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These podcasts are recordings from the Cutting Edge Issues in Development Thinking & Practice lecture series 2023/24, 2022/23, 2021/22 and 2020/21, a visiting lecture series coordinated by Professor of Development Studies, Professor James Putzel and Dr Laura Mann.
The Cutting Edge series provides students and guests with fascinating insights into the practical world of international development. Renowned guest lecturers share their expertise and invite discussion on an exciting range of issues, from climate change policy, to pressing humanitarian crises. In 2020, the series took place online, enabling us to host fantastic speakers from around the world and to stream the lectures on YouTube, opening them up to a global audience. Now we are back in person but still recording the sessions to share with our global audience.
SPEAKER 4
Hello, everybody. Welcome to this week's Cutting Edge Lecture series. We're very, very pleased to be joined by Dr. Rochelle Burgess, who is an associate professor in global health at the University College London. And she's the deputy director of the UCL centre for for global Non-communicable diseases. She was actually previously at the LSC. She did have a PhD here, and she was also a research fellow at the centre of Africa. So we're really welcoming her back today. Welcome back. She has a very long and impressive list of publications spanning both kind of development studies and social science, as well as medical journals such as the Global Health, BMJ, BMJ, The Lancet and Nature. And she's recently published a book, Rethinking Global Health Frameworks of Power Critical Approaches to Health, which I think brings together a lot of her work. And it looks at global health both in terms of its practices, but also as a kind of knowledge system through which power operates, through agenda setting and knowledge production. And when I was preparing this intro, I learned that this book is also open access, so students can definitely go and check it out. Much of her previous work has been in Southern Africa, in South Africa and Zimbabwe, but she's also worked on health issues in the UK as well as within Colombia, which I presentation today focuses on. When we asked our colleagues in working in public health in the Department for Kind of Dream speakers for this series, she was at the top of the list and looking at her presentation ahead, I can see that she's kind of looking at critical health, public health in a critical way, but also looking more broadly about power and knowledge within development studies. So it has broad relevance for all of you. Um, she's joined today on the stage by our own Philippa DeVos, who is also an associate professor in our own department. And it she works on public health policy within the context of development, focusing on issues such as health care financing, equity and access, and also migrant and refugee health, which I think she's going to bring in today especially. She's also one of my colleagues who I think asked some of the best and most thoughtful questions in seminars. So I expect her to be an excellent discussant today and help us get warmed up for our Q&A. So Rochelle is going to have 45 minutes for her presentation, and then Philippa is going to discuss for about 15 minutes and maybe have a little bit of a discussion between them before we open it out to Q&A. I want to remind you guys to keep your questions short so we have time for everybody. So without further ado, let us give Rochelle a round of applause.
SPEAKER 6
Thank you so much for that introduction. I always have these moments when can you see me? I'm so short. I have this fear that like, you can't see any of me. Is that somewhat better? Right, okay, I shouldn't I used to, like, stand on stuff. Sometimes when I talk, we'll see. When I hear introductions of my myself, I start to feel really tired in the sense that, like, you know, all of there's a lot of labour that goes into into those things. And sometimes I sort of you keep going and forget about, you know, all of that stuff. But anyway, thank you so much. It was such a what's a warm welcome and really nice to to come home, as it were. I think the last time I was in the old building, I was pregnant and my son is six years old now, so it's any indication how long it's been. So I'm. I'm here today, I'm going to speak about my my body of work, which which takes a deep interest in staying with complexity, staying with the trouble, as many say, and trying to push boundaries on what we consider treatment within mental health landscapes. Many of the theoretical positions that I hold were developed here at the LSC. I studied community health psychology with Professor Kathy Campbell, who's now emeritus. I was taught by people like Sandra Bullock, Tim Allen, Susan Rifkin, Sylvia chante, Nyla Kabir, Sumi medica. A lot of the people who I assume you read and who you're still taught by, so hopefully nothing that I say will sound too far out of the field. But it was in their work that I found found respite and an opportunity to imagine and demand more of a growing field, which, when I started my doctorate in sort of 2008, was only just launched the movement for global mental health. And this movement has always had a deep interest in ethics and justice from the perspective and orientation of service, user rights, and the jarring injustices that mark mental health service use globally, particularly for those who suffer from severe mental illness. And in the early years, a lot of their efforts were around championing access, closing the treatment gap, doing this through mobilisation of evidence, really important evidence. But along the way, I started to feel a bit of a disconnect between the voice demands of people that I spoke to. I'm a qualitative social scientist, so I spend a lot of time doing participatory research, qualitative research, and very much sort of hearing a difference between the demands of the people I spoke to and the directions that policy takes. And so it's there that that sort of interest in power and voice and criticality resides. I'm not going to talk too much about global mental health as a field today, but I'm going to focus a bit on how my time there has led to me taking choosing to take quite seriously how we stay with people's voices, how we follow that to change what constitutes care and and really sort of trying to take seriously the statement of one, one woman who I met during my ethnography in rural KwaZulu-Natal and during one of my life history interviews, she said to me, you cannot be free if you don't have money. Money sets you free. Am I wrong? And I will never forget it because I don't think she's wrong. And I think what follows is really about how we can stay with that. Let's see if I can advance these slides in any sort of way that alludes to competence. There you go. Okay, so where do I begin? Where do we begin? I want to talk about three things broadly today. So I'm going to talk about adversity as as a context quite briefly. And I want to follow some of the definitions that we use around adversity through to the narrative of how we think about responding to the mental health consequences of adversity. Then I want to speak about this notion of repair, which I've been sort of informed by the work of anthropological studies, very range of anthropological studies and perspectives on repair, and something similar called remedy, because they open up a space to sort of overcome some of the unintended consequences that can be associated with mainstream offerings of services, which at times feels as if it's turning away from the more complicated realities that people face instead of towards it. And then finally, I will spend most of my time today talking about community led approaches, which are bound up in notions of community development, which I'm sure you know lots about what they offer in terms of how we can consider new visions and new landscapes for mental health care and services and dialogues between communities and services. And I'll talk specifically about Columbia in that work where I've been working for the past, gosh, some years. I'm not math person. Less than ten years, more than five working, working with communities around sort of advancing different spaces for mental health support. So it will be no surprise to anyone here that mental health outcomes are directly related to the context of development. So the figure on this slide is taken from a 2018 paper within the Lancet Commission on Social Social. Well, the paper is on social determinants and global mental health but it's on sustainable development. The commission is on sustainable development and global mental health. And this work by Kirkland Kirkland, who's from Cape Town and is currently based at King's, does a lot of work at trying to unpack the relationships between poverty and other social factors and mental health outcomes. And what he's done here is, I think, really important work in trying to sort of highlight the the stages and the processes through which mental health becomes connected to these big contextual social, political ideas. So, for example, if we look at the one here on environmental events, you can think of things like natural disasters, conflict, climate change related migration and the proximal factors of trauma and distress that then has knock on consequences for the development of health outcomes and within sort of the mainstream literature. This is sort of been followed on. And when I say mainstream, I typically talk about things like the World Health Organisation who set sort of global standards for what we should be attempting to achieve in these spaces. So there's a W.H.O. sort of work stream that is very interested in mental health and psychosocial supports in context of adversity, adversity in this space is thought of in one of two ways. So first, in a single event. So thinking about things like accidents or natural disasters or also in context of chronic adversity. So thinking about things like poverty and violence, long term conflict or displacement and both and recognising that these things have acute so immediate but also long wave long term consequences for mental health. But I think what's really important when sort of thinking about those definitions is that in reality, we often find that things are rarely acute or chronic. So, you know, you don't necessarily have a single event, you have single events that occur alongside chronic conditions. And I'm sure this is something that chronic social conditions, chronic social processes that are driving long term experiences for people, shaping the way people live their lives. And you can really think of that quite clearly in some parts of the world. So if we talk about, for example, here, I have a bit of a snapshot of some factors related to poor mental health in the Western Pacific region, where about almost 2 billion people live, and they recently have done some amazing work in sort of revising their plan for the implementation of mental health services. And within that, they try to hold attention to things that are both chronic and also seem like an instantaneous event. So they are attentive to the ways in which, increasingly, they are small island states that make up many of the the countries in that region are particularly exposed to extreme weather events, which will then have associated mental health impacts, something like violence against women, where these conditions are more endemic and sort of connected to familial and social context around violence in the region. They also have sort of, well, not sort of they have very high rates of suicide, particularly among young indigenous populations. And I think in that context, it points to both the immediate and the