Introduction

As I waited at a crowded bus stop with Kalpana—Ashrang’s first and only psychosocial counsellor—a middle-aged woman nearby struck up a conversation. [1] The dialogue quickly slipped into a familiar groove. The woman enquired, politely, what I was doing in this out-of-the-way corner of the Himalayan foothills. By way of explanation, Kalpana began talking about the six-month psychosocial counselling training course in Kathmandu where we had first met. Her job now, she said, was to help people who were continuously worrying, who couldn’t sleep, and who were very afraid. ‘People who have a lot of heart-mind problems,’ she summarised. She continued that the counselling she did—here using the lay term for giving counsel, paraamarsa, rather than the technical term for psychosocial counselling, manobimarsa—involved having a conversation with someone to help them find a solution to their particular problem. ‘Before the earthquake there was not much of this support,’ she explained, ‘but now there is more.’

The woman listened attentively, registering understanding in her facial expression. ‘Oh, you mean people who are very afraid all the time?’ she asked, and then added, ‘there are some people like this in my village.’ She disappeared into the crowd, emerging a few minutes later with a neighbour whose daughter, she told us, had ‘this type of problem’. For months, the girl had been complaining of excessive fear and refused to leave the house, even to attend school. After some further discussion, the young mother asked how she could meet Kalpana again and the two women exchanged numbers. Kalpana reassured her that she would visit, adding, ‘Don’t be afraid. We are here. And if we can’t solve the problem, I will send someone else who can help.’

Living with a newly trained counsellor as she established the first psychosocial services in her region, I witnessed exchanges like this one on a regular basis. It quickly became clear that almost no one living in Sindhupalchok district had heard the Nepali word ‘psychosocial’ [manosaamaajik] before. More surprisingly, Kalpana also used the term sparingly, even though it was precisely the identification of a psychosocial problem that served as a gateway to counselling and other mental health services.

Intrigued, I began systematically asking counsellors across the district how they explained their work to people in the communities they served. I was particularly interested in how they navigated initial meetings with potential clients and their families, during which the status of a given problem as psychosocial (or not) was negotiated. Given a growing critical literature on psychosocial interventions, I was curious about the implications of recasting rural Nepalis’ suffering in psychosocial terms: did this framing efface or supplant other locally salient framings of distress? Did it medicalise normal responses to adversity and structural violence, undermining individual agency and throwing open the door for new forms of therapeutic governance?

In this paper, I argue that we cannot begin to answer these important questions without careful attention to the communicative practices of frontline clinicians, among whom psychosocial counsellors occupy a prominent place in Nepal. These frontline practitioners sit at the nexus of not only different vocabularies, ethnopsychologies, and ontologies of suffering, but also different regimes of value, all highly consequential in terms of how care is pursued and provided. The ways in which counsellors represent the object of their care to potential clients have tremendous implications not only for the course(s) of therapy individuals choose to pursue, but also for how notions of mental disorder and psychosocial disability take on meaning and legitimacy in relation to other locally salient readings of affliction.

In what follows, I begin by tracing the ascent of psychosocial models of care in Nepal and more widely in the field of global mental health (GMH). I then draw on conversations with psychosocial counsellors working in one predominantly rural hill district of Nepal to explore the microdynamics of what I here term ‘psychosocialisation’: the process through which varied human problems come to be construed as appropriate objects of psychosocial care (cf. Abramowitz 2014). Zooming in on the interactions of frontline counsellors and potential clients, I examine how the vague and flexible category of the ‘psychosocial problem’ is deployed in everyday practice with particular attention to its role in processes of translation.

My use of ‘translation’ here encompasses, but is not limited to, the linguistic and cultural adaptations that GMH practitioners are themselves increasingly concerned with. Drawing inspiration from science and technology studies (STS) and in particular the work of Susan Leigh Star, I understand translation as a process that strives not merely to convey meaning to people in different sociolinguistic worlds, but also to enlist their support and cooperation (Callon 1986; Callon and Law 1982; Star and Griesemer 1989; Star 2010). Star’s key intervention was her insistence that such cooperation can be achieved even in the absence of consensus about the problem at hand; for example, scientific experts, donors, bureaucrats, and amateur enthusiasts can work together to realise projects without necessarily agreeing about what is at stake (Star and Griesemer 1989; Star 2010). [2] This collaboration is facilitated, she argues, by ‘boundary objects’:

objects which are both plastic enough to adapt to local needs and the constraints of the several parties employing them, yet robust enough to maintain a common identity across sites. They are weakly structured in common use, and become strongly structured in individual-site use […] They have different meanings in different social worlds but their structure is common enough to more than one world to make them recognizable, a means of translation. (Star and Griesemer 1989, 393).

While somewhat dated and not without its shortcomings, [3] I suggest this original formulation of the boundary object helpfully singles out important qualities of the ‘psychosocial problem’ in GMH today—namely, the ways it facilitates collaboration in complex transnational therapeutic endeavours without requiring different stakeholders to first reach consensus about the nature of affliction. I then discuss the implications of this analysis for the anthropology of GMH, arguing that available critical lenses in medical anthropology fall short of capturing the distinct discursive politics at work in contemporary processes of psychosocialisation. I close by sketching some lines of inquiry that might allow us to gain greater critical traction in this young and rapidly shifting field of intervention.

‘Psychosocial interventions’ in global mental health

Leading guidelines define ‘psychosocial support’ as closely related to ‘mental healthcare’, adopting a different approach to achieve overlapping aims (Inter-Agency Standing Committee 2007). While mental health services focus on curing disorders (frequently with the help of medication), psychosocial care is generally geared towards alleviating distress or improving functioning and wellbeing using non-biological therapeutic interventions (Psychosocial Working Group 2003, 1). In recent years, psychosocial approaches have enjoyed growing popularity within global mental health (GMH), a young and interdisciplinary field concerned with scaling up mental health services in low- and middle-income countries (White et al. 2017).

