Attempts at analysis and resolution of the Boko Haram insurgency are often rooted in peace and security discourse. But what if we centred mental health discourse in dealing with violent extremism? One organization has been asking and answering this question.
Communities affected by conflict are often engaged by different stakeholders: humanitarian aid workers, policy makers, security forces, healthcare personnel, mental health workers and so on. Typically, these stakeholders will work within the boundaries of their expertise, each with their own interventions. Knowledge hierarchies, such as the supremacy of the randomized control trials (the gold standard of evidence-based methods in medicine), and the vested interests of international actors, will inform these interventions. Continuing to think and practise in closed systems simply preserves and perpetuates imperial and colonial practices.
These attempts are short-sighted and unsustainable; we must—and can—do better. Dr. Sami Timimi, fiercely criticizes psychiatric diagnoses and the medical model in psychiatry stating that:
Western mental-health institutions have been pushing the idea of ‘mental-health literacy’ on the rest of the world. Cultures are viewed as becoming more ‘literate’ about mental illness, the more they adopt Western biomedical conceptions of diagnoses like depression and schizophrenia. In the process of doing this we…imply that those cultures that are slow to take up these ideas are in some way ‘backward’.
Based in the North East, the Neem Foundation’s flagship Counselling on Wheels programme seeks to address the psychosocial aspects of the Boko Haram insurgency as a means of building resilience to violent extremism. Counselling on Wheels does this by offering a range of therapeutic psychosocial services and peacebuilding activities. The programme embodies the importance of resisting the presumed universality of Western mental health praxis that do not suit the Nigerian context and traditionally militarized responses to violent extremism—Neem’s approach fundamentally rethinks contemporary notions of mental health, peace and security. Yet, global mental health continues to enact coloniality, and peace and security continues to prefer militaristic responses to violent extremism despite evidence of an evolving and unabating conflict brutality.
GLOBAL MENTAL HEALTH: MEDICAL IMPERIALISM
Picking apart global mental health requires an interrogation of the very foundations of health. When thinking about what constitutes health, the medical field tends to think of it as biology. Illness, therefore, is presented as an issue with a person’s biology. The medical sciences sit in a reductionist tradition. Within this framework, health is distilled to the interactions occurring at the cellular level. Following this line of thought, scientists and medical practitioners are those able to manipulate biology to restore health. This framing has its benefits. For example, biomedical reductionism has given us Statins—miracle drugs that help reduce the risk of having a heart attack or stroke. While biomedical reductionism certainly has its place within the medical sciences it has also limited our understanding of what constitutes health. This biology-centric tradition ignores and obscures much broader relationships taking place within and around our bodies.
BROADENING OUR VIEWS ON HEALTH
A structural approach to health, instead, acknowledges that there are many factors within and outside the body that influence health. These factors include institutions, policies, markets, knowledge systems, media, customs, laws, and healthcare systems. By broadening the lens through which health is conceptualized in the medical sciences, we capture a much more expansive and, therefore, accurate depiction of health. This contests the tendency for medical imperialism.
Medical imperialism can be seen clearly in mental health, particularly global mental health. Dominant psychiatric constructions of mental illness have their origin in the West. These constructions favour reductionist classifications of mental illness based on post-Enlightenment psychiatric conceptions in which the mind (constructed as ‘psychology’) is located inside the body. This sentiment is emphasized by Dr. Thomas Insel, former director of the National Institute of Mental Health (NIMH), who states that ‘mental disorders are biological disorders’.
In this paradigm, biomedical reductionism offers the most accurate explanatory models, relegating other ways of knowing, such as the narrative or the experiential (for example Bronfenbrenner’s ecological systems theory places the individual within five nesting systems: Microsystem, Mesosystem, Ecosystem, Macrosystem, and Chronosystem) to lesser forms of science. Therefore, mental health concerns such as depression, schizophrenia and anxiety are distilled to the dysregulation of dopamine, or serotonin, or whatever neurotransmitter is being interrogated by the scientist.
Oversimplifying mental distress in this way lays the foundation for equally simplistic responses. This reductionist approach allows for Western-centric constructions of mental illness to be posed as universal. In turn, Big Pharma makes billions of dollars churning out and exporting ‘specific’ drugs that tackle these ‘specific’ neurotransmitter dysregulations. After all, beneath our skin we are all the same, right?
RECONSIDERING THE PEACE AND SECURITY PARADIGM
Similarly, we must reconsider peace and security paradigms. Blood, guts and gore are the typical connotations attached to violence. Violence is often then reduced to that which is physical, namely armed conflict. In turn, peace and security is rendered the pursuit of countering this physical violence; peace is made to be the state when these awful violent things—killing machinery—are not present. Johan Galtung radically defined violence as being ‘present when human beings are being influenced so that their actual somatic and mental realizations are below their potential realizations.’ Violence, therefore, is ‘the cause of the difference between the potential and the actual’. This definition offers a much more expansive entry point for interrogating conflict.
When applying Galtung’s definition, mental illness can be seen as a violence. The process of finding peace of mind must encompass and factor in the structural forces at play in the life lifecycle of mental illness. This requires a departure from Western psychiatric conceptions in which the mind is constructed simply as the interaction taking place exclusively within the brain. Instead, this pursuit of peace must see our psychology as having a root outside the body, in the interactions between our bodies and the environments they find themselves in. Placing psychology outside relocates this violence from the mental space to the socio-political space thus transforming it from a private individual problem to a public and collective one.
WESTERN SOLUTIONS FOR AFRICAN ISSUES?