long term processes that lead to poor mental health outcomes. What it means to be an indigenous person in in a place in inland is is quite. Yes, I think I will. That's all. Stop there. And then, of course, they also were very interested in the way Covid affected communities. So Covid, which emerges as this sort of immediate crisis, which has very long wave consequences, and one of the ones that was particularly concerning to people, was this idea of the way it contributed to food insecurity in places where this was not a problem before. And so, ultimately, if we think about how different social events create certain landscapes that make poor mental health a bigger reality, then we need to think a bit differently about how we might structure structure our mental health supports. I want to talk a little bit about some of the work that I do in the UK, because I think it's really illuminated for me, the the ways in which adversity is embedded within the everyday systems through which people negotiate their lives. So in the last few years, I've been doing work on the mental health consequences of the Windrush scandal in the UK and the wider hostile environment. This work, which is being conducted alongside survivors, we've identified that the core site of Traumatisation and re Traumatisation is not just the act of exclusion itself that happened to people who were stripped of their identity and their passports and told they were no longer citizens, but actually the long wave consequences of these acts, and also the dehumanising processes that are linked to their quests for justice, namely, in this context, the compensation scheme which emerges for many people as a site of re traumatisation. And so in our ongoing analysis of sort of stories from survivors, and we're doing this with stories in the public domain, we sort of really are identifying. Sort of patterns that illuminate that, how somatic systems and psychological systems are really connected to these. Political structures. And so in a way, this it makes for me something really undeniable like that. Some people live lives where adversity is unavoidable. And I think that that's something that we need to hold on to when we start to plan for services. So this slide goes through a list of sort of the prioritised interventions that are proposed within sort of mainstream guidelines for how we might work through work on the work to promote the mental health of groups living through adversity. Many of these have been tested through randomised controlled trials with different populations and found to be effective. So that's how they continue to be used and applied and expanded. And so we'll talk a little bit about each of these in turn I don't know if people are familiar with these. I'm not sure how many mental health gurus are also in the room with with me today. For the sake of those who aren't, I'll spend a little bit of time talking about each of these. So problem management plus is a type of intervention that is oriented towards individuals. It's run for individuals. But it's been it has an additional package of providing opportunities to guide people through a process of sort of problem identification and problem solving. So that sits alongside sort of your mental health promotion stuff. This is how you identify symptoms. This might be how you refer yourself to further treatment and trying to help, trying to acknowledge that there are social dimensions to people's lives that that they're dealing with. The Thinking Healthy program is rooted in principles of cognitive behavioural therapy. And so for those who aren't familiar, cognitive behavioural therapy or CBT is a intervention package where the foundational principles are connected to the need to replace and shift problematic patterns in thinking that might lead people to deepen and maintain their distress and sort of replace them with new ways of looking at and approaching the world. And so this was initially tested with populations of women with perinatal depression living in adverse settings, but has also been expanded elsewhere. And then finally, group interpersonal therapy is a group based intervention. The new guidelines that came out around this around 2020 go through a set of go through a set of stages that sort of guide people through identifying not just the sort of wider social dimensions, but the interpersonal relationships in your life that are important to enabling good mental health. It also invites key people in your life into that process. And it's had a wide range of cultural adaptations because it's felt to be connected meaningfully to many different, for lack of a better word here, local ways of thinking about the world and thinking about what's important to your well-being. So, for example, I know colleagues who have been working with this in Uganda in the context of HIV. And so what I want to say is that all of these are necessary. They become necessary in the landscape of global mental health around that point of equity, of access. One of the big reasons and strengths around these approaches is that they are delivered by lay people. And so the idea that community members can contribute to the delivery of supports, you don't need a lot of specialists because there are very few specialists available. However, I think somewhere along the way we've confused the point of necessary and sufficient. So I think that while these are necessary, they are insufficient and they become very clearly insufficient when you hold on to the reality of what adversity means. And so in his closing remarks when he gave up the post in 2020, Special Rapporteur Dennis put us wrote about global mental health, specifically, and his main concern was around this idea of a treatment gap in the sense that there is a gap of sorts, but it's not necessarily around treatment. It's in the way that we think about what the problem is to be solved. So the movement is not focussed on how poverty and social injustice produce mental distress. The focus has been on burden and cost of mental health disorders, which is not consistent with the human rights based approach that has been shown to be methodologically flawed. And what they've done is flawed, and the focus remains on individual rather than systemic change as a means of tackling the poverty and oppression of concern. And I think one of the things that has always been posed to me when I sort of bring this up is this question of, is that the job of a health practitioner? Where do they start and where do they end? Is that their responsibility? And I think. One of the things I always think about is that if that is not within your responsibility, I'm sorry that that is so hard to read, but I will read to you. I'm very good at reading to people now because I read to my son all the time. There is this. If we do not sort of do that, if we come practitioners who sort of stick within the systems without questioning it, then there is an inherent violence in ignoring the way that people talk about themselves and their needs and their lives. And there's a lot to learn in the ways that Saidiya Hartman and other black critical scholars talk about the ways in which we need to turn towards turn back towards stories, and look at the alternative framings that could exist within stories. And so in this book, Wayward lies in beautiful Experiments. She sort of reimagines a history in time for black people in America, from the voices of the people themselves. Because the only things we start to know, or that we do know are the things that get into the canon, right? So get into our peer reviewed journals, get into those spaces. But of course, to get into those spaces, you have to fit a certain paradigm. You have to speak a certain way, you have to be interested in a certain thing. And in terms of relationships to black life, it is about deficits. It's about suffering. It's about struggle, and never about illuminating the way people survive or thrive. So forgetting that even in the face of enormous structural violence, that people imagine a life, otherwise they build a life. Otherwise they live a life otherwise, not in the future, but right now. And that is such a powerful starting point. I think a much more powerful and meaningful starting point for how we might want to imagine how people living through adversity might imagine their lives in the future, and seeing the role of a practitioner to support that journey, rather than to solely be within the realms of diagnosis and. And treatment. And so this is why repair becomes so important to me. As a concept I will say that. I've come to this framework of repair. Only recently, an anthropologist named Kit Davis saw a talk of mine. I'm not an anthropologist, but I tend to hang out with a lot of them. But they make me very nervous. They're very serious. Assume they're more serious than you guys. And. And one of the reasons I think that they're, they're really serious is they're sort of very deep, deep into theory. And so Kit Davis said to me when I was at this talk that I didn't really understand why I was there. She said repair would offer you a really meaningful space to think about and advance your work. And really, what it allowed me to do was a couple of things. It allowed me to sort of pick up all of these things that I felt were problematic in the space of global health and global mental health around this idea of epistemic injustice. So epistemic injustice, this fancy way of saying not hearing people, not seeing their ways of knowing as meaningful, as valid, as critical to the work that we do. And these are sort of four spaces that I have had some time to reflect on alongside colleagues who work in this space. So this idea of what are the harms of systemic injustice, or this idea of silencing and what it creates logics of care, which is what I'll mostly talk about today. Linguistic coloniality. I won't talk about the day, but the hyper rationality and the social reproduction of colonial knowledge practices, which I will talk about today, because ultimately repair gives us this chance to. To respond to this demand that seems to be quite prevalent in global health, around whose voices should be centred around how we work to support people achieving good health and well-being in both the short and long term, and what it means in relation to how we practically work in the wake of, of, of many things. And so this term, the wake I borrow from Christina Sharp, who talks about the wake and the afterlife of colonialism, but also very much important to the global health space which lives in the active wake of colonialism, neo colonialism, all these sort of sites of very complex realities. And it allows us to really interrogate how logics of care commit epistemic injustice. And what sorts of harms might be unintentionally created by maintaining the status quo. I found a faster way to change that. So what is repair? So repair is this interest in wholeness. Richmond and and lemons talk about it in relationship to sort of anthropological anthropology of sort of religions. But I found their definition to be incredibly valued because it's ultimately this way or mode of thinking that draws our attention to the way people work to restore wholeness in their lives. So what are people doing in the here and now, when they can, when they are able to to restore wholeness and sort of going with that? And for me, it's this need to pay attention to how people try to make right ruptures in their lives, in their social world. And then this forces our logic of care beyond treatment and towards projects, potentially of social change and social justice. And in that type of space, it opens up an opportunity for practitioners to do more to to be more. I find that this also connects to another anthropological concept of remedy. And Matthew