Whereas early GMH initiatives foregrounded evidence-based psychiatric treatments, advocates have progressively rebranded the movement as one that transcends the psychiatric paradigm (Bemme and Kirmayer 2020). Bemme’s (2018) nuanced genealogical work describes how GMH actors began to downplay rigid psychiatric nosologies in favour of a broad and malleable ‘umbrella language’ for mental health, one which is well-aligned with psychosocial approaches. Leading figures in GMH now claim that the majority of problems captured in the global burden of mental disorders would be better labelled mental ‘distress’ (Patel et al. 2014a, 18) and have called for the expansion of the field’s purview from the treatment of mental illness to the promotion of mental health and wellbeing (Patel et al. 2018). The guiding problematisation of the global ‘treatment gap’ has given way to the more inclusive ‘care gap’, which explicitly eschews the ‘medical connotation’ that was seen as excluding ‘a range of effective psychosocial interventions available today’ (Pathare, Brazinova, and Levav 2018, 1; Patel et al. 2018). Indeed, the latest The Lancet commission on GMH suggests psychosocial interventions delivered by non-specialist workers should be the ‘foundation of the mental health-care system’ going forward (Patel et al. 2018, 9).

Beyond reflecting ideological developments, the embrace of psychosocial interventions in GMH is also a practical response to the challenges of implementation in diverse low-resource settings. Psychosocial interventions are more feasible to deliver through ‘task shifting’, or the delegation of clinical tasks to non-specialist workers who often lack the training to distinguish between different disorders. They are also seen as more ‘acceptable’ to people holding divergent ideas about mental illness, enabling practitioners to overcome ‘demand-side barriers’ to care (Patel 2014; Kohrt and Griffith 2015).

Thus far, social science critiques of GMH have drawn heavily on well-worn Foucauldian tropes, often adopting ‘the usual frame of the battle between medicalization and its discontents, experts and patients, and the colonizing reach of disciplines and the insurgencies beating them back’ (Béhague and MacLeish 2020, 10; see also Ecks 2020; Cooper 2016). In this vision, GMH catalyses the mass medicalisation of mental suffering across the Global South, undermining local cultural knowledge and deflecting attention away from social and structural determinants; the field is often described as an extension of or complicit with various wider efforts at social and economic control (e.g., Clark 2014; Das and Rao 2012; Mills 2014; Mills and Fernando 2016; Kottai and Ranganathan 2020; Watters 2010; Fernando 2011; Summerfield 2012).

Within this critical literature, psychosocial interventions have been described as poorly defined, amplifying the potential for appropriation and unintended consequences (Kohrt and Song 2018; Watters 2010; Pupavac 2002). For example, Abramowitz’s (2014, 25) compelling ethnographic case study in Liberia describes psychosocial interventions as a vector for ‘humanitarian social engineering’. The lack of a clear definition of psychosocial care, she argues, gave license to international organisations to remould Liberian subjectivities as they saw fit. Liberian counsellors working for these organisations were in turn empowered to act as ‘moral missionaries’, imposing their own interpretations of normative humanitarian values—at times quite forcefully—on clients and community members (Abramowitz 2014, 113).

Abramowitz’s rich ethnographic account stands as a stark warning of how psychosocial interventions can be exploited to diverse social and political ends. At the same time, it reveals the extent to which these ends are shaped by frontline clinicians, whose positioning and labour ‘complicate our all-too-routine differentiation of medical healing systems into “the global” and “the local”’ (Abramowitz 2010, 326). The next step forwards, Abramowitz (ibid.) suggests, is to bring ethnographic scrutiny to bear upon the subjective experience of these actors at the frontlines of care. What follows is an offering in this direction. After introducing my research context and methods, I provide a close reading of Nepali counsellors’ accounts of the translational work they engage in. My analysis asks: how might these accounts challenge, exceed, or refine the critical frames through which we approach the GMH project?

Psychosocial care in Nepal

Nepal is widely described in the global mental health (GMH) literature as suffering from a dire shortage of mental healthcare resources, with only a single public mental hospital and an estimated 110 psychiatrists and 15 clinical psychologists serving a population of 29 million (Sherchan et al. 2017). The first psychosocial counselling programmes were introduced during a violent Maoist insurgency that racked the country from 1996–2006 (Seale-Feldman 2020a). Exemplifying ‘task shifting’, these programmes trained two new cadres of frontline practitioners: psychosocial counsellors (four to six months of training) and community psychosocial workers (one to two weeks of training) (Kohrt and Harper 2008).

The practitioners who developed these early psychosocial programmes were influenced by medical anthropology, including research on ethnopsychology and idioms of distress (Sharma and van Ommeren 1998; Tol et al. 2005; Jordans et al. 2003). Physician-anthropologists Kohrt and Harper (2008) identify two distinct Nepali concepts of ‘mind’ that influenced service design: the ‘brain-mind’ [dimaag] located in the head, associated with rational thought and behaviour, and the ‘heart-mind’ [man] in the chest, the site of transient everyday thought and emotion. Terms associated with disorder of the brain-mind, such as ‘mental illness’ [maanaasik rog], carry stigmatising connotations of moral failure, chronicity, and severity that may deter people from engaging with services (Kohrt and Hruschka 2010; Kohrt and Harper 2008). Psychosocial programmes in Nepal have attempted to distance themselves from these connotations by claiming to address suffering in the ‘heart-mind’ (Kohrt and Harper 2008). Accordingly, the Nepali neologism for ‘psychosocial’ combines the terms man [heart-mind] and samaaj [society], and the word adopted for ‘psychosocial counsellors’, manobimarsakarta, can be translated as ‘person who advises on matters of the heart-mind’ (ibid.).

In the post-conflict period, this ‘culturally adapted’ model of psychosocial care was progressively formalised and expanded in a piecemeal fashion into different parts of the country. By the early 2010s, Nepal had become an important node in the GMH assemblage, and its flagship research programme incorporated psychosocial counsellors as one element of an essential mental healthcare package (Jordans, Luitel, Kohrt, et al. 2019; Jordans, Luitel, Garman, et al. 2019). The devastating earthquake of 2015 rallied ample funding and political support for mental health, and advocates worked to channel the sudden influx of resources towards the goal of sustainably scaling up services across the country, or ‘building back better’ (Seale-Feldman and Upadhaya 2015; Seale-Feldman 2020b; Chase et al. 2018).

