#studyGMH: Mutual learning and 'reverse innovation': learning that flows both ways

This blog is part of a series focused on our Global Mental Health MSc students' impressions of the recent King's Health Partners Global Mental Health and Psychosocial Support Conference, held 5-6 June 2017.

The problem of psychiatric imperialism persists as a critique against the globalization of mental health. The Global Mental Health and Psychosocial Support Conference tackled this head on with a series of lectures around the theme of “Mutual Learning and Reverse Innovation”.

Tree of Life: African roots

Ncazelo Ncube started off the conference with a gripping story about developing the Tree of Life workshop from her work with AIDS orphans in Zimbabwe, working as a counsellor at summer camps that the children attended. During the camp, the counsellors would set aside one day to discuss the difficulties the children had been through. Working with the children through stories about loss and pain was so difficult that the counsellors called it the “day of doom”. The counsellors dreaded having these conversations. They could not see a clear benefit, and felt burnt out.

From this difficult position, she realized that there was no need to limit the children’s narrative to a single one about loss and bereavement, one which characterized them as passive recipients. Instead, they could be creating narratives of hope. Working with colleagues from the Dulwich Centre Foundation, the Tree of life workshop was developed to allow multiple narratives to be told. Children are invited to draw a tree where the roots represent family and ancestry, the leaves represent the things they enjoy and the branches their dreams and aspirations. The trees are then put up together to create a forest. Rather than focus on the trauma, the trauma is only one part of a bigger, multi-layered story.

Tree of Life: adapted for the UK

Tree of Life workshops have since been adopted in the UK, particularly in working with black and minority ethnic (BME) populations. Angela Byrne talked about how this innovation, particularly because of its African roots, has added value to the mental health service in the UK. There is an over-representation of black African minorities detained in psychiatric institutions, and a significant treatment gap in talking therapies particularly for African-Caribbean men. Byrne describes a toxic spiral whereby service users are perceived as reluctant to engage in mental health services, prejudices amongst mental health professionals lead to more coercive responses, leading to further mistrust for mental health services amongst the black African minority population.

Byrne conducted consultations with African-Caribbean men in the UK about talking therapies as part of the Trailblazer project. They perceived talking therapies being offered as irrelevant to their lives as the therapies excluded values held in their community around heritage, culture and spirituality. The Tree of Life workshops appeared as an appealing alternative, and workshops were run as part of a community project. Byrne describes how it seemed to fast-track recovery for the men, in doing so challenging perceptions that BME populations were difficult to engage. Tree of Life workshops have now been carried out in several community settings, inpatient wards and psychiatric intensive care units. There is even a WhatsApp group used by Somali women in London to upload pictures of their ‘trees of life’ to create digital ‘forest of life’.

Mutual learning: barriers and lessons for the future

On the Global Mental Health MSc, we dedicated a lot of our time to learning about how to adapt psychotherapies developed in the West for other contexts. We had lectures about the Thinking Healthy program in India for maternal depression which utilized an adapted CBT treatment, and MANAS stepped care for depression in primary care which utilized interpersonal therapy.

There is a need to apply a critical lens to considering why certain innovations are adopted, and others are not; why certain knowledge is ranked highly, and other forms of knowledge are not. Hamdi Issa’s talk about the theoretical perspectives on reverse innovation began to explore this. Reverse innovation was initially a concept to support diffusion of services in multinational corporations across a multitude of settings. Institutional theories frame the adoption of innovations in terms of the risks that an organization is willing to take. She argued that power leads to certain knowledge being recognized as truths, creating “regimes of truths”. These “regimes of truths” are internalized, manifesting in cognitive biases in which innovations are considered acceptable. Matthew Harris continued this argument by presenting his research on explicit biases towards low-income country research amongst English clinicians.

Perhaps in the future the Global Mental Health MSc will dedicate more time to talking about mental health care innovations that have been developed in non-Western countries which are adapted and scaled up in the UK. Already there are care models that have proven successful, such as task shifting, which could be adopted in the UK which also has a mental health system that struggles to cope with high unmet needs. The same robust methods should be employed which have made global mental health successful elsewhere.

Finally, it is important for researchers to reflect upon why innovations are considered relevant, why they are adapted for a certain context and population, and whether there are any underlying biases in examining evidence from outside our comfort zone.

Children and adolescents
Humanitarian and conflict health
Empowerment and service user involvement
Treatment, care and rehabilitation
Training, education and capacity building
Depression/anxiety/stress-related disorders
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