Wolff Mayer talks about this in his work around sort of trying to differentiate between the types of ways people receive care. So differentiating between remedy, which looks at sort of situational but thought of as temporary perspectives of need that are treated by remedy. And he sort of connects that to a, a metaphor around. Disability and the way like a prosthetic provides remedy. But you might not use that all the time. And that's separated from therapy, which is a temporary relief that's working towards something permanent. And then this idea that a cure might exist. So one day you might find a cure for something and sort of trying to differentiate between these, these things as separate processes that trigger different things. And so I sort of feel as though repair and remedy create this opening for this different logic of care. And Christina Sharp's new work, Ordinary Notes, she says, I want to think of care as an antidote to violence. I want to think of care. And the register of Bonnie. I've got some reversing of letters. So body Bonnie, who outlines when she tells us that care is to cultivate anticipation of another world and to live now dedicated to the task of turning this world into a better one. And I think a logic of care in this way moves beyond bodies and towards transformation, and an opportunity for those who are willing and able to accompany others on those journeys. It also speaks to this idea, as I said, of the hyper rationality and social production of grand colonial knowledge practices. So this, for me, means a questioning of the way that some of our knowledge practices contribute to the social reproduction of certain ways of knowing. So earlier this year, in a one theory piece I wrote, I was talking about how when we think about the social, we sometimes put them in these different categories. So the first figure I showed you of the the sort of social determinants or the sustainable development goals broken up as separated things or slightly connected things. And in this sort of categorisation of the social, we sort of look at social determinants in disparate ways and not always as connected or additive. And so really what this figure here tries to do is try to orient us to two things that when you see a social determinant, it is socially determined. Something created that social determinants, something created bad housing, something created those inequalities, something created that crisis. And usually the things behind that are better encapsulated within like social political economies. So in our work here, we try to sort of think about what are the determinants of those determinants, what determines those social determinants to emerge in the context of global mental health. And what we try to do here is combine that with perspectives of intersectionality, to refuse to ignore that when you see a person, you're actually seeing multiplicities of communities intersecting. You're seeing incredible complexities. That's what makes being a human so hard. That's what makes the extension of compassion so hard. We want to simplify things, but in reality, this is people. This is always people. And so how do we create pathways? Conceptualisations. This is how I trick myself into moving faster that allow us to hold that complexity. So this is a framework that we've sort of come up with to suggest that and sort of resist the way in which sort of traditional, mainstream, westernised approaches to thinking about the social don't limit our ways of thinking about solutions. So this is it, this idea. It's drawn a lot on the work of Nancy Krieger, but it's this idea that chooses us to think about analysis as the the cause of disease in relation to political and economic structures, processes, power, and relationships, both contemporary and critically, historically. We cannot leave. There is no past. It is always present. I think the historians are really good at talking about that, because they shape the conditions where people work, live, and attempt to survive. So this is what we suggest. We suggest everybody should use something like this where you try to locate yourself or locate people within this, these matrices of intersecting social realities. And it puts the causes of mental health in a more direct relationship to how social, political and economic processes shape in the past and present shape contemporary realities. And it does away with this idea that you have something that is distal and proximal, because I imagine that anybody who tells you who is living through something does not separate something as a distal or proximal determinant. They just live it as a determinant of their life. I'm going to skip that, blah blah blah. Let's get to the case study, okay. Because I would like to hear you guys speak as well. So one of the look I fell in love with development here. I didn't know anything about development before I came to the LSC. It's a very nice place to be and think. And you're very, very lucky to be here and to have this opportunity. It will be the most stressful year of your life, but then you'll look back at it and think, oh my God, wasn't it amazing that time we saw that really weird lady talk about stuff? Anyway. But one of the most important things I learned about community and development was that it emerged as this opportunity for transformation. So community, not as a static location, but as a process through which change can occur. It sort of as a space in development studies emerges as this opportunity to transition towards local ownership of development projects, to move away from sort of interventionism and towards sort of community led, person centred, Amartya Sen type work and the key issues in development text. I'm sure maybe you guys are still reading that one. Community development is often oriented around two principles. And so the first is this idea of development of and for a community. So from within or bottom up. And the second is sort of like how development occurs via community decision making processes. But I think and I don't really want to romanticise the idea of community. Community is incredibly complex. It is a site of constant negotiation and renegotiation because as a process, it is very much connected to how we see ourselves. So we are at stake in the making and unmaking of community. But in health landscapes, a lot of times we don't hold that complexity of community. We think of community as like a target population or target group. We might think of it as a marginalised population, or a population that's linked it to protected characteristics. And these columns on the other side, communities of practice and communities of shared experience, I think, are where you start to see the more transformative notions of community. And so this is the premise on which we build our most recent project in Columbia. So this is a collaboration between two community organisations, Community Park, which is a collaborative of former guerrilla members who have reincorporated into society and are rebuilding, actively rebuilding their community, post-conflict and also with Group, which is a local NGO that works around the rights and needs and well-being for women and communities. In Florencia, which is a city centre in Kolkata, where the department where we work and largely they're they're working with people who were internally displaced by the conflict. Our academic partners are here. Some are here at the LSC, at the Department for Psychological and Behavioural Sciences, as well as partners at Universidad de Los Angeles. And so a little bit of the context and who we're working with. So I've already mentioned that our key partners are community organisations, but we're working with communities who are now the Columbia is, is is in a status of being post accord. So there has been a peace treaty signed, and they're in the process of working out what it means to ratify that peace, to bring that peace to to fruition. And so the work we're working with, communities who within that space have been recognised as victims of the conflict. And that recognition becomes really important for many reasons in terms of social, socially, in terms of gaining access to resources and supports, but also the former combatant. Sorry, not for the former guerrilla members who are now sort of rebuilding their lives now that the now that the need for their conflict has come to an end. So here they're talking about really high levels of mental health needs and just not just in these populations but also nationally. So you have millions of people who have been identified as as victims, but also people who are maybe not direct but indirectly affected. And so you have 1 in 4 people experiencing common mental disorder, and then you're also working around these sort of structural determinants of poor mental health as well. So in that department of Calcutta you've got very high levels of poverty, high levels of unemployment, and sort of the loss of, of identity that kind of can come with long term displacement for some people. So we started with this idea of wanting to work with communities, living in these spaces to determine what mental health supports should look like. We embedded this within the paradigm of participatory action research, which sort of links to emancipate more emancipatory forms of participatory research. It has roots in liberation struggles of Latin America, Asia, and and various contexts on the African continent. And the initial design is always to try and keep connection to to these contexts. And you're trying to promote development of empowerment through thinking about these things and through enabling work in areas that make sense to people. So really thought of this idea of enlightening and awakening of common peoples. And so what did this look like in practice? So in the inner circle here is the cycles of participatory action research. And on the outside are the steps of how we organised it into sort of three broad stages. So the first stage is called sort of a diagnostic stage. But really it's trying to meaningfully understand work with local communities to understand their practices around mental health, their thinking around mental health, and then also working with them to sort of make sense of how that all comes together. And. The second step around the intervention is working with large numbers of community members, who would be the users of this intervention at some point to design the intervention, and then the intervention sort of runs for a little while, and then we do an evaluation. And so we have a formal evaluation with scales and all that stuff. But we also have a participatory community led evaluation piece. Which piece which is photo voice. So if you start we started with local knowledge. We did 30 focus groups over the course of about six months, worked with hundreds of people in doing so, and organise those focus group discussions around activities like word association, where we're getting people to think about these big category ideas emotional distress, well-being, treatment, care and really separating treatment and care within that space to acknowledge that they serve to potentially serve different purposes. And also the tree of life, which is a methodology that allows people to connect past and present and sort of the future, to sort of have hopes for the future and embed that within our intervention design. So. My Spanish is really bad. I will read the English bits. But for those who can speak Spanish, the Spanish is there for you to read. What we found in both spaces. My Spanish is getting better, by the way, that my team always tells me it's getting better. But so in thinking about mental health services and people's experiences of mental health services, they sort of have this experience of therapy, which is the