My doctoral research charted this moment of optimism through 14 months of ethnographic fieldwork (2016–2017). [4] Following preliminary research among programme planners and clinicians in Kathmandu, I relocated to the rural hill community I here call ‘Ashrang’, in the heavily earthquake-affected Sindhupalchok district. In the two years following the disaster, mental health and psychosocial services had become available to Ashrang’s 6,000–8,000 residents [5] for the first time. A government-financed psychosocial support centre was established and staffed by a psychosocial counsellor (Kalpana) and two community psychosocial workers. [6] The region’s female community health volunteers (a lynchpin of the government’s health delivery system in rural areas) received training in the identification of and referral for mental health problems. A Kathmandu-based psychiatrist began visiting a pharmacy in a nearby town once a month to perform consultations, and three primary care doctors working in another nearby town received training modelled on the World Health Organization’s (WHO) mhGAP Intervention Guide and a supply of psychotropic drugs. These services and goods were free for patients with the exception of certain psychotropic drugs not on the government’s free drugs list. Referral between these different services was possible, but was limited in practice by poor coordination.

During my time in Ashrang, I lived with Kalpana and her family and participated as fully as possible in everyday community life. I conducted immersive participant observation among and interviews with frontline clinicians, former clients, and caregivers associated with the psychosocial support centre Kalpana directed. [7] I also visited and interviewed psychosocial counsellors in other parts of the district and participated in mental health and psychosocial training courses across the country. During my first months in Ashrang, Kalpana sometimes moonlighted as my research assistant and accompanied me to interviews. [8]

My ethnographic access was exceptional in two ways that are worth noting from the outset. First, the clinicians I interacted with had been trained by some of the most senior and experienced counsellors in the country at an organisation that prioritises cultural adaptation, community-based care, and anthropological insights. [9] Second, my focus was a sustainably government-financed psychosocial support programme that trained laypeople to provide counselling in their own communities. In contrast, at the national level psychosocial counselling is more often provided through short-term NGO projects and mobile teams (Seale-Feldman 2020a), while psychiatric treatments have achieved much wider coverage within the public health system to date (Chase et al. 2018). This latter point is significant because, in the many instances when clients consult biomedical providers during the course of counselling, they might find their problem suddenly refashioned as a ‘mental illness’; and, as a consequence, the complex work of psychosocialisation is swiftly undone.

As such, my account should not be read as comprehensive portrait of GMH practice in Nepal, and nor is the carefully crafted model of counselling that exists in Nepal representative of the gamut of psychosocial interventions in use internationally. Instead, what my vantage point afforded was a glimpse of one of the field’s most contextually sensitive and reflexive frontiers and the aspirational politics it embodies. In practitioner-speak, you might call this an ethnography of ‘best practice’.

In order to develop a more vivid picture of this frontier, I turn now to two ethnographic vignettes that situate processes of psychosocialisation in the everyday life and work of frontline counsellors. Each sheds some light on how the broad and flexible category of ‘psychosocial problems’ might enable cooperation among people who hold differing views of the suffering being addressed through counselling (mental health researchers, counsellors, and clients). I then draw from interviews with counsellors across the district to examine the specific challenges they faced when attempting to secure cooperation from potential clients as well as some common translational strategies they used to accomplish this. In all direct quotes that follow, words that were spoken in English rather than Nepali are italicised.

Two psychosocial problems

Translating ‘psychosocial problems’ in rural Nepal

New category, familiar complaints

Premila was a mother of four who had long lived in Kathmandu with her parents-in-law. It was not until the 2015 earthquake, several years after her training as a psychosocial counsellor, that she found employment in one of Nepal’s mental health NGOs. The job brought her to a town in the hills of Sindhupalchok where she lived in a rented flat during the week. On the weekends, she made the four-hour bus ride back to Kathmandu to see her family.

When I asked Premila how she explained what ‘psychosocial’ meant to potential clients, she affected the soothing voice she used in her counselling practice and offered a short, eloquent description of how the heart-mind’s wounds were reflected in the body as in a mirror. Yet after this poetic beginning, Premila quickly unpacked this relationship in far more concrete and mundane terms: ‘For example, if it has become hard for the heart-mind, the body feels tired, doesn’t feel like working, doesn’t feel like eating, doesn’t feel like sleeping, doesn’t feel like speaking.’

Over the course of my conversations with counsellors, I came to see this practice of example-listing as the most consistent element of psychosocialisation. Whichever metaphor they employed to locate a problem in the ‘heart-mind’, frontline counsellors unanimously went on to reel off a series of complaints and afflictions that anyone in rural Nepal could easily recognise and relate to. It was through such lists that abstract notions of a wound, illness, or problem in the heart-mind took on substance, that counsellors staked out the bounds of the new category of suffering they were trained to attend to. And in all the encounters I observed, it was in the course of listing that potential clients and community members first expressed understanding of what this new mode of care—that is, counselling—was trying to address.

Although counsellors sometimes used the word ‘symptoms’, the lists they ran through did not derive from any formal diagnostic criteria for mental disorders. Instead, they were populated with local ‘idioms of distress’, well documented in anthropological and transcultural psychiatric work in Nepal (Nichter 1981; Sharma and van Ommeren 1998; Kohrt and Hruschka 2010; Chase and Sapkota 2017). Figure 1 offers an illustrated list of complaints that counsellors frequently mentioned. ‘Psychoeducational’ posters like this one were sometimes displayed in public places or distributed in communities by mental health NGO staff to help ‘raise awareness’ about when and where members of the public should seek help for ‘heart-mind problems’. In everyday interactions with clients and families, however, counsellors rarely referred to such materials or offered exhaustive lists of possible symptoms. Instead, they generated symptom lists on an ad hoc basis, flexibly tailoring their descriptions to the particular social contexts in which they worked and, at times, to individual illness trajectories.

