Thinking beyond implementation: context and culture in global mental health

Correspondence to Dr Cristian R Montenegro; cmontenegrocortes@ gmail. com © Author(s) (or their employer(s)) 2020. Reuse permitted under CC BYNC. No commercial reuse. See rights and permissions. Published by BMJ. INTRODUCTION Global mental health is a field of research and intervention that aims to improve access to mental health on a global scale. A basic tenet in the field is the existence of a large ‘treatment gap’ for most mental disorders, especially in lowincome and middleincome countries, and the need to ‘scale up’ interventions through, among other things, ‘task shifting/sharing’ to/with community health workers, traditional healers and peers. The rise of global mental health has unearthed old controversies in psychiatry such as the universality vs cultural specificity of mental disorders, their expressions and their relationship with forces beyond the individual. 4 The consolidation of global mental health as a field has been accompanied by a strong call for interventions to be contextualised and adapted to cultural and social realities. Context here refers to, among other things, formal and informal health and social care systems, cultural values and norms, and social and political processes. 6 A central argument in this call is that mental health is, maybe to a higher degree than physical health, rooted in local definitions of personhood and the good life and that these definitions are historically and socially situated. Mental health interventions need to make sense both for local practitioners and for service users and, therefore, attention to context is crucial. Usually, these calls are addressed at a relatively specific type of intervention, involving services that start—or are designed—in one place to be then implemented in another, and whose success depends on local uptake by providers and service users. In its most simple form, this type of intervention involves a logic with three broad steps: (1) an intervention, initially conceived in the global north; (2) a set of implementers, usually trained, supervised and/or supported by representatives of global initiatives and (3) local populations, with their current and potential needs (see figure 1). In this logic of implementation, culture and context constitute layers that interventions penetrate with more or less success, acting as obstacles or enhancers for mental health and wellbeing. In this editorial, we draw on examples from Brazil and Chile to explore how, within local mental health systems, ‘contexts’ behave in ways that do not necessarily follow the logic of implementation. Context and culture are not only facilitators or barriers; they are contentious dimensions of identity (as in the case of Brazil), and their relevance is weakened by global assessment technologies (as in the case of Chile). We aim to unsettle and expand the relatively circumscribed place given to culture and context in global mental health. Brazil and Chile are two countries that stand in an ambiguous position concerning the implicit priorities of global mental health; countries that, while not easily classifiable as producers or receivers of global mental health interventions, dynamically respond to its normative and epistemic coordinates. A secondary aim for this editorial is, therefore, to explore the nature of this interaction.