big piece of how we think about mental health as relatively negative, sort of having. You know, this perspective of thinking that somebody might be able to help you, but then they just start giving you pills and you don't really understand why you don't feel listened to. And this sort of tension around actually two sort of separate knowledge systems that are in that room that are trying to sort of negotiate some shared end, but really feeling like that's not what's happening and that sort of can contribute to this wider distrust in the service. But what was really important in that sort of one geographical context, because you have different notions of community, you have different experiences or different definitions of what distrust or mistrust might look like. So it's very different. In the urban site, to the rural site, and some of the things in terms of the rural side connect to the way in which the former. FAQ members talk about how the state uses or used ideas of mental health around sort of limiting their everyday experiences. So there's a bit of concern about what it might mean to be labelled with something, and how those labels might be used against you in completely different ways. So this idea of like telling lies about our past, you say one thing and then they take that information and turn it into something else. And that's something different to how somebody in Florencia, which was our urban site, might be talking about access to hospitals and things like that. So their contact with services also looks really different. So what was really interesting is also that people had very clear accounts of how they exist outside of services, particularly in our rural communities where there are no mental health services at home services move in and out. They sort of visit and leave. And so the way in which people sort of take care of themselves connects to a lot of notions of spirituality, faith, indigenous practices, indigenous healing, which becomes really, really important for them. And it's also connected to their lives as guerrillas and the former guerrillas and what they're trying to hold on to from their past. The things that are meaningful for their identity. And so expressing and practising those things become really important. And so it sort of became really clear when we were talking to communities about care, that their care was oriented toward this idea of repair, this idea of making whole. And the way that that manifested is actually through multiple different types of practices at different levels. So you have caring for your physical environment or your territory, sort of thinking about community as place, which was really important for people from our rural communities in the city centres. They thought of the state and NGO services is really bound up and being able to contribute to care because particularly with NGOs, that's the site where a lot of needs are met in terms of the relational context, lots of importance of sort of restoring bonds and maintaining bonds with family and friends and individually about the importance of strength. Mental health is about sort of keeping the mind occupied, keeping focussed and in some in the urban spaces. They also talked a lot about how music was very therapeutic and having experiences with therapy. I'm not sure how I'm doing for time so. Five. Perfect. Thank you. So what I will do. A skip to the bit about the intervention. So in terms of the intervention, we thought, how do we take what we have learned from people's narratives to make services different, to make services better? And we thought about four things. We knew that we needed to really hold those local knowledges as being valid, need to create spaces for them to be seen as valid. We wanted it to be led by communities, and so they can drive their own responses with the vision of who they are as their identities. And we wanted the content of the intervention to vary, because trying to deliver it in these different spaces, it had to achieve slightly different ends. So this was our theory of change. And really what I want to draw your attention to is that we worked with communities in a workshop with about 100 community members for a day, sort of doing participatory activities to map out these different pieces. So what is the most important part of context? What are the outcomes that you want? What do you want to see in your life? And then we sort of went away as our sort of research team to sort of build this bit in green, to think about what the intervention needed to be. So we decided to run participatory learning and action groups as an intervention, where the aim of those groups was to build connections between community members and formal structures, and to establish leaders in communities who felt like they were able to contribute to bettering mental health. And so this is the four stages of those of that intervention. And the first reflection stage. People have an opportunity to build awareness that consciousness raising about mental health and its connection to their social worlds. And the second stage, they identify and prioritise problems. Then in the third stage, they set out a plan of action, sort of for action projects. And then the fourth stage, they evaluate the cycle sort of repeats over and over. And so to talk about what that meant in practice. So these are the posters from some of the groups that were presented at a community forum, where the different groups presented their ideas to representatives from the wider social welfare sector, showing them what their plans were to improve their mental health. I think what's really important to hold on to here is that these didn't become classic interventions, like, I need more information about depression or anxiety. It was how do we restore intergenerational dialogue? How do we create opportunities to help people be safe? How do we give young people access to better education? How do we create a holistic idea of community? This one here education part. And that was my favourite one. They sort of created these sort of co-created these community rules about what it meant to be in their community. They went around to everyone, they did a video, and they created this sort of whole paradigm for how they want their community to live. And all the interventions were varied and they all had positive impacts on people's mental health. So we're just now doing the right of our evaluation. There was a significant reduction in depression, a significant increase in mental health wellbeing for all of the people who participated in the groups. And most importantly, in our photo voice evaluations, people talked about the afterlife of their projects, the fact that what they did would stick around for longer than just those eight weeks they were working together. So for me, the future of mental health is really about or global mental health is about finding bravery to change our definitions so that we can accept that adversity is often chronic. And so what we need to be doing is creating spaces for people to repair in achieve repair when it is possible to do so. That mental health is about more than the prevention of illness, but actually about doing things that create good mental health in their lives. That an intervention that is owned about a community can buy a community can also be the foundation for structural social change, and that we can be working in both the short and long term when we are working with community actors in this way. And then the last slide is, you know, this idea of how do we do this? And I really think that community led development as an orientation to how we engage with communities about their mental health sort of offers this really powerful approach to do that shift, to see that shift in real time. And so some people might talk about it as co-production or co-design, but I think if transformation is the ideal, then we're always trying to get towards this dream. But I'm a bit of a pragmatist like my former PhD supervisor. So I think it's also important to think about the ways in which we build toward that long term dream, which is also really important. And I will stop there. Thank you for your attention. Thank you for not falling asleep. I have a smooth jazz voice, so whenever I do a lecture at like 9 or 10 a.m., it's lights out for everyone.
SPEAKER 0
Thought of you as an American. Emily Thornberry. Well. That's nice.
SPEAKER 4
Lovely voice. Okay, I'm sure you all have questions, but I'm kind of hoping you don't have questions, because I have lots of questions to ask. But I will give you guys priority, so please think of your questions. Again. I want to emphasise there's always a pattern that at the beginning I only see men asking questions and by the end I see lots of women with questions. So be brave at the start so we can have a good balance. Philippa, would you like to offer your comments? You can. Whichever you prefer. But we can turn, I think. Turn on. Or maybe they're already on.
SPEAKER 7
Yeah. Okay, I'll stay here.
UNKNOWN
That'll be more cosy. Okay.
SPEAKER 5
Okay. Well, thank you, Rochelle, for such a, you know, a talk which was so rich, full of both theory and practice. It's so rare, actually, to have the opportunity to discuss with someone and to hear from somebody who is so kind of has one foot so firmly in the kind of academic world and, but also the other foot so firmly in practice. And I think that really came across. So thank you for for kind of explaining all of the different dimensions of your work to us. And thank you to Laura and James and the Cutting Edge Team for inviting me to discuss Rochelle's work. It's a great privilege and pleasure, and I've had the best time the last over the last week, reading, having the the kind of extra impetus and reason to read lots of Rochelle's work. And thanks to you guys for coming along on your Friday evening and listening and hopefully participating. So yes. Okay, so. I think in her talk today, Rochelle didn't quite get into how much of a kind of rebel she is. Probably felt uncomfortable kind of positioning herself in that way. But you know, I really want to emphasise to you how the global mental health movement has been growing in strength in terms of its institutionalisation in journals like The Lancet, its funding obviously, there's still nowhere near enough money for mental health. But yet the global mental health movement has been quite successful in mobilising some resources and raising issues of mental ill health in international development as an important area to focus on. And this kind of it's it's not a juggernaut. It's nowhere near a juggernaut.
SPEAKER 6
But it's sometimes feels like that.
SPEAKER 5
It feels like that to Rochelle. Okay. So but Rochelle is one of the voices that is kind of daring to call out some of the really deep problems with this kind of relatively new set of institutions and, and ways of promoting framing this issue in development, which is the problem of medicalisation and individualisation of mental ill health. But these are critiques which also can be made to so many other of so many other disease programs around the world. And indeed a big inspiration, I think, for Rochelle and also for myself in working in global health, was a different critique of a different juggernaut, which was the HIV Aids programs back in the early 2000, which Kathy Campbell here at the LSC wrote about in her book, which I think you've said in one of your papers was the first book global health book you ever read. I think it was the second book I read after Barnett and Whitesides book on HIV.
SPEAKER 0
Oh yeah.
SPEAKER 5
So it was my second book that I read, and I think that deeply inspired both of us. And I would really encourage, even though it's about 20 years old now.
SPEAKER 6
Yeah, but it's still.