Figure 1. An ‘Information, Education and Communication’ handout publicly available in the resources section of TPO-Nepal’s website (Retrieved 15 September 2019 from http://tponepal.org/category/iec-materials/; designed and published in Nepal and reproduced here with permission of the copyright holder TPO-Nepal). The title reads ‘heart-mind problem’ [manko samasyaa] and viewers are told they can contact TPO-Nepal, a female community health volunteer, or a health post if they recognise any of these ‘symptoms’ in themselves or others (beginning top centre and moving clockwise): not feeling like eating, having no interest in working, being absent-minded/staring into space, being bored or frustrated, feeling your body is tired or weak, ‘taking a lot of tension’, ‘liking to stay alone’, and not being able to sleep. Additional symptoms listed at the bottom include the head and body hurting, feeling fear, getting angry, heart palpitations, feeling irritated, guilt/remorse, feeling like you can’t do anything, the inability to make decisions, anxiety and a negative view towards the future, blaming oneself, and avoiding social interaction.

Theorising translation in global mental health

Existing literature on translation in global mental health (GMH) focuses mainly on the challenges linguistic and cultural difference pose for research and intervention (van Ommeren et al. 1999; van Ommeren 2003; Snodgrass, Lacy, and Upadhyay 2017; Van Ommeren et al. 2000; Swartz et al. 2014). In this body of work, translation is understood as a process fundamentally concerned with meaning—that is, with generating representations that are both comprehensible and meaningful in a given social context. The present analysis explores the usefulness of a conceptualisation of translation informed by science and technology studies (STS), which additionally considers how representations are shaped by the desire to enlist support and cooperation (Callon 1986; Star and Griesemer 1989).

Clinicians involved in the GMH project of ‘scaling up’ are not merely charged with introducing new concepts and services in low-resource settings; they must also ensure the intended beneficiaries actually engage with them. In rural communities in Nepal, this means persuading people to invest precious time and energy in unfamiliar and potentially stigmatising forms of care intended to treat conditions accorded relatively low value. At any point, potential clients can (and often do) ‘refuse the transaction by defining its identity, its goals, projects, orientations, motivations, or interest in another manner’ (Callon 1986, 62).

The enrolment of clients in mental health and psychosocial services, we see clearly in counsellors’ accounts above, hinges on much more than dutifully conveying meaning; it calls for the translation of interests—that is, ‘the ideas or instructions [clinicians] purvey’ must be ‘translated into other people’s own intentions, goals and ambitions’ (Mosse 2005, 8). The care agendas of potential clients and their families in rural Nepal must be brought into alignment with those of frontline counsellors. This is no mere matter of tokenistic cultural sensitivity; it is fundamental to the production of ‘success’ in GMH projects (Mosse 2005). And as the growing literature on ‘demand-side barriers to care’ attests, achieving such alignment is no small feat (Patel 2014; Patel et al. 2018).

Psychosocialisation, as I saw it play out in Nepal, offers a new solution to this problem of translation, one that differs markedly from the medicalising approach of psychiatry. Instead of replacing existing illness categories and idioms of distress with a single authoritative diagnosis, it loosely repackages them in ways that shift constellations of hope and obligation, framing such suffering as requiring, worthy of, and amenable to the forms of care on offer. By grouping familiar complaints under the flexible, metaphorical umbrella headings of ‘wound’, ‘illness’, or ‘problem’ in the heart-mind, counsellors reconfigured the moral landscape of affliction without directly specifying its nature.

Yet as Star and Griesemer’s (1989) work reminds us, counsellors and laypeople in rural Nepal are only two groups of actors among many who must collaborate in order to realise the GMH ambition of extending services across low- and middle-income countries. [10] International donors, development organisations, the World Health Organization (WHO), researchers, government ministries, professionals of varied psy-disciplines, and service user advocates are also tied into these therapeutic projects, despite their often divergent understandings of what is at stake (Bemme 2018). The category of the ‘psychosocial problem’ facilitates this collaboration in much the same way as Star’s ‘boundary object’ (Star and Griesemer 1989; Star 2010).

On one hand, the definition of ‘psychosocial problems’ is vague in common use across the broader fields of global health, development, and humanitarian response. Critical social scientists have rightly drawn attention to the lack of operational definitions, the confusion between means and ends, and the blackboxing of complex mind/body/society relations it effects (Kohrt and Song 2018; Watters 2010; Pupavac 2002; Abramowitz 2014). Judging by the diversity of interventions implemented in its name, the category of ‘psychosocial problems’ might as well be defined as ‘suffering not otherwise being addressed’. Star’s work recasts this vagueness as the interpretive flexibility required for cooperation among so many diverse actors. In other words, it suggests psychosocial interventions may be gaining popularity not despite but precisely because of the lack of a unitary vision of the problems they set out to address.

On the other hand, the meaning of ‘psychosocial problems’ is relatively well-structured in its local use at specific sites. Counsellors’ accounts showed remarkable similarities, including the near-exclusive reliance on Nepali language proxies of a problem, sickness, or wound in the ‘heart-mind’ as well as the idioms of distress they populated these labels with. This local definition is now enshrined in culturally adapted counsellors’ training curricula that have been refined and formalised over a decade and adopted by leading NGOs in the sector.

Nepali psychosocial counsellors tack back and forth between these more- and less-structured definitions of ‘psychosocial problems’, enabling them to broker collaborations across geographic, disciplinary, and social distance. Able to speak in the internationally recognisable idiom of a ‘psychosocial problem’ to researchers, clinical supervisors, and the mental health specialists they refer to, they also have leeway to translate the object of their care in context-specific ways in their work with clients—ways that absorb, rather than challenge, other locally salient interpretations of suffering.

