and empire. The use of technology to impose both internal and external borders, which disproportionately “[target] migrants constructed as ‘unwanted’ and ‘risky’” is widespread, and entangled with conversations of race and crime.
The remainder of the article details the psychological harms of racial surveillance through EM, grounded in ethnography. By criminalising breaches of immigration conditionalities, the state has enmeshed the immigration and criminal justice systems, resulting in individuals being “trapped in the penal circuits and treated as ‘dangerous’ foreigners”. Despite claiming to help asylum seekers towards “rehabilitative objectives, enabl[ing] community reintegration, allow[ing] them to continue with work and other commitments”, Bhatia highlights how EM achieves none of these. Instead qualitative data demonstrates how ongoing surveillance with no upper limit pushes into substance misuse, and in combination with material deprivation and inability to work drives exacerbation of post-migratory stress. Bhatia details one participant for whom EM imposed “awkward curfew hours … which made it difficult for him to participate in social activities, resulting in deeper exclusion and isolation”.
Although provisions exist for removal of electronic tags where the person suffers demonstrable distress, in actuality this was limited to physical manifestations, while “mental distress was often disbelieved, and individuals exhibiting distress were viewed as ‘faking it’ to escape surveillance and controls”. Sick-notes from primary care physicians “were … ignored on the false premise that mental health and psychiatric issues can only be treated by the psychiatrists in secondary care, and immigration case workers, monitoring officers and private security staff frequently demanded specialist reports.”
Bhatia’s paper is a forensic cross-examination detailing the inadequacies of EM as a tool for surveillance in migrant populations and indeed at all, in addition to clearly outlining the damning mental health impacts and violence of EM surveillance.
Ortega F, Wenceslau LD.
Transcultural Psychiatry. 2020
In this paper, Ortega and Wenceslau focus on the ‘silencing of culture’ in mental health provision within Brazil, and compare domestic mental health service provision with the Global Mental Health Movement (GMHM) agenda in this context.
The authors start by acknowledging critiques of the GMHM as one that “exports a Western model of illness and treatment, under-rates the role of practitioners of traditional therapies ... and medicalizes distress while ignoring its social and economic causes in low- and middle-income countries”. This said, GMHM places a consistent emphasis on cultural aspects of mental health care, something of a divergence from domestic practice in Brazil.
Ortega and Wenceslau explore reasons why there is a dearth of integration of cultural competence into mental health service delivery in Brazil. Their point of departure is one considering in detail the conceptualisation of identity in Brazil. These centre around a certain portrayal of “a homogeneous national cultural identity, which typically downplays racial, ethnic, gender, and religious diversity”. By swallowing up and regurgitating any differences between peoples within Brazil - a process termed anthropophagy - inequities that run along class and race lines are erased. The discussion of the Brazilian Psychiatric Reform provides further useful context. Parallel to broader health system reform that moves towards universal health coverage, it seeks to understand mental healthcare not “as therapeutic isolation or moral treatment, but as ‘’the creation of socialities and subjectivities’”. Despite this shift, as Ortega and Wenceslau describe, there was a fundamental gap between ‘‘Doenc¸a dos nervos’’ - a cultural idiom used amongst Brazilian working classes emphasising “social and cultural dimensions of mental suffering: a physical vehicle for physical and moral experiences opposing biomedical understanding of distress as having a single cause” - and the understanding of psychologists and psychoanalysts, who “tended to … [psychologise] ... social problems”. In this way, there is “ignorance or misrecognition of the cultural dimension within mental health practices and interventions, through its rejection when it involves conflict between worldviews or sociocultural backgrounds, or through its reification and even caricature.” They pinpoint the conceptualisation of the interplay between religion and mental health as demonstrative of this.
The final section of the paper zones in on community-centred models of mental health care that centre cultural competence. The first spotlights the role of community health workers (ACS, agentes comunitarios de saude). ACS are members of the local community, and through understanding both “local cultural idioms and scientific knowledge and the working process of the [primary mental healthcare] team”, they play a bridging role “between these two world-views”, possessing crucial cultural competence. Although the evidence base for the effectiveness remains mixed, and there are concerns around the vulnerability of the ACS themselves to mental health issues, is it a model with great promise in overcoming the ‘silencing of culture’’ discussed throughout this paper.