SPEAKER 5
It's still absolutely saying what we need to hear in global health and in international development more broadly. So please do take a look at Cathy Campbell's Letting Them Die why HIV Aids Programs Fail. And in that, she makes a similar critique that these often well-meaning programs reproduce structural violence by medicalisation individualising the problems that people face in their everyday lives, and trying to solve these problems with, I mean, you know, at that point, I think they people it was deeply problematic that medications weren't available. So this isn't an argument against medication in this case, but solving. But as you said, it's not enough. And so. Yes. So Rochelle is really a critical voice. And I don't really have any sort of critiques of your presentation of your work. So really what I'm going to discuss is more of a more questions that I have for Asha. Also, I should say that I've been working on community development in the health financing sector. Inspired very much by Cathy Campbell. But I've just recently started moving into mental health. So I have lots of questions and lots of things that I want to discuss and learn from. Rashad. As I move into her area a little bit, I've been working on refugee and undocumented migrant access to mental health services in the NHS in England. So. So what is so radical about what Rochelle is saying? Because maybe if you don't work every day in these kind of spaces, it might not quite strike. You may not quite understand the real radical nature of what she's saying. The radical nature is that a classic intervention of this type in this part of the world, that one would imagine would be that clinical psychologist or some type of psych professional or psychiatrist, clinical psychologist, counsellor, come along and identify individuals who have who they diagnosed with mental health issues with mental illnesses. So they would use a diagnostic manual, the DSM, ICD codes, an international diagnostic manual. They would identify individuals who they would then invite to treat. With some form of therapy or medication. Rochelle does something completely different, which is she takes as her starting point the whole community. So she doesn't sort of cherry pick individuals who meet a certain threshold. But she says the whole the site of mental ill health and mental wellbeing is the community, not an individual. Is that okay that I'm saying that. Yeah. And so and that in itself is already a very brave starting point which departs from the mainstream. And then she designs or co designs interventions which bring the entire community into a form of service delivery so that people who may identify as somebody who has mental health problems or somebody who doesn't identify in that way, are all part of the conversation and who are all part of trying to build more healthy communities, better wellbeing. And okay. So what? So. So this is what Rochelle is doing. As I as I read it. Now I came across in my research people who I think believe the same things that Rochelle believes they are working in, within the institutions, within the mental health institutions, in this case in the NHS. They are clinical psychologists who told me that they have very deep, humanitarian, passionate, deep humanitarian beliefs that they've worked maybe in the past with MSF in the global South in conflict, they've been treating PTSD. So I was working with people who treat PTSD, and they were saying to me, look, we were talking. So we're talking about refugees and undocumented migrants. They were talking about the hostile environment. For those of you who are new to the UK, the hostile environment is a term that the government itself uses proudly to describe its policies in immigration. Okay, this is a this is not a critical this is not this time is not a critique that Russia or anyone is using. This is an intentional set of policies to make institutions and the immigration system as hostile as possible. Okay. The people who I was interviewing in my research were telling me, this is the source of most of my traumatised patients suffering. It is it is the structures, the, the, the institutions within which they must live their lives. But they did what Michel said. What are we supposed? They kind of said, what are we supposed to do? I'm a trained clinical psychologist, and they didn't say, I'm going to go and do community work and community development. They said, what I'm going to do is I'm going to try my best to try to add on social interventions for my clients. Right. So they said, I can't. I know that there's no point in treating the PTSD until I've helped this person secure better housing, or because the securing the better housing will be a large part of their feeling of a reduction of their symptoms. And this has been theorised by the French anthropologist Didier Faca as something called bio legitimacy. So this is legitimacy that people gain through their biology. So rather than accessing decent housing or other types of social welfare as a matter of right. They access this as a matter of their ill and suffering body or mind. And so populations are segmented and categorised as mentally ill or not mentally ill. And those who are mentally ill get some kind of extra supports for to access human rights that they, in fact, already have. Okay. And the problem and this happens, I think, in so many different mental health arenas, and this is one of the questions that I have for Rochelle, which is I believe in the global mental health movement. There are people who who passionately do want to do more than prescribing pills. It's many people. It is important to prescribe pills. I don't think anyone is saying that that should not be happening, but that there are many people who who want to do more, who want to address the structural causes of people's mental anguish. And they sort of they do it from within institutions. So you can think of theorists like James Scott or Michel Foucault who talk about these forms of resistance, which are often invisible from above or from the outside. But there are people hustling. There are people hustling within institutions that might the institutions might look structurally violent from the outside. But maybe. And I want to ask Rochelle, is it the case from the inside? There are people who are trying to make these structural changes, but from within. Now, for me, I saw some successful cases of this in some really unsuccessful cases of this, because when people's social welfare becomes an add on, a kind of optional add on, it becomes discretionary and the mental health practitioner can choose actually whether or not to add it on or not. They sometimes feel they're not choosing because of austerity and cuts, they say. They said to me, I can't. I know I should be doing this work to connect these people, to help the structural, to address the structural determinants of their ill health. But I am so burnt out. I am so exhausted. My health service is so cut by austerity that I can't do that for these people. And what did they end up doing? They actually just took them off the waiting list and they said, we can't treat those people. So paradoxically, these well-meaning people ended up excluding the most marginalised people from care because they were so well-meaning as to say that their mental ill health could not be solved without dealing with these structural issues, which they felt powerless in the end to solve. So one of my questions, Rochelle, for you is do you come across this in your work? What are your thoughts about this way of operating? Did you consider working in this way? Why do you feel for yourself that it's not a way that you want to work? I mean, I might have already said a lot about why it's not a good idea, but I'd be really curious to hear your thoughts. Because it is, I would say, anyway, a more of a sort of mainstream, possibly way of trying to address these social determinants. The last question is much more simple and probably much more familiar to all of you in terms of the concepts, which is just about community development and the dynamics from within communities. So you didn't talk today much about or the dynamics within communities in terms of the unequal distribution of power? So we know that when we do community development, and this is something I have worked on for a long time, that those with the loudest voices, those with the most social capital, often end up appropriating a community development process and being able to direct it into the direction, into the avenues that that are more beneficial to them. Because, as we know, communities are not homogenous. And they are, of course. Subject to power relations, as is everywhere and everything else. So how do you deal with that? I'm very curious about how you deal with that dynamic as you work with communities. And then another part of that community dynamic that I've often come across, and that I've been writing about in the past, is about those individuals who don't seek to appropriate the community development process, those community members, but those community members who, for one reason or another, have the greatest capacity to say, those health leaders that you talked about to take on those leadership roles and those people are often also incredibly burnt out because for some reason, the person who volunteers to run the mental health program or the community based health insurance program that I was programs I was working on also happened to be the same people who run the irrigation system, who teach in the local school, who sit on all of the committees. Those are the people, those community leaders, and they are absolutely overburdened and overwhelmed. And when we leave these community projects in there for them to lead, it jeopardises the process because they are so absolutely overburdened. And which leads to the critique that for many of these issues, like financing health care and I don't know so much about mental health, the state, we cannot that that we are asking too much of the critique is that we're asking too much of communities, and that we need the government states to take that responsibility for these very complex and arduous development and social welfare tasks. So with that, I've talked too long. I'm sorry. Laura. No. That is those are my very complex questions that I have for you. Rush out.
SPEAKER 4
Okay. I'm going to give you a few minutes, but I also want to make time for students as well.
SPEAKER 0
Can I.
SPEAKER 6
Can we take like.
SPEAKER 0
Two student.
SPEAKER 6
Questions? Yes.
SPEAKER 5
Let's do that.
SPEAKER 6
Maybe if anyone has a question that's linked to anything like that.
SPEAKER 4
Okay. So we have one down here, the lady in the white cardigan and a lady up here in a red jumper. Now, I need to encourage men to raise their hands.
SPEAKER 6
And one. There's one.
SPEAKER 4
Okay. Do you want to take three then? Yeah. Okay.
SPEAKER 8
Hi there. Suzanne. Yes.
SPEAKER 6
You're close enough that I can hear you.