The practices of frontline psychosocial workers like those I interviewed are, increasingly, where the ambitions of GMH are brought into alignment with the care aspirations of intended beneficiaries and their families in diverse low-resource settings worldwide. Importantly, the translations these practitioners effect do not necessarily efface difference or produce agreement about the nature of affliction. We see a new discursive politics at work in these Nepali counsellors’ accounts in which authority is established not by unilaterally rejecting local discourses of affliction, but by mobilising capacious therapeutic objects that flexibly absorb and accommodate them. Generating meaningful anthropological critique in this new political terrain may require rethinking the theoretical lenses through which we have historically approached the globalisation of the psy-ences. [11]

Concluding thoughts for the critical anthropology of global mental health

A growing body of scholarship highlights the limitations of well-established paradigms of medical anthropological critique in the face of increasingly complex and self-reflexive global health interventions. This account joins a chorus of voices questioning the central place of medicalisation theory in anthropological analyses of the globalisation of the psy-ences. Recent work in this vein has highlighted the singular trajectories of medicalisation in different contexts (Han 2012), the potential for medicalisation to resocialise rather than desocialise suffering (Behrouzan 2015), and the limited persuasive power of attempts to medicalise ‘outside the narrow circles of biological psychiatry’ (e.g., Kitanaka 2008, 153). A recent special issue on the ‘global psyche’ calls for a move beyond ‘the hermeneutics of suspicion underlying much medicalization scholarship to ask what other modes of critique might be possible and useful’ (Béhague and MacLeish 2020, 8).

My analysis contributes to this conversation a portrait of a therapeutic practice that has begun to escape the logics of the ‘medical’ altogether. Psychosocialisation, as described by my interlocutors in Nepal, is not only distinct from medicalisation; it may represent the very undoing of medicalisation. Where psychiatric approaches have long sought to establish mental suffering as a medical problem amenable to pharmaceutical treatment, Nepali counsellors recast embodied suffering as a social problem amenable to relational forms of intervention. Where psychiatry has navigated the field of mental suffering using as its roadmap the medical model of diagnosis and treatment, psychosocial approaches relax the medical model’s grip on care. And compared with psychoanalytic approaches that have long been the Other of biomedical psychiatry (Béhague and MacLeish 2020), psychosocial interventions are mobile, brief, and affordable—easily transported across boundaries and delegated to laypeople after short targeted training courses.

Yet this is not the only story of psychosocialisation that can be told. Indeed, in Indian-administered Kashmir, the story runs directly counter my own: psychosocial counsellors have begun to adopt the forms and therapeutics of doctors in a bid to assert their legitimacy locally, ultimately reinforcing a medical model (Varma 2012). Likewise, the confluence of humanitarian ideals and Christian morals that shaped counselling practices in Liberia (Abramowitz 2014) is a far cry from the lay knowledge of the heart-mind mobilised by practitioners in Nepal as they worked to circumvent a normative morality that apportions blame to those suffering. This diversity, I have worked to show, is not an unintended by-product of globalisation; instead, it speaks to the flexibility that makes psychosocial interventions so readily globalise-able.

My analysis of psychosocialisation, then, does not support a sweeping critique of ill-defined therapeutic objects such as ‘distress’ and ‘psychosocial problems’ in global mental health (GMH). Indeed, when therapeutic objects function as ‘boundary objects’, ill-structured ‘global’ definitions necessarily tell us very little about the proliferation of more structured local meanings they abet. If we accept that translation strives for cooperation rather than consensus, the position that scaling up psychosocial interventions will have the same harmful or homogenising effects across diverse sites of implementation becomes as untenable as the position that it will yield uniformly positive outcomes. And it is for this reason that psychosocialisation cannot operate as new master concept for analysing global social change; at least, not in the way medicalisation long has.

Instead, meaningful critiques of psychosocialisation must be grounded in close attention to processes of translation in each new social setting. Ironically, the more sweeping and nebulous the therapeutic objects adopted at the level of global policy, the more precise, contextualised, and geographically specific our critiques must be. This is a task to which the anthropologist’s epistemological toolbox is particularly well suited; it requires mastery of multiple languages, a sensitivity to history and context, a concern with emic interpretations, and a commitment to crafting bespoke critical accounts at the expense of generalisability.

As others have noted (Abramowitz 2010; Varma 2012; Kienzler 2020), the practices of frontline clinicians working within transnational mental health projects offer rich ethnographic terrain for such investigations. Practitioners with a few days to a few months of training deliver a growing proportion of mental health and psychosocial care across the Global South, and there is an urgent need for a more robust conceptualisation of their roles and contributions. As the counsellors’ accounts above attest, these actors do far more than passively transport meaning or execute the wills of their superiors; they are ‘mediators’ in Latour’s (2005) sense, creatively and agentively transforming meaning with consequences that can never be predicted at the outset. If we continue to structure our critiques around the psychiatrists at the helm of the GMH endeavour—construing community workers as mere ‘handmaidens of biomedical expertise’ (Campbell and Burgess 2012, 381)—we risk reproducing clinical hierarchies that direly undervalue the labour of frontline workers worldwide (Maes 2015; Brodwin 2013; Chase et al. 2020).

In sum, as psychosocial interventions delivered through task-shifting continue to gain traction in GMH, ethnographies of frontline practice are more essential than ever to a critical anthropology concerned with the social and political consequences of ‘scaling up’. Research on the views, interests, and communicative strategies of frontline psychosocial providers across different sites has much to teach us about the implications of shifting GMH policies for those most marginalised from centres of power and expertise. Ethnographers might further consider engaging with frontline providers as co-investigators and social critics in their own right, designing studies around the difficulties and dilemmas community workers themselves deem most pressing. Such studies, my experience suggests, could provide valuable opportunities to make more incisive and impactful critiques of GMH practice while simultaneously challenging us to refine and develop medical anthropological theory.

Acknowledgements

This research would not have been possible without the partnership of TPO-Nepal (https://tponepal.org/). I am grateful to Dristy Gurung, Dr Kamal Gautam, Nagendra Luitel, Parbati Shrestha, Sujan Shrestha, Kripa Sidgel, and Sunita Rumba for their support and guidance during my fieldwork. Pia Noel, David Mosse, Christopher Davis, Michael Hutt, Joanna Cook, and Ian Harper provided valuable comments on earlier iterations of this article, and conversations with Dörte Bemme enriched it. I received financial support for my doctoral work from SOAS University of London, the University of Cambridge (Frederick Williamson Memorial Fund Grant), and the University of Edinburgh (Tweedie Exploration Fellowship). I also benefitted from a two-month research residency at the Brocher Foundation.