The second model the authors look more closely at is Community Therapy (TC, terapia comunitaria), consisting of six phases: welcoming, selecting a theme, contextualisation, problematisation, closing, and appreciation. It is described by the authors not as “psychotherapy, [or] … a public therapy for an individual, but a form of community therapy emerging from a problem brought by an individual and chosen by the community to organise the discussion”. Specifically, by centering a “multiplicity of contexts and local knowledges and practices'' alongside experiences of the individual, it harnesses again the socio-cultural element of care that existing domestic mental health services lack; its efficacy is underscored by a strong empirical literature base.
This paper provides a valuable exploration of the limitations of the current Brazilian mental health care from the perspective of integrated cultural considerations, and puts forward two models of care that directly centre these. A worthwhile read for a deeper understanding of Brazilian mental healthcare provision, with potential lessons for translation of community-centred, culturally competent models of mental health care into other local contexts.
Ortega F, Wenceslau LD.
Can Fam Physician. 2019;65(4):274-281.
Rates of mental health issues, including addiction and suicide, are disproporationately elevated amongst Indigenous populations around the world. These are intimately linked to “underlying economic, social, and political inequities that are legacies of colonization and the government’s attempt at ‘cultural genocide’” as described in the Canadian context. Existing mental health services are institutionally racist and cater poorly, if at all, to Indigenous mental health needs in a culturally sensitive and appropriate manner. This discrepancy in mental health outcomes and poorly adapted services are particularly jarring juxtaposed with the “wealth of diverse healing traditions that have endured [within these Indigenous communities] despite the cultural oppression of colonization”.
In contrast to the euro-centric, biomedical model, “Elders tend to view mental illness in spiritual and social terms, as rooted in disconnection from families, traditions, communities, the land, and one’s self and spirit; and view healing as requiring the re-establishment of these connections.” Elders could provide a degree of cultural continuity - “[this] relies upon a community’s effort to maintain its cultural institutions and practices, [and] has been identified as a strong community-level protective factor against suicide among Indigenous peoples”.
In this prospective cohort study set in a Western Canadian inner city primary care clinic, Tu et al explored whether involvement of Indigienous Elders in the routine primary mental health management of self-identifying indigenous patients with depressive symptoms or suicidal ideation was beneficial. Note that the “target population … was adult Indigenous clinic patients who were interested in connecting with an Elder.”
The primary outcome measure employed was the Patient Health Questionnaire 9 (PHQ-9) scale, with secondary measures including emergency department attendance rates pre- and post-intervention and changes in suicide risk (measured with the SBQ-R [Suicidal Behaviors Questionnaire–Revised]). Patients were followed for 6 months, with outcomes measured at the before intervention and, 1, 3 and 6 months after the end of the 6-month intervention, which consisted of a variable number of Elder visits (from 1 to 21 visits, median 3 visits).
At baseline “68% of participants had moderate to severe depressive symptoms (PHQ-9 score of ≥10) ... and 34% had elevated risk of suicide (SBQ-R score of ≥ 7)”. The authors noted a “statistically significant 5-point and 2-point decrease in PHQ-9 and SBQ-R scores, respectively, at 1 month … [and] sustained at the 3- and 6-month” marks. Similarly, “there was a 46% reduction in total ED visits (150 vs 81) and a 56% reduction in mental health–related ED visits (80 vs 35)”.
The authors unpack the ‘treatment effect’ with the assistance of semi-structured interviews that accompanied the quantitative data collection, showing clear link through several pathways between mental health and connection to Elders, grounded in trust, openness and hope that Elders instilled. “Protective factors against suicide [from Elders included] … providing social supports; promoting a sense of belonging; connecting with family, peers, and community; drawing on spiritual, religious, or moral beliefs; and developing a positive self-appraisal and identity.”
This is a powerful and urgent paper that urges for a community-centred model of care that builds mental health interventions for Indigenous folk upon the Elders of that community. There is great potential to consider translation of ideas here in other local contexts.