More than one-quarter of the world’s nation states are currently experiencing war and conflict, with a notable recent increase in African crises. At the same time, exportation of ‘advanced’ Western epistemologies to the ‘developing’ world is widespread in mental health discourse and praxis. These two realities, mental illness and unabating conflict, share an intimate relationship; where there is conflict there is trauma. We know that communities impacted by conflict are affected by Post-Traumatic Stress Disorder, depression and anxiety. Yet, while these issues find their location in Africa, the scholarship and (proposed) interventions rarely originate from the continent itself.
We can see two ways in which medical imperialism is at play within the global mental health market. First is through the West deeming itself the presider of the entire global mental health knowledge ecosystem by dictating what knowledge is valued and, therefore, should be distributed. Second, is the imposition of interventions designed and tested in the West on non-western communities. After five years of existence, the Lancet Global Health, the global health holy grail, published 637 papers referencing Africa, of these only 55 discussed mental health and were penned by actors in the West.
In a Cochrane review (the highest form of evidence base within the medical field) of psychological therapies for the treatment of mental disorders in low- and middle-income countries or ‘LMICs’ affected by conflict, most of the interventions evaluated came from the international actors. This simply reinforces existing power structures and hierarchies resulting in a biased evidence base that positions professionals and populations in non-Western contexts merely receivers of the global mental health expertise. In this dynamic, fraught with imbalances of power, the knowledge production and practices around mental health of the LMICs are decreed inconsequential.
When we interrogate the literature discussing global mental health, we must be suspicious of the exportation of Western psychiatric categories or instruments that measure and manage illness in non-Western communities. The assumption that frameworks constructed in the West can be translated into any context globally is erroneous and arrogant. Challenging biomedical reductionism hegemony through a more expansive framing of (mental) health provides a more useful pathway to resisting practices that may be harmful to vulnerable communities.
REFRAMING PEACE AND HEALTH IN NORTHERN NIGERIA
The Boko Haram conflict in north-east Nigeria has created a situation of acute and enduring humanitarian need over the past decade. Boko Haram has attacked both government forces and civilians, carried out suicide attacks, and mass kidnappings. An estimated 41 thousand people have died, with more than three million people displaced by this conflict. A narrow definition and operationalization of peace and security limits the breadth of the responses to conflict. State-sanctioned solutions have typically been militarized yet yielded limited success. We have seen that simply eradicating the leader of this insurgency does not uproot an ideology that forms the basis for harm at this large a scale. An armed response is insufficient. Therefore, all stakeholders need to expand and reconfigure what constitutes a comprehensive response to the problems presented by Boko Haram.
An appreciation of the relationship between trauma and violent extremism offers a vital key to a fuller approach to preventing and countering violent extremism. Trauma, and ill mental health is rarely a consideration of insecurity. By centring trauma in managing violent extremism, we are made to consider the vulnerabilities of communities in greater detail and with greater care. This lens offers more clues about how violent extremism manifests and is maintained because it requires the blurring of disciplinary confines and authentic interdisciplinary work. For example, a peacebuilding intervention would need to consider the psychological wellbeing of communities they seek to engage with—trauma may be a barrier to reconciliation.
Using the trauma-violent extremism lens forces us to simultaneously expand our notions of health, as well as peace and security. Looking through this lens challenges the convenient myths of psychiatric universalism and perceiving violent extremism as a phenomenon requiring a predominantly militarized response. Health as a bridge to peace is a useful framework that illustrates the richness of having expansive notions of health and peace and security.
In the Neem Foundation’s Counselling on Wheels programme, interventions are designed and delivered predominantly by academics and practitioners from the North East. Alongside these interventions, there is ongoing interdisciplinary research work capturing vast amounts of data. A 2020 evaluation found that the Counselling on Wheels programme engaged close to two thousand people from a range of stakeholder groups, and over ten thousand people from more than forty local communities through psychotherapy interventions. The evidence demonstrated that the Counselling on Wheels programmes significantly reduced people’s mental distress as well as vulnerability to violent extremism.
This model offers an entry point towards a decolonial approach to global mental health and peace and security. The researchers and practitioners within Neem reflect the diverse socio-political and economic backgrounds of the communities they serve, thus reducing the epistemic and experiential gap. Neem challenges existing power imbalances in knowledge production and the practices that emerge from it by decentring hegemonic Western definitions of mental distress and insecurity. Instead, the organization reconfigures the definitions of health and insecurity by expanding them to include the structural factors at play. Health, therefore, ceases to merely be a biological phenomenon, and peace and security an issue that is dealt with simply by adopting militaristic approaches. This is exciting, but there is still some way to go in the aspiration of using health as a bridge to peace.
While Counselling on Wheels boasts delivering psychosocial support and counselling services to over 31 thousand beneficiaries in Borno State, why isn’t the government relying on it? Perhaps this is to do with legitimacy. This programme sits between the tension of forming new ways whilst having to exists within paradigms that dictate a particular discourse and praxis. Counselling on Wheels must prove its legitimacy to the very systems it seeks to disrupt. Inherently, this requires compromise. For example, to capture the trauma of the affected communities, the counsellors may rely on psychological metric tools that were designed in the West. Whist this will yield data that demonstrates the scope of the problem, and the ways in which Counselling on Wheels has alleviated it, it risks reinforcing the very dominant framings of mental health it challenges. This has implications on the impact on policy and funding.
Similarly, what are peace metrics beyond a lack of armed conflict – how will we know that Boko Haram is defeated? Different ways of understanding and sustaining peace will be needed to move beyond militarized peace and security.
Organizations must develop an imagination and a maturity that helps them to discern which tools to use to dismantle the master’s house⎈
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