About the author

Liana E. Chase is an assistant professor of anthropology at Durham University. Her research sits at the nexus of anthropology and psychiatry, exploring the implications of social diversity and inequality for mental healthcare. Chase has a longstanding regional focus on the Nepal Himalaya, where she has been involved in anthropological research for over a decade. Her work has been published in a range of journals including The Lancet Psychiatry, Social Science and Medicine, Transcultural Psychiatry, and Global Mental Health. She is currently beginning fieldwork for a three-year ethnographic study of ‘Peer-supported Open Dialogue’, an innovative approach to mental healthcare being trialled in the UK's NHS.

References

Abramowitz, Sharon. 2014. Searching for Normal in the Wake of the Liberian War. Philadelphia, PA: University of Pennsylvania Press.

Abramowitz, Sharon. 2010. ‘Trauma and Humanitarian Translation in Liberia: The Tale of Open Mole’. Culture, Medicine and Psychiatry 34 (2): 353–79. https://doi.org/10.1007/s11013-010-9172-0.

Béhague, Dominique P., and Kenneth MacLeish. 2020. ‘The Global Psyche: Experiments in the Ethics and Politics of Mental Life’. Medical Anthropology Quarterly 34 (1): 5–20. https://doi.org/10.1111/maq.12570.

Behrouzan, Orkideh. 2015. ‘Medicalization as a Way of Life: The Iran-Iraq War and Considerations for Psychiatry and Anthropology’. Medicine Anthropology Theory 2 (3): 40–60. https://doi.org/10.17157/mat.2.3.199.

Bemme, Doerte. 2018. ‘Contingent Universals, Aggregated Truth: An Ethnography of Knowledge in Global Mental Health’. PhD thesis. Montreal: McGill University.

Bemme, Dörte, and Laurence J. Kirmayer. 2020. ‘Global Mental Health: Interdisciplinary Challenges for a Field in Motion’. Transcultural Psychiatry 57 (1): 3–18. https://doi.org/10.1177/1363461519898035.

Brodwin, Paul. 2013. Everyday Ethics: Voices from the Front Line of Community Psychiatry. Berkeley, CA: University of California Press.

Callon, Michel. 1986. ‘Some Elements of the Sociology of Translation: Domestication of the Scallops and the Fishermen of St. Brieue Bay’. Sociological Review Monography 32: 57–78. https://doi.org/10.1111/j.1467-954X.1984.tb00113.x.

Callon, Michel, and John Law. 1982. ‘On Interests and Their Transformation: Enrolment and Counter-Enrolment’. Social Studies of Science 12 (4): 615–625.

Campbell, Catherine, and Rochelle Burgess. 2012. ‘The Role of Communities in Advancing the Goals of the Movement for Global Mental Health’. Transcultural Psychiatry 49 (4): 379–395. https://doi.org/10.1177/1363461512454643.

Chase, Liana E., Kedar Marahatta, Kripa Sidgel, Sujan Shrestha, Kamal Gautam, Nagendra P. Luitel, Bhogendra R. Dotel, and Reuben Samuel. 2018. ‘Building Back Better? Taking Stock of the Post-Earthquake Mental Health and Psychosocial Response in Nepal’. International Journal of Mental Health Systems 12 (44): 1–12. https://doi.org/10.1186/s13033-018-0221-3.

Chase, Liana E., Dristy Gurung, Parbati Shrestha, and Sunita Rumba. 2020. ‘Gendering Psychosocial Care: Risks and Opportunities for Global Mental Health’. Lancet Psychiatry. Web. https://doi.org/10.1016/S2215-0366(20)30483-1.

Chase, Liana E. and Damayanti Bhattarai. 2013. ‘Making Peace in the Heart-Mind: Towards an Ethnopsychology of Resilience among Bhutanese Refugees’. European Bulletin of Himalayan Research 43: 144–166.

Chase, Liana E., and Ram P. Sapkota. 2017. ‘“In Our Community, a Friend Is a Psychologist”: An Ethnographic Study of Informal Care in Two Bhutanese Refugee Communities’. Transcultural Psychiatry 54 (3): 400–422. https://doi.org/10.1177/1363461517703023.

Clark, Jocalyn. 2014. ‘Medicalization of Global Health 2: The Medicalization of Global Mental Health’. Global Health Action 7 (1): 24000. https://doi.org/10.3402/gha.v7.24000.

Cooper, Sara. 2016. ‘Global Mental Health and Its Critics: Moving Beyond the Impasse’. Critical Public Health, 26 (4): 355–358.https://doi.org/10.1080/09581596.2016.1161730.

Das, Anindya and Mohan Rao. 2012. ‘Universal Mental Health: Re-evaluating the Call for Global Mental Health’. Critical Public Health 22 (4): 383–389. https://doi.org/10.1080/09581596.2012.700393.

Ecks, Stefan. 2020. ‘A Medical Anthropology of the “Global Psyche”’. Medical Anthropology Quarterly 34 (1): 143–147. https://doi.org/10.1111/maq.12569.

Fernando, Suman. 2011. ‘A “Global” Mental Health Program or Markets for Big Pharma?’ Open Mind 168 (22): 2353.

Han, Clara. 2012. Life in Debt: Times of Care and Violence in Neoliberal Chile. Berkeley, CA: University of California Press.

Harper, Ian. 2014. Development and Public Health in the Himalaya: Reflections on Healing in Contemporary Nepal. London: Routledge.

Inter-Agency Standing Committee. 2007. IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC.