SPEAKER 8
Okay. So my name is Duffy. I actually have a background in global health, and I've done a lot of work on distal and proximal mental health impacts on people who've endured sexual and gender based violence. So my question is two part. And it's somewhat related to that. So one, how do you convince development practitioners and funders to focus on improving distal mental health outcomes and strengthening deficiencies within social determinants, other social determinants of health, rather than simply focusing on solving what's on fire in this precise moment, while acknowledging that what we are doing right now is frequently not enough. And the second part is coming from someone who did work in community health and got very burnt out. How do you prevent burnout among mental health practitioners, or those of us who are inspiring mental health practitioners that want to work within the humanitarian field?
SPEAKER 4
Okay. Fabulous.
SPEAKER 9
I. Hi, it was really great to have a female speaker today, so thank you. I'm Michaela, I'm from South Africa, so I just wanted to ask a bit about the work that you've done in South Africa and specifically how you think community led development works in a context after apartheid with such bad inequality, high rates of Gender-Based violence, a lack of a functioning health care system, you know, whether it's mental or physical, but also mental health as a kind of race and class issue where it's often seen as a white or an upper class issue as well, as you mentioned, kind of kind of in a post-conflict society in a context like South Africa, where we didn't really prosecute anyone for what they did during apartheid. And the last part of the question is just you mentioned that your Spanish is getting better. So I was just wondering, how's your Zulu?
SPEAKER 4
So okay, I don't. And this gentleman here with the. Hello.
S11
Hi, my name is Heiko. I just have a question in the context and the case study that you've presented, which I think that would be really helpful when I get back to the field one day. So I know that the issue of mental health is widespread. Going back to the case of Colombia, I wonder, as you emphasised a lot in community based approaches, I wonder on what criteria did you use in selecting such community and how our other neighbouring communities are involved as an important starting point on where a geographical location we start on, on this matter and specifically on the problem analysis.
SPEAKER 0
Thank you.
SPEAKER 6
The problem analysis.
S11
Yeah. Why such community and not the neighbouring communities, if possible. Thank you.
SPEAKER 4
Okay. Let's start with these three. And Philip has many questions.
SPEAKER 6
Sometimes I think I missed the LSD. And then I realise I really do. I want to talk about. I'm going to start with Michael.
SPEAKER 4
I was wondering.
SPEAKER 6
Am I loud enough? But I also know I'm being recorded, so. Okay. Is that better? Yeah, that's much better. Yeah. Okay. Thanks. Thanks. So. I will start with Philippines because I think it leads into being able to answer. Do you say Duffy and Mikayla some of Michaela's questions? So. This idea of working within, from within the profession and the necessity of I mean, I think. These aren't either or things. I think they are examples of the multiple types of work that need to be happening concurrently in order for a change to happen. When I did my field work for my PhD, one of my my papers of my PhD is actually on practitioner perspectives and practitioners who are saying how they subvert the system. They made up their own diagnostic category. That sort of allowed you to hold on to complexity. And it was in those dialogues with them that I sort of made the decision, one, that I would not become a practitioner because I'd been playing around with that idea for a while, and two, that I would spend time I would continue to drive critique because. You can't keep asking people to work in broken systems. There needs to be some type of space and some type of work that is happening simultaneously to change that system from the outside. The reason that we have to do these microcosms of resistance is because the stuff on the outside is taking too long, so somebody needs to be on the outside. Shift, trying to shift policy, trying to create that other space, trying to talk about different things, trying to create examples and models that people are taught that enable that kind of work to just become a part of regular practice. If we continue to think that, we will just sort of like treat the individual social dimensions of people's lives and see change. You will never stop practitioner burnout, ever. You will never fix an unequal system created by apartheid. There needs to be work happening at multiple spaces at any given time. I recently been really inspired by the work of Deepa Iyer or Deepa. Deeper wire and she writes about social change ecosystems. I don't know if people are familiar with this ecosystem social change ecosystem map. The thing that's so fantastic about her work is it reminds us that you need like maybe 12, 11 or 12 different roles that are all contributing to this shared goal of justice, liberation, solidarity, storytellers, guides, experimenters, frontline responders, visionaries, builders, caregivers, healers. Disrupt. You need all of them. It's only through that cumulative work because justice work is painful. I think we can see in the world right now that we are in a very painful, heavy moment. I'm here. I've been struggling a lot. Personally. I sort of struggled with how much of that to reveal, but I think it's important to sort of name the weight that you carry when you do that work, and name the weight of the world that exists around you, and to make time for grieving that, to make time for holding loss. Nobody's giving us time to do that right now. It seems impossible. I'm a big crier, so don't be surprised. That will come, but I will. I will say that I think a lot of burnout comes from not having enough space. To fall apart at the things that you see, at the things that you witness, at the things that you are asked to carry as a practitioner, as a somebody working for justice, as somebody working on the front lines of harrowing things, as somebody connected to. Hard places at hard times, the suffering of others. There are things you carry that you pick up that need to be put down. You have to put them down, otherwise everybody will be burned down. And so a better system is one that recognises how it's connected to those things, to those violences and cares for people within them. And I think. You guys are the ones that will build a better world than the one we have. And I think the systems that you build will be aware of that, because we're actually in a space where people are able to talk about their mental health. I also have lived experience of the use of mental health systems that have been a little bit racist. Not so bad because I was in Canada. At the time. But I think the fact that I can say that now, I could not have said it ten years ago. So I think a part of that work is also about recognising any small wins that you might be able to. The point. My Zulu was always bad. Zulu is very hard. It got okay, but then I didn't go back. I went, I did some work in South Africa with the population. And then I see it's all right. There's like bits inside of me that really want to get back to, to be able to, to do that. I think community led work in South Africa. It's a really interesting question. It's a. I was sat in the green room and I realised that I was sitting next to Nelson Mandela's photo and my brain just sort of exploded a bit as well as my heart. But I enjoyed Peterson, who was a mentor of mine, who is connected to the global mental health movement and is one of those people who resonates very deeply with a lot of the critiques and limitations that I've been talking about today. Her work has always been about trying to strengthen a system, trying to enable the system to appropriately hold community led work, because in an unequal space, in a historically unequal space, there needs to be also a ceding of power and also a resourcing of these organisations to enable us to get to a point of equity. And so that in order to do that, you sort of need to think about what types of resources the system needs to create a space where people are able to better mobilise and work in relation to it and with it. And so she has used the moment created by the movement for Global Mental Health to do some really amazing systems work around the primary health care system, because South Africa also has spectacular policy. Landscapes like the mental health policy in South Africa is beautiful. The implementation of it has been difficult. And so a big part of trying to work around that implementation is about how we sometimes think about research, I think is redistributive justice. I don't know how many people say that about research, but I sort of see it as this thing to say, here is all this money here. I noticed all the new buildings and how do we move that resource in order to do different things with it? And I think it is through the ways in which research can be mobilised to drive systems, strengthening systems work. And and I don't really like the phrase capacity building, but I think it sort of sort of will hold here. Is it Heiko? Heiko, did I say that close to right. Okay. Your question connects to your second one. Philipp. Around. Sort of like the reality of community dynamics. And how do you choose which community gets something in which community doesn't? So. I'll talk about two things in the Columbia case. We started with community organisations, and our community organisations told us where to work. I didn't go in and say, let's work here or not here. I didn't have that embedded knowledge of Kolkata because I hadn't worked in Kolkata before, but they did. They have been doing the work and they knew exactly where this work needed to be done and would resonate. But also, this is part of a much longer body of work. I work a bit like an anthropologist. I go somewhere and I try to stay there until somebody tells me to leave. But it's the idea that that community is is the first of many. And we're and we continue the work and, and and we've built a model. So a big part of making sure that a community, one community is one is one of many is that a lot of the additional partners to our work are strategically chosen, like policymakers who would be interested in the intervention that communities designed. We also included an economic costing, something I never would have said before I came to the LSC, like we did an economic costing of the value of the intervention because we wanted to be able to say to people, this is how much it will cost. This is it's cheaper than doing this, and you can do it here and we will help you do it here. And here is the package for you to do it here. And those were the kinds of things we thought about when we started. So that's the thing about I think action research sort of orients you to that, that question of what does your work leave behind. But because we started with that, this idea of sort of conflict in internal conflict in communities. Internal dynamics. It made me actually think of some work that I've done in Nigeria, and I worked on this trial. To improve the health of children under five children with pneumonia. And it's it was a participatory intervention. And when we did the scoping work for this study, we did this huge thing called we did community conversations. So, you know, the method. So we did that in this big community of place with close to 300 people. And we talked about power then. So before we went to do this intervention, we had a fairly good idea of where the problems with power would be. And that's where we started. So I think how you get around that is you assume always assume that there will be problems with power because you're dealing with people, and people are imperfect and and so how do you anticipate that? And so in the intervention, we had a session that was on power dynamics in households because the intervention stood no chance if he didn't have a space to talk about that before. And that's only possible because. We started with those questions before we did the before or anything else. But typically when you do scoping work, it's very limited. You know, I had like four months and a huge team of amazing sort of young researchers in, in Jigawa. And we designed this thing of huge conversations in communities. And because that was resourced we were able to do it. So I think it's also in research and thinking about how seriously we take learning from past mistakes and and costing methods that allow us to do that.
