Challenges for implementing a global mental health agenda in Brazil: The “silencing” of culture

Abstract

Since its emergence in 2007, Global Mental Health has been a growing and polemic area of study, research and practice in mental health worldwide. Despite having a significant endogenous academic production and innovative policy experiences, the Brazilian mental health field and its actors make few references to, and scarcely dialogue with, the Global Mental Health agenda. This article explores an aspect of this divergence between Global Mental Health initiatives and public mental health care in Brazil regarding the role of culture within mental health policies and practices. Our hypothesis is that part of this difficulty can be attributed to the low relevance of the cultural dimension for the Brazilian mental health field, here referred to as the “silencing of culture.” We examine the possible historical roots of this process with reference to theories of “anthropophagy” and “cultural uniformity” in the context of Brazilian cultural matrices. We then describe two recent experiences in public mental health care that incorporate cultural competence through the work of community health workers and the example of community therapy. We argue that the development of cultural competence can be decisive in enabling an improved dialogue between research and practice in Brazilian mental health and global mental health initiatives.

Global Mental Health: Interdisciplinary challenges for a field in motion

“…This special issue of Transcultural Psychiatry provides a snapshot of current interdisciplinary work that reflects the complexity and ongoing evolution of GMH. The authors reflect on the histories and colonial legacies of violence inscribed in mental suffering and programming (Capella, Jadhav, & Moncrieff, 2020;Hickling, 2020;Ortega & Wenceslau, 2020), on current models of culturally responsive intervention and implementation (Bustamante Ugarte et al, 2020;Hatcher et al, 2020;Honikman, Field, & Cooper, 2020;Mascayano et al, 2020;Shehadeh et al, 2020;Verhey et al, 2020) and on the challenges to mental well-being from the impending conditions of catastrophic climate change (White, 2020). Another set of contributions challenge established narratives on psychological suffering and trauma after war (Medeiros, Nanicha Shrestha, Gaire, & Orr, 2020), natural disaster (Newnham et al, 2020), and cultural practices of female genital cutting (Omigbodun, 2020).…”

“…Although most societies are culturally diverse, attention to culture in mental health services generally has not been a priority. Ortega and Wenceslau's (2020) discuss the ways in which the public mental healthcare system in Brazil actively discounted cultural difference as a meaningful level of engagement with patients, historically focusing instead on social class. The somatic idiom of distress nervos, for example, has been attributed to low-income rural women.…”

Global Mental Health and Pharmacology: The Case of Attention Deficit and Hyperactivity Disorders in Brazil

“…GMH initiatives have revitalized old controversies in psychiatry around the universality or cultural specificity of mental disorders. Critics of GMH argue that it promotes a Western, biomedical model of illness and treatments as well as the expansion of the Pharma industry; neglects practitioners of traditional therapies; disregards cultural influences on cause, course and outcome of mental disorders, as well as explanations for mental distress; medicalizes suffering and ignores social and economic determinants of mental health (Summerfield, 2012;Clark, 2014;Kirmayer and Swartz, 2014;Ortega and Wenceslau, 2020). GMH advocates have refuted such criticism and stressed their engagement with local communities and attention to context and culture in the design of the interventions.…”

“…The GMH agenda has also raised important criticism especially from transcultural psychiatrists and anthropologists. Overall, such objections outline the biology vs. culture controversies and denounce the neglect of social, political, and economic processes associated to mental health diagnostics, treatments, and research (Summerfield, 2012;Clark, 2014;Kirmayer and Swartz, 2014;Ortega and Wenceslau, 2020).…”

Articulations between the Global Mental Health project and the cultural aspects of care in the Psychosocial Care and Primary Health Care Network in Brazil

“…Based on Darcy Ribeiro's analysis of culture in Brazil, Ortega & Wenceslau (2019) will state that cultural differences support the class difference that leads to discrimination and stratification, and that the Brazilian Psychiatric Reform (RPB) describes cultural differences as economic and social differences, that is, as class differences.…”