Jordans, Mark J. D., Nagendra P. Luitel, Emily Garman, Brandon A. Kohrt, Sujit D. Rathod, Pragya Shrestha, Ivan H. Komproe, Crick Lund, and Vikram Patel. 2019. ‘Effectiveness of Psychological Treatments for Depression and Alcohol Use Disorder Delivered by Community-Based Counsellors: Two Pragmatic Randomised Controlled Trials within Primary Healthcare in Nepal’. The British Journal of Psychiatry 1–9. https://doi.org/10.1192/bjp.2018.300.

Jordans, Mark J. D., Nagendra P. Luitel, Brandon A. Kohrt, Sujit D. Rathod, Emily C. Garman, Mary De Silva, Ivan H. Komproe, Vikram Patel Id, and Crick Lund. 2019. ‘Community-, Facility-, and Individual-Level Outcomes of a District Mental Healthcare Plan in a Low-Resource Setting in Nepal: A Population-Based Evaluation’. PLoS Medicine 16 (2): e1002748.https://doi.org/10.1371/journal.pmed.1002748.

Jordans, Mark J. D., Weitse A. Tol, Bhogendra Sharma, and Mark van Ommeren. 2003. ‘Training Psychosocial Counselling in Nepal: Content Review of a Specialized Training Program’. Intervention: The International Journal of Mental Health, Psychosocial Work and Counselling in Areas of Armed Conflict 1 (2): 18–35.

Kienzler, Hanna. 2020. ‘“Making Patients” in Postwar and Resource-Scarce Settings. Diagnosing and Treating Mental Illness in Postwar Kosovo’. Medical Anthropology Quarterly 34 (1): 59–76. https://doi.org/10.1111/maq.12554.

Kitanaka, Junko. 2008. ‘Diagnosing Suicides of Resolve: Psychiatric Practice in Contemporary Japan’. Culture, Medicine and Psychiatry 32 (2): 152–176. https://doi.org/10.1007/s11013-008-9087-1.

Kohrt, Brandon A., and James L. Griffith. 2015. ‘Global Mental Health Praxis: Perspectives from Cultural Psychiatry on Research and Intervention’. Kirmayer, J. Laurence, Robert Lemelson, and Constance A. Cummings, eds. Re-Visioning Psychiatry. Cambridge: Cambridge University Press. 575–612.https://doi.org/10.1017/CBO9781139424745.029.

Kohrt, Brandon A., and Ian Harper. 2008. ‘Navigating Diagnoses: Understanding Mind-Body Relations, Mental Health, and Stigma in Nepal’. Culture, Medicine and Psychiatry 32 (4): 462–91. https://doi.org/10.1007/s11013-008-9110-6.

Kohrt, Brandon A., and Suzan J. Song. 2018. ‘Who Benefits from Psychosocial Support Interventions in Humanitarian Settings?’ The Lancet 6 (4): 354–56. https://doi.org/10.1016/S2214-109X(18)30102-5.

Kohrt, Brandon A., and Daniel J. Hruschka. 2010. ‘Nepali Concepts of Psychological Trauma: The Role of Idioms of Distress, Ethnopsychology and Ethnophysiology in Alleviating Suffering and Preventing Stigma’. Culture, Medicine and Psychiatry 34 (2): 322–52. https://doi.org/10.1007/s11013-010-9170-2.

Kottai, Sudarshan R. and Shubha Ranganathan. 2020. ‘Task-Shifting in Community Mental Health in Kerala: Tensions and Ruptures’. Medical Anthropology 39 (6): 538–552. https://doi.org/10.1080/01459740.2020.1722122.

Latour, Bruno. 2005. Reassembling the Social: An Introduction to Actor-Network-Theory. Oxford: Oxford University Press.

Maes, Kenneth. 2015. ‘Task-Shifting in Global Health: Mental Health Implications for Community Health Workers and Volunteers’. Kohrt, Brandon A., and Emily Mendenhall, eds. Global Mental Health: Anthropological Perspectives. Walnut Creek, CA: Left Coast Press. 291–308.

Mills, China. 2014. Decolonizing Global Mental Health: The Psychiatrization of the Majority World. New York City, NY: Routledge.

Mills, China and Suman Fernando. 2014. ‘Globalising Mental Health or Pathologising the Global South? Mapping the Ethics, Theory and Practice of Global Mental Health’. Open Access 1 (2): 188–202.

Mosse, David. 2005. Cultivating Development: An Ethnography of Aid Policy and Practice. New York City, NY: Pluto Press.

Nichter, Mark. 1981. ‘Idioms of Distress: Alternatives in the Expression of Psychosocial Distress: A Case Study from South India’. Culture, Medicine and Psychiatry 5: 379–408.

Patel, Vikram. 2014. ‘Rethinking Mental Health Care: Bridging the Credibility Gap’. Intervention: Journal of Mental Health and Psychosocial Support in Conflict Affected Areas 12: 15–20.

Patel, Vikram, Shekhar Saxena, Crick Lund, Graham Thornicroft, Florence Baingana, Paul Bolton, Dan Chisholm, Pamela Y. Collins, Janice L. Cooper, Julian Eaton, Helen Herrman, Mohammad M. Herzallah, Yueqin Huang, Mark J. D. Jordans, Arthur Kleinman, Maria Elena Medina-Mora, Ellen Morgan, Unaiza Niaz, Olayinka Omigbodun, Martin Prince, Atif Rahman, Benedetto Saraceno, Bidkut K. Sarkar, Mary De Silva, Ilina Singh, Dan J. Stein, Charlene Sunkel, and Jürgen Unützer. 2018. ‘The Lancet Commission on Global Mental Health and Sustainable Development’. The Lancet 392 (10157): 1553–98. https://doi.org/10.1016/S0140-6736(18)31612-X.

Pathare, Soumitra, Alexandra Brazinova, and Itzhak Levav. 2018. ‘Care Gap: A Comprehensive Measure to Quantify Unmet Needs in Mental Health’. Epidemiology and Psychiatric Sciences 27 (5): 463–67. https://doi.org/10.1017/S2045796018000100.

Peters, Larry. 1978. ‘Psychotherapy in Tamang Shamanism’. Ethos 6 (2): 63–91.