SPEAKER 7
Yeah, building it in right from the start.
SPEAKER 4
Okay. We have a question upstairs here, and let's have the gentleman at the front. So.
SPEAKER 0
Okay. Thank you.
S12
Hello. My name is Rewa and I'm from Lebanon. My first question is about. So mental health, typically societal views around it. So you see in many communities just talking about mental health is still a taboo. So what would you do to address this issue before you even start a particular intervention? And my second question is about Covid. How do you see Covid did affect the whole access to mental mental health services and public health in general?
SPEAKER 0
Sorry. What was your name? Could you say it a bit?
S12
Rewa. Rewa? Yes.
S13
Hello, my name is Jaren. Thank you very much for your talk. I had a question relating to the limitations of the biomedical model, and I think throughout your talk you kind of refer to you sort of reference capacity building, improving the functionalism of different communities as a social process through community. But could you also talk about the dream and care and the sort of pragmatic tensions that you encountered, and why you think these are relevant to the. You want me to.
SPEAKER 6
Redo the end of the talk? Did you feel I rushed it? I felt I rushed it too. I think that's fair. Jared.
S13
Not that you rushed it, but more about you mentioned there's like a pragmatic tension. Why do you find that? Why do you find there to be attention? Exactly.
SPEAKER 6
Yeah. Okay.
SPEAKER 4
Okay. And the lady up here in the green jumper.
S14
Thank you for your presentation. My name is Marina. I'm a postgrad student.
SPEAKER 4
Could you speak a little bit more into the microphone? Okay.
S14
Like this is better. Yeah. And so I just wanted to build up a bit on the question of riba and specifically with the context to the slide that you presented about the gorilla combat and certain, let's say, mechanisms that prevent them to access into mental health. So do you have any specific like good practices or examples, whereas the which enabled these types of population to engage with mental services. And what worked specifically well with mental health interventions towards the population, who has a certain resistance of engaging with mental services?
SPEAKER 4
Okay. We'll start with those three. And I'm hoping I think we'll have another round as well.
SPEAKER 0
Okay.
SPEAKER 6
I'll try. I mean, I don't know. Jared asked a really deep question. Why do I why do I feel I'm going to start with that one? Because I think it sort of connects a bit to to the others, the, the pragmatic tensions I feel in my work. I think that comes. And see. It's definitely going to take a long time. I put the book down. I think it comes from. So this idea of trying to hold complexity also comes from my own, as I said, experience as a service user of formal mainstream services. So I really love that Philippa called me a radical. I don't call myself a radical very much. But one of the and I think one of the reasons that I don't feel as radical as some other voices in the global in the the critique spaces of global mental health, like Derek Summerfield, for example. Is that? Even with the limitations of the biomedical model. When I see somebody find repair in its use that has validity, that has importance, that has meaning. Because that is how that person has been able to achieve repair in their lives. Sometimes a diagnostic category does something amazing for a person. Something amazing, something powerful, something important. And if you really want to take equity seriously, equity is about enabling people to be able to make all have all of the options available to them. And I think it would be inappropriate to say just because you've got a broken social world means you shouldn't also have the right to say, actually, I think psychotherapy is great. It's about how do you as like you were saying about the the client, some of your participants talking about their clients, how do you treat PSD if you don't have any stability in someone's life? Maybe you create stability in someone's life and see that as an important part of a process of enabling some sort of deeper therapeutic work. And there are modalities of therapy, things like systemic family therapy, which is if I do go into therapeutic practice, it will probably be there tries to hold sort of sort of psychological well-being within the bounds of family dynamics, social dynamics, structural dynamics tries to hold that complexity historically in people's lives, but also remain like holding on to the fact that we we do still have individual choice. And so I think the pragmatic tension comes from me around saying, trying to say that things are both necessary and insufficient. And that's where the big tension comes to me, because my life would be much easier if I was either mainstream or a deep critic. But the fact that I try to sit across these spaces and force people to sit in that discomfort of being across those spaces is is a tension is hard. But I think that's why I find dealing with these notions of care and repair as such. Nice words that are able me to do that boundary crossing with people across disciplines, hopefully. I think that's what Kit was trying to say when she was like, if you're looking to convince people, this idea of repair might really help, you not have to have so many uncomfortable conversations with psychiatrists. It's only psychiatrists who yell at me when I go to talks, and then the nurses hug me. I always find that really interesting. But also, yes, there are amazing psychiatrists who I mean, Derek Summerfield is a psychiatrist, like his critique is embedded in his practice of psychiatry. So I'm not batting up psychiatrist. So this idea around. Who's Ray was, and I'm sorry, the post was a PhD student. I didn't catch your name. He said it's super postgraduate. Marina. Marina. Okay. This idea of, like, mental health and society. How do you. When there's a lot of stigma around mental health, how do you do that work? I think what has been really interesting coming from the Columbia work, right, when you're trying to sort of access the general population, we found that a lot of people sort of came to the intervention with their stigmas. They brought them there. And I think sometimes if you do it the other way, where you sample people who have a diagnostic category or whatever, you actually are enabling the contact that is necessary for stigma to be broken down, really. And so we had these really interesting moments of awakening for people within these groups who were able to feel that mental health was about more than they had anticipated. It was being about this through. I mean, the big mechanism that underpins the intervention that we designed is dialogue, is dialogue within your group and across groups, because it's the cross group dialogue that becomes the opportunity for sort of transformation and things like that. And so I think that's very much how how we did it and how we saw former guerrilla members start to think differently about mental health in relation to themselves, in relation to their ongoing work and mobilisation work in their communities, actually. And then you always also ask the question about access to mental health during Covid. Something really interesting happened in Covid, whereas that usually it takes everyone about ten years to realise mental health is a thing. And it took them about five minutes, which I was pleased about but not satisfied. And the peace in nature that was mentioned was about came from like a rant. I was on some sort of thing and I was ranting and I had no idea who was on this mail list. And someone said, can you write that in a thing? And I was like, I guess let's try. I'll just record myself yelling in my office. But what we sort of found, what I sort of thought about there was that it changed. It opened a space for people to think about mental health, but the ways in which we responded didn't change. So you had a lot of discussion about the power of mental health and mobile mental health to, like, create waves of access for people who had never had access before. That was happening in a way that was totally decontextualised from things like, well, the people who have access to. That kind of like capacity are always the same people. It's not the most marginalised, the marginalised. It's not, you know, most of the global South, which will and inequities within the global South that sort of determine your ability to access sort of reliable internet for you to be able to do some sort of online CBT course. But but also that, you know, Covid also reminded us of how deeply embedded these social inequalities are. And I just felt a bit for me that the way the mental health response happened just sort of mirrored existing inequalities. It wasn't an opportunity to sort of do deep, transformative work, but it did still open a space. I think more comfort for people, for policymakers to actually start talking about mental health. And I think that's really important because if you can get policymakers and have conversations with policymakers around things like financing and and why it's so important, it's so costly for you not to invest in these things, then that is a huge part of the battle, I think.
SPEAKER 4
Okay, so I want to fit in. There's a question up at the front here and there's a question here. Rochelle, how many questions do you think you can answer in ten minutes? Well while paying attention to your own mental health. Bearing in mind that many.
SPEAKER 6
People who are about to ask questions are also staying for the drinks portion of this.
SPEAKER 0
Evening.
S15
Fifth Street.
SPEAKER 4
That's a very good way of.
SPEAKER 6
Let's see how far we go. If you feel my answer was incomplete and you would like more, find me at the bar. Assuming there is a bar, I don't know what.