Psychosocial Working Group. 2003. ‘Psychosocial Intervention in Complex Emergencies: A Conceptual Framework’. Edinburgh: Psychosocial working group.

Pupavac, Vanessa. 2002. ‘Pathologizing Populations and Colonizing Minds: International Psychosocial Programmes in Kosovo’. Alternatives 27: 489–511.

Raikhel, Eugene and Dörte Bemme. 2016. Postsocialism, the Psy-ences and Mental Health. Transcultural Psychiatry 53 (2): 151-175. https://doi.org/10.1177/1363461516635534.

Rose, Nikolas. 2006. ‘Disorders Without Borders? The Expanding Scope of Psychiatric Practice’. BioSocieties 1 (4): 465–84. https://doi.org/10.1017/S1745855206004078.

Sapkota, Ram P., Kate Danvers, Wietse A. Tol, and Mark J. D. Jordans. 2007. Advanced Reader for Community Psychosocial Workers. Kathmandu: Sahara Paramarsha Kendra/USAID.

Sherchan, Surendra, Reuben Samuel, Kedar Marahatta, Nazneen Anwar, Mark H. van Ommeren, and Roderico Ofrin. 2017. ‘Post-Disaster Mental Health and Psychosocial Support: Experience from the 2015 Nepal Earthquake’. WHO South-East Asia Journal of Public Health 6 (1): 22–29. https://doi.org/10.4103/2224-3151.206160.

Seale-Feldman, Aidan. 2019. ‘Relational Affliction: Reconceptualizing “Mass Hysteria”’. Ethos 47 (3): 307–325. https://doi.org/10.1111/etho.12245.

Seale-Feldman, Aidan. 2020a. ‘Historicizing the Emergence of Global Mental Health in Nepal (1950–2019)’. Himalaya 39 (2): 29–43. https://digitalcommons.macalester.edu/himalaya/vol39/iss2/7.

Seale-Feldman, Aidan. 2020b. ‘The Work of Disaster: Building Back Otherwise in Post-Earthquake Nepal’. Cultural Anthropology 35 (2): 237–263. https://doi.org/10.14506/ca35.2.07.

Seale-Feldman, Aidan, and Nawaraj Upadhaya. 2015. ‘Mental Health after the Earthquake: Building Nepal’s Mental Health System in Times of Emergency’. Fieldsights. Web. 14 October. http://www.culanth.org/fieldsights/736-mental-health-after-the-earthquake-building-nepal-s-mental-health-system-in-times-of-emergency.

Sharma, Bhogendra, and Mark van Ommeren. 1998. ‘Preventing Torture and Rehabilitating Survivors in Nepal’. Transcultural Psychiatry 35 (1): 85–97. https://doi.org/10.1177/1363461510368892.

Snodgrass, Jeffrey G., Michael G. Lacy, and Chakrapani Upadhyay. 2017. ‘Developing Culturally Sensitive Affect Scales for Global Mental Health Research and Practice: Emotional Balance, Not Named Syndromes, in Indian Adivasi Subjective Well-Being’. Social Science and Medicine 187: 174–83. https://doi.org/10.1016/j.socscimed.2017.06.037.

Star, Susan Leigh. 2010. ‘This Is Not a Boundary Object: Reflections on the Origin of a Concept’. Science Technology and Human Values 35 (5): 601–17. https://doi.org/10.1177/0162243910377624.

Star, Susan Leigh, and James R Griesemer. 1989. ‘Institutional Ecology, “Translations” and Boundary Objects: Amateurs and Professionals in Berkeley’s Museum of Vertebrate Zoology, 1907–39’. Social Studies of Science 19 (3): 387–420. https://doi.org/10.1177/030631289019003001.

Summerfield, Derek. 2012. ‘Afterword: Against “Global Mental Health”’. Transcultural Psychiatry 49 (3–4): 519–30. https://doi.org/10.1177/1363461512454701.

Swartz, Leslie, Sanja Kilian, Justus Twesigye, Dzifa Attah, and Bonginkosi Chiliza. 2014. ‘Language, Culture, and Task Shifting—An Emerging Challenge for Global Mental Health’. Global Health Action 7 (1): 23433. https://doi.org/10.3402/gha.v7.23433.

Tol, Wietse A., Mark J. D. Jordans, Sushama Regmi, and Bhogendra Sharma. 2005. ‘Cultural Challenges to Psychosocial Counselling in Nepal’. Transcultural Psychiatry 42 (2): 317–33. https://doi.org/10.1177/1363461505052670.

Van Ommeren, Mark, Bhogendra Sharma, Suraj Thapa, Ramesh Makaju, Dinesh Prasain, Rabindra Bhattarai, and Joop de Jong. 1999. ‘Preparing Instruments for Transcultural Research: Use of the Translation Monitoring Form with Nepali-Speaking Bhutanese Refugees’. Transcultural Psychiatry 36 (3): 285–301. https://doi.org/10.1177/136346159903600304.

Van Ommeren, Mark. 2003. ‘Validity Issues in Transcultural Epidemiology’. The British Journal of Psychiatry: The Journal of Mental Science 182: 376–78. https://doi.org/10.1192/bjp.182.5.376.

Van Ommeren, Mark, Bhogendra Sharma, R. Makaju, Suraj Thapa, and Joop de Jong. 2000. ‘Limited Cultural Validity of the Composite International Diagnostic Interview’s Probe Flow Chart’. Transcultural Psychiatry 37 (1): 119–29. https://doi.org/10.1177/136346150003700107.

Varma, Saiba. 2012. ‘Where There are only Doctors: Counselors as Psychiatrists in Indian-Administered Kashmir’. Ethos 40 (4): 517–535. https://doi.org/10.1111/j.1548-1352.2012.01274.x.

Watters, Ethan. 2010. Crazy Like Us: The Globalization of the Western Mind. London: Robinson.

White, Ross G., David M. R. Orr, Ursula M. Read, and Sumeet Jain, eds. 2017. The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health. London: Palgrave Macmillan. https://doi.org/10.1057/978-1-137-39510-8.