SPEAKER 4
So we have two. And then there is about three more. Not counting my own questions, but I will ask you them later. Maybe we could. James has a.
SPEAKER 0
Question.
SPEAKER 5
Maybe we could hear all of the questions and not answer all of the questions.
SPEAKER 4
Okay, let's do that. See how I can connect them down here.
S16
Hi, I. Can you hear.
SPEAKER 0
Me? No.
S17
My dear.
S16
Okay. Can you hear me? Yes. Okay. My name is Shar. So I think you talked a bit about the value of expanding kind of the limited diagnostic categories in mental health, but I was kind of wondering how we can go about enforcing that in clinical settings. And I'm thinking kind of about Joseph, given his work on First Nations health care workers and the use of the diagnostic category of historical and intergenerational trauma to recognise a whole range of different symptoms from depression, substance abuse, suicidal ideation and other physical comorbidities, and then kind of how that diagnostic category has been used to do medicalized and pharmaceutical as healing and treatment approaches that can emphasise a reconnection with indigenous culture and language and community. Sorry, that's not a dark question.
SPEAKER 0
It's not dark at all.
S16
Long question. Sorry.
SPEAKER 0
Is it dark?
SPEAKER 6
It's not dark. That was super hopeful. Okay.
SPEAKER 4
Okay. And the question here, and could you just pass it down this row? This whole row is a productive space. But we're going to go upstairs first.
SPEAKER 0
But.
SPEAKER 9
Hi, my name is Ayesha. Thank you so.
S18
Much for being here. My question is actually pretty short hopefully. So it's actually interested in some of the methodologies that you mentioned, namely being participatory action research. So I'm just wondering did you experience any roadblocks or challenges through using PA maybe perhaps in a socially conservative context? And if so, how did you mitigate this?
SPEAKER 0
Tastic.
S16
Hi, my name is.
S19
Sorry, my name is Daisy and I was just really curious about. Especially as we were talking. You were talking about Colombia and then South Africa. So do you think that these kind of community participatory mental health programs are as transformational as ADR? So alternative dispute resolution, especially when we have we had like the truth, Justice and Reconciliation Committee in South Africa. So do you think that it would harm the progress of like this community approach to mental health, or do you think it could benefit it? Or do you think they should work together or separately, or especially in post-conflict societies?
SPEAKER 0
Okay.
SPEAKER 6
I'm sorry, Megan to the microphone. So I guess.
SPEAKER 0
Hi.
S19
Can you hear me?
SPEAKER 0
Yeah, a little bit.
S20
Hi, I'm Mathilde, and I want to know how you're handling having these results that are very real, but mostly qualitative and having the pressure from funders and government to be able to prove to them what's happening quantitatively. So I was working last year on the community based mental health program in Scotland that had amazing qualitative results. Practitioners, community and individuals really, really excited. And the pilot was funded by the government. But to be able to have that quality, they had to cut down the number of people they were supporting. And so the conclusion from the government was you're not meeting the targets, it's not meeting what we're expecting. And so we're not considering this result. And the programme got shut down. And I was wondering, are you getting some freedom from being an academic and not having to report your results in the same way as getting this private government funding, or is there. Yeah. How are you handling, supporting and creating these new projects?
SPEAKER 0
Okay.
SPEAKER 4
And this will be the final question and speak with it like this okay.
S21
Hi, I'm Zara, I'm from the London School of Hygiene and Tropical Medicine. I'm just wondering, even within a community, obviously adversity leads to different manifestations of mental illness. And to what extent are community led approaches in different to that heterogeneity in mental health conditions? Might there be a place for some kind of person centred elements to acknowledge that? And also. To what extent should communities bear the burden for their own treatment and the capacity for them to do that even through suffering adversity? And have you seen any adverse effects on communities in your work?
SPEAKER 0
Okay.
SPEAKER 4
So Rochelle, we do need to finish in about four minutes to six. So good luck.
SPEAKER 6
Sure. I had not heard of the use of intergenerational trauma as a diagnostic category before. Thank you for sharing that. I think it's really powerful. I think there is a lot to learn from indigenous communities in Canada in the way that they are able to have ownership in health related spaces. Some work that I do in southwest London around mental health systems change draws on some sort of interventions, like similar things. But I'm just basically I'm saying thank you for telling me that. I'm going to tell them about it. I, I don't think about expanding diagnostic categories. I think about expanding responses around existing diagnostic categories. I think regardless of your the whatever category label they give you, there should be an opportunity for you to bring your full self to a space. So I'm not a diagnostic categories person, even though I recognise there's lots of interesting stuff going on there. Aisha asked me about methodologies. PA, I'm going to connect this to Matt's question about funders. So one of the big one of the big roadblocks around doing PA is how long it takes, like meaningfully to do PA takes a really long time. Or any meaningful co-production work will take longer than the space of a regular grant. And I think that I do this work in parallel to other work that I do in other spaces where I sort of critique the way funding is allocated for certain types of projects. I think those that work has to go together. In the meantime, while I'm waiting for that kind of change to happen, one of the things that I ultimately end up doing is a lot of like unpaid, foundational work. So I work in places where I have known people for a very long time. I use my life resources to maintain those relationships, to support their independent projects of change. And when the opportunity emerges for us to. Transition funding from the academy to community spaces. We then are able to take to make use of that. And I think that that that sort of tension around how we talk about impact is part of a much broader problem with how we talk about impact and define impact. And maybe that will be the next thing I talk about when I come back in another ten years time or something. Was it, Daisy? Yeah. Your question about ADR. I think that community participatory, participatory approaches sort of go in parallel with those things. I don't think they sort of necessarily dis potentially disrupt them. I think they potentially could be a mechanism through which people think, through what retribution like restoration, retribution, reparation needs to look like from like a bottom up. I think they're sort of in relation to each other. And interestingly, a very long time ago, I wrote a paper with a colleague of mine who does a lot of work on the violence against women space, and she was doing work in Rwanda. And she was one of the things she looked at was how, like women groups around violence are actually just mental health spaces. You'd be surprised about how many places that were already doing good mental health work. It's just that we're stuck in this problematic limitations of the definition of what mental health is and isn't. And so I would encourage you this thinks back to burnout. We don't need to automatically create new things. We could look at what's happening and look at what the benefits are for mental health, to scaling up this existing practice, or tweaking this existing practice rather than adding new things. Where we worked in Columbia, there were no things to add to we. So we created new things. And then I think the last question was Zahra. Around how does community led approaches leave space for individual need? It's not about right. I think it depends on the type of intervention you create. I think there aren't a lot of them right now that acknowledge the need for people to access individual support before they can come into a group, but it's definitely something that I have found in some of my other intervention work that I've done with women who've experienced trauma is that sometimes your trauma is so live that actually you cannot participate in a group setting, and you need to have some individual work that's happening alongside of that to move you back into it. And I think there's one program that I heard of in Guatemala where it was actually structured that way, which is sort of the first time I heard about someone trying to do PR for mental health, and they and they had this separate individual space. And in all of my projects, we start with the community. There's no diagnostic barrier for entry. But when people do come in, if we see that they are in need of help, there is funded mechanisms for them to access that. That is a part of what gets budgeted into every project, which is another thing that is not, I think, normal practice, but probably should be. And I think I did it. Did I do it? Yes.
SPEAKER 4
Yeah, that was very impressive. And. Well, thank you so much, Rochelle. I have to say, and I'm not just doing this to sweet talk you. This was one of my favourite cutting edge lectures that I've heard in the last few years, and I think it's helpful for thinking about how this moves across disciplines. I was sort of thinking, as I was listening to your talk about within economics and within agricultural science, the degree to which practitioners believe themselves to be kind of observing passively phenomena in the world, or whether they're kind of aware of the infrastructure through which their disciplines are produced, right through which economics or through which agriculture works. So I want the students to kind of think about the ways that different disciplines are kind of aware of the way that the knowledge system is part of the system. So, yes, let's thank her again for this great talk. I also want to draw your attention to next week's talk, which is the Russia-Ukraine war consequences for global security and development. We have three speakers. Julia and Anna will be talking particularly about the the conflicts within Russia, in Ukraine. David Luke is an economist who will be speaking particularly about the impacts on the global economy and particularly within African countries. And Mark Lowcock is also sort of taking that global view of the impacts of this war on other countries and on the global context for development. So please join us for next week.Thank you guys very much.